卵圆孔未闭与脑卒中参考幻灯片

? The 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).
Stroke. 2008;39:3131 –3136. Stroke. 2002;33:706 –711.
Cerebrovasc Dis. 2009;28:349 –356. 10
1]:S26-S30.
RoPE: 鉴别卒中相关PFO的指标
Risk of Paradoxical Embolism Score
? 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).
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
1
PFO发生率
N Engl J Med. 1988;318:1148 –1152. 3 (Circulation. 2005;112:1063-1072.)
PFO相关临床疾病发生率
? 有10％~40％的PFO可发生缺血性卒中
PFO与脑卒中
Stroke. 2010;41:S26-S308.
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 19399.)
N Engl J Med 2012;366:19391-9.
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%。
– 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 PFO
4
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
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血栓穿越PFO
case 1
case 2
BMJ Case Rep 2016
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
Percutaneous PFO Closure
Surgical PFO Closure
? 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
12 (Circulation. 2005;112:1063-1072.)
CLOSURE I 研究
? percutaneous closure of the PFO with the STARFlex device ? 909 patients were enrolled ? 2 years of follow-up
Eur heart j 2015
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不明原因脑卒中患者的PFO 检出率
Relationship of Cryptogenic Stroke With PFO
Prevalence of PFO in 160 patients
年龄小于55 岁的脑卒中患者，PFO 与脑卒中关系密切
N Engl J Med. 1988;318:1148 –17152. (Circulation. 2005;112:1063-1072.)
Data from trials of disc occluder
Stroke/TIA/Death
Baidu Nhomakorabea
Recurrent Stroke
Logrank P=0.0885
Logrank P=0.0103
? Among patients with PFO and CS, closure reduced recurrent stroke
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Device Closure of PFO After Stroke
-临床荟萃研究
? 2,303 patients
? 2 devices (STARFlex ) and Amplatzer PFO Occluder evaluated in 3 trials
? The primary composite outcome was stroke, TIA, or death; the secondary outcome was stroke.
PFO attributable fraction and estimated 2 year risk of stroke /TIA
? 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;8111:1–7
再发脑卒中的预防
Medical Therapy
6.8%
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5组.5%者，中低危患者较多
? Closure with a device did not offer a greater benefit than medical therapy alone
for the prevention of recurrent stroke or TIA