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约25％成年人存在PFOPFO发生率NEnglJMed.1988;318:1148–1152.(Circulation.2005;112:1063-1072.)有10％~40％的PFO可发生缺血性卒中即使PFO患者抗凝治疗，仍有3％~10％发生脑栓塞高达30~40％偏头痛患者存在PFO高达48-70％的先兆偏头痛患者存在PFOPFO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PFOBMJCaseRep2016Eurheartj2015case2case1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RelationshipofCryptogenicStrokeWithPFONEnglJMed.1988;318:1148–1152.(Circulation.2005;112:1063-1072.)PrevalenceofPFOin160patientsStroke.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JournalofStrokeandCerebrovascularDiseases,2013:pp1399-14041399.)PFO，脑卒中复发的致病因素？PrevalenceofConventionalRFsinCSPatientsWith(+)andWithout(-)PFOPFOPrevalenceinCSvsStrokeofKnownCauseStroke.2008;39:3131–3136.Stroke.2002;33:706–711.CerebrovascDis.2009;28:349–356.Stroke.2010;41[suppl1]:S26-S30.•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Neurology2013;81:1–7RiskofParadoxicalEmbolismScorePFOattributablefractionandestimated2yearriskofstroke/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.)MedicalTherapyPercutaneousPFOClosureSurgicalPFOClosureCLOSUREI研究•ClosurewithadevicedidnotofferagreaterbenefitthanmedicaltherapyaloneforthepreventionofrecurrentstrokeorTIA•Thecumulativeincidenceoftheprimaryendpointwas5.5%intheclosuregroupascomparedwith6.8%inthemedical-therapygroup(P=0.37)•2.9%and3.1%forstroke(P=0.79)•3.1%and4.1%forTIA(P=0.44).•percutaneousclosureofthePFOwiththeSTARFlexdevice•909patientswereenrolled•2yearsoffollow-upNEnglJMed2012;366:991-9.6.8%5.5%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46.6～72.7%。DeviceClosureofPFOAfterStroke-临床荟萃研究•AmongpatientswithPFOandCS,closurereducedrecurrentstroke•asignificantbenefitofPFOclosurewhencomparedwithASA(1.4vs.3.6%,P=0.03)•VitaminKantagonistsperformedaswellasPFOclosure(3.0vs.2.5%,P=0.86).JAmCollCardiol2016;67:907–17•2,303patients•2devices(STARFlex)andAmplatzerPFOOccluderevaluatedin3trials•Theprimarycompositeoutcomewasstroke,TIA,ordeath;thesecondaryoutcomewasstroke.Stroke/TIA/DeathRecurrentStrokeLogrankP=0.0885LogrankP=0.0103DatafromtrialsofdiscoccluderPercutaneousclosureofPFOincryptogenicembolism-临床荟萃研究•PFOclosurewithAMPappearssuperiortomedicaltherapyinpreventingstrokesinCS•NosignificantdifferencesfoundforSTFandHLXwhencomparedwithmedicaltherapy•Theprobabilitytobebestinpreventingstrokeswas77.1%forAMP,20.9%forHLX,1.7%forSTF,and0.4%formedicaltherapy..•fourrandomizedtrials(2963patientswith9309patient-years•InvestigateddeviceswereAmplatzer(AMP),STARFlex(STF),andHELEX(HLX).EuropeanHeartJournal(2015)36,120–128长期疗效对比：PFO封堵vs药物治疗•PFOclosurewasm...
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