KTB 2013: Heart Holes

Feb 11, 2013

A tiny hole, which can go unnoticed, can cause lots of damage. Some can lead to fatigue, shortness of breath, even changes in heart size. Others can be silent threats of stroke.

Dr. Prasanna Kumar is a Cardiologist with Prairie Cardiovascular in Carbondale. He says Atrial Septal Defects – or ASD’s – are among the most-common congenital defects found in adults. While the holes usually close in early infancy or even childhood, some never heal; that can lead to problems later in life.

"Because the top chambers are low-pressure chambers, many times patients don't have any symptoms until they get up to age 40. That's when they start noticing shortness of breath, or fatigue, or swelling. Those are indirect signs of stress on the right side of the heart, causing enlargement and increased pressure buildup in the lung arteries."

ASD’s allow blood to flow from the left to the right upper chambers of the heart, meaning oxygen-rich blood mixes with oxygen-poor blood. That mixed-up blood then moves to the lungs, leading to the symptoms which can send people to the doctor seeking help.

Diagnostic tools include an echocardiogram, and other scans of the heart. Dr. Kumar says while it is the second most common congenital defect, an ASD is rare in adults. It affects only one in a thousand to 15-hundred people.

Treatment for an ASD is a patch for the hole. Doctors insert it through the femoral artery. Dr. Kumar says it resembles a dumbbell:

"It has two discs, one on either side. So we kind of release one disc on the left side of the heart, pull back, and release the other disc on the right side of the heart in such a way that the septum is sandwiched.

Once the patch is placed, patients are typically kept overnight for observation. But Doctor Kumar says most of them are able to get up and walk around with in a few hours of the procedure, and see an improvement in their initial symptoms within a few days.

While the patch works for some patients, experts say it's not always the best way to treat ASD. Sometimes surgery is necessary to close the hole, which requires a longer recovery and includes some increased risk.

The more common kind of heart hole is a Patent Forman Ovale – or PFO. The PFO is found in 20-25% of the population, though in most people it doesn’t cause a problem.

Dr. Kumar the PFO occurs when two flaps between the upper chambers of the heart fail to fuse as a baby develops.

"Sometimes it leaves a gap without fusing. That gap is called a PFO. It generally tends to let blood from the right side of the heart to the left side, because that's how the blood flows in the baby when it is inside the womb. So it tends to maintain that pattern of flow."

Symptomatically, PFO’s can be harder to diagnose. In many cases, patients and doctors are unaware of them until something else happens, causing them to look for a PFO. Dr. Kumar says these holes don’t leave a lot of markers for doctors and patients to watch for:

"Important ones to know are, number one the stroke, which is due to paradoxical embolism. There is some association between migraine headaches and having PFO's. But once again, it's not certain that closing the holes would definitely help the migraines, and it's still in the research phase."

And while this type of hole may sound similar to an ASD, Dr. Kumar says a PFO can pose a different, and sometimes more serious, threat.

"There is an association between the PFO and what we call a paradoxical embolism, meaning a blood clot going from the right side of the heart, crossing through the PFO, and going up to the brain. That could play a role in causing stroke."

Most of the time, the patient who suffers a stroke is otherwise a-symptomatic. They are young, with no other major risk factors for a stroke. When that happens, cardiologists look for the PFO, and if they find one… begin the process of deciding how to treat it.

The jury is still out on how best to treat PFO’s. Some doctors say blood-thinning medicine and careful monitoring will be enough. But Dr. Kumar says new research shows that may not be the best approach:

"This showed that there is a significant reduction in reducing your risk of having another stroke, when you have the holes closed. The numbers were more than 50%, like 50-70% significant stroke risk reduction when you have the holes closed."

Surgical treatment for a PFO is similar to that of an ASD. A device is inserted through a catheter, which closes the hole and keeps blood from flowing in the wrong direction in the heart. Patients are monitored, and in many cases are also walking within a few hours and discharged soon after the procedure.

Dr. Kumar says seeing a physician on a regular basis is a good way to keep track of any changes in your heart health. Along with a proper diet and exercise, doctors say checkups will help keep your heart healthy and will allow them to watch for potential risks in the future.