Things to know about PFO, a common heart defect

There’s a good chance you may be walking around with a hole in your heart.

“It’s as common as having blue eyes or being left-handed,” said Dr. Phillip Horwitz, a cardiologist and the executive director of the University of Iowa’s Heart and Vascular Center. “For most people this is a normal variant in the heart.”

The condition is patent foramen ovale, or PFO: a hole between the left and right atria (upper chambers) of the heart. Dr. Richard Kettelkamp, structural cardiologist and medical director at St. Luke’s Heart Care Clinic in Cedar Rapids, explains the PFO is a “fetal remnant” that’s usually corrected as the body develops.

“Rarely is it a problem, but there are times when a PFO can be associated with a stroke, particularly in young people,” Kettelkamp said.

The hole exists to allow the mother’s oxygen-rich blood to bypass the lungs of her fetus. The opening usually closes naturally soon after birth, but that doesn’t occur in about 25 percent of the population — the condition known as a PFO.

“It’s a connection that’s present in everyone,” Horwitz said. “In most people it seals, but something like one in four, one in five people are running around with this. Most people with a PFO aren’t going to have any symptoms related to it and shouldn’t have anything done about it.”

“The right and the left circulations are kind of parallel circuits,” said Dr. Ryan Hollenbeck, Mercy Medical Center cardiologist. “Normally there’s no communication of those two systems.”

“It’s a potential hole” in most people, Kettelkamp said. “It’s not there all the time.”

But for a subset of that one-in-four, a PFO can lead to quality-of-life issues.

“It’s usually (found) in adults or young adults who have a stroke,” Hollenback said. “That blood clot could theoretically find its way across that hole, and if the blood clot goes to the brain, that’s a stroke.”

Dr. Richard Kettelkamp. Submitted photo.

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Dr. Phillip Horwitz. Submitted photo.

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Dr. Ryan Hollenbeck. Submitted photo.

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“Younger people who have strokes, some of those appear to be related to blood clots crossing these PFOs,” Horwitz said. “It’s people who are younger and who don’t have a lot of other risk factors. Fixing them can reduce future strokes by a small amount.”

That’s the only reason Hollenbeck performs surgery to close a PFO.

“In the right patient it can be a preventive measure to reduce the risk of having another stroke,” he said.

Some patients may experience swelling in the legs or lung congestion. Scuba divers with an undetected PFO may experience decompression illness, but the most common symptoms for non-divers is shortness of breath and fatigue that seems to become more prevalent with age.

“The oxygen levels drop, and some of those people will be short of breath and it affects their endurance,” Horwitz said. “I encounter those people about once a year.”

In one recent case, a woman in her sixties reported the shortness of breath and fatigue she’d experienced her entire life seemed to worsen until a sudden fainting spell caused her to fall and strike her head — an uncommon but not unknown experience among those with an unaddressed PFO.

The woman’s fall led her to consult the family doctor, who referred her to Unity Point’s cardiologists.

After a comprehensive round of tests including an EKG, ultrasound and stress tests, as well as a brain MRI and the use of a heart monitor, the condition was confirmed.

Fortunately, the procedure to seal a PFO, cardiac catheterization, is a relatively low-risk outpatient procedure assuming the patient has no other cardiac issue.

“They usually go home the same day,” Kettelkamp said.

Kettelkamp used a catheter to repair the patient’s heart. He was the first in Cedar Rapids to practice the non-invasive technique in 2006.

“People can usually go back to normal activities in about a week,” Horwitz said. “In general, it’s a well-tolerated and a relatively safe procedure.”

“The technology’s really cool,” Hollenbeck said. “This thing grasps the septum and pulls it together and it grows into the wall of your heart and becomes part of your heart. It’s a pretty slick procedure. We watch them for a few hours, and we send them home the same day, and they take it easy for about a week.”

Oftentimes, the symptoms’ progressive nature leads many people to chalk them up to simply getting older.

“It’s pretty easy to say as we get older ‘I’m just running out of steam,’” Kettelkamp said. “It’s not abrupt. When it’s a valve problem, it progresses over years. If you’re not as active as you used to be, that can be a tip-off.”

While a PFO itself is often easily treated, its symptoms are often shared with more serious conditions. Much of the PFO-related testing is done to confirm the patient isn’t experiencing other more serious cardiac issues, such as aortic stenosis.

“The most common symptom for structural heart disease is just shortness of breath with exertion,” Kettelkamp said. “A patient might say ‘Last summer I could mow the entire yard without stopping. This year, I’m stopping three times.’”

A physician can often pick up on heart-valve issues by listening through a stethoscope.

“Oftentimes with valve disease you’ll hear a murmur, and your doctor can pick up this turbulent blood flow,” Kettelkamp said. “You obviously don’t want to ignore chest pain. It might not be valve disease, but it could be other things that are equally concerning.”