Patent Foramen Ovale

Prior to a few weeks ago I had never heard of Bret Michaels.  I’ve now learned he’s a musician in the “glam metal” band Poison and has had some health difficulty recently.  While most of my readers are probably avid fans of hair bands and need no primer on Poison’s rise to stardom in the 80’s (you may even have their classic rock ballad “Every Rose Has Its Thorn” as your cell phone ring tone) I am somewhat more sheltered and had to look up his information on the internet prior to writing this blog post.

While I take no pleasure in the suffering of others, I have to confess that I find it useful when a celebrity suffers from some heart related problem.   For a few days or weeks the issue of heart health rises to public discourse and gives everyone an opportunity to become more educated.  Also, since I have to come up with a different topic to write on every week, I am relieved when something interesting falls into my lap.  When a famous person launches a heart problem into the public spotlight it makes my job that much easier.

Such was the case recently with Mr. Michaels, who is also apparently a recent winner of the reality TV show The Apprentice and a multi-talented fellow, with screen-writing and acting credits to his name.  At the age of 6 (according to his entry on Wikipedia) he was diagnosed with type 1 diabetes and for years has used his fame to advocate on behalf people with this illness.  Comments from adoring fans on his website attest to his likeable character.

Earlier this year Mr. Michaels was admitted to the hospital for an excruciating headache only two weeks after undergoing emergency appendectomy.  Tests showed a subarachnoid hemorrhage—a bleed in the brain—that appears to have required no urgent therapy.  Just one month later he returned to the hospital after suffering temporary numbness to the left side of his body and was diagnosed with a transient ischemic attack (TIA), or ministroke.  Evaluation of his heart revealed that Mr. Michaels was born with a patent foramen ovale (PFO) and that this had been the apparent cause of his brief stroke symptoms.  His doctors maintain that Mr. Michael’s recent ailments—the appendicitis, the brain bleed, his underlying diabetes, and his TIA—are all unrelated to each other.  What this means, of course, is that Bret Michaels is one really unlucky fellow and is on pace to match reputations with the Biblical, boil-plagued Job (although for his sake I hope Mr. Michaels is not actually the subject of a wager between God and the devil).

One relationship worth exploring, however, is the connection between a PFO and his stroke symptoms.  To understand this relationship you need to learn more about a PFO, and to do that we need to go back, back, back . . .  (cue the flashback music) . . .

Back to when you were an embryo.  As you rested in the warm embrace of your mother’s womb your lungs sat dormant, bathed in amniotic fluid and serving no purpose other than to prepare for the moment the doctor spanked your bottom and you took your first breath of air.  Before your birthday, oxygen entered your body not through your mouth but through a constant flow of blood coming from your umbilical cord.

(These days your blood reenters your heart through the right atrium, is passed into the right ventricle, and is then squeezed out to the lungs.  In the lungs it dumps off the unwanted stuff (carbon dioxide), picks up the good stuff (oxygen), then returns to the left atrium and ventricle to be pumped out to the body.)

Back when you were the source of morning sickness for your long suffering mother the blood took something of a detour after it entered your heart through the right atrium.  Since passage through the wet lungs was not necessary the blood was shunted through a hole in the heart and was pumped directly out to the body.  The hole in the heart, called a foramen ovale (literally, oval hole) was a normal and necessary part of your cardiac anatomy.  According to your body’s owner’s manual this hole was supposed to seal shut the moment you popped out into the labor and delivery ward and belted out your first scream.  From that point on, the blood dutifully passed through the lungs to be loaded with oxygen prior to heading out to the body.

Unfortunately, somewhere between 15 and 25 percent of all people continue to have a persistent hole where the foramen ovale existed (this is, of course, the PFO), and Bret Michaels is one of them.  In most people this PFO never represents any problem.  In a rare minority, however, various issues can arise.

In the case of Mr. Michaels an embolic stroke seems to be the problem.  As he recovered from his other health problems he likely developed a small clot in one of the veins of his legs that dislodged and headed toward his heart.  In the “non-PFO” patient such a clot would end up in the small capillaries of the lungs where it would quietly dissolve and result in no untoward effect.  The PFO in Mr. Michaels allowed the clot to bypass the filtration system of the lungs and proceed directly to the brain where it briefly choked off blood flow to his valuable neural tissue (possibly the region of the brain responsible for an appreciation of power chords and spandex pants).  Luckily he suffered no long-term effects.

Stroke is not the only problem associated with a PFO.  There is increasing evidence to suggest that patients with a PFO are more likely to suffer routine migraine headaches and there are ongoing research trials meant to better explain this relationship (including a study being done here in Omaha—see below).  Deep sea divers with PFOs are at particular risk of neurological problems as they deal with pressure changes and nitrogen gas bubbles.

Surgeons used to repair the PFO by cracking the chest and sewing a patch over the opening.  We are fortunate these days to have a less invasive, slick approach to the problem that can plug the PFO with minimal risk and discomfort.  In my practice we have an expert in the area of PFO closure, Dr. Himanshu Agarwal, and I turned to him for a couple of questions regarding this issue:

Question: How successful is PFO closure?

Dr. Agarwal: Catheter-based closure is more than 99% successful in plugging the PFO and in preventing recurrence of cryptogenic stroke.  Our team at Bergan Mercy has completed approximately 30 cases in the last 3 years with a 100% technical success rate.

Question: As a patient, how tough would it be to undergo this procedure?

Dr. Agarwal: The risks are similar to those associated with a cardiac catheterization and include less than a 1% risk of any major neurovascular or cardiac trauma. Operating time is only 10 to 30 minutes.  Since the procedure requires vascular access through the vein (rather than the artery, as with the cardiac catheterization), the patient can get up and walk after only a couple of hours.

Question: As a doctor, how would you rate the technical difficulty of this procedure (scale of 1-10, one being the Dutch kid sticking his finger in the dike, and 10 being BP successfully plugging the oil leak in the Gulf of Mexico)?

Dr. Agarwal: 2 or 3

Question: What do you think of the link between PFO and migraine headaches?

Dr. Agarwal: There is a strong correlation between PFO and migraine headaches, as well as between closure of the PFO and improvement in the headache syndrome. You can read more on the subject in a publication from the American Headache Society.

Question: What’s your role in researching this link?

Dr. Agarwal: We are part of the ongoing PREMIUM Migraine Clinical Trial and are actively enrolling subjects with migraine headaches.

Question: Who should be screened for a PFO?

Dr. Agarwal: Patients less than 55 who have cryptogenic stroke or those with recurrent stroke; deep sea divers or those who frequently suffer from high altitude hypoxemia; patients planning to undergo posterior fossa surgery (a type of brain surgery usually performed in a sitting position—the presence of a PFO would necessitate a supine positioning during surgery); and patients with frequent, unexplained hypoxemia.

Question: You didn’t include migraine sufferers?

Dr. Agarwal: That’s what the research is for.

Well put.  Thanks to Dr. Agarwal for sharing his expertise with us.

It appears PFO closure is in the stars for Bret Michaels.  According to his website, the musician has recovered and is now back to performing rock ballads to sold-out stadiums.  I wish him well and thank him for helping to educate us on the subject of PFO and for giving me a topic for this week’s blog post.  Hopefully his streak of bizarre health woes won’t continue—I don’t want to have to rely on his bad luck for too many more articles.