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New heart procedure corrects "hole in the heart" defect

Juston McGaffey isn't one to schedule routine visits to his doctor. But when his recurring headaches began to include vision trouble, he knew it was time to find out what was wrong.  

McGaffey's visit to MercyCare North led to two surprising discoveries: his symptoms were being triggered by small strokes, and they were linked to a defect in his heart known as patent foramen ovale (PFO), or "hole in the heart."

Looking back, the 31-year-old Cedar Rapids man can describe the warning signs he had for almost a year.

"I used to have headaches a lot. But then last December, these blind spells came on," McGaffey says. "I'd have no peripheral vision. After about 15 minutes, it would come back. Then I'd get a really bad headache that would last for a couple hours."

Tests confirmed that McGaffey had a PFO, an opening in the wall between the upper two chambers of his heart. It is congenital, meaning it's a defect that exists at birth.

Normally, this flap closes shortly after birth. If it remains open, it is considered a defect.

PFOs are not uncommon; they affect one in five people. The cause may be a viral infection or genetics, but in 95% of cases, a cause can't be identified. Most patients reach adulthood with an undetected PFO without any significant symptoms. But even though most have no symptoms, PFO is the most likely cause of stroke in patients under age 55.

The condition predisposes a person to stroke when small, often undetectable clots form in the pelvic region or lower extremities. If a clot breaks loose and pressure to the right side of the heart increases during strain or activity, that clot can cross through the PFO and reach the brain or other organs.

Often, a PFO is not diagnosed until a child or adult with this defect has a transient ischemic attack (TIA), which has stroke-like symptoms lasting less than 24 hours; or a full stroke, which leaves more permanent damage.

McGaffey was experiencing TIAs.

The usual care for someone who's had a stroke is blood-thinning medications such as aspirin or prescription drugs like Coumadin. But there are risks and inconveniences associated with long-term use of blood-thinners: ulcers, internal bleeding, and curtailing activities that might result in injury. For a young person, like McGaffey, it can mean a major lifestyle change.

Fortunately, Dr. Andrew Peterson, a neurologist with Physicians' Clinic of Iowa, and Dr. Richard Kettelkamp, a cardiologist with Cardiologists, P.C., examined McGaffey and agreed he was a good candidate for a catheter-based PFO closure procedure.

On Feb. 13, Dr. Kettelkamp performed the procedure, which had not previously been available in Cedar Rapids , on McGaffey at Mercy Medical Center 's Katz Cardiovascular Center. The main advantage of this catheter-based approach is that it permanently seals the PFO without the need for open-heart surgery, which can require much longer recovery.

In the procedure, a small puncture is made in the crease at the top of the thigh and a catheter is inserted into the femoral vein. A PFO closure device (which resembles two opened, square umbrellas lying against each other) is moved through the catheter into the heart, to the defect. Once in place, the device is expanded to straddle each side of the defect, becoming a permanent implant, preventing abnormal blood flow between the two heart chambers. The catheter is removed and the patient is hospitalized overnight. Within a few days, tissue begins to grow over the device, and it becomes a part of the heart wall within six months.

Today, McGaffey has no more headaches or blurred vision.

"I feel better since the procedure than I ever felt before," McGaffey says. "I don't get as tired as much as I used to. I can walk a lot longer."

McGaffey's youth and stroke symptoms led Drs. Peterson and Kettelkamp to suspect a PFO.

"PFOs can be found incidentally," says Dr. Kettelkamp, "but a young person having a stroke sends out red flags. In that case, the heart is involved about 50% of the time."

It's important for a patient like McGaffey to be evaluated by a cardiologist and neurologist to ensure proper treatment, Dr. Kettelkamp stresses. Dr. Peterson referred McGaffey to Kettelkamp, currently the only cardiologist performing this procedure.

"Properly-selected patients will do much better with this procedure than medication," Dr. Kettelkamp notes. "Juston would have a lifelong need for medications, whereas this is really a cure."

The procedure became accepted as a mainstream treatment about five years ago, Dr. Kettelkamp says. He began performing the procedure while at University of Iowa Hospitals and Clinics.

Stroke is the greatest threat with PFOs, but they have also been linked to heart attacks, he adds, and studies are currently to explore a possible link between PFOs and migraines.