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Suggest treatment for congenital PFO and TIA

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Posted on Fri, 31 Jul 2015
Question: I am a 39 year old female with congenital PFO(Patent Foramen Ovale) & ASA (Atrial Septal Aneurysm). I also was diagnosed with SVT (Supraventricular Tachycardia), a regurgitating mitral valve with thickened leaflets, and stage 1 diastolic dysfunction in the left ventricle.

I recently suffered a TIA. I lost complete vision in my right eye. My brain MRI revleaed mild diffuse cerebral cortical volume loss and minimum chronic subcortical / periventricular white matter change. What does this mean? I'm being told to take aspirin and that's it. My research is revealing a startling relationship between PFO & ASA with stroke and TIA. I have read that there is up to a 33 FOLD probability of stroke/TIA in patients <45 years when they have both PFO & ASA. Isn't there something I should do besides aspirin? I understand that PFO closure with device doesn't show significant success, but what about closure of patent foramen ovale (PFO) using radiofrequency? Would this take care of the ASA as well?

I am a fitness instructor and triathlete with no other risk factors for TIA. I don't take any medications (other than aspirin), I am not overweight, I don't smoke, I eat healthy, and other than noted above, I have no risk factor for stroke/TIA. I believe I had another TIA the other night - I lost complete vision in the right eye the first time, and this time I lost partial vision in the left eye. I want to be proactive... I don't want to wait for this to happen again and it be worse the next time. HELP!
doctor
Answered by Dr. Erion Spaho (44 minutes later)
Brief Answer:
PFO should be closed and Warfarin should be started.

Detailed Answer:
Hello and thanks for using HCM.

I have read your question and understand your concerns.

It is true, both, PFO and ASa, increase significantly risk of cryptogenic stroke (including TIA and ischemic strokes).

There is no evidence that closing PFO will prevent stroke, but when stroke happens, closure is indicated.

Succes of PFO closure ranges from 70% to 95% with different procedures,and successful closure improves ASA too.

Prevention of stroke in your case depends on transesophageal ultrasound results, if evidence of thrombus treatment consists on Warfarin use, if low risk (or no thrombi),
Aspirin is used.

In my opinion, you had two strokes episodes, so warfarin should be used.

I suggest you to discuss with your treating Doctor about above mentioned possibilities of your treatment.

Warfarin should be adjusted regarding to INR levels and this should be followed up by your Doctor.

Hope I helped you. I remain at your disposal for further questions and clarifications.

Take care.


Above answer was peer-reviewed by : Dr. Neel Kudchadkar
doctor
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Follow up: Dr. Erion Spaho (2 hours later)
Thank you VERY much!

What are your thoughts regarding Robot- PFO closure using radiofrequency ablation instead of the foreign device? How can I find out who the best surgeons are for this procedure? I don't want to be on blood thinners for the rest of my life as I have a VERY active lifestyle - cycling, hiking, rock-climbing... all no good for blood thinners!

Also, what are your thoughts regarding the mitral valve regurgitation, thickened mitral valve leaflets and SVT? Are these related to the risk of stroke along with the PFO/ASA?

Lastly, my blood work all came back normal with the exception of these anomalies... What do you make of them? Interrelated to the TIAs?
o     Revealed low Alkaline Phosphatase (32 U/L – Normal = 34-115)
o     High Range for Lymphocytes (37.8% - Normal = 20-40%)
o     Low Range for Neutrophils (52.8% - Normal = 50-70%)
(autoimmune? Bacteria in blood?)

I am grateful for your expertise! XXXXXXX
doctor
Answered by Dr. Erion Spaho (17 hours later)
Brief Answer:
Radiofrequency results appropriate if PFO diameter < 7 mm.

Detailed Answer:
Welcome back XXXXXXX

Radiofrequency closure of PFO results in good outcome ( 90%), if the diameter of PFO is 7 or less millimeters, above 7 milimeters, there is no good outcome.

Mitral valve regurgitation is related partially to ischemic stroke (embolism), but in young patients (or people), there is no such relation, so in your case, there is no additional risk of stroke.

Blood thinners should be used if necessary, their use benefits are compared with probable side effects.

About blood tests results, neutrophils and leukocytes are within normal range, so there is no need to worry about.

Low alkaline phosphatase could be related to liver disfunction or bone demineralization, there's no relation to stroke. I shouldn't worry about blood tests results.

The choice of surgeon is yours, you should choose an experienced one. I'm shure you can find someone appropriate around your location.

Hope I helped you. Wishing you good health.



Above answer was peer-reviewed by : Dr. Raju A.T
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Answered by
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Dr. Erion Spaho

Neurologist, Surgical

Practicing since :2004

Answered : 4426 Questions

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Suggest treatment for congenital PFO and TIA

Brief Answer: PFO should be closed and Warfarin should be started. Detailed Answer: Hello and thanks for using HCM. I have read your question and understand your concerns. It is true, both, PFO and ASa, increase significantly risk of cryptogenic stroke (including TIA and ischemic strokes). There is no evidence that closing PFO will prevent stroke, but when stroke happens, closure is indicated. Succes of PFO closure ranges from 70% to 95% with different procedures,and successful closure improves ASA too. Prevention of stroke in your case depends on transesophageal ultrasound results, if evidence of thrombus treatment consists on Warfarin use, if low risk (or no thrombi), Aspirin is used. In my opinion, you had two strokes episodes, so warfarin should be used. I suggest you to discuss with your treating Doctor about above mentioned possibilities of your treatment. Warfarin should be adjusted regarding to INR levels and this should be followed up by your Doctor. Hope I helped you. I remain at your disposal for further questions and clarifications. Take care.