I'm a 55 year old masters swimmer who's been competing and training for over 30 years. I had a stroke after an early morning swim 15 years ago, with an extensive workup subsequently revealing nothing but a patent foramen ovale--a common and usually inconsequential atrial septal heart defect. Since that time, I've been on Coumadin anticoagulation and haven't had any more strokes. However, I have had transient spells of confusion after workouts, that I had either ignored or ascribed to hypoglycemia, as they resolved quickly, usually after eating. My latest episode lasted longer, and my wife was there to witness it, so I ended up in the hospital and had a bunch of tests (CT, MRI, Cardiac Echo, EEG). Now my doctors think these have been TIA's, and that I may need a surgical closure of the atrial septal defect. I was wondering if any other masters swimmers have experienced this, as the Valsalva maneuver that one performs while swimming (like the breakout after a turn) reproduces the breath-holding, then sudden relaxation and inhalation that they asked me to perform during the echocardiogram, in order to bring out the abnormal blood flow through the patent foramen ovale. I felt just like I do during a workout when I was having the Echo. I'll bet this is something that isn't unique to me. Has anyone else had similar episodes?
Former Member
Kevin, I've not experienced a stroke or TIA, but the mechanism you describe seems plausible. There is at least one caution I'd venture to the conclusion. Let me explain.
I'm an internist with a special interest in warfarin (aka Coumadin) anticoagulation. I've recently suffered a mild heart attack, so I'm in a similar emotional state when it comes to being a health care consumer.
There's no doubt that while training we're performing a Valsalva maneuver with regularity, even if your intensity isn't high. Of course, the higher the intensity, the harder and longer we do a Valsalva, the greater the pressure on the right side of the heart, and the greater the likelihood of a right to left shunt, which could precipitate a stroke or TIA. While that part of the logic hangs together well, I'm skeptical you're passing clots. My main issue is that if your anticoagulation is going well, you should be at very low risk of what we term thromboembolic events, otherwise understood as throwing clots.
It can be very difficult to diagnose TIA's, unless your symptoms are characteristic of impaired blood flow to a certain part of the brain. I won't at all make an attempt to propose an alternative explanation. It just seems from the information you present that there is some diagnostic uncertainty.
In the end it comes down to PFO closure or continued warfarin therapy. PFO closures have become much more streamlined, but I'd interrogate whomever is proposing to do this procedure closely: how many times have they done the planned procedure, what are the specific alternatives, & what is the projected risk. Don't accept glib avoidance of discussion of risk; any procedure carries it, and unless they're willing to be up front, I'd be cautious.
Kevin, after doing a little more reading, I want to put a slightly different emphasis on my earlier post.
First, it seems that management of a PFO requires a fair amount of individual judgement. Not all PFO's are the same. As you probably are aware, they are very common, yet in fact adverse events associated with them aren't. So its hard to generalize.
Second, you may be the exception in that it sounds you have a clear indication for warfarin, as most experts advise aspirin as an anti-platelet agent instead. Don't take this as a question of your treatment; you're just different than a lot of folks with PFO's.
The issue of a estimating benefit of procedures to close the PFO is very tricky. Our institution does the procedure but only in carefully selected cases. The devices approved are safe and do what they are designed for, but so it seems that they don't eliminate stroke risk; you can have small clots that form from many sites and surfaces. I think you would need aspirin even if you had a closure.
Sorry to muddy the water, but this is what happens often in medicine; the evidence doesn't always point to a clear answer, and judgement is required based on the particulars of your situation and the best available information.
Good luck!
