卵圆孔未闭与脑卒中PPT参考课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2020/1/8,#,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,韩宝石 朱 航 郭 军1,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,2,PFO的发病率和相关致病机制提 纲2,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.),3,约25成年人存在PFOPFO发生率N Engl J Me,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,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,4,有1040的PFO可发生缺血性卒中PFO相关临床疾病发,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,5,PFO导致卒中机制外周静脉系统血栓5,血栓穿越,PFO,BMJ Case Rep 2016,Eur heart j 2015,case 2,case 1,6,血栓穿越PFOBMJ Case Rep 2016case 2,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,7,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，,Stroke.2010;41:S26-S30.,PFO,与脑卒中,8,Stroke.2010;41:S26-S30.PFO与脑卒,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.),9,不明原因脑卒中：PFO与梗死的关系PFO 与不明原因的脑卒中,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,Stroke.2008;39:31313136.,Stroke.2002;33:706 711.,Cerebrovasc Dis.2009;28:349 356.,Stroke.2010;41suppl 1: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,10,PFO，脑卒中复发的致病因素？Prevalence of C,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,11,传统危险因素越少，卒中与PFO的关系越密切Risk of P,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,12,再发脑卒中的预防PFO封堵 vs 药物治疗，PFO封堵预防再,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 TIA,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).,percutaneous closure of the PFO with the STARFlex device,909 patients were enrolled,2 years of follow-up,N Engl J Med 2012;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,13,CLOSURE I 研究Closure with a dev,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%,。,14,RESPECT研究RESPECT研究14,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 patients,2 devices(STARFlex)and Amplatzer PFO Occluder evaluated in 3 trial,s,The 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,15,Device Closure of PFO After St,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 CS,No 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-years,Investigated devices were Amplatzer(AMP),STARFlex(STF),and HELEX(HLX).,European Heart Journal(2015)36,120128,16,Percutaneous closure of PFO in,长期疗效对比：,PFO,封堵,vs,药物治疗,PFOclosurewas more effective than medical treatment for the secondary prevention,PFO 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,17,长期疗效对比：PFO封堵vs药物治疗 PFOclosure,RESPECT,研究,最终结果,Data from August 2003-May 2016,Mean Follow-up:5.9 years(0-12 years),Device,Mean 6.3 years;Total 3141 patient-years,Medical Management,Mean 5.5 years;Total 2669 patient-years,PFO closure with the AMPLATZER,TM,PFO Occluder,was more beneficial than medical management alone,18,RESPECT研究最终结果Data from August,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 1399-1404,19,PFO形态与不明原因卒中的关系PFO diameter19,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,）,20,高危PFO:心脏杂志 2015,27（4）20,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