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ESC2018丨PFO封堵:复发性卒中风险降低的介入方法

2018-09-01 国际循环编辑部 国际循环

2018年欧洲心脏病学学会大会上,英国伦敦帝国理工学院哈默史密斯医院Iqbal Malik博士发表卵圆孔未闭(PFO)封堵可降低卒中复发风险的精彩报告,并指出ESC成员国每年大约有150万次卒中发病,美国每年有80万次卒中发病,其中,近1/3是隐源性卒中。

2018年欧洲心脏病学学会大会上,英国伦敦帝国理工学院哈默史密斯医院Iqbal Malik博士发表卵圆孔未闭(PFO)封堵可降低卒中复发风险的精彩报告,并指出ESC成员国每年大约有150万次卒中发病,美国每年有80万次卒中发病,其中,近1/3是隐源性卒中。

隐源性卒中患者中PFO高达40%,而健康人群中的患病率约为20%~25%。关于这是否存在因果因素,历史上一直存在争议。“很难证明因果关系,然而,PFO与隐源性卒中存在巨大的关联”,Iqbal Malik博士说,“现在有三项主要试验的证据表明,PFO封堵确实可降低卒中复发风险,并且可应用于特定患者”。

自20世纪90年代以来,通过基于导管的方法进行经皮PFO封堵以降低卒中复发风险。然而,既往发表的随机对照试验并未证明器械封堵优于药物治疗。“尽管如此,CLOSE and REDUCE两项进一步试验的数据更新了RESPECT试验的长期结果,”Malik博士解释说,“我们确实有PFO封堵带来获益的证据。”近期,在EHJ杂志上发表的分析,其中Malik博士是共同作者,包括这些最新的试验数据。它证实,在特定的隐源性卒中患者的卒中预防中,PFO封堵优于药物治疗,特别是对中度以上分流的患者。

哪些患者最适合这种干预?Malik博士强调,选择合适的患者至关重要,这种治疗并不适用于每位患者,试验中的患者已证实卒中,大多数患者分流较高。因此,需进行MRI扫描以确诊卒中,以及使用气泡造影超声心动图或经颅多普勒评估分流大小。适合PFO封堵的患者往往更年轻,没有糖尿病高血压,并且不吸烟。对确实有其他血管危险因素的患者应该接受药物治疗,例如,有良好的证据表明,在患有颈动脉粥样硬化疾病,服用降压药物的高血压患者和心房颤动服抗凝药物的患者中,需服用抗血小板药物治疗。老年患者(例如,年龄超过60岁)应接受药物治疗,然而,重要的是,要考虑生理年龄和个人健康,而不仅仅是实际年龄。

Malik博士指出,PFO封堵是一种侵入性手术,存在相关风险,干预时出现严重并发症的概率为1%,如卒中,心肌梗死和内出血。因此,必须事先仔细评估房间隔的解剖结构,以尽量减少与手术相关的风险。正如他解释的那样,“经食管超声心动图将有助于验证是否存在心房间隔瘤,并确认存在心脏分流而不是肺分流。”在手术过程中,Malik博士使用球囊穿过PFO以便更准确地评估差距,他说“并非所有的心脏病专家都使用球囊,但我认为这是获取PFO大小和路径形状信息的最佳方式,然后,再选择用于封堵的设备”。

已发布的试验显示,手术相关事件,CLOSURE-1试验最高(5.9%),该试验使用了已被撤回的StarFlex器械。目前,可用的器械与短期心房颤动、心悸等相关,但这通常会在几周内得到解决,并且尽管心房颤动发生,但已证实卒中减少。

在评估PFO封堵与药物治疗时,Malik博士强调平衡利益与风险的重要性。通过进行PFO封堵,可将患者的卒中复发风险从1%降低至0.5%,虽相对风险降低50%,但实际数字很小。因大多数卒中患者没有明显原因,他们希望尽一切可能减少卒中复发机会。现有技术和证据表明,PFO封堵是有效的,2年后,手术本身的1%风险已被抵消,患者可得净收益。

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  2. [GetPortalCommentsPageByObjectIdResponse(id=1909732, encodeId=d6d71909e3233, content=<a href='/topic/show?id=8f1f42518d8' target=_blank style='color:#2F92EE;'>#复发性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=86, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42518, encryptionId=8f1f42518d8, topicName=复发性)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=hb2008ye, createdTime=Fri Jun 28 17:28:00 CST 2019, time=2019-06-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1924756, encodeId=c9071924e562f, content=<a href='/topic/show?id=f9dc1412453' target=_blank style='color:#2F92EE;'>#PFO#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=14124, encryptionId=f9dc1412453, topicName=PFO)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=726030, createdName=Boyinsh, createdTime=Mon Sep 24 12:28:00 CST 2018, time=2018-09-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1785794, encodeId=b4841e8579460, content=<a href='/topic/show?id=1cb16995e7' target=_blank style='color:#2F92EE;'>#ESC2018#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=6995, encryptionId=1cb16995e7, topicName=ESC2018)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f4c124, createdName=neurowu, createdTime=Fri Mar 29 20:28:00 CST 2019, time=2019-03-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1820672, encodeId=41ad18206e2b2, content=<a href='/topic/show?id=0c6a1009105e' target=_blank style='color:#2F92EE;'>#风险降低#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=100910, encryptionId=0c6a1009105e, topicName=风险降低)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=fd18451, createdName=xre2008, createdTime=Fri Aug 02 10:28:00 CST 2019, time=2019-08-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1281288, encodeId=dfa41281288f2, content=<a href='/topic/show?id=455f36085f0' target=_blank style='color:#2F92EE;'>#卒中风险#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=36085, encryptionId=455f36085f0, topicName=卒中风险)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=仁心济世, createdTime=Mon Sep 03 11:28:00 CST 2018, time=2018-09-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1026139, encodeId=b5f21026139bf, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Sat Sep 01 23:28:00 CST 2018, time=2018-09-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1045804, encodeId=e55b10458049d, content=中风是俗称,应该称为缺血性卒中吧, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=guging, createdTime=Sat Sep 01 23:28:00 CST 2018, time=2018-09-01, status=1, ipAttribution=)]
    2018-09-24 Boyinsh
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    2019-03-29 neurowu
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    2018-09-01 健健

    卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!

    0

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    2018-09-01 guging

    中风是俗称,应该称为缺血性卒中吧

    0

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