Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland.
Kardiol Pol. 2012;70(12):1258-63.
Incidence of patent foramen ovale (PFO) has been estimated at 25% in the general population and 6% for larger defects. Data on the relationship between PFO morphology and the risk of stroke are limited. PFO closure has become a common practice in many centres, although recent guidelines limit indications for such treatment to patients with cryptogenic (recurrent) stroke.
To investigate whether PFO morphology assessed by transoesophageal echocardiography (TOE) differed between patients with symptoms and those who had an asymptomatic PFO.
We analysed 88 consecutive patients (48 female, 40 male; mean age 36.1 ± 16.2 [range 18-59] years) who underwent TOE before transcatheter PFO closure due to a cryptogenic cerebrovascular event (Group I) and compared them to 88 consecutive patients (49 female, 39 male; mean age 35.7 ± 14.2 [range 18-57] years) with an asymptomatic PFO found incidentally on TOE (Group II). The diagnosis of stroke was based on the occurrence of a new acute focal neurological deficit, with neurological signs and symptoms persisting for >24 h, subsequently confirmed by computed tomography and/or magnetic resonance imaging. Multiplane TOE was conducted as per guidelines using commercially available instruments. The interatrial septum was viewed in the transverse midoesophageal 4-chamber view and the longitudinal biatrial-bicaval view. PFO was diagnosed with intravenous injections of agitated saline while the patient was at rest and during the Valsalva manoeuvre. We analysed PFO size (resting and maximal separation of the septum primum and secundum during the Valsalva manoeuvre), tunnel length (maximal overlap of the septum primum and secundum), presence of an atrial septal aneurysm (excursion 〉 15 mm), shunt severity (mild: 3-5, moderate: 6-25, severe 〉 25 microbubbles) and prominence of the Eustachian valve.
The two groups did not differ with respect to age and sex distribution. Group I showed larger PFO size (maximal separation 3.9 ± 1.4 vs. 1.3 ± 1.3 mm, p 〈 0.0001), longer tunnel length (14 ± 6 vs. 12 ± 5.5 mm, p 〈 0.05) and a greater frequency of atrial septal aneurysm (55% vs. 15%, p 〈 0.0001) compared to Group II (controls). Group I was also characterised by a higher proportion of large PFOs (≤ 4 mm; 50% vs. 18%, p 〈 0.001) and severe shunt (40% vs. 2%, p 〈 0.0001).
PFO in symptomatic patients is larger in size, has a longer tunnel and is more frequently associated with atrial septal aneurysm. Asymptomatic patients with PFO characteristics similar to that seen in stroke patients require more careful clinical evaluation. It may be debated whether such patients should be recruited to prospective trials to evaluate indications for PFO closure in stroke prevention.
卵圆孔未闭（PFO）的发生率在普通人群中估计为 25%，而较大缺陷的发生率为 6%。关于 PFO 形态与中风风险之间关系的数据有限。PFO 封堵已成为许多中心的常见做法，尽管最近的指南将此类治疗的适应证限制为有隐源性（复发性）中风的患者。
研究经食管超声心动图（TOE）评估的 PFO 形态是否在有症状和无症状 PFO 的患者之间存在差异。
我们分析了 88 例连续因隐源性脑血管事件而行经导管 PFO 封堵的患者（I 组），这些患者在接受 TOE 检查前均有症状（48 例女性，40 例男性；平均年龄 36.1 ± 16.2 [范围 18-59] 岁），并与 88 例连续因偶然在 TOE 检查中发现无症状 PFO 的患者（II 组）进行比较（49 例女性，39 例男性；平均年龄 35.7 ± 14.2 [范围 18-57] 岁）。中风的诊断基于新发急性局灶性神经功能缺损，神经症状和体征持续＞24 小时，随后通过计算机断层扫描和/或磁共振成像证实。使用商业上可用的仪器按照指南进行多平面 TOE。在横向中隔 4 腔视图和纵向双房-双腔视图中观察房间隔。在患者休息和瓦尔萨尔瓦动作期间静脉注射搅动的盐水来诊断 PFO。我们分析了 PFO 大小（在瓦尔萨尔瓦动作期间房间隔 primum 和 secundum 的静息和最大分离）、隧道长度（房间隔 primum 和 secundum 的最大重叠）、是否存在房间隔瘤（游离壁位移＞15 mm）、分流严重程度（轻度：3-5，中度：6-25，重度＞25 个微泡）和欧氏瓣的突出程度。
两组在年龄和性别分布方面无差异。I 组的 PFO 较大（最大分离 3.9 ± 1.4 对 1.3 ± 1.3 mm，p 〈 0.0001），隧道较长（14 ± 6 对 12 ± 5.5 mm，p 〈 0.05），房间隔瘤更常见（55%对 15%，p 〈 0.0001），与 II 组（对照组）相比。I 组还具有更大比例的大 PFO（≤ 4 mm；50%对 18%，p 〈 0.001）和严重分流（40%对 2%，p 〈 0.0001）。
症状性患者的 PFO 较大，隧道较长，更常与房间隔瘤相关。具有与中风患者相似 PFO 特征的无症状患者需要更仔细的临床评估。是否可以辩论是否应将此类患者纳入前瞻性试验中，以评估中风预防中 PFO 封堵的适应证。
