Category: Latest Articles

Percutaneous Minimally Invasive PFO Device Closure

Introduction
Patent foramen ovale (PFO) is a common abnormality, with an occurrence of 20-34% in the adult population. Most of the time, a PFO does not pose a high medical risk and can be a benign incidental finding. However, in some patients, PFO may open widely, causing paradoxical embolus (blood clots that break off from the venous circulation) to enter into the arterial circulation. This is known to be associated with cryptogenic stroke and systemic embolisation, with PFO being the most common cause of cryptogenic stroke in patients younger than 55 years old.

Percutaneous closure of PFO, a minimally invasive procedure to close the PFO using a device can help patients with cryptogenic stroke to reduce the risk of recurrent stroke. Other potential indications for closure include systemic embolisation, decompression sickness, platypnoea-orthodeoxia syndrome, amaurosis fugax, and migraine with aura.

What is a PFO?

In short, a PFO is a small hole in the heart. In the majority of the infants, closure of the foramen ovale occurs naturally after birth as negative intrathoracic pressure caused by the infants’ first breaths will cause the PFO to close. In some cases, the primum and secundum atrial septa fail to fuse completely, causing the foramen ovale to remain patent, enabling a continuous communication between the left and right heart.

Many times, a PFO may remain undetected throughout a person’s lifespan. However, when a blood clot breaks off and travels from the venous to arterial circulation (from right to left heart) through the PFO, it may start to cause serious medical conditions such as (cryptogenic) stroke, as well as decompression sickness in divers.

How to assess a PFO?

The first method of imaging to detect the presence of PFO is a transthoracic echocardiogram (TTE), or cardiac ultrasound. It is a non-invasive and safe method to see the heart. Using an ultrasound technique called color flow doppler, computerized colorization of these signals can help to identify if there is any blood flow communication between the right and left heart.

Agitated saline contrast (bubble) study is also performed to assess for a PFO. A sterile salt solution is shaken until tiny bubbles are formed which is then injected into a vein. Combined with a technique called the Valsalva maneuver to transiently increase the pressure in the right atrium, a positive bubble study whereby bubbles appear on the left side of the heart will indicate the presence of PFO.
The findings can subsequently be confirmed via transoesophageal echocardiography (TEE). The cardiologist inserts a probe through the mouth into the oesophagus (gut) to see the heart using ultrasound. A TEE is able to visualize the heart better and clearer as the distance of the TEE probe to the heart is nearer. A patient undergoing the TEE procedure has to fast (strictly no food, no water) for at least 6 hours before.

Percutaneous Minimally Invasive PFO Device Closure

The PFO device closure is performed in a catheterization laboratory with fluoroscopic (live X-ray) and TEE guidance. It is a minimally invasive procedure whereby the cardiologist implants the device across the PFO, through a catheter (plastic tube), inserted via the leg vein in the groin. The device acts like a double-sided umbrella that opens on each side of the heart between the top chambers, thereby sealing up the hole. It can be performed with mild sedation, within an hour, and with one night’s day in the hospital.

View this video published by Abbott Cardiovascular to learn more about the PFO Occluder:

To read up more on decompression sickness in divers, read the follow article:

Device closure in Scuba Divers

References:

https://onlinelibrary.wiley.com/doi/full/10.1111/joim.13143

https://my.clevelandclinic.org/health/diseases/17326-patent-foramen-ovale-pfo

https://www.revespcardiol.org/en-diagnosis-quantification-patent-foramen-ovale–articulo-S188558571000071X

https://www.icrjournal.com/articles/patent-foramen-ovale-closure-2019#:~:text=In%20this%20brief%20review%2C%20the,the%20strengthening%20evidence%20for%20closure.

https://www.graphicnews.com/en/pages/18720/science-fixing-a-hole-in-the-heart

September 17, 2020

Teleconsultation with our Doctors

Due to the Covid-19 travel restrictions, we will now offer Tele-consultation online to our overseas patients.

Please see the following guide to book a Teleconsultation with Dr Paul Chiam or. Dr Lim Choon Pin

Email us at enquiry@heartvascularcentre.com, call us at +65 6735 3022 or whatsapp us at +65 96640822 to enquire and book a teleconsultation session.
Our teleconsultation will be via Google-Meet or Zoom.
Ensure that you have the following on your device:

Camera/Video and Microphone option.
Gmail account for Google-meet/ Google-meet app installed on your phone,

https://play.google.com/store/apps/details?id=com.google.android.apps.meetings&hl=en_SG

https://apps.apple.com/us/app/zoom-cloud-meetings/id546505307

https://meet.google.com/

Zoom application installed on your phone

https://play.google.com/store/apps/details?id=us.zoom.videomeetings&hl=en_SG

https://apps.apple.com/us/app/zoom-cloud-meetings/id546505307

4. Teleconsultation Fees:

Contact us for more details on the charges. Once we receive the payment, you can secure the booking for teleconsultation and the exact date and time will be set.

5. For payment, we accept:

Overseas Remittance (Bank Transfer)
AMEX cardless- transaction
PayNow to our corporate account, UEN No: 201410445Z

*note: that bank fees are chargeable to patient

6. Send a remittance advice or proof of payment to us.

7. On the date of teleconsultation

Meeting via Google-meet or Zoom
We will provide the meeting code/ password
Teleconsultation commences

*note: you may contact us to check if certain tests should be done prior the teleconsultation, e.g. blood tests or ECG

8. Follow up after consultation

Next appointment (if any)
Medications for overseas delivery/ Prescriptions

Featured image credits: Png vectors created by 30000005111 – lovepik.com

April 27, 2020

Covid-19 and Your Heart

written by Dr Lim Choon Pin

During this Covid-19 virus outbreak, many patients with chronic heart diseases may be worried about how their underlying heart conditions can be affected by the virus. While there is still much to be discovered about the short- and long-term effects the Covid-19 virus, here is a summary of what we know about the virus and the heart so far and how you can protect yourself.

Effects of Covid-19 on the heart

Patients who have a heart condition are at the same risk of catching the virus as any other person. The virus is spread by breathing in respiratory droplets in the air or touching your face, eyes or mouth after coming into contact with contaminated surfaces. Therefore, EVERYONE is at risk.
Patients with chronic heart conditions are at a higher risk of developing more severe forms of the infection if they do catch the virus.
The main organ that Covid-19 virus affects is the lungs. However, it can also cause damage to other organs. The virus can affect the heart in the following ways:
1. by causing inflammation of the heart muscles (myocarditis and pericarditis)
2. triggering abnormal heart rhythm (arrhythmias)
3. triggering heart failure symptoms
4. triggering a heart attack

This can happen even in people without pre-existing heart conditions.

ACE-inhibitors (e.g. Enalapril, Perindopril etc) and ARBs (e.g. Valsartan, Candesartan etc) are common medications used to treat hypertension, heart failure, heart attacks and kidney diseases. There are some debates that suggest that these medications could theoretically increase the risk infection by the Covid-19 virus; however, these same drugs may also protect from the severe form of illness. There is currently no convincing clinical evidence supporting these hypotheses, therefore many international professional bodies such as the World Health Organisation, American Heart Association, European Society of Hypertension and the Ministry of Health of Singapore have recommended patients should continue taking these medications in view of their beneficial effects for these chronic medical conditions.
Medications such as Hydroxychloroquine and Azithromycin are still unproven in the treatment of Covid-19. Moreover, they could also result in life-threatening arrhythmias, especially in patients with underlying heart disease. Therefore, you should not self-medicate with these unproven medications.
Vaccinations against influenza and pneumococcus are important for patients with heart disease. While they do not protect against Covid-19, it is still important to be current with these vaccinations as cardiac patients are still susceptible to these infections even during the Covid-19 outbreak.

You cannot prevent the effects of Covid-19 virus on your heart. However, you can do the following to protect yourself from catching the infection during this outbreak and keeping your heart healthy.

Practice good hygiene practices like:
1. Regular and thorough handwashing with soap, especially before eating or touching your face.
2. Avoid people who are sick.
3. Avoid crowded places. Go out only for essential activities.
4. Wear a mask when going outdoors.
5. Practise physical distancing. Stay at least one metre away from people around you when you are out.

2. Continue regular exercises 30 minutes a day for 5 days each week. Consider switching to indoor static exercises if you are unable to do walks alone or with a mask on in your neighbourhood.

3.Continue to eat a healthy diet. Do not binge on snacks and instant noodles when you are confined in your home.

4. You may consider delaying your reviews with your doctors if you feel completely well. Speak to your cardiologist whether it is safe to do so.

5. It is also important that you have enough supply of medications. Do not stop any cardiac medications without first consulting your doctor – this can potentially be harmful to you.

6. Do not delay seeing your doctor or going to the emergency department if you have symptoms such as worsening chest pain, palpitations, shortness of breath or fainting. While patients are recommended to avoid non-essential visits to the hospital, if you have any active heart-related symptoms, it is not safe to delay assessment. You can be assured that the hospitals will still be able to care for you safely during this period.

We hope that this information can enable all cardiac patients with the necessary information to tide through this difficult period.

Wishing all of you good health. Stay Home and Stay Safe!

From all of us at The Heart and Vascular Centre

April 8, 2020

COVID-19 Updates

As the situation of the pandemic is evolving, we will continue to update our health advisories according to Singapore government guidelines.

For more information on the coronavirus situation in Singapore, please visit the Ministry of Health website (click here).

Visitor and patient advisory

All patients and visitors to the Medical Centre are required to fill the visitor registration forms and health declaration form before entering. Every department, including the Radiology clinic (X-ray), Laboratory (for blood tests) and our clinics, will also require the patient and his/her caregiver to fill in health declaration forms.

Please note that each patient is allowed only ONE person to accompany him. All visitors are required to follow social isolation and infection prevention and control measures. These include:

Washing of hands with soap and water for at least 20 seconds, or applying at least 60% alcohol-based disinfection rub on hands before entry
Bringing of own mask and ensuring that the mask is worn at all times
Maintaining social distancing of at least 2 metres from the other patients and visitors
Not communicating and interacting with other patients or visitors

Anyone who has had travelled abroad within the last 14 days or had close contact with a confirmed COVID-19 patient will be denied entry to the medical centre and our clinics.

All non-essential visits such as consultations for health screening are to be deferred.

We are still able to render services to patients with the following conditions:

Unstable symptoms and emergency conditions such as breathlessness, heart attack etc
Chronic diseases with recent relapses and/or poor control, and medication refills
Procedures or surgeries required to prevent deterioration of the patient’s condition
Cancer chemotherapy echocardiography surveillance

Medication Refills

Local patients can come to our clinics to top up their medications. If delivery is preferred, please contact our clinic at 6735 3022 or 6694 0140 for more details. Please note that delivery fee is chargeable.

For International patients, we encourage you to obtain your medications for your local clinics and pharmacies. You can contact us via whatsapp +65 9664 0822 or +65 9236 1026 if you require prescriptions or further clarifications.

However, if delivery of medications from our clinic is preferred, do note that we use an outsourced delivery service, and the total charges will depend on your local taxation fees, delivery and administrative charges.

International patients

We are currently unable to accept new medical appointments for international patients due to local regulations that restrict short-term visitors from any country from entering Singapore.

Existing patients who require critical follow-ups or medical evaluation (approval is based on a case-by-case basis) may still come to Singapore. Their attending specialists can request for a waiver of the requirement to enter Singapore ONLY if ALL of the following criteria is fulfilled:

The patient has healthcare needs requiring specialist management that cannot be met in his/her home country AND
The patient is currently under the attending specialist’s active follow-up AND
The attending specialist certifies that delay in continuation of treatment will lead to serious, life-threatening adverse outcomes

If approved, a waiver approval letter will be sent to the patient. The patient is allowed to bring only 1 accompanying visitor to Singapore and upon arrival, the patient (and accompanying visitor) will need to serve a 14-day Stay Home Notice (SHN). For medical evacuation patients who require direct admission to the hospital, they may serve the 14-day SHN in the hospital but their accompanying visitor will need to serve the 14-day SHN in a separate residence as they are not allowed to enter our hospital.

Please contact the Parkway Regional Office in your home country for more information and assistance. Contact details for Parkway Regional Offices: https://www.mountelizabeth.com.sg/plan-your-visit/patient-assistance-centres

Please note that the above information are obtained from the following sites:

https://www.mountelizabeth.com.sg/novel-coronavirus-updates

https://www.moh.gov.sg/covid-19

https://www.gov.sg/features/covid-19

April 3, 2020

Planning for a Coronary Angioplasty Procedure

If you are being planned for a coronary angioplasty procedure, our cardiologist will first take your consent for procedure after explaining to you the risks that may be involved in the procedure.

Before your procedure, please inform our doctor and clinic staff what insurance policies you may have that could cover your outpatient clinic consultations and tests, and inpatient procedures. You could check with your insurance agent or HR (if corporate insurance) to find out about your coverage. For most corporate and personal insurance schemes, preauthorisation is usually required to obtain a Letter of Guarantee for the admission process, to ensure that your hospital stay and procedure costs will be covered. You can help by initating the request with your insurance agent or HR, after which we will do the necessary paper work and submit them to your insurance company for approval. The process for approval takes on average 3-5 working days.

Preadmission Tests

Before admission, you will be required to do some tests, including blood tests and an ECG. Other cardiac tests such as an echocardiography may also be done.

Admission and Procedure Day

On the day for the coronary angioplasty, you will need to register at the hospital’s admission office 2 hours before the time of the procedure. You will also be required to fast for 4 hours before the time of the procedure. You can still take your medications 4 hours before, or otherwise if advised by our cardiologist.

The admissions office will arrange a room for you where they will prepare you for the procedure. Nearer to the procedure time, you will be brought down to the cardiac catherisation laboratory where the angioplasty procedure will be performed. An angioplasty procedure usually takes approximately 1 to 2 hours time, depending on the complexitity of the procedure.

During the angioplasty, local anesthesia will be administered to numb the area where a sheath (tube) will be inserted, usually at the radial artery (wrist) or less commonly at the femoral artery (groin). Our cardiologist then inserts a catheter (thin flexible tube) into the sheath and thread it towards the heart to perform the angioplasty. An x-ray camera is used to project images onto a screen to help our cardiologist guide the catheter to the heart artery.

When the catheter is properly positioned, our cardiologist injects a contrast dye (also called radiographic contrast agent) through the catheter into the heart and its arteries. Most people do not feel the dye injection. Rarely, some may feel a minor discomfort or a warm sensation, typically lasting only a few seconds, in their chest, and even more rarely, lightheadedness or nausea.

At the segment of the artery blockage (narrowing), a thin wire (called guidewire) is passed across the blockage. Next, a long, thin flexible tube (balloon catheter) with a small uninflated balloon at its tip is threaded through the catheter, over the guidewire and to where the artery is blocked. The balloon is inflated at the position of blockage. As the balloon inflates, it cracks and flattens the plaque against the wall of the artery. Some patients feel minor discomfort when it is inflated. Medication may also be given to some patients who experience more pain. A coronary artery stent is then put in place to hold up the artery walls, thus treating the blockage.

After the Procedure

After the angioplasty is performed, you will be monitored in the High-dependency unit or Coronary care unit for one night. The morning after, our cardiologist will assess your condition and prepare you for your discharge from hospital. After coronary angioplasty with stenting, you will require 2 types of blood thinning medications. We will also schedule a follow-up appointment in our clinic to review your condition after discharge.

For more information, please call our clinic at 6735 3022 or 66940140.

November 22, 2019

What is WATCHMAN LAA Device Closure?

What is WATCHMAN?

WATCHMAN LAA Device is FDA approved, an alternative to taking warfarin lifelong, for patients who are suffering from atrial fibrillation that is not due to heart valve problems, also known as non-valvular Afib.

It is a permanent implant that is done via a minimally invasive procedure, which can reduce the risk of stroke, without the risk of bleeding that can come with the long-term use of warfarin. It was found that left atrial appendage closure with WATCHMAN is as effective as warfarin in preventing strokes in patients with atrial fibrillation, and strokes in Watchman recipients are 55% less likely to be disabling, according to a meta-analysis of 5-year outcomes in the PREVAIL and PROTECT AF randomized trials.

This device therapy has addtional benefits over warfarin, such as significantly reduced risks of mortality, non–procedure-related major bleeding, and hemorrhagic stroke, Saibal Kar, MD, reported in presenting the results of the meta-analysis at the Transcatheter Cardiovascular Therapeutics annual educational meeting (TCT) in 2017.

How does WATCHMAN LAA Closure Device prevent Stroke?

In atrial fibrillation, the heart pumps irregularly and there is a tendency for blood to pool in a part of the heart chamber, called the left atrial appendage (LAA). As the blood pools, a clot may form, and when it escapes from the LAA and travel to the rest of the body, it can cut off the blood supply to the brain, resulting in a stroke. In patients with non-valvular Afib, more than 90% of stroke-causing clots that come from the heart are formed in the LAA.

The WATCHMAN LAA device fits right into the LAA, permanently closing it so as to prevent blood clots from escaping, thus reducing the risk of stroke.

How is the WATMAN LAA Device Implanted?

The device is implanted into the heart via a minimally invasive procedure. The doctor cuts a small hole in the leg vein and inserts a narrow tube, similar to the angioplasty when a stent is required. Using transesophageal echocardiography and Xray, the doctor guides the WATCHMAN into the left atrial appendage (LAA). The procedure is done under general anesthesia and takes about an hour. Patients commonly stay in the hospital overnight and leave the next day.

What to expect after the procedure?

After the procedure, the patients will require to continue their warfarin until the LAA is permanently closed off. Heart tissue will grow over the implant, which blocks out the blood clots, and to verify that this has happened, transesopheal echocardiography tests will be performed.

After than the patient will still require blood thinners, but those of a lower bleeding risk than warfarin.

Studies on WATCHMAN LAA Device Closure

“This is not a first-line therapy. But we know there is a large number of patients who cannot tolerate long-term anticoagulation. And this is the ideal therapy for stroke prophylaxis in that group of patients,” according to Dr. Kar, director of interventional cardiac research at Cedars-Sinai Medical Center in Los Angeles.

The patient-level meta-analysis of 5-year outcomes included 1,114 patients with atrial fibrillation who were randomized 2:1 to the Watchman device or warfarin, with 4,343 patient-years of follow-up. This was a fairly high–stroke risk population, with CHA2DS2-VASc scores in the 3.6-3.9 range, and 40% of patients aged 75 years or more. At baseline, 23% of subjects had a history of stroke or transient ischemic attack.

At 5 years’ follow-up, the composite endpoint of all stroke or systemic embolism was the same in the two study arms. However, the rate of hemorrhagic stroke was 80% lower in the Watchman group, the risk of disabling or fatal stroke was reduced by 55%, the rate of cardiovascular or unexplained death was 41% lower, all-cause mortality was reduced by 27%, and postprocedure major bleeding was 52% less frequent in the device therapy group. All of these differences achieved statistical significance, the cardiologist reported at the meeting sponsored by the Cardiovascular Research Foundation.

In the PREVAIL trial, 92% of patients were able to stop taking warfarin just 45 days after the procedure, while 99% of patients were able to stop taking warfarin within 1 year after the procedure.

Please watch the following videos from Boston Scientific, to learn more about the WATCHMAN LAA device closure.

References:

Holmes DR Jr, Kar S, Price MJ, et al. Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol. 2014;64(1):1-12.

https://www.mdedge.com/clinicalneurologynews/article/155532/stroke/watchman-device-prevails-stroke-prevention

https://www.watchman.com/en-us/resources.html

Images credits:

Boston Scientific

https://www.watchman.com/content/dam/watchman/downloads/download-center/WATCHMAN_DTP_Brochure.pdf

August 26, 2019

Left Ventricular Assist Device and How it works

What is a LVAD?

A left ventricular assist device (LVAD) is a mechanical pump implanted inside a patient’s chest to help the heart to pump blood around the body. It helps to bear the stress of the heart by circulating the blood to the rest of the body, allowing the heart to rest while other organ functions are sustained by the pump. The LVAD helps patients with advanced heart failure by relieving their symptoms such as shortness of breath and weakness, improving their exercise capacity and prolonging their survival.

How does the LVAD work?

The LVAD is implanted via an open heart surgery, with one end attached to the tip of the left ventricle (main pumping chamber of the heart) and the other end to the aorta (main artery of the body). Blood is pumped out of the left ventricle into the aorta by the LVAD. An insulated electrical cable (driveline) passes from the device, through the skin, to connect the pump to an external controller and electrical power source (two battery packs) outside of the patient’s body. The controller and battery packs are usually carried in a pouch that is slung on the shoulder or worn around the waist. The batteries are rechargeable.

Which patients require LVAD?

Patients with advanced heart failure have a poor quality of life and a one-year survival rate of less than 50%. Those who should consider an LVAD surgery include patients who have severely impaired left heart function AND:
a. have frequent disabling heart failure symptoms like breathlessness at rest or on mild exertion despite being treated with oral medications, OR
b. have frequent hospital admissions for heart failure, OR
c. have critically low blood pressure and require intravenous medications or mechanical devices to boost the blood pressure. These patients are usually confined to the Intensive Care Units (ICUs).

After a successful LVAD implantation, majority of patients experience markedly improved exercise capacity and reduced hospital readmissions. In Singapore, the 5-year survival rate of patients on LVAD support is more than 80%.
The LVAD can be implanted to temporarily support patients while they await a heart transplant (Bridge-to-Transplant) or as a permanent support (Destination Therapy).

Consult your cardiologist about LVAD if you continue to experience heart failure symptoms not controlled by your medications.

Here are some publications from Abbott, of the Momentum 3 Trial involving their Heartmate III LVAD, sharing from their website:

https://www.cardiovascular.abbott/us/en/momentum3publications.html

The MOMENTUM 3 (Multicenter Study of MagLev™ Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3™) investigational device exemption (IDE) clinical study was designed to evaluate the safety and effectiveness of HeartMate 3™ Left Ventricular Assist System (LVAS) by demonstrating non-inferiority to the HeartMate II™ LVAS when used for the treatment of advanced refractory left ventricular heart failure.

Final Report of the Two-year Principal Outcomes in the MOMENTUM 3 Full Cohort

https://www.nejm.org/doi/full/10.1056/NEJMoa1900486

Mehra, M.R., Uriel, N., Naka, Y., Cleveland, J.C., Yuzefpolskaya, M., …Goldstein, D.J., for the MOMENTUM 3 Investigators. (2019). A Fully Magnetically Levitated Left Ventricular Assist Device – Final Report. N Engl J Med. https://www.doi.org/10.1056/NEJMoa1900486

The data from two-year followup of the MOMENTUM 3 full cohort demonstrates:

Clinical superiority of the HeartMate 3 LVAS when compared to the HeartMate II LVAS
Less frequent need for pump replacement with HeartMate 3 LVAS
Lower rate of stroke and disabling stroke with HeartMate 3 LVAS
Lower rate of gastrointestinal bleeding with HeartMate 3 LVAS

Other Publications:

2 Year Primary Outcomes in the MOMENTUM 3 Long-term Cohort

https://www.nejm.org/doi/full/10.1056/NEJMoa1800866

Quality of Life and Functional Capacity Outcomes at 6 months in the MOMENTUM 3 Short-term cohort

https://www.jhltonline.org/article/S1053-2498(17)32085-5/fulltext

August 26, 2019

Device Closure of PFO in Scuba divers with Decompression sickness

Suba diving is a popular sport in many countries. While the general risk of death or major injury during scuba diving is small (<0.001% per dive), one of the notable risks include decompression sickness.

Decompression sickness, also known as divers’ disease, is caused by nitrogen bubbles forming in the diver’s tissues during his ascent. These bubbles can form in or migrate to any part of the body, causing varied levels of symptoms, ranging from simple symptoms involving skin rashes and pain in the joints to more serious symptoms which can lead to paralysis or even death when the other organs such as the central nervous system (including brain), are involved.

The connection between Patent Foramen Ovale (PFO) and decompression sickness was first described in the 1980s. Foramen ovale is a hole between the top chambers of the heart in the fetus which is normally closed by a flap within the first breaths at birth. However, in about 27% of the adults, the flap does not seal the gap causing it to remain open (patent), hence allowing blood to travel from the right to the left heart chambers during occasions when the chest pressure is raised. In the event of decompression sickness in divers, the bubbles in the venous system can by pass the lungs where they were supposed to be filtered out, and travel directly to the arterial system through the PFO and left side of the heart. The arterial system includes arteries to the brain, spinal cord and heart. Blood formation in the arterial system also known as arterial gas embolism, is far more dangerous as it can result in blockage in the blood supply to the brain or spinal cord, leading to stroke or paralysis.

Currently, in most countries, routine screening for PFO in divers is not recommended. Suggested recommendations for divers with diagnosed PFO and a history of decompression sickness include cessation of diving, a conservative approach to diving, and PFO closure.

Transcatheter Device Closure of the PFO is the implantation of an occluder device across the PFO through a catheter (plastic tube) inserted via the leg vein in the groin. The device acts like a double-sided umbrella that opens on each side of the atrial wall between the top chambers of the heart to seal the PFO. This helps to eliminate the chance of arterial embolization, allowing the diver to return to unrestricted diving. It is a minimally invasive procedure, which can be performed with mild sedation, and takes less than one hour, with one night stay in the hospital. Most patients can return to normal activity in two days, but they must take anti-coagulation medication and blood thinners for three to six months. Other restrictions include: no elective dental care (such as cleanings) for three months, no contact sports for three months, and no heavy lifting for one week. After implantation, divers must abstain from the sport for three to six months.

Before proceeding to do the transcatheter PFO closure, the patient has to undergo a transthoracic echocardiogram or a heart scan, with an ‘agitated bubble saline study’ to see if there is any possible sign of PFO. After which, a transoesophageal echocardiogram (similar to a scope), will be performed to help confirm the diagnosis.

Although there are no consensus criteria for PFO closure in divers currently, several studies have established that the incidence of PFO is two to six times greater in divers who experience a neurological decompression; and that catheter-based PFO closure is shown to lead to complete elimination of arterial bubbles after simulated dives, suggesting that PFO closure in continuing divers have a relevance in preventing symptomatic (major decompression sickness) and asymptomatic (ischaemic brain lesions) neurological events. There is a small risk of complications with PFO closure which should be discussed with the cardiologist.

Sources:

http://www.alertdiver.com/294

https://heart.bmj.com/content/97/23/1932.long

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6220018/

https://en.wikipedia.org/wiki/Decompression_sickness

Primary Transcatheter Patent Foramen Ovale Closure Is Effective in Improving Migraine in Patients With High-Risk Anatomic and Functional Characteristics for Paradoxical Embolism

https://link.springer.com/article/10.1007/s12471-018-1153-x

March 26, 2019

TAVI/ TAVR now shown to be Equal or Better than Open Heart Surgery

During the latest American College of Cardiology (ACC) 68th Annual Scientific Session held in New Orleans, LA, on March 2019, data presented demonstrated strong evidence that Transcatheter Aortic Valve Implantation (TAVI/ TAVR) is non-inferior or even better than open-heart surgery for aortic valve replacement for low-risk patients with aortic stenosis. Two studies, PARTNER 3 and the Evolut TAVR in Low-Risk Patients trial were presented.

The PARTNER 3 trial exceeded noninferiority expectations, with investigators reporting that treatment with the balloon-expandable Sapien 3 transcatheter heart valve (Edwards Lifesciences) was better than surgery for the prevention of death, stroke, and rehospitalization at 1 year, the study’s primary endpoint.

In the Evolut Low-Risk trial, which tested the self-expanding CoreValve, Evolut R, and Evolut PRO (Medtronic) valves in a low-risk patient population, the 24-month estimated incidence of death or disabling stroke was similar in the TAVR and surgical arms, meeting the definition of statistical noninferiority but not superiority.

Michael Reardon, MD (Houston Methodist DeBakey Heart and Vascular Center, TX), the co-principal investigator of the Evolut Low-Risk TAVR trial and cardiac surgeon, said TAVI/ TAVR should be the preferred strategy across the entire risk spectrum of patients. When discussing treatment options in low-risk patients with severe aortic stenosis, unless he mentions the benefits of TAVI/ TAVR, “I have not truly given informed consent,” he added.

The results of the trials were said to change the landscape of treatment for severe aortic stenosis.

From a patient’s perspective, only one-third of the TAVR patients from the trial underwent general anesthesia and very few were taken to the intensive care unit after the procedure. TAVR patients were hospitalized for shorter periods after valve replacement and the vast majority were discharged home or to self-care. “In the first 30 days, they have almost complete recovery to normal functional status,” said Martin Leon, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), one of the lead PARTNER 3 investigators. All of this, said Leon, “is very powerful from the standpoint of a new therapy for low-risk patients.”

“If you had a TAVR, you’re going to be out of the hospital in less than half the time as surgery patients and more likely to go directly home,” said Reardon. “The hemodynamics are what we’ve come to see in all the randomized trials with the supra-annular valve, that is single-digit mean gradients and [effective orifice areas] that are 2 [cm2] or above.”

Both trials are now published in the New England Journal of Medicine following an embargo break ahead of the ACC presentation.

The Heart and Vascular Centre performs TAVI with Edwards Sapien S3 valve, Corevalve Evolut R and Evolut Pro, along with a FDA approved Cerebral Protection Device for stroke prevention during the procedure.

Sources:

https://www.tctmd.com/news-acc-2019-low-risk-trials-cement-role-tavr-alongside-or-place-surgery

ACC 2019: Evolut TAVI as good as surgery for low-risk patients

Percutaneous Minimally Invasive PFO Device Closure

Teleconsultation with our Doctors

Due to the Covid-19 travel restrictions, we will now offer Tele-consultation online to our overseas patients.

Covid-19 and Your Heart

COVID-19 Updates

Planning for a Coronary Angioplasty Procedure

What is WATCHMAN LAA Device Closure?

What is WATCHMAN?

How does WATCHMAN LAA Closure Device prevent Stroke?

How is the WATMAN LAA Device Implanted?

What to expect after the procedure?

Left Ventricular Assist Device and How it works

What is a LVAD?

How does the LVAD work?

Which patients require LVAD?

Device Closure of PFO in Scuba divers with Decompression sickness

TAVI/ TAVR now shown to be Equal or Better than Open Heart Surgery

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