卵圆孔未闭与脑卒中2018 韩宝石ppt课件.pptx
,卵圆孔未闭封堵临床医学证据与对策,韩宝石 朱 航 郭 军中国人民解放军总医院,PFO的发病率和相关致病机制PFO与脑卒中、偏头痛的关系PFO封堵术预防卒中的有效性PFO的干预对策,提 纲,约25成年人存在PFO,PFO发生率,N Engl J Med. 1988;318:1148 1152.(Circulation. 2005;112:1063-1072.),有1040的PFO可发生缺血性卒中即使PFO患者抗凝治疗，仍有310发生脑栓塞高达3040偏头痛患者存在PFO高达48-70的先兆偏头痛患者存在PFO,PFO相关临床疾病发生率,PFO导致卒中机制,外周静脉系统血栓突发右向左分流Valsalva动作咳嗽,血栓穿越PFO,BMJ Case Rep 2016Eur heart j 2015,case 2,case 1,不明原因脑卒中患者的PFO检出率,年龄小于55岁的脑卒中患者，PFO与脑卒中关系密切,Relationship of Cryptogenic Stroke With PFO,N Engl J Med. 1988;318:1148 1152.(Circulation. 2005;112:1063-1072.),Prevalence of PFO in 160 patients,Stroke. 2010;41:S26-S30.,PFO与脑卒中,不明原因脑卒中：PFO与梗死的关系,PFO 与不明原因的脑卒中相关PFO 大小与脑梗死负荷呈正相关,Journal of Stroke and Cerebrovascular Diseases, 2013: pp 1399-1404 1399.),PFO，脑卒中复发的致病因素？,Prevalence of Conventional RFs in CS Patients With (+) and Without (-) PFO,PFO Prevalence in CS vs Stroke of Known Cause,PFO是脑卒中发生的重要预测指标PFO 是再发脑卒中的重要危险因素 无传统危险因素的脑卒中患者，可以预测其PFO检出率较高,RoPE: 鉴别卒中相关PFO的指标,传统危险因素越少，卒中与PFO的关系越密切卒中与PFO的关系越密切，再发卒中的可能性越小 Neurology 2013;81:17,Risk of Paradoxical Embolism Score,PFO attributable fraction and estimated 2 year risk of stroke /TIA,再发脑卒中的预防,PFO封堵 vs 药物治疗，PFO封堵预防再发卒中的效果更好外科修补术的全因死亡率未下降,(Circulation. 2005;112:1063-1072.),Medical Therapy,Percutaneous PFO Closure,Surgical PFO Closure,CLOSURE I 研究,Closure with a device did not offer a greater benefit than medical therapy alone for the prevention of recurrent stroke or TIAThe cumulative incidence of the primary end point was 5.5% in the closure group as compared with 6.8% in the medical-therapy group (P = 0.37)2.9% and 3.1% for stroke (P = 0.79) 3.1% and 4.1% for TIA (P = 0.44).,percutaneous closure of the PFO with the STARFlex device909 patients were enrolled2 years of follow-up,N Engl J Med 2012;366:991-9.,对大多数高危患者，无论是医生、还是患者均选择PFO封堵术最终入组者，中低危患者较多,RESPECT研究,RESPECT研究美国62个中心、加拿大7个中心通过对980例隐源性脑卒中患者进行封堵与药物治疗的随机对照试验。研究发现：在降低脑卒中风险方面，封堵器治疗优于单独药物治疗，封堵治疗将脑卒中风险降低46.672.7%。,Device Closure of PFO After Stroke -临床荟萃研究,Among patients with PFO and CS, closure reduced recurrent stroke a significant benefit of PFO closure when compared with ASA (1.4 vs. 3.6%, P=0.03)Vitamin K antagonists performed as well as PFO closure (3.0 vs. 2.5%, P=0.86).,J Am Coll Cardiol 2016;67:90717,2,303 patients2 devices (STARFlex ) and Amplatzer PFO Occluder evaluated in 3 trialsThe primary composite outcome was stroke, TIA, or death; the secondary outcome was stroke.,Stroke/TIA/Death,Recurrent Stroke,Logrank P=0.0885,Logrank P=0.0103,Data from trials of disc occluder,Percutaneous closure of PFO in cryptogenic embolism -临床荟萃研究,PFO closure with AMP appears superior to medical therapy in preventing strokes in CSNo significant differences found for STF and HLX when compared with medical therapy The probability to be best in preventing strokes was 77.1% for AMP, 20.9% for HLX, 1.7% for STF, and 0.4% for medical therapy.,four randomized trials (2963 patients with 9309 patient-yearsInvestigated devices were Amplatzer (AMP), STARFlex (STF), and HELEX (HLX).,European Heart Journal (2015) 36, 120128,长期疗效对比：PFO封堵vs药物治疗,PFOclosurewas more effective than medical treatment for the secondary preventionPFO closure resulted in a significant 64% relative risk reduction for death,Circulation 2012;125:803812.,308 patients , percutaneous PFOclosure(150 patients) or medical treatment (158 patients)followed up prospectively for up to 15 years.,Ten-year outcome,RESPECT研究最终结果,Data from August 2003 - May 2016,Mean Follow-up: 5.9 years (0-12 years)DeviceMean 6.3 years; Total 3141 patient-yearsMedical ManagementMean 5.5 years; Total 2669 patient-years,PFO closure with the AMPLATZERTM PFO Occluder was more beneficial than medical management alone,PFO形态与不明原因卒中的关系,PFO diameter larger PFOs may be more prone to transit of thrombotic material Degree of right to left shunting: Length of the PFO ( tunnels 8 mm ) Atrial septal aneurysm ASA may themselves be pathogenic or may promote R-L shunting Eustachian valves and Chiari networks Journal of Stroke and Cerebrovascular Diseases, 2013: pp 1399-1404,卵圆孔未闭处理策略中国专家共识中国医师协会心血管内科医师分会,高危PFO: PFO 合并ASA 或房间隔活动度过大（6.5mm）PFO 伴有静息LS 及PFO 较大(4mm)PFO 合并过长的VE 或Chiari 网等解剖特征,心脏杂志 2015,27（4）,对策-药物或封堵,药物治疗再次脑卒中风险低，3.26.8%长期抗凝和抗血小板出血风险,获益大风险小 获益大风险大 获益小风险小 获益小风险大,风险,获益,介入封堵安全有效出血风险低手术相关并发症,PFO可引起偏头痛偏头痛的程度较重，其性质表现为一侧头部的搏动性疼痛，伴有畏光畏声、恶心呕吐，常不能正常工作学习、持续1天或更长。少数偏头痛患者每次伴有发作前的先兆感觉信号，常见有闪光幻觉和其他视觉缺损。,偏头痛（MA）患者PFO发生率为3040，有先兆偏头痛患者更是高达48-70。MA患者心内右向左分流的患病率显著高于正常人群，与CS的患病率相当。另外，在偏头痛患者中MRI证实PFO的发生是没有偏头痛患者的13倍。,PFO与偏头痛的相关性,PFO在MA中患病率明显增高，这与对不明原因脑梗死的研究结果一致，说明偏头痛的可能机制是矛盾栓塞。fMRI研究表明，视觉先兆患者的枕叶皮层有短暂性低灌注，TCD和SPECT研究发现，PFO患者更易出现后循环血栓。JAMA谈到在频繁发作MA的患者中，亚临床的后循环供血区梗死的发生率增加了15倍。Neurology认为青年人偏头痛梗死更容易发生在后循环。,PFO发生偏头痛的可能机制,PFO致MA机制推测：静脉微血栓矛盾栓塞；化学物质如5羟色胺等未经肺循环清除，触发偏头痛。PFO封堵可减少偏头痛发作。,PFO发生偏头痛的可能机制,Azarbal等回顾评估了不明原因卒中患者，偏头痛患病率为42，其中62为有先兆者，封堵术后一年，有60的偏头痛完全缓解，其余40部分缓解。,PFO闭合装置,双盘型PFO封堵器,双盘型PFO封堵器,Solysafe 封堵器,Premere封堵器,封堵片,缝合装置,射频闭合装置,具有不明原因卒中病史，同时证实有PFO存在右向左分流者；有先兆症状的偏头痛合并PFO患者；PFO合并房间隔瘤；PFO伴随反复发生肺栓塞并DVT10 mm以上的大PFO；右向左分流的大PFO；有PFO的潜水员。,PFO封堵术的适应症,Whrle J总结了11个研究 1970个PFO封堵的患者0.2发生TIA1.1发生置入物血栓没有死亡、心肌梗塞、卒中或其他引起长期后遗症的事件较严重的并发症术后封堵器表面血栓形成，抗血小板治疗可以把封堵器血栓风险性降到更低释放封堵装置导致心脏填塞的发生率不到0.1。,卵圆孔介入封堵手术为治疗不明原因或隐源性脑卒中及偏头痛提供了一个新的可能治愈的方法，使该病可能不在是一个终身疾病。偏头痛患者发生卵圆孔未闭是否要治疗尚无统一标准，但一定要进行综合考虑，因偏头痛发作频繁影响患者自理生活时可考虑介入封堵治疗。,
