卵圆孔未闭治疗的证据_Taub英文.ppt

Patent Foramen Ovale: an evidence based approach Cynthia Taub, M.D., F.A.C.C., F.A.S.E. Director, Non-invasive Cardiology Montefiore Medical Center (East Campus) Albert Einstein College of Medicine Patent Foramen Ovale An anatomical variant of the interatrial septum Prevalence: 27% in general (autopsy 965 normal heart) 35% in young ( 30 yo) 20% in old ( 80 yo) Diagnostic tests: TTE or TEE Subsequent Clinical Trials Northern Manhattan Stroke Study Retrospective, 95 pt first ischemic stroke had TEE. PFO present in 45% cryptogenic stroke vs. 23% pt with known cause of stroke (p=0.02) Steiner et al. Stroke 1998; 29:944-948 Mayo Clinic (SPARC Study) Determine the association of PFO, ASA and stroke prospectively in a unselected population sample Prospective 585 pt, unselected, 45 yo TEE 24% PFO present 5 yr f/u PFO was not significantly associated with stroke The role of ASA is unclear PICSS: prospective, 630 pt (265 with cryptogenic stroke, 365 with known stroke origin). In this study, PFO is associated with cryptogenic stroke At 2 yr f/u, on medical therapy, no difference in recurrent stroke or death based on PFO status. Homma et al Circulation 2002;105:2625-2631 Meta-analysis of PICSS and French PFO study: 1211 pt (846 cryptogenic and 365 known cause stroke pts) the relative risk of recurrent stroke or death in pt with PFO 0.96 Messe et al Neurology 2004;62:1042-1050 Approaches to PFO and stroke Medical therapy Antiplatelet therapy Anticoagulation therapy Percutaneous device therapy Surgical closure Do nothing Meta-analysis 2250 pt: 1355 pt PFO closure; 895 medical therapy after cryptogenic stroke PFO device complications: Major 1.5% (death, bleeding need transfusion, tamponade, surgery, massive PE) Minor 7.9% (atrial arrythmia, device fx, embol with retrieval) One year recurrent stroke: PFO closure: 0%-4.9% Medical therapy: 3.8%-12% Limitations of These Trials Patient and physician bias for trial enrollment Their strong feelings about effectivenes