September 27, 2021
Services Focus on Reducing Second Strokes Among People with Common Heart Disorder
Hackensack University Medical Center has established a Heart and Brain Center to evaluate and treat people with patent foramen ovale (PFO) — a small hole in the heart — who have had a stroke not due to other causes and who are at risk of a second stroke. The clinic is a collaboration between the medical center’s renowned cardiology and neurology experts in one multidisciplinary program and is the first of its kind in New Jersey.
PFO is a condition that as many as one in four people are born with. People with PFO have a hole between the left and right atria (upper chambers) of the heart. This hole exists in everyone before birth, but most often closes shortly after being born. In people with PFO, the hole fails to close naturally after a baby is born. The hole can vary in size.
If someone with PFO develops a blood clot in the legs or other part of the body, it may travel to the heart, cross through the hole, and travel to the brain, where it can cause what is called an embolic stroke. “Even a very small clot can cause a lot of damage to the brain,” explained cardiologist Joseph E. Parrillo, MD, chair of the Heart and Vascular Hospital at Hackensack University Medical Center.
Closing the PFO through an interventional heart procedure can reduce the risk of a second stroke in people who had a first stroke. Only about 1% of patients with a PFO experience a stroke, however, and among those, not everyone needs to have the closure procedure. That’s where the Heart and Brain Clinic comes in.
“Most PFOs are of no significance,” noted neurologist Martin S. Gizzi, MD, PhD, director of the Division of Cerebrovascular Diseases and the Comprehensive Stroke Center at Hackensack University Medical Center and professor of Neurology at Hackensack Meridian School of Medicine. “We established this center to formally bring together heart and brain specialists to examine each patient, discuss their test results, and determine the best course of action for people with PFO who have had a stroke. It’s not appropriate to close the PFO in everyone who has one, so we have to be selective.”
“We have a well-developed structural heart program through the Heart and Vascular Hospital and a well-developed stroke program through our Comprehensive Stroke Center,” added Florian P.Thomas, MD, PhD, founding chair and professor, Department of Neurology at Hackensack University Medical Center and Hackensack Meridian School of Medicine. “We have academic programs in interventional heart and stroke care that offer the ideal combination of expertise, all in one medical center.”
The center enables patients to see a structural cardiologist and stroke neurologist during the same visit. The team meets four times a month and offers patients services such as:
- Diagnosis. Confirmation of the stroke and its cause, such as small vessel disease, atrial fibrillation, carotid artery narrowing (stenosis), or intracranial stenosis (narrowing of arteries in the brain). About one-third of patients don’t have a known cause of their stroke, and half of those are embolic strokes. Strokes with an unknown cause are called “cryptogenic” strokes.
- Evaluation. To determine if a patient who had a cryptogenic stroke has a PFO, doctors order tests such as echocardiography (ultrasound to see how the heart is beating and examine its structures) and a bubble test — safely introducing microbubbles into the patients blood to see where they filter out. If the bubbles collect in the left atrium, the patient could have a PFO. Its size can be determined via echocardiography.
- Treatment or Monitoring. Cardiologists, interventional cardiologists, and neurologists collaborate in team meetings to discuss each patient’s case and test results and determine the next steps: either a 40-minute procedure to close the PFO (inserting a small plug over the hole through a catheter) or follow-up visits with monitoring only. PFO closure is completed on an outpatient basis, so patients can go home the same day.
“Our commitment to science and having teams from multiple disciplines working together is what makes this program really special,” said Tilak K.R. Pasala, MD, interim director, Structural and Congenital Heart Program and the structural interventional cardiologist who performs PFO closure procedures. He noted that prior recommendations once stipulated that PFO closure was not indicated until a patient had a second stroke. But the results of three studies published in 2017 in the New England Journal of Medicine showed that outcomes were better if the procedure was performed after a first stroke, resulting in recent changes to the guidelines. “That’s where the evidence is now,” Dr. Pasala added.
The Heart and Brain Center has been running for several months at Hackensack University Medical Center and is accepting new patient referrals. The center will also be expanded to Hackensack Meridian JFK University Medical Center, which has a robust stroke care center. “We are excited to be able to extend our expertise to other hospitals in our network so that more patients can benefit from the research-based heart and stroke care that Hackensack Meridian Health is able to offer to our communities,” concluded Mark D. Sparta, FACHE, president and chief hospital executive, Hackensack University Medical Center and executive vice president of Population Health, Hackensack Meridian Health.
“The interprofessional collaboration at the Heart and Brain Center provides exceptional care, expertise and state of the art technology to achieve best outcomes and coordination in care for our patients,” said Lisa Tank, MD, chief medical officer at Hackensack University Medical Center.