What is patent foramen ovale closure?
Before birth every baby has a small flap-like opening between the two upper chambers of the heart, called the foramen ovale. In most people it seals soon after birth, but in about one in four adults it stays partly open; this is a patent foramen ovale, or PFO. Usually it causes no trouble at all. Occasionally a small clot from the veins slips through the opening into the left side of the heart instead of being filtered by the lungs, and travels to the brain causing a stroke. Closure is a procedure in which a small double-disc device is placed across the opening through a catheter, sealing it permanently as the body grows its own lining over the device.
Why is it done?
Closure is considered mainly for younger and middle-aged patients who have had a stroke for which no other cause can be found, where the PFO is the most likely explanation. Studies have shown that closing the opening in carefully selected patients reduces the chance of another stroke more than medication alone. The decision is made together by your cardiologist and a neurologist after tests to exclude other causes of stroke, and it usually involves a bubble study and an ultrasound of the heart through the gullet to confirm and size the opening. Closure is not recommended simply because a PFO has been found by chance, and it is not a proven treatment for migraine.
What happens on the day?
You come in fasting for a day case or one-night stay. In the catheterisation laboratory a drip is placed, the groin is numbed with local anaesthetic and you are given sedation, or occasionally a general anaesthetic. A catheter is passed from the vein in the groin to the heart, the opening is crossed with a soft wire, and the closure device is advanced in a collapsed state and opened so that one disc sits on each side of the wall. X-ray and ultrasound confirm that the device is well seated and that the leak has stopped before it is released. The procedure typically takes forty-five to ninety minutes.
What to expect afterwards
You lie flat for a few hours so the groin seals and are usually home the same day or the next morning. Expect some bruising and tenderness in the groin, and avoid heavy lifting and strenuous exercise for about a week. You will take antiplatelet medication, usually aspirin with or without a second agent, for several months while the device becomes covered by the body lining. Antibiotic cover before dental treatment is advised for the first six months. Follow-up includes an ultrasound of the heart at around six months to confirm complete closure. Most patients then return to entirely normal activity, including exercise and, for divers, a return to diving once cleared.
Possible complications
Closure is generally low risk, but complications occur in a small number of patients. The most common are bruising or bleeding at the groin. Atrial fibrillation, an irregular fast rhythm, may appear in the first weeks and usually settles, sometimes needing temporary medication. Less common problems are bleeding into the sac around the heart, movement or, very rarely, dislodgement of the device requiring retrieval or surgery, clot forming on the device, infection, a small residual leak, or a nickel allergy reaction. Stroke during the procedure is rare. Sedation and the gullet ultrasound have their own small risks, including a sore throat. Your cardiologist will discuss these against the risk of another stroke without closure.
This information does not replace a consultation. Please discuss your own risks and options with your cardiologist.