Das offene Foramen ovale: Epidemiologie klinischer Manifestationen und Prävention

Zusammenfassung

Mehrere Fall-Kontroll-Studien fanden ein gehäuftes Auftreten des offenen Foramen ovale (PFO) bei Patienten mit kryptogenem Hirninfarkt. Die neurologische Dekompressionskrankheit bei Tauchern, das seltene Platypnoe-Orthodeoxie-Syndrom und die refraktäre Hypoxämie nach Rechtsherzinfarkt oder schwerer Lungenerkrankung können ebenfalls im Zusammenhang mit einem PFO auftreten. Neu wird auch eine Assoziation zwischen PFO und Migräne mit Aura diskutiert. Aufgrund der bestehenden Diskrepanz zwischen der hohen Prävalenz des PFO in der Bevölkerung und der relativ niedrigen Inzidenz jeder einzelnen klinischen Entität sind bis heute weder die pathophysiologischen Mechanismen noch die therapeutischen Strategien eindeutig geklärt. Bei der Sekundärprävention paradoxer Embolien werden Thrombozytenaggregationshemmer, Vitamin-K-Antagonisten oder der kathetergestützte Verschluss des PFO eingesetzt. Die Frage, ob man die katheterinterventionelle Behandlung allen oder nur selektionierten Patienten empfehlen soll, muss noch durch randomisierte Studien mit Risikostratifizierung beantwortet werden. Auch innerhalb der medikamentösen Sekundärprävention ist es nicht klar, ob die orale Antikoagulation der Therapie mit Azetylsalizylsäure (ASS) überlegen ist. Die Indikation zum interventionellen Verschluss des PFO ist im Falle rezidivierender paradoxer Embolien (v. a. bei Vorliegen eines Vorhofseptumaneurysmas) oder eines Platypnoe-Orthodeoxie-Syndroms grundsätzlich gegeben. Diese Behandlung sollte auch bei schwerer Dekompressionskrankheit erwogen werden. Ob man den Rechts-links-Shunt bei Migräne mit Aura behandeln sollte, muss in prospektiven Studien geklärt werden.

Abstract

Several case-control series demonstrated a higher prevalence of patent foramen ovale (PFO) among patients with cryptogenic strokes than in the general population. The refractory hypoxemia following right-sided myocardial infarction or severe lung disease, the rare platypnea-orthodeoxia syndrome, and the neurological decompression sickness in divers could also be attributed to patency of the foramen ovale. Recently, an association between migraine with aura and PFO has been reported. Despite the high prevalence of PFO among the general population, the incidence of its clinical manifestations is relatively low. Hence neither the pathophysiological mechanisms nor the therapeutic strategies have been clearly defined yet. At present, a transcatheter closure of the patent foramen ovale represents a promising alternative to lifelong antithrombotic treatment for secondary prevention of paradoxical embolism. The question whether this intervention should be offered to all patients with PFO or only to selected patients at high risk awaits the answer from randomized trials with risk stratification. Issues about medical treatment are not yet resolved either. Whether oral anticoagulation is more effective than acetylsalicylic acid for secondary prevention in patients with PFO and cryptogenic stroke is still a matter of debate. Interventional closure of PFO is generally accepted for treatment of recurrent paradoxical emboli, particularly in the face of an atrial septal aneurysm, and of the platypnea-orthodeoxia syndrome. This treatment should be considered also for patients with severe decompression sickness. Whether patients suffering from migraine with aura would benefit from closure of PFO has yet to be studied.

Literatur

• 1 Cohnheim J. Thrombose und Embolie. Vorlesung über allgemeine Pathologie. Berlin; Hirschwald 1877 1: 134
• 2 Strunk B L, Cheitlin M D, Stulbarg M S. et al . Right-to-left interatrial shunting through a patent foramen ovale despite normal intracardiac pressures.  Am J Cardiol. 1987;  60 413-415
• 3 Del Sette M, Angeli S, Leandri M. et al . Migraine with aura and right-to-left shunt on transcranial Doppler: a case-control study.  Cerebrovasc Dis. 1998;  8 327-330
• 4 Anzola G P, Magoni M, Guindani M. et al . Potential source of cerebral embolism in migraine with aura: a transcranial Doppler study.  Neurology. 1999;  52 1622-1625
• 5 Chen W J, Kuan P, Lien W P. et al . Detection of patent foramen ovale by contrast transesophageal echocardiography.  Chest. 1992;  101 1515-1520
• 6 Hausmann D, Mugge A, Becht I. et al . Diagnosis of patent foramen ovale by transesophageal echocardiography and association with cerebral and peripheral embolic events.  Am J Cardiol. 1992;  70 668-672
• 7 Belkin R N, Pollack B D, Ruggiero M L. et al . Comparison of transesophageal and transthoracic echocardiography with contrast and color flow Doppler in the detection of patent foramen ovale.  Am Heart J. 1994;  128 520-525
• 8 Sun J P, Stewart W J, Hanna J. et al . Diagnosis of patent foramen ovale by contrast versus color Doppler by transesophageal echocardiography: relation to atrial size.  Am Heart J. 1996;  131 239-244
• 9 Di Tullio M, Sacco R L, Venketasubramanian N. et al . Comparison of diagnostic techniques for the detection of a patent foramen ovale in stroke patients.  Stroke. 1993;  24 1020-1024
• 10 Job F P, Ringelstein E B, Grafen Y. et al . Comparison of transcranial contrast Doppler sonography and transesophageal contrast echocardiography for the detection of patent foramen ovale in young stroke patients.  Am J Cardiol. 1994;  74 381-384
• 11 Klotzsch C, Janssen G, Berlit P. Transesophageal echocardiography and contrast-TCD in the detection of a patent foramen ovale: experiences with 111 patients.  Neurology. 1994;  44 1603-1606
• 12 Zanette E M, Mancini G, De Castro S. et al . Patent foramen ovale and transcranial Doppler. Comparison of different procedures.  Stroke. 1996;  27 2251-2255
• 13 Webster M W, Chancellor A M, Smith H J. et al . Patent foramen ovale in young stroke patients.  Lancet. 1988;  2 11-12
• 14 Pearson A C, Labovitz A J, Tatineni S. et al . Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology.  J Am Coll Cardiol. 1991;  17 66-72
• 15 Hagen P T, Scholz D G, Edwards W D. Incidence and size of patent foramen ovale during the first ten decades of life: an autopsy study of 965 normal hearts.  Mayo Clin Proc. 1984;  59 17-20
• 16 Movsowitz C, Podolsky L A, Meyerowitz C B. et al . Patent foramen ovale: a nonfunctional embryological remnant or a potential cause of significant pathology?.  J Am Soc Echocardiogr. 1992;  5 259-270
• 17 Fisher D C, Fisher E A, Budd J H. et al . The incidence of patent foramen ovale in 1,000 consecutive patients. A contrast transesophageal echocardiography study.  Chest. 1995;  107 1504-1509
• 18 Arquizan C, Coste J, Touboul P J. et al . Is patent foramen ovale a family trait? A transcranial Doppler sonographic study.  Stroke. 2001;  32 1563-1566
• 19 Nellessen U, Daniel W G, Matheis G. et al . Impending paradoxical embolism from atrial thrombus: correct diagnosis by transesophageal echocardiography and prevention by surgery.  J Am Coll Cardiol. 1985;  5 1002-1004
• 20 Nelson C W, Snow F R, Barnett M. et al . Impending paradoxical embolism: echocardiographic diagnosis of an intracardiac thrombus crossing a patent foramen ovale.  Am Heart J. 1991;  122 859-862
• 21 Johnson B J. Paradoxical embolism.  J Clin Pathology. 1951;  4 316-332
• 22 Lethen H, Flachskampf F A, Schneider R. et al . Frequency of deep vein thrombosis in patients with patent foramen ovale and ischemic stroke or transient ischemic attack.  Am J Cardiol. 1997;  80 1066-1069
• 23 Overell J R, Bone I, Lees K R. Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies.  Neurology. 2000;  55 1172-1179
• 24 Cabanes L, Mas J L, Cohen A. et al . Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age. A study using transesophageal echocardiography.  Stroke. 1993;  24 1865-1873
• 25 Bogousslavsky J, Garazi S, Jeanrenaud X. et al . Stroke recurrence in patients with patent foramen ovale: the Lausanne Study. Lausanne Stroke with Paradoxal Embolism Study Group.  Neurology. 1996;  46 1301-1305
• 26 Mas J L, Zuber M. Recurrent cerebrovascular events in patients with patent foramen ovale, atrial septal aneurysm, or both and cryptogenic stroke or transient ischemic attack. French Study Group on Patent Foramen Ovale and Atrial Septal Aneurysm.  Am Heart J. 1995;  130 1083-1088
• 27 De Castro S, Cartoni D, Fiorelli M. et al . Morphological and functional characteristics of patent foramen ovale and their embolic implications.  Stroke. 2000;  31 2407-2413
• 28 Mas J L, Arquizan C, Lamy C. et al . Patent Foramen Ovale and Atrial Septal Aneurysm Study Group. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both.  N Engl J Med. 2001;  345 1740-1746
• 29 Nedeltchev K, Arnold M, Wahl A. et al . Outcome of patients with cryptogenic stroke and patent foramen ovale.  J Neurol Neurosurg Psychiatry. 2002;  72 347-350
• 30 Homma S, Sacco R L, Di Tullio M R. 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
• 31 Dearani J A, Ugurlu B S, Danielson G K. et al . Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic events.  Circulation. 1999;  100 (Suppl 19) II171-175
• 32 King T D, Mills N L. Nonoperative closure of atrial septal defects.  Surgery. 1974;  75 383-388
• 33 Bridges N D, Hellenbrand W, Latson L. et al . Transcatheter closure of patent foramen ovale after presumed paradoxical embolism.  Circulation. 1992;  86 1902-1908
• 34 Hung J, Landzberg M J, Jenkins K J. et al . Closure of patent foramen ovale for paradoxical emboli: intermediate-term risk of recurrent neurological events following transcatheter device placement.  J Am Coll Cardiol. 2000;  35 1311-1316
• 35 Windecker S, Wahl A, Chatterjee T. et al . Percutaneous closure of patent foramen ovale in patients with paradoxical embolism: long-term risk of recurrent thromboembolic events.  Circulation. 2000;  101 893-898
• 36 Wahl A, Meier B, Haxel B. et al . Prognosis after percutaneous closure of patent foramen ovale for paradoxical embolism.  Neurology. 2001;  57 1330-1332
• 37 Mattle H P, Nedeltchev K, Arnold M. et al . Medical versus endovascular secondary prevention of TIAs and stroke in patients with patent foramen ovale: a case controlled study.  Cerebrovasc Dis. 2001;  11 (Suppl 4) 42
• 38 Braun M U, Fassbender D, Schoen S P. et al . Transcatheter closure of patent foramen ovale in patients with cerebral ischemia.  J Am Coll Cardiol. 2002;  39 2019-2025
• 39 Wilmshurst P T, Byrne J C, Webb-Peploe M M. Relation between interatrial shunts and decompression sickness in divers.  Lancet. 1989;  2 1302-1306
• 40 Germonpre P, Dendale P, Unger P. et al . Patent foramen ovale and decompression sickness in sports divers.  J Appl Physiol. 1998;  84 1622-1626
• 41 Schwerzmann M, Seiler C, Lipp E. et al . Relation between directly detected patent foramen ovale and ischemic brain lesions in sport divers.  Ann Intern Med. 2001;  134 21-24
• 42 Bove A A. Risk of decompression sickness with patent foramen ovale.  Undersea Hyperb Med. 1998;  25 175-178
• 43 Wilmshurst P T, Nightingale S, Walsh K P. et al . Effect on migraine of closure of cardiac right-to-left shunts to prevent recurrence of decompression illness or stroke for haemodynamic reasons.  Lancet. 2000;  356 1648-1651
• 44 Sztajzel R, Genoud D, Roth S. et al . Patent foramen ovale, a possible cause of symptomatic migraine: a study of 74 patients with acute ischemic stroke.  Cerebrovasc Dis. 2002;  13 102-106
• 45 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
• 46 http://www.amplatzer.com/physicians/pfo/pctrial/.