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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46 http://www.amplatzer.com/physicians/pfo/pctrial/.
Prof. Dr. med. Heinrich P. Mattle
Neurologische Universitätsklinik · Inselspital
Freiburgstraße 4
3010 Bern · Schweiz
Email: Heinrich.Mattle@insel.ch