卵圓孔未閉封堵術(shù)：爭論與發(fā)展（中英文）

AndrewD.Michaels,MD,MAS,FACC,FAHADirector,CardiacCatheterizationLaboratoryandInterventionalCardiologyUniversityofUtah,SaltLakeCity,Utah胎兒循環(huán)胎兒期，氧合血液由臍靜脈經(jīng)下腔靜脈進(jìn)入右房血流由下腔靜脈經(jīng)過Eustachian瓣流到卵圓窩.出生后房間隔發(fā)育Hagen,Scholz.MayoClinProc1984;59:17-20.人口的75％

人口的25%PFO相關(guān)臨床綜合癥體位相關(guān)呼吸困難Platypneaorthodeoxia減壓病/高原性肺水腫腦血管事件/TIA偏頭痛PlatypnoeaOrthodeoxia罕見直立體位引起的呼吸困難，伴有低氧血癥機(jī)制：右向左房間分流Aigneretal.EurJCardiothorSurg2008;33:268.Medinaetal.Circulation2001;104:741.PlatypneaOrthodeoxia減壓病對230名無癥狀潛水者進(jìn)行研究27%有PFO需要減壓艙治療者:19%有PFO2%無PFOTortietal.EurHeartJ2004;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(jī)制:靜脈血栓反常性體循環(huán)栓塞癥.PFO通道內(nèi)原位血栓形成造成栓塞血栓流經(jīng)PFO服用阿司匹林的PFO患者腦血管事件/TIA復(fù)發(fā)率較高M(jìn)asetal.NEJM2001;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(fù)發(fā)性腦卒中研究Mohretal.NEJM2001;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(jī)接受阿司匹林325mg或華法林治療結(jié)論:

抗血小板及抗凝治療有效（無效）率相當(dāng)。Windeckeretal.JACC2004;44:750-8.Khairyetal.AnnIntMed2003;139:753-60.藥物治療(6個研究)N=8953.8-12.0%4.9PFO封堵術(shù)

(10個研究)N=13550-4.9%3.01年腦卒中/TIA復(fù)發(fā)率死亡/腦卒中/TIA事件/100人年P(guān)FO封堵器PFOASDAmplatzerPFOSTARFlexAmplatzerASOCardioSEALHelexAmplatzerCribiformASD左房傘植入右房傘植入植入前植入后偏頭痛與PFO的關(guān)系A(chǔ)nzola.Neurology1999;52:1622-5.Sztajzel.CVDiseases2002;13:102-6.Wilmshurst.Lancet2000;356:1648-51.Kruit.JAMA2004;294:427-34.卵圓孔未閉與偏頭痛之間可能的病理生理相關(guān)性經(jīng)過PFO的微小栓子可引起偏頭痛.體液因子（如5－HT)免受肺降解,引起偏頭痛.MIST研究結(jié)果DowsonA,etal.Circulation2008;117:1397-404.

無偏頭痛發(fā)作患者,n03131.0偏頭痛發(fā)作頻率/月,mean±SD4.82±2.443.23±1.804.51±2.173.53±2.130.14

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

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

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

Pvalue偏頭痛隨機(jī)臨床試驗(yàn)NMTMedicalclosedMISTII(January24,2008).PREMIUM(AGAMedical)及ESCAPE(StJudeMedical)仍在進(jìn)行中.Mullenetal.Circulation2006;114:1962-7.結(jié)論結(jié)論P(yáng)atentForamenOvaleClosure:

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