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Is PFO closure Back in the “Dark Ages”?

Posted Jul 30 2012 2:30pm

Are Closure Devices for Patent Foramen Ovale (PFO) and Atrial Septal Defects (ASD) safe? Do they offer a better quality of life over medical management? Should you exercise with/without closure? What exercises are safe? Can you have sex with a PFO? Should you fly? Is scuba safe? Is device erosion a real risk? Will my insurance pay for PFO closure?

Why don’t we have these answers and more, why STILL don’t we have closure?

PFO Closure-Still in the Dark Ages? Know-Stroke.org

If you think that we are making progress in this important and potentially very profitable area of medicine, think again. For example, look at the information I’ve provided in this post from a large insurers website on PFO and particularly the policy benefits. Under the policy benefits look at what changes were made on “7/30/2010: Policy statement section revised.” I’ve highlighted it for you below.

If you take the time to compare the date of the policy changes to when a report was released a month prior that “put closure to PFO closure” you’ll see that we still haven’t really emerged from the “dark ages” with PFO closure 2 years after this study report was released. Read this great article on the PFO Research Foundation’s website for more on why one failed study proved costly for patients with PFO.

Quick Background:

A report back in June of 2010 when a now bankrupt NMT Medical announced preliminary results of Closure 1 PFO/Stroke Trial really had the medical community and device industry at odds because the investigation failed to reach primary end point. Read more about it here…

Fast Forward

I’d like to think we are still making progress for patients with PFO. I realized at the time of release that even though the Closure 1 study was poorly designed and the device was not the best, that the press would be all over it. After all, I had comfort in knowing there is plenty of great hard work being done out of a desire and shear passion for progress by patients like myself and others who are involved with the PFO Research Foundation. But I have to say I am again questioning if we are indeed “back in the dark ages” with PFO closure. Over the last several weeks I’ve spoken with several patients by phone who could essentially have been me 6 years ago, when I had my stroke and it was revealed I had a PFO. All those questions I listed at the top of this post are the same ones these patients and many others with PFO still have unanswered. The fact remains, that “gray area” and that term “cryptogenic” stroke still haunts fellow PFO patients. If you are still faced with having more questions than answers when it comes to PFO (patent foramen ovale) closure, the best advice I can give is you have to get all the facts. I’d suggest, if you haven’t already start by getting a free copy of the PFO Patient Guide . That is a start, but the fact remains you still have to do the “heavy lifting”, that is the research, at a time when you probably are not feeling your best. Remember, a PFO closure procedure can cost between $30-60,000 so that should certainly be considered as well as if your insurance will cover it (should you be fortunate enough to be covered). Even with that said, be aware of your insurance companies policies, read the fine print, and be prepared. Here’s BCBS’s policy below, you should check your insurer and individual state as things change all the time in the insurance world, as I hopefully illustrated for you in this example. I’ve also included the text as it appears on BCBS website and the important insurance code references for medical procedures often related to PFO/ASD.

PFO DESCRIPTION

Patent Foramen Ovale (PFO), a component of fetal cardiovascular circulation, consists of a communication between the right and left atrium that functions as a vascular bypass of the uninflated lungs. The ductus arteriosus is another feature of the fetal cardiovascular circulation consisting of a connection between the pulmonary artery and the distal aorta. Prior to birth the foramen ovale is held open by the large flow of blood into the left atrium from the inferior vena cava. Over a course of months after birth, an increase in left atrial pressure and a decrease in right atrial pressure result in the permanent closure of the foramen ovale in most patients. However, a patent foramen ovale (PFOs) may be detected in 25% of adult patients. Although common, PFOs are typically clinically insignificant and are not associated with right to left shunting with blood. However, they may be associated with paradoxical embolus, in which an embolus arising in the venous circulation gains access to the arterial circulation through the PFO, resulting in a stroke or transient ischemic attack (TIA). Therefore, there has been interest in either open surgery or transcatheter approaches to close the PFO in patients with a history of embolic stroke of unknown cause, also known as cryptogenic stroke.

Cryptogenic stroke is defined as an ischemic stroke occurring in the absence of potential cardiac, pulmonary, vascular, or neurological sources.  An ischemic stroke is classified as cryptogenic in up to 40% of cases, and may be even higher in younger populations.  Conventional medical therapy consists of either antiplatelet therapy (aspirin, clopidrogel, or dipyramidole given alone or in combination) or oral anticoaguation with warfarin.  In general, patients with a known clotting disorder or evidence of pre-existing thromboembolism are treated with warfarin and patients without these risk factors are treated with antiplatelet agents.

Two transcatheter devices received approval for marketing from the U.S. Food and Drug Administration (FDA) in 2002 as a treatment for patients with cryptogenic stroke and patent foramen ovale: the CardioSeal Septal Occlusion System and the Amplatzer® Patent Foramen Ovale occluder.  Both received FDA approval through a Humanitarian Device Exemption (HDE), a category of FDA approval that is applicable to devices that are designed to treat a population of less than 4,000 patients per year.  This approval process requires the manufacturer to submit data on the safety and the probable clinical benefit.  Clinical trials validating the device effectiveness are not required.  The labeled indications of both limits the use of these devices to closure of PFO in patients with recurrent cryptogenic stroke due to presumed paradoxical embolism through a patent foramen ovale and who have failed conventional drug therapy.

Following this limited FDA approval, the use of PFO closure devices increased by over 50-fold, well in excess of the 4,000 per year threshold intended under the HDE.  As a result, in 2006, the FDA withdrew the HDE approval for these devices.  At this time, the FDA also reiterated the importance of randomized, controlled trials of PFO closure devices versus medical therapy, and noted that ongoing trials were hampered by slow enrollment.  Withdrawal of the HDE approval was, in part, intended to spur greater enrollment in ongoing randomized, controlled trials of these devices.  Currently, all uses of closure devices to treat PFO are off-label uses.

In contrast to patent foramen ovale, which represents the persistence of normal fetal cardiovascular physiology, atrial septal defects (ASDs) represent an abnormality in the development of the heart that results in free communication between the atria. ASDs are categorized according to their anatomy. For example, ostium secundum ASDs are the third most common form of congenital heart disorder and one of the most common congenital cardiac malformations in adults, accounting for 30%–40% of these patients over the age of 40. Ostium secundum describes defects that are located midseptally and are typically near the fossa ovalis. Ostium primum defects lie immediately adjacent to the atrioventricular valves and occur commonly in patients with Down’s syndrome. Sinus venous defects occur high in the atrial septum and are frequently associated with anomalies of the pulmonary veins. The ASD often goes unnoticed for decades because the physical signs are subtle and the clinical sequelae are mild. However, virtually all patients who survive into their sixth decade are symptomatic; less than 50% of patients survive beyond 40 to 50 years due to heart failure or pulmonary hypertension related to the left-to-right shunt. Patients with ASDs are also at risk for paradoxical emboli.

Repair of ASDs is recommended for those with pulmonary systemic flows exceeding 1.5:1.0. Despite the success of operative repair, there has been interest in developing a catheter-based approach to ASD repair in order to avoid the risks and morbidity of open heart surgery. A variety of devices have been researched over the past 20 years; technical challenges include minimizing the size of device so that smaller catheters can be used; developing techniques to properly center the device across the ASD, and ensuring that the device can be easily retrieved or repositioned if necessary. Late failures due to mechanical fatigue have also been a concern. Early devices such as the Rashkind hook device and the Lock Clamshell device were limited by their large size and technical malfunctions. At present, there are 2 devices that are FDA approved for ASD closure: the AMPLATZERSeptal Occluder, and the GORE HELEX  Septal Occluder.

POLICY

Closure of patent foramen ovale using a transcatheter approach is considered investigational. (There are currently no transcatheter devices with FDA approval or clearance for this indication.)

Transcatheter closure of secundum atrial septal defects may be considered medically necessary when using a device that has been FDA approved for that purpose and used according to the labeled indications.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member’s specific benefit plan language.

POLICY HISTORY

5/2001: Approved by Medical Policy Advisory Committee (MPAC)

2/13/2002: Investigational definition added

4/18/2002: Type of Service and Place of Service deleted. Code Reference section completed.

6/4/2002: Amplatzer® Septal Occluder and Amplatzer® Patent Foramen Occluder receive FDA approval

3/6/2003: Code Reference section updated

4/17/2003: Code Reference section updated

11/5/2003: Code Reference section updated, ICD-9 diagnosis code V12.59 deleted, HCPCS C1817 deleted

4/22/2004: CPT code 93580 note added

1/23/2007: Policy reviewed, no changes

1/6/2009: Policy reviewed, investigational language per the closure of a patent foramen ovale inserted

7/30/2010: Policy statement section revised.  Closure of patent foramen ovale using a transcatheter approach is considered investigational.  There are currently no transcatheter devices with FDA approval or clearance for this indication. Code Reference section revised to remove ICD-9 diagnosis codes 435.8, 444.9 and 745.61. CPT Codes 37204 and 75894 and ICD-9 Procedure Code 35.71 were removed from the Covered Codes Table because of changes in policy statement (closure of PFO are now considered investigational).  Description was revised for ICD-9 Diagnosis code 745.5.

09/28/2011: Policy reviewed; no changes.

05/09/2012: Removed link to Amplatzer® Devices policy and added link to Transcatheter Closure of Patent Ductus Arteriosus policy.

 

 

INSURANCE CODE REFERENCE

Covered Codes

Code Number Description
CPT-4
93580 Percutaneous transcatheter closure of congenital interatrial communication (i.e., fontan fenstration, atrial septal defect) with implant Note: Trans-esophageal echocardiography services (93303-93317 and intracardiac echocardiography (93662) can be reported separately and in addition to code 93580.Codes 93501, 93529-93533, 93539, 93543, and 93555 should not be reported in addition to codes 93580. According to CPT coding guidelines, these services are included in code 93580.
ICD-9 Procedure
35.52 Repair of atrial septal defect with prosthesis, closed technique
ICD-9 Diagnosis
745.5 Ostium secundum type atrial septal defect (Description revised 07-30-2010)

SOURCE(S)

Blue Cross Blue Shield Association policy # 2.02.09

Bottom line:

The answer to the question,

“Can you have Sex with a PFO”?

I am not a physician, so you’ll have to ask your own. Be prepared, your doctor may say after all, they must have in the dark ages, right?

David Dansereau,MSPT


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