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Permeables Foramen ovale (PFO) als Todesursache

  • B. MeierEmail author
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Zusammenfassung

Etwa ein Viertel der Bevölkerung hat ein permeables (aufklappbares) Foramen ovale (PFO). Bei ungefähr jedem 20. ist das PFO häufig geöffnet, weil es entweder mit einem Vorhofseptumaneurysma oder einer Eustachi-Klappe beziehungsweise einem Chiari-Netzwerk vergesellschaftet oder einfach groß ist. Vor 140 Jahren hat der Deutsche Cohnheim zum ersten Mal darauf hingewiesen, dass das ein PFO paradoxe Embolien ermöglicht und dadurch Hirnschläge auftreten können. Ein signifikant erhöhtes Sterberisiko durch das PFO wurde in einer Vergleichsstudie gezeigt und kann erklären, dass die Prävalenz des PFO mit dem Alter abnimmt. Mittels randomisierter Studien wurde bewiesen, dass zerebrale Rezidivereignisse signifikant reduziert werden durch den im Jahr 1992 erstmals beschriebenen Schirmverschluss des PFO. Dieser Eingriff ist der sicherste und einfachste in der modernen Kardiologie und er erzielt wohl die beste Nettobilanz (Ereignisverhinderung minus Komplikationen). Er rettet Leben nicht nur durch Verhinderung von Hirnschlägen, sondern auch durch Verhinderung von Herzinfarkten. Man spricht von einer mechanischen Impfung. Zusätzlich verbessert der PFO-Verschluss Migränesymptome und zyanotische Dyspnoe in gewissen Patienten. Selbst der primärpräventive PFO-Verschluss muss ein Thema werden für Richtlinien und Krankenversicherer. Es ist viel wahrscheinlicher, dass man bereut, ein bekanntes PFO nicht verschlossen zu haben, als dass man bereut, es verschlossen zu haben.

Schlüsselwörter

Perkutaner Schirmverschluss Hirnschlag Transiente ischämische Attacke Herzinfarkt Mortalität 

Patent foramen ovale with a license to kill

Abstract

A patent foramen ovale (PFO) is present in about one of four, and one of its dangerous forms (large or associated with atrial septal aneurysm, Eustachian valve, or Chiari network) in one of twenty people. About 140 years ago, the PFO was shown to have the potential to result in death due to stroke and also myocardial infarction. The described decrease of the prevalence of a PFO with age may be a consequence of this. Therefore, it comes somewhat as a surprise that the PFO is taken rather lightly by the medical community. Percutaneous PFO closure with implantable devices has been around for over two decades and since then has proven to be the simplest and safest technique in interventional cardiology. Nonetheless, it is rarely applied and not recommended in current guidelines except for a few situations. Countless nonrandomised comparisons have invariably pointed to a clinical benefit of PFO closure in the secondary prevention of paradoxical cerebral events in patients with or without competitive reasons for stroke. Even a survival benefit of PFO closure was shown in a comparison over 10 years. However, the first three publications of randomised trials were not significant in the protocolled sense. PFO closure did reduce recurrent events compared to medical therapy by up to 80% but the statistical significance postulated was only reached in one of the three trials when the results were analyzed as treated or per predefined subgroups, like patients with atrial septal aneurysm, large PFO, or all PFO closure patients compared to treatment with acetylsalicylic acid only. Recently, a preplanned longer-term analysis of this trial and two additional randomised trials including higher risk PFOs reached the hypothesised statistical significance. This may be a turning point in the attitude towards PFO closure. In addition, PFO closure improves migraine and dyspnoea in certain patients. It appears, though, that it will take time until the full potential of PFO closure will be reflected in respective guidelines and reimbursement algorithms and adequately exploited by referring physicians (mostly neurologists) and interventional cardiologists. This reluctance will continue to cost innumerable preventable strokes, myocardial infarctions, and deaths around the world. The low risk of PFO closure must be weighed against even death if a PFO is left open; it is much more likely that one regrets not having closed a PFO than having closed it.

Keywords

Percutaneous device closure Stroke Transient ischemic attack Myocardial infarction Mortality 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

B. Meier erhielt Vortragshonorare von Abbott und Lepu.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Supplementary material

Video 1 zeigt die dreidimensionale echokardiographische Darstellung eines großen Thrombus, dessen obere Hälfte durch das PFO hindurch in den linken Vorhof ragt.

Literatur

  1. 1.
    Abecasis J, Ribeiras R, Gabriel H et al (2014) Thrombus entrapment: the clue for coronary embolism. Eur Heart J 35:2971CrossRefGoogle Scholar
  2. 2.
    Agarwal S, Bajaj NS, Kumbhani DJ et al (2012) Meta-analysis of transcatheter closure versus medical therapy for patent foramen ovale in prevention of recurrent neurological events after presumed paradoxical embolism. JACC Cardiovasc Interv 5:777–789CrossRefGoogle Scholar
  3. 3.
    Bridges ND, Hellenbrand W, Latson L et al (1992) Transcatheter closure of patent foramen ovale after presumed paradoxical embolism. Circulation 86:1902–1908CrossRefGoogle Scholar
  4. 4.
    Carroll JD, Saver JL (2013) Patent foramen ovale and cryptogenic stroke. N Engl J Med 369:91–92PubMedGoogle Scholar
  5. 5.
    Carroll JD, Saver JL, Thaler DE et al (2013) Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 368:1092–1100CrossRefGoogle Scholar
  6. 6.
    Cheng TO (1999) Platypnea-orthodeoxia syndrome: etiology, differential diagnosis, and management. Catheter Cardiovasc Interv 47:64–66CrossRefGoogle Scholar
  7. 7.
    Cohnheim J (1877) Thrombose und Embolie: Vorlesung über allgemeine Pathologie. Ein Handbuch für Ärzte und Studierende. Hirschwald, Berlin, S 134Google Scholar
  8. 8.
    Devendra GP, Rane AA, Krasuski RA (2012) Provoked exercise desaturation in patent foramen ovale & impact of percutaneous closure. JACC Cardiovasc Interv 5:416–419CrossRefGoogle Scholar
  9. 9.
    Furlan AJ, Reisman M, Massaro J et al (2012) Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 366:991–999CrossRefGoogle Scholar
  10. 10.
    Hagen PT, Scholz DG, Edwards WD (1984) Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 59:17–20CrossRefGoogle Scholar
  11. 11.
    Jarral OA, Saso S, Vecht JA et al (2011) Does patent foramen ovale closure have an anti-arrhythmic effect? A meta-analysis. Int J Cardiol 153:4–9CrossRefGoogle Scholar
  12. 12.
    King T, Mills N (1974) Nonoperative closure of atrial septal defects. Surgery 75:383–388PubMedGoogle Scholar
  13. 13.
    Knauth M, Ries S, Pohimann S et al (1997) Cohort study of multiple brain lesions in sport divers: role of a patent foramen ovale. BMJ 314:701–705CrossRefGoogle Scholar
  14. 14.
    Konstantinides S, Geibel A, Kasper W et al (1998) Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation 97:1946–1951CrossRefGoogle Scholar
  15. 15.
    Lowe G (2007) Is venous thrombosis a risk factor for aterial thrombosis? Lancet 370:1742–1744CrossRefGoogle Scholar
  16. 16.
    Mas JL, Derumeaux G, Guillon B et al (2017) Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med 377:1011–1021CrossRefGoogle Scholar
  17. 17.
    Mattle HP, Evers S, Hildick-Smith D et al (2016) Percutaneous closure of patent foramen ovale in migraine with aura, a randomized controlled trial. Eur Heart J 37:2029–2036CrossRefGoogle Scholar
  18. 18.
    Meier B (2008) Closure of the patent foramen ovale with dedicated Amplatzer occluders: closing in on a mechanical vaccination. Catheter Cardiovasc Interv 72:80–81CrossRefGoogle Scholar
  19. 19.
    Meier B, Kalesan B, Mattle HP et al (2013) Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 368:1083–1091CrossRefGoogle Scholar
  20. 20.
    Meier B (2014) Patent foramen ovale and closure technique with the Amplatzer occluder. Scientifica (Cairo) 2014:129196Google Scholar
  21. 21.
    Pavoni D, Zanuttini D, Spedicato L et al (2012) Large interatrial thrombus-in-transit resulting in acute myocardial infarction complicated by atrioventricular block and cardiogenic shock. J Am Coll Cardiol 59:1329CrossRefGoogle Scholar
  22. 22.
    Pickett C, Villines T, Ferguson M et al (2014) Cost effectiveness of percutaneous closure versus medical therapy for cryptogenic stroke in patients with a patent foramen ovale. Am J Cardiol 114:1584–1589CrossRefGoogle Scholar
  23. 23.
    Pilgrim T, Meier B, Khattab A (2013) Death by patent foramen ovale in a soccer player. J Invasive Cardiol 25:162–164PubMedGoogle Scholar
  24. 24.
    Saver JL, Carroll JD, Thaler DE et al (2017) Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med 377:1022–1032CrossRefGoogle Scholar
  25. 25.
    Schwerzmann M, Seiler C, Lipp E et al (2001) Relation between directly detected patent foramen ovale and ischemic brain lesions in sport divers. Ann Intern Med 134:21–24CrossRefGoogle Scholar
  26. 26.
    Shanoudy H, Soliman A, Raggi P et al (1998) Prevalence of patent foramen ovale and its contribution to hypoxemia in patients with obstructive sleep apnea. Chest 113:91–96CrossRefGoogle Scholar
  27. 27.
    Sondergaard L, Kasner SE, Rhodes JF et al (2017) Patent foramen cvale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 377:1033–1042CrossRefGoogle Scholar
  28. 28.
    Sørensen HT, Horvath-Puho E, Pedersen L et al (2007) Venous thromboembolism and subsequent hospitalisation due to acute arterial cardiovascular events: a 20-year cohort study. Lancet 370:1773–1779CrossRefGoogle Scholar
  29. 29.
    Tanzi A, Onorato O, Casilli F et al (2016) Is the search for right-to-left shunt still worthwhile? Acta Neurol Scand 133:281–288CrossRefGoogle Scholar
  30. 30.
    Tobis JM, Charles A, Silberstein SD et al (2017) Percutaneous closure of patent foramen ovale in patients with migraine: the PREMIUM trial. J Am Coll Cardiol 70:2766–2774CrossRefGoogle Scholar
  31. 31.
    Wahl A, Jüni P, Mono ML et al (2012) Long-term propensity score-matched comparison of percutaneous closure of patent foramen ovale with medical treatment after paradoxical embolism. Circulation 125:803–812CrossRefGoogle Scholar
  32. 32.
    Wahl A, Praz F, Tai T et al (2010) Improvement of migraine headaches after percutaneous closure of patent foramen ovale for secondary prevention of paradoxical embolism. Heart 96:967–973CrossRefGoogle Scholar
  33. 33.
    Wilmshurst PT, Nightingale S, Walsh KP et al (2000) Effect on migraine of closure of cardiac right-to-left shunts to prevent recurrence of decompression illness or stroke or for haemodynamic reasons. Lancet 356:1648–1651CrossRefGoogle Scholar

Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2019

Authors and Affiliations

  1. 1.Universitätsklinik für Kardiologie, Departement Herz und GefässeInselspitalBernSchweiz

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