HEALTH MATTERS: Small hole in heart can usually be treated with medical therapy

Q. My wife is 39 years old and suffered a stroke. Although she has recovered completely, her doctors found that the stroke was caused by a small hole in her heart. What should we do about it?...

Dr. Joshua Wynne
Dr. Joshua Wynne

Q. My wife is 39 years old and suffered a stroke. Although she has recovered completely, her doctors found that the stroke was caused by a small hole in her heart. What should we do about it?

A. That's great that she's recovered completely. It sounds like your wife unfortunately suffered a rare complication of a common condition. It turns out that about one in four otherwise healthy people have a small hole between the two upper chambers of the heart (the atria). This hole is all that is left of the large hole that all of us had when we were embryos, which permits our mother's blood to nourish us by bypassing our immature lungs.

In most of us, that hole closes completely shortly after birth, but for about 25 percent, a small pinhole remains open. It has no other significance, except it forms a possible route for a blood clot to get to the brain. What happens is that a small blood clot, usually formed in the veins of the legs, passes through the tiny hole and lodges in an artery to the brain.

In most of us, our lungs would filter the clot out of the blood, but your wife had the misfortune to have the clot "escape." Treatment is with aspirin and/or a blood thinner. We used to close the hole with surgery or with an umbrella-like device that we are able to insert through a vein in the leg, but we now know that closing the tiny hole usually is not necessary and patients do quite well with just medical therapy.

Q. A friend of mine had a heart attack and, while recovering, suffered a stroke. His doctor told him the heart attack led to the stroke. How so?


A. As treatment of heart attacks has become better over the years, this feared complication has decreased in frequency. Here's how they occur: Strokes typically are caused by a blood clot in one of the arteries leading to the brain that interrupts the supply of blood.

The clot may form in the artery itself (a so-called thrombus) or form elsewhere and then break loose only to lodge in the brain artery (an embolus). It is the latter mechanism that likely occurred to your friend. A heart attack typically occurs when the cholesterol buildup in an artery that feeds the heart splits open and exposes the cholesterol-rich material to the blood stream. A clot then forms on the fissure in the side of the artery and a blood clot ensues, blocking blood flow to the heart muscle, which forms the wall of the heart.

The resulting damage to the heart muscle is what we mean by a heart attack. If the damage to the heart muscle is extensive enough, a portion of the heart wall stops beating, and a blood clot can then form inside the heart directly on the damaged heart muscle. A portion of the blood clot then breaks loose and is pumped out of the heart, only to lodge in one of the arteries going to the brain. This likely is what happened to your friend. There is one other important causes of stroke and that is when there is bleeding into the brain itself. This may be caused by a weakness (called an aneurysm) in one of the brain arteries.

Wynne is vice president for health affairs at UND, dean of the School of Medicine and Health Sciences, and a professor of medicine. He is a cardiologist by training.

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The content of this column is for informational purposes only and does not substitute for professional medical advice or care. The information provided herein should not be used for diagnosing or treating a health problem or disease. If you have or suspect you may have a health problem, you should consult your health care provider. Never disregard professional medical advice or delay in seeking it because of something you have read in this column.

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