Cardioseal not healing

[dsl]

Please excuse me if this is the incorrect forum for this issue. My husband is 53; last fall he began experiencing episodes that were first diagnosed as TIAs. After several episodes a TEE was done. A PFO was discovered. Our GP and our neurologist recommended closure.  In December, a Cardioseal was inserted.  In March ‘08 a follow-up TEE was done. The seal was not completely healed.  Another follow-up TEE was performed yesterday; healing has not progressed since March.

After the current TEE and the one in March, the doctor mentioned a “small flap of tissue” that he felt was interfering with closure; he also referred to the flap as an aneurysm. When reviewing some relevant sites on the Internet we discovered the flap might be called an Atrial Septal Aneurysm (ASA). This condition was not mentioned when the initial TEE was performed in December ‘07.  Can the insertion of a Cardioseal for a PFO repair cause an ASA to develop?  How is this condition treated?  What is the long-term outlook?  All the information I’ve googled on PFO and ASA together (at least, what I can understand) is very distressing. I’m worried that in trying to resolve one problem we’ve created an even bigger one. The doctor who performed the TEEs told us to consult with the doctor who inserted the seal. We have scheduled an appointment but it’s several weeks off. I’d like information so we can ask intelligent questions. My husband currently takes Plavix, 81mg aspirin, Altace, Ziac, Zocor and 50mg of Topamax daily. Our current neurologist believes his original condition may be a migraine variant. Please help me – I’d be deeply appreciative of any information. Thank you.

[Darcy Green Conaway, MD]

I will address the whole notion of PFO and stroke (TIA) first. ABotu 30% of the population has a PFO--it is a normal variant. Now in some people it is very large. I am not a big believer in the PFO/stroke relationship (unless someone is very young and has no other reason to stroke-- in a male who is 53 years old it could be due to atherosclerosis from high blood pressure, obesity, smoking, etc). So for a stroke to be due to a PFO the blood first has to have a reason to cross from the right atrium into the left atrium (not usually the case since the pressures are higher on the left-- so sometimes a cough or strain can do this); THEN you have to be a clot that crosses from left to right; THEN of all the blood that gets pumped out to the body, the clot has to be in that small amount of blood that goes to the brain. I think the PFO/stroke relationship is questionable at best. Having said that, there are times I believe it can happen. Your questions about whether the closure causes the aneurysm--I suppose it is possible but aneurysmal septums can occur and can occur with PFO. When the occur with a PFO the rate of stroke is felt to be higher. I hope this is helpful. Does your husband have other risk factors such as obesity, smoking , high cholesterol, hypertension? If so, he should very aggressively treat these.

[dsl]

I appreciate the response but it really doesn't answer the questions any further than the information we've already found on the internet. We know that PFO/stroke link is largely theory; our GP and former neurologist were grabbing at straws trying to determine the cause of the episodes. The PFO was purely circumstantial. We do not believe (nor does our current neurologist) so-called TIAs were in fact, TIAs at all. He had dozens of these without any residual damage. My husband's episodes have lessened in frequency and severity since he started on Topamax. I need to know what treatment options are available for the PFO and the ANA. Can the seal be removed, or replaced? How is an ASA treated, especially in conjunction with a PFO? Is there a surgical option or just meds? What is the long-term outlook for individuals with a PFO and ASA; I know the risk of stroke is higher. How much higher - and what can be done to reduce the risk? My husband does not smoke, is not overweight and his blood pressure and cholesterol are both well under control. I am frustrated because no one provides us with a solid answer. All I'm sure of at this point is that he's had a procedure that was probably completely unnecessary and he may now be at greater risk for a stroke. Does he need to be on Plavix the rest of his life? Since the episodes mimic a TIA and he's now got a greater risk of stroke, how am I supposed to differentiate between the two? These episodes are not infrequent - we could spend a lot of time in the ER. No one appears willing to address my questions. They tapdance around the issue; the cardiologist who did the TEE told the news and then took off like his rearend was on fire. I know you cannot diagnose him over the internet but we need help.