卵圆孔未闭封堵术：争论与发展(中英文).ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,卵圆孔未闭封堵术：争论与发展,May 9,2009,Andrew D.Michaels,MD,MAS,FACC,FAHA,Director,Cardiac Catheterization Laboratory and Interventional Cardiology,University of Utah,Salt Lake City,Utah,胎儿循环,胎儿期，氧合血液由脐静脉经下腔静脉进入右房,血流由下腔静脉经过,Eustachian,瓣流到卵圆窝,.,出生后房间隔发育,宫内,出生后,Hagen,Scholz.Mayo Clin Proc 1984;59:17-20.,人口的,75,人口 的,25%,Platypnea Orthodeoxia,1949,年至今已有文献报道近,100,例,PFO,常伴有,:,主动脉瘤,胸廓畸形,肺切除术后,约,50,例已接受封堵术,减压病,对,230,名 无症状潜水者进行研究,27%,有,PFO,需要减压舱治疗者,:,19%,有,PFO,2%,无,PFO,Torti et al.Eur Heart J 2004;25:1014-20.,隐匿性脑卒中,40,岁男性，突发失语,既往史无特殊,.,无明显脑卒中病因,.,TEE:,发现房间隔瘤与,PFO.,常见伴发症,:,50%,隐匿性脑卒中患者有,PFO.,推测机制,:,静脉血栓反常性体循环栓塞症,.,PFO,通道内原位血栓形成造成栓塞,血栓流经,PFO,首例,PFO,伴血栓形成报道于,1876.,既往通过超声心动图及术中见到嵌顿于,PFO,的血栓,.,但无法观察到小栓子的流程。,服用阿司匹林的,PFO,患者脑血管事件,/TIA,复发率较高,Mas et al.NEJM 2001;345:1740-6.,581,名患者有隐匿性脑卒中,均接受阿司匹林治疗,华法林阿司匹林复发性脑卒中研究,Mohr et al.NEJM 2001;345:1444-51.,N=2206,缺血性脑血管事件,(56%,腔梗,;25%,隐匿性,;13%,大血管性,),随机接受阿司匹林,325mg,或华法林治疗,结论,:,抗血小板及抗凝治疗有效（无效）率相当。,药物治疗,vs.PFO,封堵术,Windecker et al.JACC 2004;44:750-8.,308,名 隐匿性脑卒中伴,PFO,患者,随机接受药物治疗或,PFO,封堵术治疗,药物治疗,vs.PFO,封堵术,:,观察性研究的荟萃分析,Khairy et al.Ann Int Med 2003;139:753-60.药物治疗,(6,个研究,),N=895,3.8-12.0%,4.9,PFO,封堵术,(10,个研究,),N=1355,0-4.9%,3.0,1,年脑卒中,/TIA,复发率,死亡,/,脑卒中,/TIA,事件,/100,人年,PFO,封堵器,PFO,ASD,Amplatzer PFO,STARFlex,Amplatzer ASO,CardioSEAL,Helex,Amplatzer,Cribiform ASD,左房伞植入,右房伞植入,植入前,植入后,偏头痛与,PFO,的关系,12,人口患有偏头痛,(,女性,18%;,男性,6%),偏头痛患者中,存在,PFO,的占：,48%,的偏头痛伴视觉先兆,123%,的偏头痛不伴视觉先兆,20%,正常人,隐匿性脑卒中伴,PFO,患者中偏头痛发生率,52%,有偏头痛伴视觉先兆,2,71%,封堵术后症状缓解,3,偏头痛患者较正常人,MRI,检查病变阳性率高,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.,卵圆孔未闭与偏头痛之间可能的病理生理相关性,经过,PFO,的微小栓子可引起偏头痛,.,体液因子（如,5,HT),免受肺降解,引起偏头痛,.,MIST,研究结果,Dowson A,et al.Circulation 2008;117:1397-404.,无偏头痛发作患者,n,0,3,1,3,1.0,偏头痛发作频率,/,月,meanSD,4.82,2.44,3.23,1.80,4.51,2.17,3.53,2.13,0.14,MIDAS,总评分,median(range),36,(3108),17,(0270),34,(2189),18,(0240),0.88,头痛天数,/3,月,(MIDAS),median(range),27,(070),18,(090),30,(580),21,(080),0.79,HIT-6,总评分,meanSD,67.2,4.7,59.5,9.3,66.2,5.1,58.5,8.6,0.77,术前,术前,术后,术后,P value,手术组,(n=74),假手术组,(n=73),偏头痛随机临床试验,NMT Medical closed MIST II,(January 24,2008).,PREMIUM(AGA Medical),及,ESCAPE(St Jude Medical),仍在进行中,.,PFO,封堵器技术现况与展望,目前封堵器技术的局限性,大型，永久性植入物,.,远期并发症：心率失常，炎症，糜烂，血栓形成，过敏反应,.,未来的封堵器技术,小型封堵器,.,生物可吸收,(BioSTAR).,可缝合封堵器,.,射频消融,.,Mullen et al.Circulation 2006;114:1962-7.,结论,目前隐匿性脑卒中的药物治疗疗效欠佳,.,研究提示存在高危复发脑卒中的亚组,.,尚无随机临床试验支持任何药物治疗,经皮,PFO,封堵术可能成为隐匿性脑卒中预防的主要干预手段,.,安全,.,非随机临床试验资料提示对可有效预防脑卒中,.,有待关于脑卒中与偏头痛的进一步临床研究结果,.,结论,Patent Foramen Ovale Closure:Controversies and Accomplishments,May 9,2009,Andrew D.Michaels,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,Eustachian 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 pulmonary 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 cases 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;25:1014-20.,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 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 al.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 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 2003;139:753-60.,Medical Therapy,(6 studies),N=895,38-12.0%,4.9,PFO Closure,(10 studies),N=1355,0-4.9%,3.0,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 12%of population(18%F;6%M),Incidence of PFO in patients with migraine,48%if migraine with aura,1,23%if migraine without aura,20%in controls,Incidence of migraine in cryptogenic stroke with PFO,52%had migraine with aura,2,71%had suppression post-closure,3,Migraine patients have 13 times higher incidence of MRI lesions,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.,Potential Pathophysiologic Association Between PFO and Migraine,Microembolism through PFO triggers migraine.,Humoral factors(i.e.,serotonin)escape pulmonary degradation,triggering migraine.,Published MIST Results,Dowson A,et al.Circulation 2008;117:1397-404.,Patients with no migraine attacks,n,0,3,1,3,1.0,Frequency of migraine attacks/mo,meanSD,4.82,2.44,3.23,1.80,4.51,2.17,3.53,2.13,0.14,Total MIDAS score,median(range),36,(3108),17,(0270),34,(2189),18,(0240),0.88,Headache d/3 mo(MIDAS),median(range),27,(070),18,(090),30,(580),21,(080),0.79,HIT-6 total score,meanSD,67.2,4.7,59.5,9.3,66.2,5.1,58.5,8.6,0.77,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 Technologies,Large,permanent implants.,Late complications:,arrhythmia,inflammation,erosions,thrombus,allergic reactions.,Future Device Technologies,Smaller profile devices.,Bioabsorbable(BioSTAR).,Suture-based devices.,Radiofrequency ablation.,Mullen et al.Circulation 2006;114:1962-7.,Current medical therapy insufficient for patients with cryptogenic stroke.,Subgroups at high-risk for recurrent CVA are identifiable.,No RCT data in support of,any treatment,.,Percutaneous PFO closure is likely to become a cornerstone of cryptogenic CVA prevention.,Safe.,Non-randomized data suggests efficacy for CVA prevention.,Await clinical trial results for CVA and migraine.,Conclusions,