Heart Health

Patent Foramen Ovale

June 1, 2010

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.

  1. Eric Van De Graaff, MD

    Karen, Either approach will be fine. Warfarin therapy is the most time-tested method for handling this problem; and, yes, you'd need to stay on it indefinitely. At some point in the future you may find yourself in a position where your insurance does cover repair and you can have it done. I was a USAF doctor at Landstuhl Regional Medical Center (near Ramstein AB) in 2003-04. Every now and then I know that hospital will have an army cardiologist who is trained in PFO closure. If you're anywhere near that area you may wish to check into that option. Good luck, Dr. VDG

  2. Eric Van De Graaff, MD

    Ms. Hopson, I can sympathize with your frustration in this regard and your anxiety is understandable. Your cardiologist is quite correct in that there are no clinical trials that provide conclusive evidence that closing your PFO will limit your risk of future stroke. We have relatively good data that suggest that people with PFOs and MRI-proven strokes benefit from closure, but in individuals with TIAs alone the trial results have been mixed. The best data involve patients with recurrent stroke (or TIA) or recurrent stroke while on therapy (aspirin, Plavix or warfarin) I took an informal poll among my colleagues who participate in PFO closure and they tell me that in your case--without MRI evidence of stroke--they would likely not recommend routine closure, rather opting for aspirin therapy alone. I know my input will not help you rest easy about whichever decision you reach, but I hope that you'll have a better understanding of how little information we have on this subject. I don't know what I would do if I were in your shoes--I suppose I'd lean toward fixing the PFO, simply because of how low-risk and relatively simple the procedure is. Good luck with this and I wish you all the best. Dr. VDG

  3. Eric Van De Graaff, MD

    Dr. Priest, I'm relieved to hear you've enjoyed a full recovery from your recent stroke and that you've elected to have your PFO repaired in the near future. I had a discussion with my group's expert on the subject (cited in the original blog post), Dr. Himanshu Agarwal, who tells me that our protocol for antithrombotic therapy is similar to what is being recommended to you. We have patients on aspirin and clopidogrel for 6 months following the procedure, then aspirin alone. As you can imagine the data on which this recommendation is made is pretty sparse--the 6-month recommendation for Plavix is intended to prevent thrombus formation on the device itself until it has a chance to endothelialize. There is no data to suggest that warfarin is any better than antiplatelet medications prior to PFO closure. Unfortunately, the science of PFO closure and strokes is still very young. Good luck with your procedure and your health, and thanks for the comments. Dr. VDG

  4. Eric Van De Graaff, MD

    Michelle, Let me start by saying how frightening it must be to suffer a stroke at such a young age and lose part of your vision. I imagine that the new finding of bubbles leaking around the closure must cause you considerable concern. I don't know the answer to your dilemma and I dare say that we (in the medical community) don't have enough data from research studies to be able to provide a proven solution. Having said that I'm happy to offer my opinion (for what it's worth). Your initial PFO sounds like it was very large and I'm sure the closure occluded the majority of the defect. That in and of itself probably cut your risk of stroke substantially. We know from post-mortem studies that atrial septal PFOs are often accompanied by other extremely small holes called fenestrations. It is possible that your PFO closure was complete but that you continue to have a small amount of flow across these fenestrations. While a repeat closure is possible I don't think, based on the information you provided, that a second procedure would necessarily decrease your stroke risk. The doctor who did your initial closure is most likely more expert on this subject than I and will be able to give you a better opinion. I sincerely hope you have no further problems in the future and I wish you the best of luck. Dr. VDG

  5. Eric Van De Graaff, MD

    Heidi, I share your curiosity about the link between PFO and ischemic colitis. On a cursory search of the medical literature I am able to find no information that might help you make your decision. As I stated in a response to another reader, I have my doubts that a clot small enough to pass through a PFO could trigger ischemic colitis. I wish I could be of more help. I wish you the best for your health. Dr. VDG

  6. Dr. Van De Graaff, MD

    Sheila, Thanks for the question. I'm glad to hear that you recovered fully from your brief episode of aphasia. Out of everything you described the most concerning to me is the finding of the transcranial Doppler study showing evidence of extensive right-to-left shunting. I'm obviously biased about this type of scenario and would encourage you to take another look at nonsurgical PFO closure (despite the lack of FDA indication). If you decide to stay with medical therapy (which, by the way, has yet to be proven inferior to PFO closure) then I think you are on the therapy I would choose for you. The use of aspirin is likely adequate for prevention of microemboli and the dose is likely not terribly important (see http://blogalegent.com/node/89 for a discussion of aspirin dose). If you have any degree of risk of falling I would also argue against the use of warfarin. In summary, I think your choice of therapy is very appropriate and will likely serve you well. Good luck with everything. Dr. VDG

  7. Eric Van De Graaff, MD

    R.A. Trevorah (from Tamaqua): This sounds like a very frightening episode. I hope you have recovered well from your stroke. First off, let me say, take my advice with a grain of salt. Without looking over all the details of your case I may not be providing you with an opinion based on all the data. If all else is normal (normal carotid ultrasound, no history of AF, etc.) and the only abnormality is the PFO, I'd definitely recommend having it fixed. The complication rate is low and the success rate is high. After that the question becomes "do you need to still be on warfarin?" I would argue that a combination of PFO closure and an aspirin/Plavix combination would be an optimal approach and would eliminate the risk and hassle of warfarin. You may wish to find another cardiology group in your area that has a person skilled in PFO closure, and go to them for a second opinion. Good luck and thanks for the question. Dr. VDG

  8. Karen

    Hi i am a 43 yr old woman suffered a stroke on 10 march this year while undergoing tests to decide why i hada stroke doctors found a pfo, i must tell you this is a complicated story as i am living in germanyas my husband is in forces and german docs wanted to go ahead with closure but unfortunately the health services i am under declined funding this is now 3months later and i am on warfarin daily , i am just looking for adviceas to whether a closure is best possible procedure or to stay on warfarin for rest of my life? any advice help with this matter would be greatly appreciated Karenw

  9. s hopson

    Hi I am a relatively healthy 39 yr woman with a young family. I appear to have suffered a TIA approx a month ago, complete loss of use of right arm for a few mins. I have had all sorts of tests and all clear/negative. The final check was a TEE where the PFO was diagnosed. My neurologist refered me immediately to a cardiologist recommending closure. When I met with the cardiologist he said I fell into a grey area and whilst he agreed to undertake the closure he was keen to advise there were no clinical trials saying this would reduce my risk of further TIA. I am booked to have the procedure this week and am very worried. Will this fix the problem or not, I feel am living on egg shells. Am I going to constantly at risk. Am now on aspirin. Please can you give your view. Cholesterol and BP are both in healthy range, Kind regards

  10. David Priest

    Dr. VDG, Thanks for a great blog. I am a 38 year old otherwise healthy physician. I had a small left hemispheric stroke a couple of weeks ago during a bowel movement and as you can guess was found to have a PFO. I had had a left shoulder injury (3rd degree AC joint separation) a couple of months prior to this and I wondered if the clot could have come from there but doppler studies did not reveal any clot in my shoulder. I do not have diabetes, hypertension, clotting disorders, or high cholesterol. I have made a full, rapid recovery. I was taking an 81 mg aspirin daily at the time this happened and now I am on aspirin and plavix. I am going to have a PFO repair on June 13th given my age and the fact I was on aspirin when this happened. I am planning to take plavix for 6 months after the procedure and then just aspirin alone. What post procedure regimen do you use? Would you have me on warfarin now? Any other advice or things to think about? Thanks! Dave

  11. Michelle

    I am a healthy 44 year old female, six months ago I had a stroke. Spent a week in the hospital trying to figure out why. It was found that I had a large hole in my heart. The bubble test was "very positive" as the doctor put it. I had a pfo closure seven days after my stroke. I went today for my six month check up and they did a bubble test and I failed it. Said I had several bubbles pass over but was not an extreme amount. Doctor says I either have another hole or the first one still has a small hole around the closure. Said he could not tell by the bubble test. He says I'm at risk for mini strokes and if I have any they will do another pfo closure. Is this something I should worry about? I don't want to have any more strokes of any kind...mini or not. I have lost a lot of my vision from the first stroke and I feel luckly that was it. Should I look into getting this hole closed or is it not an issue? Thanks for your time, Michelle

  12. Heidi

    Ultimately I would really like to reach the kcb person that Left a question . Out of nowhere I developed ischemic colitis With no real medical history. First they thought I had a blood disorder, then auto immune disease, then maybe C diff may be the cause, and now the kicker.. Now they say that I have a pfo That has been there my whole life Is the culprit. I cannot find any information On pfo and ischemic colitis. Do I Have it closed? Is it totally unrelated, Are there Any diagnostics that can confirm The correlation between the two. ??

  13. KCB

    This is kcb. My experience sounds much like yours. It appears that my IC was just bad luck. I had all sorts of tests and the PFO was the only thing that was found. None of the docs were willing to say that the PFO was the cause of the IC but they couldn't rule it out either. I was told that the hole was small & they left the closure decision up to me and so far I have not had it closed. I was given the impression that it can neither be ruled out nor confirmed. The interventional cardiologist did change my aspirin dosage from baby to one full strength aspirin daily.

  14. Patty

    I read with interest KCB's diagnosis of Ischemic Colitis and later PFO. That is exactly what happened to me. I had and was diagnosed with a bout of Ischemic Colitis in May with a follow up colonoscopy in June. The colonoscopy showed no problems. I had another bout of IC in September. When I saw my regular Dr., she did an echocardiagram with IV bubble and it showed a PFO. I also suffer from intermitant migraines. Currently I am taking an asprin a day.

  15. scarlet

    Hello, Please, what are the accepted recommendations when a 5 YO Cardioseal has failed (positive bubble test after TIA). Also, what are the best institutions & cardiac surgeons in this field(re-repair)? Thanks in advance, Scarlet

  16. Dr. VDG

    Crystal, Thanks for your question and I apologize that I didn't reply earlier--I wanted to speak to a couple of my expert partners before responding. Dr. Ruby Satpathy is an experienced interventionist whose specialized training included the closure of PFOs. Here are her thoughts on your question:   "Cardioseal has a failure risk of 15%-20% versus a risk of under 5% with the Amplatzer/Helex device. It is normal to have minimal shunting by color Doppler until 6-12 months with any device, but not after that. Ideally there should not be any shunting (as assessed by agitated saline--or "bubble"--study) right after the procedure.   "If she has a 5-year-old Cardioseal, I would be curious to know if her shunting is just by color or both color and saline, and if the flow is mild, moderate, or severe. With mild shunting, and no recurrent symptoms, it is probably advised to be conservative and take aspirin and plavix, or coumadin (based on assessment of overall patient risk profile).   "However, with any shunting that is more than mild, the chance of recurrent events is unfortunately 4 times higher than the risk prior to PFO closure. Recomendations include minimally-invasive surgical closure or placement of another percutaneous device. You can go either way and I have seen both. The caveat is to make sure there is no fracture of Cardioseal device, at which point surgery becomes the only option."   Scarlet, your options for doctors obviously depend on where you live. Most metropolitan areas have cardiologists who specialize in this area and can provide you with a good opinion. If you live anywhere near Omaha come see Dr. Satpathy or Dr. Agarwal in my group. They're both skilled and experienced and can give you an opinion that might help give you a better idea of which course to take. Good luck! Dr. VDG

  17. r. a. trevorah

    3/1/10 i had a tia and i could not speak correctly. i was flown to a bethlehem, pa hospital where i spent 10 days and had several tests to see why i suffered the tia. there was no indication of any clots anywhere in my body. but they did find a pfo in my heart (i am 66 yrs old). it was a terrifing experience especially since i had watched my father take a stroke after several tias and fade away day after day until dying 6 months later. i have seen two cardiologists and they both want me to wait until i have another tia. i DO NOT want to wait. i never want to have another tia or a severe stroke. i am on warfarin at this time. please let me know your opinion. thank you for your time and trouble, r.a. trevorah (tamaqua, pa)

  18. Patty

    No, it was never recommended to repair the PFO, just the asprin regimen. I'm very comfortable with this as I'm 51 years old and in good health. If I hadn't had the IC, I probably wouldn't have found the PFO. I still haven't been able to determine if the Colitis is related to the PFO ~ it doesn't make sense to me!

  19. Darlene

    If Bret Michaels chose to close his PFO woudln't have have to be on warfarin for the rest of his life?

  20. KCB

    Last Aug, I was dx w/ischemic colitis. After a 6 day hospital stay & much testing, a PFO was found and determined to be the cause. Both my cardiologist & interventional cardiologist have left the decision to repair the PFO up to me. What would you recommend?

  21. Dr. Van De Graaff

    KCB, Ischemic colitis? I can't say that I feel too confident about that as a reason to have the PFO closed. The type of clots that pass through a PFO are always very small, but even a tiny clot can cause trouble in the brain if the clot makes its way up into the head. I'm a little skeptical that such a small clot could be the cause of a case of ischemic colitis. The problem is that PFOs are common among the general population and yours could be an innocent bystander in your recent illness. If I were in your shoes I'd probably look for a second opinion. Hope this helps. Good luck and thanks for the comment. Dr. VDG

  22. Dr. VDG

    Darlene, You're right about the warfarin. If Bret Michaels chooses to have his PFO fixed (and I've not seen that he's had this done yet, but then again I don't do a very good job of keeping track of such celebrities) he won't need to be on the blood thinner. If he decides he likes his PFO and wants to keep it then it would be wise for him to stay on warfarin. My guess is he'll get it fixed. Thanks. Dr. VDG

  23. Sheila

    I was diagnosed with an atrial septal aneurysm and PFO in May of this year. In April I had an episode of aphasia that lasted aproximately three minutes. At the time I thought the aphasia was a TIA. Since the aphasia lasted only 3 minutes I made an appointment with PCP instead of calling 911. I went to my PCP who sent me on to have a carotoid doppler which was normal. I had an echocardiogram where they weren't able to visualize the heart for PFO. I had a Transcranial Doppler Bubble study and which was positive for a grade 5 PFO with right to left shunting. My cardiologist was not convinced the aphasia was TIA related because of my migraine history. He had me see a stroke specialist about the aphasia. With my migraine history (which has been primarily visual disturbances 98% of the time and only occasionally a full blown headache) he wanted an opinion on whether the aphasia was due to a migraine (I did not know aphasia could be caused by migraines). About 45 minutes prior to the episode of aphasia I had an occular migraine (didn't think to relate the two). I saw the stroke specialist who believes that the aphasia was migraine related. Prior to this episode of aphasia I had never had it related to the visual disturbances of migraine and I'm still confused as to why all the sudden after years of the visual disturbances and the occasional full blown headache all the sudden I would develope aphasia as a part of my migraine problem. I am still on the fence about the aphasia being migraine related. I am not sure what to think. After much research I have chosen medical management of my PFO and atrial septal aneurym. My cardiologist currently has me on 325mg of asprin a day and the neurologist added 1200mg of fish oil as well. They chose not to do coumadin as I have a fall history due to Rheumatoid Arthritis and difficulty walking. I came across your blog and found the statitics for PFO closure interesting. One reason I chose medical management was that the research I did showed that the closure devices used in PFO closure were not yet FDA approved. The fact they werent' approved frightened me alot and was a big reason I chose medical management. The other is I have had 17 surgeries and honestly I am terrified of more. I worry about would happen if something went wrong with the closure device. So the question what are your feelings on medical management if you had a patient who wanted to go that route. Do you even recomment it and if so what would your recommendations be for aspirin dosage or would you prefer comadin even if the patient had a fall history.

  24. KCB

    I was interested to read Patty's entry regarding her IC & finding of the PFO. I have not had another episode of IC & as of now have not had the PFO repaired. My daily aspirin dosage was upped from a baby aspirin to a full asprin. I also had two colonoscopies (both fine). I'm wondering if Patty could respond as to whether a PFO repair was recommended in her case. Thanks.

  25. Kim Kelso

    So do you think we can recurit him to be screened for our Premium trial?

  26. Jena

    Not only has Bret Michaels brought heart issues to the mainstream public, he has made us all wonder, yet again, what he is hiding under his bandana. Thanks for the refresher course on the foramen ovale. When I read that I could hear Dad's voice in my head teaching the same thing.

  27. Tara

    I think we could! The news said he's not having surgery until the fall, we could get him right in and fix him up! Now, how do we get a hold of him?!

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