Persistierendes Foramen ovale, Reinfarktrisiko und Sekundärprophylaxe

Zusammenfassung

In der aktuellen Schlaganfallbehandlung bestehen nach wie vor erhebliche Unsicherheiten bezüglich der adäquaten sekundärprophylaktischen Behandlung bei Patienten mit einem PFO nach ischämischem Hirninfarkt. Die kontrovers geführte Diskussion gewinnt durch die Möglichkeit des perkutanen PFO-Verschlusses mit stark wachsenden Interventionsraten in den letzten Jahren weiter an Bedeutung. Als diagnostisches Verfahren geringer Invasivität und zufrieden stellender Sensitivität und Spezifität wurde 1991 erstmals die indirekte Darstellung eines RLS über eine transkranielle dopplersonografische Embolidetektion nach periphervenöser Kontrastmittelgabe beschrieben. Aktuelle bevölkerungsbezoge Studien mittels transkranieller Dopplersonografie und multivariater Analyse konnten den in kleinen Fallkontrollstudien vielfach beschriebenen Zusammenhang zwischen PFO und Hirninfarkt nicht bestätigen, sodass sich die Frage stellt, ob sich diese Assoziation durch „Confounding” erklären lässt, da Alter und Geschlecht in vorherigen Studien mit einer positiven Assoziation zwischen PFO und Hirninfarkt nicht berücksichtigt worden sind. Unabhängig von der weiterhin kontroversen Diskussion bezüglich der Kausalität des Zusammenhangs zwischen PFO und Hirninfarkt existieren mittlerweile Ergebnisse großer multizentrischer Studien, welche belegen, dass das PFO keinen unabhängiger Risikofaktor für das erneute Auftreten eines Hirninfarkts darstellt. Es zeigte sich zudem kein Einfluss von Shuntgröße oder begleitendem Vorhofseptumaneurysma auf das erneute Auftreten zerebrovaskulärer Ereignisse. Damit gibt es nach aktueller Studienlage keine Evidenzgrundlage für eine generelle Antikoagulation bei Patienten mit PFO nach (kryptogenem) Schlaganfall. Spätestens nach den Ergebnissen der Closure-1-Studie ist ein interventioneller Verschluss zur generellen Rezidivprophylaxe bei Patienten mit einem PFO von neurologischer Seite aus als nicht indiziert abzulehnen.

Abstract

In current treatment of stroke there are still substantial uncertainties about the appropriate secondary prevention for patients with patent foramen ovale (PFO) after first-ever ischaemic stroke. The contentious issue takes on greater significance by the possibility of interventional PFO closure with sharply growing numbers of interventions in the last few years. In the year 1991 the first implicit evidence of a right-to-left shunt via transcranial detection of emboli after i.v. contrast agent administration (c-TCD) was described and can be considered as a slightly invasive diagnostic tool with sufficient sensitivity and specificity. Currently conducted studies by means of c-TCD and multivariate analysis were not able to verify a causal relationship between PFO and stroke, which was often described in some small, mainly case-control, studies, and brought up the question if this statistical relationship has mainly been brought about by confounding, as age and gender of PFO patients have been disregarded in early studies. Notwithstanding the above, results of multicentric studies show that PFO is not associated with recurrent stroke. Furthermore, neither shunt volume nor concomitant atrial septal aneurysm have a significant impact on the recurrence of stroke. Therefore, there is no sustainable evidence for oral anticoagulation in patients with PFO. Furthermore, an interventional PFO closure should be rejected since the results of the closure I study.

Schlüsselwörter

offenes Foramen Ovale (PFO) - Rechts-Links-Shunt - kontrastmittelgestützte transkranielle Dopplersonografie - kryptogener Schlaganfall - interventioneller PFO-Verschluss

Keywords

patent foramen ovale - right-to-left shunt - contrast-enhanced transcranial Doppler sonography - cryptogenic stroke - interventional PFO closure

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