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Aktuelle Neurologie 2003; 30(3): 107-113
DOI: 10.1055/s-2003-38267
Übersicht
© Georg Thieme Verlag Stuttgart · New York

Das offene Foramen ovale: Epidemiologie klinischer Manifestationen und Prävention

Patent Foramen Ovale: Epidemiology and Prevention of Clinical ManifestationsK.  Nedeltchev1 , M.  Arnold1 , S.  Windecker2 , M.  Schwerzmann2 , B.  Meier2 , H.  P.  Mattle1
  • 1Neurologische Universitätsklinik und Poliklinik, Inselspital, Bern, Schweiz
  • 2Schweizerisches Herz- und Gefäßzentrum Bern, Inselspital, Universität Bern, Schweiz
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Publication History

Publication Date:
27 March 2003 (online)

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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.

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Prof. Dr. med. Heinrich P. Mattle

Neurologische Universitätsklinik · Inselspital

Freiburgstraße 4

3010 Bern · Schweiz

Email: Heinrich.Mattle@insel.ch

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