When the medical news about Israeli Prime Minister Ariel Sharon's initial stroke - and the proposed course of treatment - was flashed around the world, Dr. David L. Fischman was clearly more informed than most others about the condition.
An interventional cardiologist at the Jefferson Heart Institute, Fischman, who earned his medical degree at New York Medical College and continued his training at Memorial Sloan-Kettering Cancer Center and then at Thomas Jefferson University Hospital, had some concerns about the announced strategy. The prime minister was put on potent blood thinners, and was to undergo a procedure known as Patent Foramen Ovale to close a small hole between the two heart chambers, a form of heart catheterization.
"The condition is actually fairly common during gestation, but often corrects itself. In individuals who have it, it may go unnoticed unless a stroke occurs, generally in a very young person, which triggers further exploration," said Fischman. "Mr. Sharon was definitely way above the average age for the PFO procedure, and many of us believed that there were actually other causes for his stroke."
The other deep concern from the start was the choice of such powerful blood thinners to be administered to the Israeli leader, and the timing of the proposed PFO procedure, which has been done at Jefferson for the past several years - but within stringent parameters.
"The conventional approach in this country is not to proceed with the PFO until at least six to eight weeks have elapsed from the time of the stroke," said Fischman. "Our protocol also dictates that the procedure is not done until and unless there has been a second stroke, except under certain conditions."
While he was careful to note at the time of this interview that he and his colleagues did not have the benefit of seeing Ariel Sharon's medical records, Fischman definitely expressed a sense that decisions made might have been very different in the United States.
Other Factors to Consider
There have been other general medical concerns about several factors: the manner in which the prime minister was transferred from his ranch to Hadassah Hospital in Jerusalem - by ambulance, not a waiting helicopter; his hasty return to work after his first stroke; and even whether the heart catheterization was advised.
"Again, we look at Mr. Sharon's age, which suggests that there were other conditions existing that may have caused his stroke," said Fischman. "Also, in this country we use the procedure very cautiously. The guidelines are very prudent and restrictive."
The three surgeries to stop the bleeding in the premier's brain were definitely complicated by the specific blood thinners prescribed for the patient, according to Fischman.
The procedure for the repair of a hole in a patient's heart has actually gotten simpler over the years, suggested the Jefferson interventional cardiologist. "The rate of success is high, under the appropriate circumstances," noted Fischman, who also indicated that trials are still going on to determine the specific usage for the PFO procedure.
An additional area of investigation has considerably heightened interest in the condition. "There is thought in some quarters that migraine headaches may be caused by PFOs. And migraines affect a very large population, so this has major implications," said Fischman. "The procedure may actually be a potential cure for migraines, so there are investigational studies going on, including two at Jefferson."
In discussing the PFO procedure, the physician allowed that while it is "straightforward," it is also invasive.
"Our philosophy has to be cautious," stressed the doctor. "As with any surgery, things can go wrong, so you never go into a surgery without great and careful deliberation."