卵圓孔未閉封堵術：爭論與發(fā)展（中英文）.ppt

1、卵圓孔未閉封堵術：爭論與發(fā)展May 9, 2009,Andrew D. Michaels, MD, MAS, FACC, FAHA Director, Cardiac Catheterization Laboratory and Interventional Cardiology University of Utah, Salt Lake City, Utah,胎兒循環(huán),胎兒期，氧合血液由臍靜脈經下腔靜脈進入右房 血流由下腔靜脈經過Eustachian 瓣流到卵圓窩.,出生后房間隔發(fā)育,宮內 出生后,Hagen, Scholz. Mayo Clin Proc 1984; 59: 17-20.,

2、人口的75 人口 的25%,PFO相關臨床綜合癥,體位相關呼吸困難 Platypnea orthodeoxia 減壓病/高原性肺水腫 腦血管事件/TIA 偏頭痛,Platypnoea Orthodeoxia,罕見 直立體位引起的呼吸困難，伴有低氧血癥 機制：右向左房間分流,Aigner et al. Eur J Cardiothor Surg 2008; 33: 268. Medina et al. Circulation 2001; 104: 741.,Platypnea Orthodeoxia,1949年至今已有文獻報道近100例 PFO 常伴有: 主動脈瘤 胸廓畸形 肺切除術后 約50例

3、已接受封堵術,減壓病,對230名 無癥狀潛水者進行研究 27% 有PFO 需要減壓艙治療者: 19% 有PFO 2% 無 PFO,Torti et al. Eur Heart J 2004; 25: 1014-20.,隱匿性腦卒中,40歲男性，突發(fā)失語 既往史無特殊. 無明顯腦卒中病因. TEE: 發(fā)現(xiàn)房間隔瘤與 PFO. 常見伴發(fā)癥: 50% 隱匿性腦卒中患者有 PFO. 推測機制: 靜脈血栓反常性體循環(huán)栓塞癥. PFO 通道內原位血栓形成造成栓塞,血栓流經 PFO,首例 PFO伴血栓形成報道于1876. 既往通過超聲心動圖及術中見到嵌頓于PFO的血栓. 但無法觀察到小栓子的流程。,服用阿司

4、匹林的PFO患者腦血管事件/TIA復發(fā)率較高,Mas et al. NEJM 2001; 345: 1740-6.,581 名患者有隱匿性腦卒中 均接受阿司匹林治療,華法林阿司匹林復發(fā)性腦卒中研究,Mohr et al. NEJM 2001; 345: 1444-51.,N=2206 缺血性腦血管事件 (56% 腔梗; 25%隱匿性; 13% 大血管性) 隨機接受阿司匹林325mg 或華法林治療 結論: 抗血小板及抗凝治療有效（無效）率相當。,藥物治療 vs. PFO封堵術,Windecker et al. JACC 2004; 44: 750-8.,308名 隱匿性腦卒中伴PFO患者 隨機接

5、受藥物治療或PFO封堵術治療,藥物治療 vs. PFO 封堵術:觀察性研究的薈萃分析,Khairy et al. Ann Int Med 2003; 139: 753-60.,1年腦卒中/TIA 復發(fā)率,死亡/腦卒中/TIA 事件/100 人年,PFO 封堵器,PFO,ASD,Amplatzer PFO,STARFlex,Amplatzer ASO,CardioSEAL,Helex,Amplatzer Cribiform ASD,左房傘植入,右房傘植入,植入前,植入后,偏頭痛與PFO的關系,12人口患有偏頭痛 (女性18% ; 男性6% ) 偏頭痛患者中 存在PFO的占： 48%的偏頭痛伴視覺

6、先兆 1 23%的偏頭痛不伴視覺先兆 20% 正常人 隱匿性腦卒中伴PFO患者中偏頭痛發(fā)生率 52% 有偏頭痛伴視覺先兆2 71% 封堵術后癥狀緩解3 偏頭痛患者較正常人MRI檢查病變陽性率高13倍4,Anzola. Neurology 1999;52:1622-5. Sztajzel. CV Diseases 2002;13:102-6. Wilmshurst. Lancet 2000;356:1648-51. Kruit. JAMA 2004;294:427-34.,卵圓孔未閉與偏頭痛之間可能的病理生理相關性,經過PFO的微小栓子可引起偏頭痛. 體液因子（如5HT) 免受肺降解,引起偏頭痛

7、.,MIST研究結果,Dowson A, et al. Circulation 2008; 117: 1397-404.,術前,術前,術后,術后,P value,手術組 (n=74),假手術組(n=73),偏頭痛隨機臨床試驗,NMT Medical closed MIST II (January 24, 2008). PREMIUM (AGA Medical) 及 ESCAPE (St Jude Medical) 仍在進行中.,PFO 封堵器技術現(xiàn)況與展望,目前封堵器技術的局限性 大型，永久性植入物. 遠期并發(fā)癥：心率失常，炎癥，糜爛，血栓形成，過敏反應. 未來的封堵器技術 小型封堵器. 生物

8、可吸收(BioSTAR). 可縫合封堵器. 射頻消融.,Mullen et al. Circulation 2006; 114: 1962-7.,結論,目前隱匿性腦卒中的藥物治療療效欠佳. 研究提示存在高危復發(fā)腦卒中的亞組. 尚無隨機臨床試驗支持任何藥物治療 經皮 PFO封堵術可能成為隱匿性腦卒中預防的主要干預手段. 安全. 非隨機臨床試驗資料提示對可有效預防腦卒中. 有待關于腦卒中與偏頭痛的進一步臨床研究結果.,結論,Patent Foramen Ovale Closure:Controversies and Accomplishments May 9, 2009,Andrew D. Mic

9、haels, MD, MAS, FACC, FAHA Director, Cardiac Catheterization Laboratory and Interventional Cardiology University of Utah, Salt Lake City, Utah,Fetal Circulation,During fetal life, oxygenated blood returning from the umbilical vein enters the RA through the IVC. Blood flow is directed by the Eustachi

10、an valve from the IVC to the fossa ovalis and through the PFO.,Post-Natal Septal Development,In Utero After Birth,Hagen, Scholz. Mayo Clin Proc 1984; 59: 17-20.,75% of Population 25% of Population,Clinical Syndromes Associated with PFO,Platypnea orthodeoxia Decompression sickness/high-altitude pulmo

11、nary edema CVA/TIA Migraine,Platypnoea Orthodeoxia,Uncommon syndrome Dyspnea induced by upright posture, with associated hypoxemia Mechanism: right-to-left interatrial shunting,Aigner et al. Eur J Cardiothor Surg 2008; 33: 268. Medina et al. Circulation 2001; 104: 741.,Platypnea Orthodeoxia,100 case

12、s in literature since 1949 PFO associated with: Aortic aneurysm Chest deformity Post-pneumonectomy 50 have undergone device closure,Decompression Sickness,230 asymptomatic divers surveyed 27% had a PFO Decompression chamber required: 19% with a PFO 2% without a PFO,Torti et al. Eur Heart J 2004; 25:

13、 1014-20.,Cryptogenic Stroke Case,40 yo man with sudden aphasia. No medical history. No obvious cause of stroke. TEE: atrial septal aneurysm and PFO. Associations: 50% of people with cryptogenic stroke have a PFO. Presumed mechanism: Paradoxical embolism of venous thrombus. In-situ thrombosis within

14、 PFO tunnel with embolization.,Thrombus in transit through PFO,First case of PFO with thrombus described in 1876. Thrombus caught in PFO has been seen by echo and at surgery. However, passages of small emboli are impossible to prove.,Higher CVA/TIA Recurrence Rate in Patients with PFO + ASA,Mas et a

15、l. NEJM 2001; 345: 1740-6.,581 patients with cryptogenic stroke All treated with aspirin,Warfarin-Aspirin Recurrent Stroke Study,Mohr et al. NEJM 2001; 345: 1444-51.,N=2206 with ischemic CVA (56% lacunar; 25% cryptogenic; 13% large vessel) Randomized to ASA 325mg vs Warfarin Conclusion: Antiplatelet

16、 and anticoagulant therapy equally (in)effective,Medical Therapy vs. PFO Closure,Windecker et al. JACC 2004; 44: 750-8.,N=308 with cryptogenic CVA and PFO Randomized to medical therapy or PFO closure,Medical Therapy vs. PFO Closure:Meta-Analysis of Observational Studies,Khairy et al. Ann Int Med 200

17、3; 139: 753-60.,Recurrent CVA/TIA 1-Year,Death/CVA/TIA Events/100 pt yrs,PFO Devices,PFO,ASD,Amplatzer PFO,STARFlex,Amplatzer ASO,CardioSEAL,Helex,Amplatzer Cribiform ASD,Left Atrial Disc Deployment,Right Atrial Disc Deployment,Pre,Post,Association Between Migraine and PFO,Migraine headache affects

18、12% of population (18% F; 6% M) Incidence of PFO in patients with migraine 48% if migraine with aura1 23% if migraine without aura 20% in controls Incidence of migraine in cryptogenic stroke with PFO 52% had migraine with aura2 71% had suppression post-closure3 Migraine patients have 13 times higher

19、 incidence of MRI lesions4,Anzola. Neurology 1999;52:1622-5. Sztajzel. CV Diseases 2002;13:102-6. Wilmshurst. Lancet 2000;356:1648-51. Kruit. JAMA 2004;294:427-34.,Potential Pathophysiologic Association Between PFO and Migraine,Microembolism through PFO triggers migraine. Humoral factors (i.e., sero

20、tonin) escape pulmonary degradation, triggering migraine.,Published MIST Results,Dowson A, et al. Circulation 2008; 117: 1397-404.,Baseline,Baseline,Post,Post,P value,Implant (n=74),Sham (n=73),Migraine Randomized Clinical Trials,NMT Medical closed MIST II (January 24, 2008). PREMIUM (AGA Medical) and ESCAPE (St Jude Medical) still enrolling.,Current and Future PFO Device Technologies,Limitations of Current Device Technol