Persistierendes Foramen ovale – aktuelles Vorgehen

Zusammenfassung

Das persistierende Foramen ovale (PFO) kann bei 25 – 30% der Bevölkerung nachgewiesen werden. Über ein PFO kann es zu einer paradoxen Embolie und zum Schlaganfall kommen. Nach neueren Studien scheint der PFO-Verschluss bei Patienten mit kryptogenem Schlaganfall embolisch-ischämische Rezidive effektiver vermeiden zu können als eine medikamentöse Therapie.

Abstract

A patent foramen ovale (PFO) can be found in 25 to 30 percent of individuals in transesophageal echocardiography. Most patients with isolated PFO are asymptomatic and no specific therapy is needed. However, if paradoxical embolism occurs via a PFO the most common clinical manifestation is cryptogenic stroke. In younger patients with ischemic stroke a PFO is more prevalent than in the general population. Double-disc-devices with a left and a right atrial disc, connected by a short waist are the most common used interventional PFO occluder devices to prevent secondary ischemic stroke. CLOSURE I, PC and RESPECT published in 2012 and 2013 showed no significant advantage of interventional PFO occlusion compared to medical therapy. However, the latest trials, presented in 2017 (REDUCE, CLOSE und RESPECT extended follow up) could demonstrate a significant benefit for occluder implantation in selected PFO patients. Interventional PFO occlusion with modern devices is a safe and efficient procedure for secondary ischemic stroke prevention in selected patients. Future focus needs to be placed on identification and structured evaluation of patients with symptomatic PFO, who will benefit from a PFO occluder implantation more than from medical therapy alone.

Schlüsselwörter

persistierendes Foramen ovale - PFO - Okkluder - paradoxe Embolie - kryptogener Schlaganfall

Key words

patent foramen ovale, PFO, occluder, paradoxical embolism, cryptogenic stroke

• Literatur

• 1 Porstmann W, Wierny L, Warnke H. Der Verschluß des Ductus arteriosus persistens ohne Thoracotomie. Thoraxchirurgie 1967; 15: 199-203
• 2 King TD, Mills NL. Nonoperative closure of atrial septal defects. Surgery 1974; 75: 383-388
• 3 Rashkind WJ, Cuaso CE. Transcatheter closure of atrial septal defects in children. Eur J Cardiol 1977; 8: 119-120
• 4 Schünke M, Schulte E, Schumacher U et al. Septierung des Herzens (Septum atriale, interventriculare und aorticopulmonale). In: Schünke M, Schulte E, Schumacher U et al., Hrsg. Prometheus LernAtlas – Innere Organe. 2., überarbeitete und erweiterte Auflage. 2009
• 5 Schünke M, Schulte E, Schumacher U. et al. Septierung des Herzens (Septum atriale, interventriculare und aorticopulmonale). In: Schünke M, Schulte E, Schumacher U et al., Hrsg. Prometheus LernAtlas – Innere Organe. 2., überarbeitete und erweiterte Auflage. Stuttgart: Thieme; 2009
• 6 Dowson A, Mullen MJ, Peatfield R. et al. Migraine Intervention With STARFlex Technology (MIST) trial: a prospective, multicenter, double-blind, sham-controlled trial to evaluate the effectiveness of patent foramen ovale closure with STARFlex septal repair implant to resolve refractory migraine headache. Circulation 2008; 117: 1397-1404
• 7 Lamy C, Giannesini C, Zuber M. et al. Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale: the PFO-ASA Study. Atrial Septal Aneurysm. Stroke 2002; 33: 706-711
• 8 Köster R, Hamm C. Angeborene Herz- und Gefäßfehlbildungen. In: Arastéh K, Baenkler H, Bieber C et al., Hrsg. Duale Reihe Innere Medizin. 3. Auflage. Stuttgart: Thieme; 2012
• 9 Di Tullio MR, Sacco RL, Sciacca RR. et al. Patent foramen ovale and the risk of ischemic stroke in a multiethnic population. J Am Coll Cardiol 2007; 49: 797-802
• 10 Homma S, Sacco RL, Di Tullio MR. et al. Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. Circulation 2002; 105: 2625-2631
• 11 Furlan AJ, Reisman M, Massaro J. et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012; 366: 991-999
• 12 Kernan WN, Ovbiagele B, Black HR. et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45: 2160-2236
• 13 Messé SR, Gronseth G, Kent DM. et al. Practice advisory: Recurrent stroke with patent foramen ovale (update of practice parameter): Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2016; 87: 815-821
• 14 Mas JL, Derumeaux G, Guillon B. et al. Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke. N Engl J Med 2017; 377: 1011-1021
• 15 Carroll JD, Saver JL, Thaler DE. et al. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 2013; 368: 1092-1100
• 16 Saver JL, Carroll JD, Thaler DE. et al. Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke. N Engl J Med 2017; 377: 1022-1032
• 17 Søndergaard L, Kasner SE, Rhodes JF. et al. Patent Foramen Ovale Closure or Antiplatelet Therapy for Cryptogenic Stroke. N Engl J Med 2017; 377: 1033-1042
• 18 Shah R, Nayyar M, Jovin IS. et al. Device Closure Versus Medical Therapy Alone for Patent Foramen Ovale in Patients With Cryptogenic Stroke: A Systematic Review and Meta-analysis. Ann Intern Med 2018; 168: 335-342
• 19 De Rosa S, Sievert H, Sabatino J. et al. Percutaneous Closure Versus Medical Treatment in Stroke Patients With Patent Foramen Ovale: A Systematic Review and Meta-analysis. Ann Intern Med 2018; 168: 343-350
• 20 Amin Z, Hijazi ZM, Bass JL. et al. Erosion of Amplatzer septal occluder device after closure of secundum atrial septal defects: Review of registry of complications and recommendations to minimize future risk. Catheter Cardiovasc Interv 2004; 63: 496-502
• 21 Teoh K, Wilton E, Brecker S. et al. Simultaneous removal of an Amplatzer device from an atrial septal defect and the descending aorta. J Thorac Cardiovasc Surg 2006; 131: 909-910
• 22 Cecconi M, Quarti A, Bianchini F. et al. Late cardiac perforation after transcatheter closure of patent foramen ovale. Ann Thorac Surg 2006; 81: 29-30
• 23 DeSimone CV, Friedman PA, Noheria A. et al. Stroke or transient ischemic attack in patients with transvenous pacemaker or defibrillator and echocardiographically detected patent foramen ovale. Circulation 2013; 128: 1433-1441
• 24 Krasuski RA, Hart SA, Allen D. et al. Prevalence and repair of intraoperatively diagnosed patent foramen ovale and association with perioperative outcomes and long-term survival. JAMA 2009; 302: 290-297