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Persistierendes Foramen ovale – Intervention oder Arzneitherapie

Patent foramen ovale—intervention or pharmaceutical treatment

  • Arzneimitteltherapie
  • Published:
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Zusammenfassung

Hintergrund

Bei 40–50 % der Patienten mit kryptogenem Schlaganfall wird ein persistierendes Foramen ovale (PFO) diagnostiziert. Das zusätzliche Vorliegen eines Vorhofseptumaneurysmas potenziert das Risiko eines erneuten Schlaganfalls.

Ziel

Die wichtigsten Änderungen in der Evidenz zum interventionellen Verschluss des PFO bei Patienten mit kryptogenem Schlaganfall werden beschrieben. Dies schließt die Vorgaben für die Diagnosestellung und die Indikation zum interventionellen Verschluss ein. Weiterhin wird ein Überblick über die antithrombozytäre Therapie mit und ohne orale Antikoagulation gegeben.

Datenlage

Der Nutzen und das Risiko der interventionellen und der medikamentösen Behandlung waren bisher nicht ausreichend belegt. Im Jahr 2017 wurden zwei prospektive, randomisierte Studien (CLOSE und REDUCE) und die Langzeitergebnisse der RESPECT-Studie veröffentlicht, 2018 folgten die Ergebnisse von DEFENSE-PFO. Nun lässt sich die Abwägung der Therapieoptionen besser beurteilen. Alle vier Studien zeigen, dass der interventionelle Verschluss des PFO einer alleinigen medikamentösen Therapie bei Patienten mit kryptogenem Schlaganfall im Alter unter 60 Jahren überlegen ist.

Schlussfolgerung

Es zeigt sich eine signifikante Reduktion in der Inzidenz von erneuten Schlaganfällen bei Patienten mit interventionellem PFO-Verschluss im Vergleich zur medikamentösen Therapie. Die Komplikationsrate des PFO-Verschlusses ist sehr niedrig. Insbesondere jüngere Patienten (<60 Jahre) profitieren von einem PFO-Verschluss.

Abstract

Background

Approximately 40–50% of patients with cryptogenic stroke have a patent foramen ovale (PFO). A concomitant atrial septal aneurysm aggravates the risk of recurrent stroke.

Objective

The most important changes regarding the evidence for interventional closure of a PFO in patients with cryptogenic stroke are described. This includes the prerequisites for making a diagnosis and the indications for interventional treatment. The article also provides an overview about platelet aggregation inhibitor treatment with and without oral anticoagulation.

Current data

The balance between benefits and risks of interventional versus pharmaceutical treatment in patients with cryptogenic stroke and PFO has so far not been sufficiently proven. In 2017 two prospective randomized trials (CLOSE and REDUCE) and the long-term follow-up results of the RESPECT study were published, followed by the results of the DEFENSE-PFO study in 2018. A better assessment of the weighing up of the treatment options can now be made. All four studies showed that the interventional treatment of PFO is superior to pharmaceutical treatment alone for patients with cryptogenic stroke under 60 years of age.

Conclusion

There was a significant reduction in the incidence of recurrent stroke in patients with interventional PFO closure compared with pharmaceutical treatment. The complication rate of PFO closure is very low and younger patients (<60 years) in particular benefit from PFO closure

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Authors and Affiliations

  1. Abteilung Kardiologie, Kerckhoff Herz und Thorax Zentrum, Benekestr. 2–8, 61231, Bad Nauheim, Deutschland

    C. Liebetrau & C. W. Hamm

  2. Medizinische Klinik I, Abteilung Kardiologie/Angiologie, Universitätsklinikum Gießen, Gießen, Deutschland

    C. Liebetrau & C. W. Hamm

  3. Standort RheinMain, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Frankfurt am Main, Deutschland

    C. Liebetrau

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Correspondence to C. Liebetrau.

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C. Liebetrau und C.W. Hamm geben an, dass kein Interessenkonflikt besteht.

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

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Liebetrau, C., Hamm, C.W. Persistierendes Foramen ovale – Intervention oder Arzneitherapie. Internist 59, 981–992 (2018). https://doi.org/10.1007/s00108-018-0459-5

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  • DOI: https://doi.org/10.1007/s00108-018-0459-5

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