Patent Foramen Ovale repair

So, you've been referred for a PFO closure. What is a PFO? Hopefully you know by now, it's a patent foramen ovale. It is not a hole in the heart. It is a little flap that is present in a quarter of the whole population. You will have been referred for PFO closure because either you've been unfortunate enough to have a stroke, where the only cause might be this thing in the heart, or you have, you're a diver and you've had decompression illness. Those are the two standard indications for PFO closure in the majority of patients. It's a fairly common procedure to be done and it's a very safe procedure to be done but you need to understand why it's actually being done and it's an approach to try and reduce either the risk of decompression illness if you were a diver or the risk of recurrent stroke. The pros and cons of it will have been discussed with you in clinic. My job here today is to describe what might happen on the day and what the long-term follow-up is. So we're going to do it usually under general anaesthesia. We'll place a puncture point in your leg and that leg will therefore hurt a little bit thereafter. It's only in the vein and therefore the risk of bleeding is fairly low from it. We'll also often make your throat slightly sore because we're going to do a transesophageal echocardiogram. Usually when you've had one of those as part of your screening process so you will know what that feels like. You may have had that one done under local anaesthesia and sedation. Well you're usually asleep for this part of the treatment procedure so you won't know about it but you may wake up with a sore throat. We pass a small wire across the flap and then put a double umbrella device through that flap so that one umbrella opens on one side of the flap, the other on the other side of the flap, thereby sealing the flap. Now the theory is that a small amount of grit can go across the flap when you cough or sneeze and the flap opens very momentarily. a device in place, it can't do that. So although a few bubbles might still go across if we injected some agitated saline and watched it very carefully, the hope is that even if a few bubbles go across, a larger bit of grit can't go through the mesh that is this double umbrella device and thereby the risk of anything further happening to you is reduced. We use it as a day case procedure, so you'll be woken up from the general anesthetic, you'll feel a bit groggy. If you react badly to anesthetics, well, it is an anesthetic and therefore you react badly to this one as well, so be prepared for that if you've had one before. Most people wake up a little bit groggy, a few hours later they're feeling as right as rain, a little sore in the groin, and by the end of the day we'll be sending you home again. You need to have someone with you because you may still be a little bit groggy, I don't want you travelling by public transport to go home at the end of the day, and that puncture point in the leg may bleed, unlikely, but it may bleed at the end of the day, and if you're at home You need someone with you to either press on the groin or make the phone call to ask for some help to occur. So what are the complications that can occur? Well, we've punctured a vein that can be bleeding or bruising from that. Very rarely is it getting infected because, of course, we clean the skin very thoroughly. So as long as you keep it dry for four or five days afterwards, it should not get infected. We're then placing wires and kit inside the heart, so that can cause internal bleeding. The device is very unlikely to move but occasionally it can dislodge and therefore these procedures are only done in centres where we have the technology to snare it out again, go fishing and pull it out if it moves, unlikely to move as I say, or call the surgeon and try and fish this device out and if we're doing that we'll seal the hole at the same time. Those are very unlikely to occur. We're playing with the heart. We can set off small clots and that can cause a heart attack or stroke and of course if the internal bleeding, the heart attack or stroke is very serious, then might result in death. All of those complications put together, and I mean all of them, are probably 1%, so 1 in 100 risk of all of those complications put together. The risk of dying is actually very small. So it will have been discussed with you before, you will have read the patient information sheet. If you're uncomfortable about this sort of procedure, there's no right or wrong. You can defer it, you can delay it forever, discuss it with your doctor again. no imperative to suddenly go through it because you happen to be in the hospital. Always discuss it with your doctor as you sign the consent form. What do you expect afterwards? Take a week off work. Don't drive for a week. I'm worried that you might be looking at your leg. That might hurt. You're not looking at the road. It could cause an accident. So take a week off driving, a week off work, and after that you can do pretty much what you like. You'll be on some extra blood thinners, aspirin and a slightly stronger version of aspirin, probably for a month or two afterwards. The duration depends on what your condition is. But you'll then have some follow-up, maybe at a month, maybe at three months. Some doctors do a follow-up echocardiogram to really assess what's going on. Some people do it in more detail. And some just say, look, the device was very well sat and we'll follow you up clinically. If you've had no further events, no further strokes, no further decompression, then maybe that's good enough. So the follow-up that you have varies depending on your condition and what your local protocol is.