ADVERTISEMENT

• JOBS
• CE
• Cardiopulmonary
• Geriatrics &
  Home Health
• Neurology
• Pediatrics
• Sports & Orthopedics
• PT Toolbox
• HOME

Search Over 1026 PT Jobs

State All States Alaska Alabama Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

Specialty All Specialties Physical Therapy Physical Therapy Assistant Physical Therapy Manager

Keywords

• Print This
• Select Text Size:
• 

A few years ago, then-39-year-old David Dansereau, MS, PT, began having trouble with fine motor skills, migraine headaches, and unremitting fatigue. After months of testing and provisional diagnoses ranging from multiple sclerosis to lupus, doctors concluded that the father of three from Cumberland, R.I., had suffered a stroke.

A lifelong athlete, Dansereau had been the picture of health for most of his life. But echocardiography revealed something other tests had missed: a patent foramen ovale. PFO, a common congenital heart defect present in one in five individuals, is an incomplete closure of the atrial septal wall that in rare cases is associated with cryptogenic stroke.

Although PFOs have long been thought to be asymptomatic, the PFO-stroke connection is gaining attention and the first randomized, controlled trials are underway to evaluate the safety and effectiveness of PFO closure with transcatheter devices.

“The most important thing to know is that PFO is very common and usually not associated with any ill effects,” says Samir Kapadia, MD, director of the Interventional Cardiology Fellowship Program at Cleveland Clinic in Cleveland, Ohio.

Before birth, everyone has an opening between the heart’s atrial chambers. “I call it a curtain in the wall,” Kapadia says. Because babies in the womb can’t use their own lungs, they instead get filtered, oxygenated blood from their mothers via the placenta. The cardiac “curtain” allows oxygenated blood to travel through the fetus’s heart to the brain. Although the opening usually closes shortly after birth, the curtain never seals in as much as 30% of the population, resulting in a latent hole in the heart.

Heart Connections

PFO is usually diagnosed by echocardiography. When a patient performs a Valsalva maneuver or coughs, increased right atrial pressure may cause blood to be forced through the PFO into the left atrium. Alternatively, a saline solution filled with dissolved microbubbles can be injected intravenously, revealing a PFO if the bubbles pass from the right to the left side of the heart, where they can be detected by ultrasound of the cranial arteries.

Patients who have had a stroke, transient ischemic attack, or stroke symptoms should be screened for PFO when no other risks are apparent. Divers also should be screened, Kapadia says.

Although PFO usually poses no risk, some studies show a connection between PFO and cryptogenic stroke in patients younger than 55. Stroke can occur when a blood clot, which ordinarily would be filtered in the lungs, passes through the opening and travels directly to the brain. A blood clot also can form within the PFO itself.

Less data are available showing an association between PFO and strokes of unknown origin in patients 55 and older, although a study published in a recent issue of the New England Journal of Medicine showed a greater prevalence of PFO among both younger and older patients who had a cryptogenic stroke than for those who had a stroke of known cause.

PFO also is correlated with high-altitude pulmonary edema, platypnea-orthodeoxia syndrome (orthostatic dyspnea and deoxygenation), and decompression sickness, says Stanford University School of Medicine assistant professor David P. Lee, MD, director of the Cardiac Catheterization and Coronary Intervention Laboratories and the Interventional Cardiology Fellowship Program at Stanford Hospital and Clinics in Palo Alto, Calif.

Some evidence also links PFO with migraine headaches. Dansereau’s migraines disappeared after he underwent a procedure to close the PFO.

But the association has not yet been proven, Lee says. A large randomized study — the Migraine Intervention with StarFlex Technology (MIST) trial — failed to show that PFO closure eliminated migraines, although 42% of the closure group reported a 50% drop in headache days compared to 23% who went through a placebo procedure.

Vulnerable Hearts

Researchers don’t know why PFO is problematic in rare instances.

“Some think it has to do with the size or shape of the PFO tunnel,” Lee says. “It has been shown that larger PFOs in patients who have had a stroke have a greater chance of another neurologic event, but this hasn’t been entirely established in a clinical trial.”

The standard care for patients with cryptogenic stroke is blood-thinning medication, such as prescription drugs warfarin (Coumadin) or clopidrogrel (Plavix), which prevent blood clots from forming.

“Closure of a PFO should be considered only if the patient is not a good candidate for medications,” Lee says.

Open heart surgery was the only option for PFO closure a generation ago. Today interventional cardiologists use septal repair implants to seal the hole. The device is inserted through a catheter and implanted at the PFO, and tissue grows around it to seal the septum.

European doctors currently are experimenting with a radiofrequency procedure that causes scar tissue to form and eventually close the PFO.

But many doctors are approaching the issue with caution; about 8,000 PFO closures were performed in the U.S. last year, which some experts say is too high.

Kapadia says he performs PFO closure on one in 10 patients who come in for a consultation for the procedure. Closure is not recommended for older patients, he says, because other stroke risk factors may be involved.

Hearty Implications

“Some of the literature says patients with PFO have a decreased tolerance for exercise,” says Suzanne Tinsley, PhD, PT, associate professor in the physical therapy program at the Louisiana State University Health Sciences Center in New Orleans and chair of the Stroke Special Interest Group of APTA’s Neurology Section. Tinsley cautions PTs to keep this in mind with patients with diagnosed PFO, as well as any contraindications to exercise if they are taking blood thinners.

With any patient, complaints about neurological symptoms, such as sudden numbness or balance problems, should raise a red flag. “Don’t just pass it off,” she says. “It could be something beyond what we can treat.” If this occurs, PTs should refer patients to the appropriate physician, and educate patients about stroke symptoms and the importance of seeking immediate medical treatment, Tinsley advises. 

After PFO closure, patients should refrain from heavy lifting or performing exercises that require prolonged breath holding for six weeks, Kapadia says.

Doctors think Dansereau’s recent stroke was not his first. As a teenager he fell one day at hockey practice and lost use of the left side of his body for a few minutes. He and a coach chalked it up to the fall, and he never told anyone of the incident until recently.

After having to shut down his practice to rehabilitate from his stroke, Dansereau is seeing patients again full time and raising awareness about PFO and stroke. He also is raising money for stroke research by training for the Boston Marathon as a member of Tedy’s Team, founded by New England Patriot Tedy Bruschi, who suffered a stroke and then returned to professional football after PFO closure.

---

Barbara Marquand is a medical writer for the Gannett Healthcare Group. To comment, e-mail pteditor@gannetthg.com.

© Copyright 2009 Gannett Healthcare Group