Overview of Catheter Management of Patent Foramen Ovale
A Patent Foramen Ovale (PFO) is a small, usually harmless, hole between the two upper chambers of the heart. It’s quite common, present in one in five people, and doesn’t discriminate between genders. However, its size can increase as you get older, even though fewer older people tend to have it.
This small hole has been linked to both heart-related and non heart-related health issues. Most notably, it’s been connected to cryptogenic stroke, a type of stroke whose cause is unknown. The PFO can act like a tunnel, allowing clots to move from the right side to the left side of the heart, which could lead to a stroke. Often, a PFO is discovered during tests after a stroke occurs.
This link between PFO and cryptogenic stroke has prompted researchers to study whether closing the PFO might help to prevent strokes from reoccurring. In general, studies have found that combining a PFO closure with medicine is more effective in preventing repeated cryptogenic stroke than medicine alone. However, closing a PFO hasn’t been found to reduce the risk of temporary strokes or overall death rate. Some studies also found higher rates of short-term irregular heartbeats after PFO closure, though the long-term effects are still unknown.
Financially, closing a PFO to prevent cryptogenic stroke has been found to possibly be cost-effective. Interestingly, a study found that the effectiveness of PFO closure depends on the type of device used to close it.
The most certain way to diagnose a PFO is by using a specific type of ultrasound test of the heart (a transesophageal echocardiogram) combined with a bubble test following a special breathing technique called a Valsalva maneuver. Once discovered, doctors can then decide if treatment is needed.
There are three general types of treatment available: surgery, a non-surgical procedure using a thin tube called a catheter, and medication. Nowadays, more patients are choosing the catheter procedure because it is less invasive than surgery.
Anatomy and Physiology of Catheter Management of Patent Foramen Ovale
A patent foramen ovale (PFO) refers to an opening that is leftover from a part of a baby’s heart known as the fetal foramen ovale. When a baby is developing in the womb, this opening allows blood to move from the right side of the heart to the left side. This opening is supposed to close up naturally once the baby is born. However, in about 1 out of every 4 people, this opening doesn’t close.
While most people with a PFO don’t experience any symptoms or health issues, there are some who do. It is these few people who should consider getting their PFO evaluated for possible treatment, which could involve closing the opening.
Why do People Need Catheter Management of Patent Foramen Ovale
The procedure of closing the PFO (Patent Foramen Ovale) via catheter, a method known as transcatheter PFO closure, is suggested in specific instances. These instances could include those where:
– You’ve had multiple unexplained strokes, which doctors think were caused by a blood clot traveling through the PFO (this is known as a ‘paradoxical embolism’).
– You’ve had recurrent TIA or transient ischemic attacks, which are mini-strokes that typically only last for a few minutes but could last up to 24 hours.
– You have a history of blood clots that dislodge and travel to another part of your body (paradoxical peripheral embolisms).
– You’ve experienced decompression sickness, a condition generally encountered by deep-sea divers when they ascend too quickly to the surface.
– You suffer from migraines; some research suggests that PFO might play a role in causing migraines in some patients.
When a Person Should Avoid Catheter Management of Patent Foramen Ovale
A percutaneous transcatheter PFO closure is a procedure used to close a hole in the heart. However, there are some situations where a person might not be able to have this procedure due to specific health issues. These include:
If the hole in the heart is too large, specifically larger than 25 mm, it may be safer to go for a surgery instead of using the transcatheter closure method.
Active endocarditis, which is an infection of the heart lining, bacteremia and fungemia which are conditions where bacteria or fungi are in the blood, and current sepsis, a life-threatening reaction to an infection, can all make it too risky to perform this type of procedure.
In case of an intracardiac mass, which is an abnormal growth in the heart, or if the structure of the patient’s heart makes it difficult to safely deliver the device used in the procedure, it might not be advisable to perform a percutaneous transcatheter PFO closure.
Equipment used for Catheter Management of Patent Foramen Ovale
The procedure will be done in a specialized room called the cardiac catheterization laboratory. It’s a clean and highly equipped medical room where heart-related procedures are performed.
The medical team performing the procedure will be wearing sterile gowns, gloves, and use sterile drapes to ensure cleanliness and prevent infections.
They will use an echocardiogram, which is a special type of imaging test that uses sound waves to create images of your heart. This helps them see the structure of your heart and how it’s functioning.
Fluoroscopy is another type of imaging tool they’ll use. It’s like an X-ray that allows the doctors to get real-time, moving images of your heart.
The doctors will have a device called a PFO occluder ready. This is a small device that they can place into the hole in your heart to close it.
A code cart will be in the room too, just in case. This is a set of emergency supplies and medications that can be used if an unexpected heart rhythm problem, or ‘arrhythmia’, occurs during the procedure.
The team will use what’s called a balloon-tipped angiographic catheter or a pigtail catheter, along with a guidewire. The catheter is a long, thin tube that they can place into a blood vessel and guide to your heart. The guidewire helps them do this. The balloon-tip or pigtail shape at the end helps them navigate and perform the procedure accurately.
Who is needed to perform Catheter Management of Patent Foramen Ovale?
A specialist heart doctor, known as an interventional cardiologist, is the one who performs a procedure to close the small opening in the heart, known as a PFO (Patent Foramen Ovale). This doctor has undergone specialized training to ensure they can do this procedure effectively and safely. During the procedure, the cardiologist works with a team of other medical professionals.
This team usually includes a surgical first assistant who helps the cardiologist with the procedure. A cardiac nurse, a nurse specifically trained to care for patients with heart conditions, is also part of the team. They assist and provide care before, during, and after the procedure.
Additionally, a cardiac cath lab technician is also present during the procedure. This technician prepares and manages medical equipment that can view and treat the heart without needing open surgery. This entire team of professionals works together with the main goal of ensuring your heart procedure is a success and your well-being is prioritized throughout the process.
Preparing for Catheter Management of Patent Foramen Ovale
Before undergoing a heart procedure known as percutaneous transcatheter PFO closure, several steps are taken to assess if a person is a good candidate for this treatment. This begins with taking images of the brain and then using an echo test with a special bubble study. Other tests such as a chest X-ray, an electrocardiogram (which measures the electrical activity of your heart), and blood tests are also done to check the patient’s overall health and kidney function.
Additionally, individuals who are about to have a PFO closure are usually given antiplatelet medicines, like aspirin and Plavix, daily before the procedure. These medications help to prevent blood clots. For those who require constant treatment to prevent blood clots, they may only need to take Warfarin, and then switch to a different medication called low-molecular-weight heparin before and after the procedure.
One hour prior to the procedure, a dose of IV antibiotics is administered to prevent any infections from occurring. The antibiotics you might receive may include cefazolin or vancomycin, especially if you’re allergic to penicillin. As a part of the preparation process, you should carry on having a normal amount of fluid, which can be done through an IV drip with normal saline to make sure your blood volume remains stable during the operation.
How is Catheter Management of Patent Foramen Ovale performed
To treat a condition called Patent Foramen Ovale (PFO), a procedure termed ‘transcatheter PFO closure’ is performed. PFO is a hole between the two chambers of the heart, and this procedure works by placing a device to close it.
The process begins with your doctor accessing a blood vessel, often in your leg (femoral venous site). This choice of access is commonly used as it’s the safest and simplest way of reaching your heart. Once the site is ready, the doctor will give you a dose of a medicine known as heparin to prevent blood clotting. More heparin will be given as needed during the procedure.
You will also be given oxygen through a nasal tube to keep your blood oxygen levels high. This is a precautionary step to address potential air bubbles that may enter during the treatment.
The doctor will then use a special tube, known as a catheter, to capture images of the space inside your heart (left atrial). A device called a multipurpose catheter is positioned in a vein leading to your heart, and then directed to a particular spot called the ‘fossa ovalis’.
Once the catheter is in place, a guide wire is advanced into the PFO to the left side of your heart. The doctor will check the catheter’s position and measure the pressure in your heart. If difficulty is encountered passing the wire, the doctor might use different types. The catheter is then replaced by a guide or flex sheath.
Using this sheath, the doctor can determine the size of the PFO using a small inflatable device (balloon). The closure device is then chosen based on the PFO size. This device consists of two parts (or discs), one being positioned within each heart chamber on either side of the PFO.
The device discs are attached to the septum, the wall separating the right and left sides of the heart. The doctor will then use an imaging technique (contrast) to confirm the device is in the correct location. Further tests are carried out such as viewing the discs, examining the space between the discs and performing ‘RA angiography’ that evaluates the function and position of the device.
There are different methods of guidance during this procedure – using direct vision (fluoroscopy), echocardiographic (sound wave imaging) guidance, or both. There’s ongoing debate about which of these options is more effective. While one study suggests that using echocardiography shortens the procedure and removes the need for general anesthesia, using fluoroscopy increases procedure time and cost.
Once the procedure is complete, an ultrasound of the chest (transthoracic echocardiography) with a bubble study, will be performed to double-check the device’s position and evaluate remaining flaws. An electrocardiogram and chest x-ray are also done to screen for any complications and verify the procedure’s correctness.
You will be given medicines preventing blood clotting for six months. It’s also recommended to avoid dental procedures during these first six months, as they can increase the risk of heart infection (endocarditis). If dental treatment is necessary, you should take antibiotics to prevent infection. Follow-up evaluations using chest ultrasound will be scheduled at one and six months after the procedure.
Possible Complications of Catheter Management of Patent Foramen Ovale
Research shows that about 7% of people who have a PFO closure, a type of heart procedure, experience complications. Older individuals, especially those above 60 years, tend to have a higher risk of something going wrong. Additionally, people who’ve previously had a stroke, which is a condition where blood flow to part of your brain is cut off, are more likely to encounter problems compared to those who’ve had a transient ischemic stroke, which is a mini-stroke that doesn’t last very long.
The complications that might happen, listed from most common to least common, include:
* Arrhythmia, which means your heart is beating irregularly. The most common type is called atrial fibrillation.
* Vascular complications, or problems with your blood vessels.
* Hemorrhage/hematoma, which refers to bleeding or collection of blood outside blood vessels in your body.
* Cardiac tamponade/perforation, or a serious problem where fluid builds up around your heart or there’s a hole in your heart.
* The worst complication is loss of life.
* Pneumothorax/hemothorax, or a condition where air or blood fills up the space around your lungs.
* Occluder embolus, or a problem where a device used to close the PFO moves from its original place.
* Finally, people may experience infection after the procedure.
What Else Should I Know About Catheter Management of Patent Foramen Ovale?
A patent foramen ovale (PFO) is a hole in the heart that didn’t close as it should after birth. Not everyone with PFO needs to have it closed. However, for some patients, closing the PFO can help prevent serious health problems, like strokes. It’s very important that family doctors understand when a patient might benefit from PFO closure, so they can refer them for treatment. If the PFO is larger than 25 mm (about 1 inch), it probably can’t be closed with a minimally invasive procedure and might need surgery. This is an essential piece of information to share with the patient.
Whenever you’re considering a procedure or surgery, it’s important to be aware of possible complications. With PFO closure, the most common complication is an irregular heartbeat, also known as arrhythmia. There is also a small chance of death. However, your doctor would only recommend this procedure if they believed the benefits outweighed the risks.
