This is one of my recent patients. This is a very complex case, so listen closely because I'll be picking on the panel to comment on what you would do. She's 47 years old and she has a history of migraines that have been awful. She does have a history of atherosclerotic disease. She had PCI in the past. She used to have risk factors that were out of control, in part related to her lifestyle choices and obesity. She had gastric bypass and she had marked improvement in her diabetes and her hypercholesterolemia. She's seen a neurology and all of the notes say migraine versus TIA. It's not really a time when it's clear which is the diagnosis. She's been managed on dual anti-platelet therapy. She's had multiple MRIs of her brain and the note that I quoted from neurology said she's trialed many medications without success. She was prescribed Botox for treatment of migraines, but it was denied by her insurance. She continues to miss days of work due to migraine despite close follow-up with neurology and doing everything she can about her risk factors. So we talked about the role of PFO closure and migraine related to our PFO guidelines that were just published. And we say that persons that are experiencing migraines without a prior stroke, and we say stroke, we don't mean TIA, we suggest against the routine use of PFO closure for the treatment of migraine. This is a conditional recommendation, which means that some patients, particularly those with debilitating migraines who failed medical therapy and who place a high value on the uncertain benefit of having their PFO closed and a lower value on the uncertain harms may reasonably choose PFO closure. I just love these guidelines. So many of our guidelines before, we stood up like we knew the truth, and we told patients you have to do this, even when there was uncertainty in the evidence. And it's when there's uncertainty in the evidence, that is when shared decision-making is most appropriate, when we can share what is known about the risks and benefits and listen to patients' values and preferences. And this is one of the first times that the guidelines have pushed us towards that. In the neurology note, it also said maybe she had a history of TIA. Similar, Sky Guideline panel suggests against PFO closure, although particularly those with recurrent high probability TIAs who place a high value on the uncertain benefits and a low value on procedural risks may reasonably choose PFO closure. So this patient was referred to me for PFO closure from an outside hospital, one of our satellite hospitals. I couldn't see the TTE images, tried to get them. So I had the report that suggested in the bubble study, the saline contrast study, they thought there was a PFO present because of negative contrast in the right atrium adjoining the interatrial septal aneurysm. So she did have an ASA. And the idea was that the pressure in the left atrium is higher than the right atrium, so blood flow was going across potentially a PFO, and no bubbles were going the other way. So we tried to raise the pressure on the right side to make it clear whether there's a right to left connection by doing Valsalva, for example, but I didn't do the TTE. I wasn't there. So it's hard to know. So we moved on to a TEE for further clarification. The TEE report, and I'll show you the images in a minute, suggested there was no intracardiac shunting either by color flow or by a bubble study. But they note, I think they saw a PFO on the TTE before. So here are the images of the interatrial septum just to the left above the aortic valve with color flow. You can see that it appears that the interatrial septum is very thin and it's mobile. And here's the bubble study. You can see what they were seeing on the TTE, that there is a lot of mixing between the bubbles and contrast there, but there was not any evidence of right to left shunting. So I have a patient with migraine or TAA, but I don't have evidence yet that there's a PFO. This negative contrast is not quite enough. So how far do we push it to see if she has a PFO, particularly when we're acting on a conditional recommendation rather than a prior stroke? So now I'm going a little bit away from the guidelines to just real-world practice, tough decision-making. And everyone might tackle this differently. What would be the additional testing you would do to prove or disprove a right to left shunt? The patient wants a definitive answer. During TEE sometimes people can't do a valsalva because blood flow actually comes from the legs across a PFO. If you've got an IV in the arm, it might be that it's not directed in the right way. This is an image of interventional cardiologists who do PFO closure that was published in The Atlantic in 2021. It told the story of a PFO operator that searched so hard for PFOs in the cath lab that he would do transeptal punctures in order to put the device in. He got in a lot of trouble and also put a lot of emphasis on us that we don't necessarily need to search so hard that we're creating a problem when there wasn't one there. You exemplified the focus of this presentation is the strength of the conditional recommendation, that we're in a new era, I feel, where we can have patient preferences included in the decision-making. And I cannot overemphasize enough the neurology partnership. It starts with understanding the diagnosis, migraine versus TIA, maximizing medical therapy. None of that is in my purview, making sure that they're at a point and in agreement with me that if there is a PFO found, it would be appropriate to close. And so understanding the limitations of echocardiography and the role of invasive assessment for PFO. We don't have good decision aids for patients with migraine or TIA for the decision of PFO, although I've tasked Dr. Goldswig to partner with me at CardioSmart to develop them. Instead I had to use the decision aid from Magic App, which is actually specific to patients who have prior stroke and a PFO, and there was uncertainty here. But I did walk her through that decision using this tool and talk about the potential impact of closure. And she opted to not proceed with an invasive assessment, which is what I offered her. She felt with all the uncertainty on all sides, she would prefer not to go to the cath lab. We were able to get our charity care program, which is fantastic, to sponsor her Botox. And she continues to try to seek relief with non-interventional therapies for her migraine.

migraines

PFO closure

patient values

shared decision-making

non-interventional therapies