卵圆孔未闭封堵术：争论与发展中.ppt

卵圆孔未闭封堵术：争论与发展May9,2009,AndrewD.Michaels,MD,MAS,FACC,FAHADirector,CardiacCatheterizationLaboratoryandInterventionalCardiologyUniversityofUtah,SaltLakeCity,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.MayoClinProc1984;59:17-20.,人口的75人口的25%,PFO相关临床综合症,体位相关呼吸困难Platypneaorthodeoxia减压病/高原性肺水肿脑血管事件/TIA偏头痛,PlatypnoeaOrthodeoxia,罕见直立体位引起的呼吸困难，伴有低氧血症机制：右向左房间分流,Aigneretal.EurJCardiothorSurg2019;33:268.Medinaetal.Circulation2019;104:741.,PlatypneaOrthodeoxia,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PFO2%无PFO,Tortietal.EurHeartJ2019;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,Masetal.NEJM2019;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,Mohretal.NEJM2019;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,Windeckeretal.JACC2019;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,Khairyetal.AnnIntMed2019;139:753-60.,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,AmplatzerPFO,STARFlex,AmplatzerASO,CardioSEAL,Helex,AmplatzerCribiformASD,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%有偏头痛伴视觉先兆271%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.Neurology2019;52:1622-5.Sztajzel.CVDiseases2019;13:102-6.Wilmshurst.Lancet2000;356:1648-51.Kruit.JAMA2019;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5HT)免受肺降解,引起偏头痛.,MIST研究结果,DowsonA,etal.Circulation2019;117:1397-404.,术前,术前,术后,术后,Pvalue,手术组(n=74),假手术组(n=73),偏头痛随机临床试验,NMTMedicalclosedMISTII(January24,2019).PREMIUM(AGAMedical)及ESCAPE(StJudeMedical)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.,Mullenetal.Circulation2019;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,PatentForamenOvaleClosure:ControversiesandAccomplishmentsMay9,2009,AndrewD.Michaels,MD,MAS,FACC,FAHADirector,CardiacCatheterizationLaboratoryandInterventionalCardiologyUniversityofUtah,SaltLakeCity,Utah,FetalCirculation,Duringfetallife,oxygenatedbloodreturningfromtheumbilicalveinenterstheRAthroughtheIVC.BloodflowisdirectedbytheEustachianvalvefromtheIVCtothefossaovalisandthroughthePFO.,Post-NatalSeptalDevelopment,InUteroAfterBirth,Hagen,Scholz.MayoClinProc1984;59:17-20.,75%ofPopulation25%ofPopulation,ClinicalSyndromesAssociatedwithPFO,PlatypneaorthodeoxiaDecompressionsickness/high-altitudepulmonaryedemaCVA/TIAMigraine,PlatypnoeaOrthodeoxia,UncommonsyndromeDyspneainducedbyuprightposture,withassociatedhypoxemiaMechanism:right-to-leftinteratrialshunting,Aigneretal.EurJCardiothorSurg2019;33:268.Medinaetal.Circulation2019;104:741.,PlatypneaOrthodeoxia,100casesinliteraturesince1949PFOassociatedwith:AorticaneurysmChestdeformityPost-pneumonectomy50haveundergonedeviceclosure,DecompressionSickness,230asymptomaticdiverssurveyed27%hadaPFODecompressionchamberrequired:19%withaPFO2%withoutaPFO,Tortietal.EurHeartJ2019;25:1014-20.,CryptogenicStrokeCase,40yomanwithsuddenaphasia.Nomedicalhistory.Noobviouscauseofstroke.TEE:atrialseptalaneurysmandPFO.Associations:50%ofpeoplewithcryptogenicstrokehaveaPFO.Presumedmechanism:Paradoxicalembolismofvenousthrombus.In-situthrombosiswithinPFOtunnelwithembolization.,ThrombusintransitthroughPFO,FirstcaseofPFOwiththrombusdescribedin1876.ThrombuscaughtinPFOhasbeenseenbyechoandatsurgery.However,passagesofsmallemboliareimpossibletoprove.,HigherCVA/TIARecurrenceRateinPatientswithPFO+ASA,Masetal.NEJM2019;345:1740-6.,581patientswithcryptogenicstrokeAlltreatedwithaspirin,Warfarin-AspirinRecurrentStrokeStudy,Mohretal.NEJM2019;345:1444-51.,N=2206withischemicCVA(56%lacunar;25%cryptogenic;13%largevessel)RandomizedtoASA325mgvsWarfarinConclusion:Antiplateletandanticoagulanttherapyequally(in)effective,MedicalTherapyvs.PFOClosure,Windeckeretal.JACC2019;44:750-8.,N=308withcryptogenicCVAandPFORandomizedtomedicaltherapyorPFOclosure,MedicalTherapyvs.PFOClosure:Meta-AnalysisofObservationalStudies,Khairyetal.AnnIntMed2019;139:753-60.,RecurrentCVA/TIA1-Year,Death/CVA/TIAEvents/100ptyrs,PFODevices,PFO,ASD,AmplatzerPFO,STARFlex,AmplatzerASO,CardioSEAL,Helex,AmplatzerCribiformASD,LeftAtrialDiscDeployment,RightAtrialDiscDeployment,Pre,Post,AssociationBetweenMigraineandPFO,Migraineheadacheaffects12%ofpopulation(18%F;6%M)IncidenceofPFOinpatientswithmigraine48%ifmigrainewithaura123%ifmigrainewithoutaura20%incontrolsIncidenceofmigraineincryptogenicstrokewithPFO52%hadmigrainewithaura271%hadsuppressionpost-closure3Migrainepatientshave13timeshigherincidenceofMRIlesions4,Anzola.Neurology2019;52:1622-5.Sztajzel.CVDiseases2019;13:102-6.Wilmshurst.Lancet2000;356:1648-51.Kruit.JAMA2019;294:427-34.,PotentialPathophysiologicAssociationBetweenPFOandMigraine,MicroembolismthroughPFOtriggersmigraine.Humoralfactors(i.e.,serotonin)escapepulmonarydegradation,triggeringmigraine.,PublishedMISTResults,DowsonA,etal.Circulation2019;117:1397-404.,Baseline,Baseline,Post,Post,Pvalue,Implant(n=74),Sham(n=73),MigraineRandomizedClinicalTrials,NMTMedicalclosedMISTII(January24,2019).PREMIUM(AGAMedical)andESCAPE(StJudeMedical)stillenrolling.,CurrentandFuturePFODeviceTechnologies,LimitationsofCurrentDeviceTechnolo