Interventional PFO and ASD Closure - Medical Experts

The patent foramen ovale (PFO) is a connection between the right and left atria that persists after birth. In the womb, the foramen ovale forms part of the foetal circulatory system. With the first breaths, the pressure conditions in the right atrium change, so that it normally closes functionally.

An atrial septal defect (ASD), on the other hand, is a congenital heart defect. In the atrial septum, there is a lack of tissue or a genuine opening. This anatomical abnormality must be assessed differently from a PFO.

This connection allows blood to flow between the atria. This blood flow is known as a shunt. In the case of a PFO, a venous blood clot can enter the arterial circulation and travel on to the brain. Such a paradoxical embolism can contribute to a stroke.

Around 25 per cent of the healthy population have a PFO. The detection of a small opening alone is therefore not, in itself, an indication for closure.

The following points are relevant for cardiological assessment:

• ASD: Depending on the findings, closure may be performed via catheter or surgically. Following treatment, symptoms as well as enlargement and strain on the right ventricle may subside.
• Postural hypoxaemia: PFO closure is considered in a small number of patients; in one case series, the procedure was successful in 76 individuals.

An incidentally detected PFO without a history of stroke does not, in itself, warrant treatment. In a review of randomised trials, PFO closure carried out solely to prevent migraine did not significantly reduce the frequency or severity of migraine attacks.

The technical success rate is high, but this does not replace an individual risk-benefit assessment. At a follow-up examination in an observational study, 98.5% of the treated PFOs were closed. A meta-analysis also found a high success rate for catheter-based ASD closure in adults.

Before the procedure, the structure of the communication is assessed to determine whether it can be closed using a catheter.

A transoesophageal echocardiogram may be required prior to ASD catheter closure. This involves examining the heart via the oesophagus, producing more detailed images than external ultrasound.

The imaging shows the location and shape of the opening, as well as the surrounding heart septum. If the defect is too complex for the minimally invasive catheter procedure, surgery may be a more suitable option.

The interventional closure is performed via a blood vessel in the groin. The occluder is an implant that covers the connection between the two sides. For a PFO closure, a local anaesthetic may be sufficient; a general anaesthetic is not required for every procedure.

The typical procedure:

1. The doctor punctures the femoral vein.
2. A catheter is advanced through the blood vessel to the heart.
3. The folded-up ‘umbrella’ is guided through the catheter to the opening.
4. The occluder is released into the defect.
5. Once the catheter has been removed, the puncture site is dressed.

PFO closure can be performed under fluoroscopic guidance. The duration of the procedure itself depends on the findings. Following an uncomplicated procedure, same-day discharge is possible; for patients discharged later as part of a multicentre study, the median length of stay was one night.

Serious complications are rare but possible. In a meta-analysis, they occurred in 1.9 per cent of procedures following catheter-based ASD closure and in 6.8 per cent following surgical closure. These results cannot be directly applied to every individual case.

Relevant risks include:

• Atrial fibrillation: This cardiac arrhythmia occurs more frequently following PFO closure than with drug therapy alone.
• Dislodged occluder: The implant may enter the bloodstream and may need to be surgically removed. An international study documented this complication following catheter-based ASD closures.

The individual risk depends, amongst other things, on the anatomy of the defect and any underlying medical conditions. Before consent is given, the doctor should explain how frequently complications occur at the respective centre and how a displaced implant is managed there.

After treatment, the position of the implant and the puncture site are checked. In one study, doctors examined the heart using ultrasound and checked the groin before discharge.

Medications such as aspirin and clopidogrel are prescribed following the procedure. In a PFO study, participants took aspirin and clopidogrel for three months, followed by aspirin alone. Following an ASD closure, study participants were prescribed six months’ worth of aspirin or a combination of both medicines, as decided by their doctor.

Your personal medication plan must be finalised before discharge. Do not stop taking these medicines on your own initiative. At an outpatient follow-up appointment six months after PFO closure, a clinical examination and a transoesophageal contrast echocardiogram can show whether blood is still flowing through the opening.

For a secundum-type ASD, the options are catheter closure or surgical treatment, depending on the anatomy and findings. The decisive factor is whether the occluder can be securely anchored in the atrial septum.

Statutory health insurance covers medically necessary hospital treatment. For inpatient PFO or ASD closure, the hospital must have a contract with statutory health insurers. Medical necessity is assessed prior to the procedure.

Those with statutory health insurance aged 18 and over usually pay 10 euros per day in hospital, up to a maximum of 28 days per year. Optional services agreed upon voluntarily must be paid for by the patient themselves unless they have suitable supplementary insurance.

It is not possible to specify a reliable standard price for self-pay patients, either as a fixed euro amount or as a price range. Anyone who has to pay for the procedure privately will receive written information about the estimated costs before treatment.

Those with private health insurance should submit a cost estimate to their insurer in advance. They will receive an invoice for the hospital treatment; they can then submit the payment receipts to their private health insurer.

An additional qualification in interventional cardiology from the German Society of Cardiology goes beyond general specialist training. This can serve as an indicator of quality when searching for a suitable doctor.

You can ask the following questions during your initial consultation:

• Why is the procedure advisable given my diagnosis, and is my defect suitable for catheter-based closure?
• What medication and follow-up checks are planned afterwards?

You can find specialists in PFO and ASD closures at a hospital or cardiac centre at the end of this text.