卵圆孔未闭封堵术：争论与发展（中英文）

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.EurJCardiothorSurg2008;33:268.Medinaetal.Circulation2001;104:741.PlatypneaOrthodeoxia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PFOTortietal.EurHeartJ2004;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服用阿司匹林的PFO患者脑血管事件/TIA复发率较高Masetal.NEJM2001;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.NEJM2001;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。Windeckeretal.JACC2004;44:750-8.Khairyetal.AnnIntMed2003;139:753-60.药物治疗(6个研究)N=8953.8-12.0%4.9PFO封堵术

(10个研究)N=13550-4.9%3.01年脑卒中/TIA复发率死亡/脑卒中/TIA事件/100人年PFO封堵器PFOASDAmplatzerPFOSTARFlexAmplatzerASOCardioSEALHelexAmplatzerCribiformASD左房伞植入右房伞植入植入前植入后偏头痛与PFO的关系Anzola.Neurology1999;52:1622-5.Sztajzel.CVDiseases2002;13:102-6.Wilmshurst.Lancet2000;356:1648-51.Kruit.JAMA2004;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.Circulation2008;117:1397-404.

无偏头痛发作患者,n03131.0偏头痛发作频率/月,mean±SD4.82±2.443.23±1.804.51±2.173.53±2.130.14

MIDAS总评分,median(range)36(3–108)17(0–270)34(2–189)18(0–240)0.88

头痛天数/3月(MIDAS),median(range)27(0–70)18(0–90)30(5–80)21(0–80)0.79

HIT-6总评分,mean±SD67.2±4.759.5±9.366.2±5.158.5±8.60.77

Pvalue偏头痛随机临床试验NMTMedicalclosedMISTII(January24,2008).PREMIUM(AGAMedical)及ESCAPE(StJudeMedical)仍在进行中.Mullenetal.Circulation2006;114:1962-7.结论结论PatentForamenOvaleClosure:

ControversiesandAccomplishments

May9,2009AndrewD.Michaels,MD,MAS,FACC,FAHADirector,CardiacCatheterizationLaboratoryandInterventionalCardiologyUniversityofUtah,SaltLakeCity,UtahFetalCirculationDuringfetallife,oxygenatedbloodreturningfromtheumbilicalveinenterstheRAthroughtheIVC.BloodflowisdirectedbytheEustachianvalvefromtheIVCtothefossaovalisandthroughthePFO.Post-NatalSeptalDevelopmentInUteroAfterBirthHagen,Scholz.MayoClinProc1984;59:17-20.75%ofPopulation 25%ofPopulationClinicalSyndromesAssociatedwithPFOPlatypneaorthodeoxiaDecompressionsickness/high-altitudepulmonaryedemaCVA/TIAMigrainePlatypnoeaOrthodeoxiaUncommonsyndromeDyspneainducedbyuprightposture,withassociatedhypoxemiaMechanism:right-to-leftinteratrialshuntingAigneretal.EurJCardiothorSurg2008;33:268.Medinaetal.Circulation2001;104:741.PlatypneaOrthodeoxia~100casesinliteraturesince1949PFOassociatedwith:AorticaneurysmChestdeformityPost-pneumonectomy~50haveundergonedeviceclosureDecompressionSickness230asymptomaticdiverssurveyed27%hadaPFODecompressionchamberrequired:19%withaPFO2%withoutaPFOTortietal.EurHeartJ2004;25:1014-20.CryptogenicStrokeCase40yomanwithsuddenaphasia.Nomedicalhistory.Noobviouscauseofstroke.TEE:atrialseptalaneurysmandPFO.Associations:50%ofpeoplewithcryptogenicstrokehaveaPFO.Presumedmechanism:Paradoxicalembolismofvenousthrombus.In-situthrombosiswithinPFOtunnelwithembolization.ThrombusintransitthroughPFOFirstcaseofPFOwiththrombusdescribedin1876.ThrombuscaughtinPFOhasbeenseenbyechoandatsurgery.However,passagesofsmallemboliareimpossibletoprove.HigherCVA/TIARecurrenceRateinPatientswithPFO+ASAMasetal.NEJM2001;345:1740-6.581patientswithcryptogenicstrokeAlltreatedwithaspirinWarfarin-AspirinRecurrentStrokeStudyMohretal.NEJM2001;345:1444-51.N=2206withischemicCVA(56%lacunar;25%cryptogenic;13%largevessel)RandomizedtoASA325mgvsWarfarinConclusion:Antiplateletandanticoagulanttherapyequally(in)effectiveMedicalTherapyvs.PFOClosureWindeckeretal.JACC2004;44:750-8.N=308withcryptogenicCVAandPFORandomizedtomedicaltherapyorPFOclosureMedicalTherapyvs.PFOClosure:

Meta-AnalysisofObservationalStudiesKhairyetal.AnnIntMed2003;139:753-60.MedicalTherapy(6studies)N=8953.8-12.0%4.9PFOClosure(10studies)N=13550-4.9%3.0RecurrentCVA/TIA1-YearDeath/CVA/TIAEvents/100ptyrsPFODevicesPFOASDAmplatzerPFOSTARFlexAmplatzerASOCardioSEALHelexAmplatzerCribiformASDLeftAtrialDiscDeploymentRightAtrialDiscDeploymentPrePostAssociationBetweenMigraineandPFOMigraineheadacheaffects12%ofpopulation(18%F;6%M)IncidenceofPFOinpatientswithmigraine48%ifmigrainewithaura123%ifmigrainewithoutaura20%incontrolsIncidenceofmigraineincryptogenicstrokewithPFO52%hadmigrainewithaura271%hadsuppressionpost-closure3Migrainepatientshave13timeshigherincidenceofMRIlesions4Anzola.Neurology1999;52:1622-5.Sztajzel.CVDiseases2002;13:102-6.Wilmshurst.Lancet2000;356:1648-51.Kruit.JAMA2004;294:427-34.PotentialPathophysiologicAssociationBetweenPFOandMigraineMicroembolismthroughPFOtriggersmigraine.Humoralfactors(i.e.,serotonin)escapepulmonarydegradation,triggeringmigraine.PublishedMISTResultsDowsonA,etal.Circulation2008;117:1397-404.

Patientswithnomigraineattacks,n03131.0Frequencyofmigraineattacks/mo,mean±SD4.82±2.443.23±1.804.51±2.173.53±2.130.14

TotalMIDASscore,median(range)36(3–108)17(0–270)34(2–189)18(0–240)0.88

Headached/3mo(MIDAS),median(range)27(0–70)18(0–90)30(5–80)21(0–80)0.79

HIT-6totalscore,mean±SD67.2±4.759.5±9.366.2±5.158.5±8.60.77

BaselineBaselinePostPostPvalueImplant(n=74)Sham(n=73)MigraineRandomizedClinicalTrialsNMTMedicalclosedMISTII(January24,2008).PREMIUM(AGAMedical)andESCAPE(StJudeMedical)stillenrolling.CurrentandFuturePFODeviceTechnologies