卵圆孔未闭封堵术争论与发展PPT课件.ppt

卵圆孔未闭封堵术 争论与发展 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5 HT 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 pneumonectomy 50haveundergonedeviceclosure 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 LimitationsofCurrentDeviceTechnologiesLarge permanentimplants Latecomplications arrhythmia inflammation erosions thrombus allergicreactions FutureDeviceTechnologiesSmallerprofiledevices Bioabsorbable BioSTAR Suture baseddevices Radiofrequencyablation Mullenetal Circulation2019 114 1962 7 Currentmedicaltherapyinsufficientforpati