Fatale Skotomisierung des offenen Foramen ovale (PFO) Bernhard Meier Universitätsklinik für Kardiologie Inselspital Bern Interessenkonflikt: Forschungsunterstützung und Honorare St. Jude Medical Intricacy of Adult Interven2onal Cardiology Procedures • Preven2on • Therapy LAA Closure PFO Closure ASD Closure Paravalvular MitraClip (Mitral) Leak Closure TAVI PCI Palmares der kathetergestützten Herzeingriffe 1953 Rubio-Alvarez 1966 Rashkind 1966 Porstmann 1972 1975 1975 1977 1981 1982 1982 Galiano King Gianturco Grüntzig Singer Gallagher Inoue 1983 1986 1987 1990 1994 1998 2000 2001 Lababidi Puel Simpson Palacios Sigwart Waxman Bonhoeffer Sievert 2002 Cribier Pulmonale Draht-Klappenaufdehnung bei angeborener Verengung Atriale Septostomie (Aufdehnung des Foramen ovale bei angeborener Herzmissbildung) Verschluss des Ductus Botalli (Querverbindung zwischen den grossen Gefässen, die sich nach der Geburt nicht spontan verschlossen hat) Koronare Drahtrekanalisation bei akutem Herzinfarkt Verschluss des Vorhofseptumdefekts Verschluss von Gefässfisteln mit Drahtkringeln Koronardilatation (Ballon-Herzkranzgefässaufdehnung) Ballonaufdehnung einer Isthmusverengung der Hauptschlagader Verödung einer elektrischen Leitung im Herzen (His-Bündel) Ballonaufdehnung der verengten Mitralklappe (zweitwichtigste Herzklappe) Ballonaufdehnung der verengten Aortenklappe (wichtigste Herzklappe) Stentimplantation im Herzkranzgefäss Plaque-Exzision aus dem Herzkranzgefäss (Atherektomie) 1992 Bridges: PFO Verschluss Balloneröffnung des Perikards Alkoholschrumpfung der überdicken Herzkammerscheidewand Zugang in den Herzbeutel durch das Herzohr für Medikamentengabe Ersatz der Pulmonalklappe (drittwichtigste Herzklappe) Verschluss des linken Vorhofohrs als Alternative zur Blutverdünnung bei Vorhofflimmern Ersatz der Aortenklappe TEE PFO and ASA Angiography LA LA PFO PFO Zinsli Annemarie 08.11.1941, 05.07.2010 Baden RA ASA RA ASA Eustachian Valve Weshalb ist ein PFO gefährlich? Thrombus Stuck in PFO (Ramani GV, J Am Coll Cardiol 2012;59:e19) • 77-year-old woman • chest pain and dyspnea --> surgery with good outcome “caught in the act” Ariel Sharon (Scheinermann) 1928-2014 Coma after cerebral hemorrhage 2006-2014 January 11, 2014 • It was the evening of December 18, 2005. • Ariel Sharon (78 years, prime minister of Israel), was on his way home, when he suddenly had difFiculties articulating. • He was diagnosed with a transient ischemic attack (TIA) and recovered quickly. • A plausible reason for his TIA was identiFied: a patent foramen ovale (PFO). • He was slated to undergo percutaneous PFO closure after the Holidays on January 5, 2006. • Until the procedure, the prime minister was treated with low-‐molecular weight heparin. • However, the day before the scheduled procedure, he collapsed at home. • Hemorrhagic stroke was the diagnosis. • Tragically, he never recovered from this incident and remained in a coma for 8 years, until his death in January 2014. Pflegefachfrau mit 2 Teenager-Buben, 39jährig wird nie mehr sprechen wegen eines Hirnschlags Sie hatte seit 10 Jahren unter schwerer Migräne gelitten! PFO and Migraine 74 patients 73 patients Dowson A, Circulation. 2008;117:1397-1404 Migraine and Stroke Meta-Analysis Schürks M, BMJ 2009;339:b3914 Migraine and Coronary Problems Metaanalysis Schürks M, BMJ 2009;339:b3914 PFO Causing MI Courtesy Fabian Nietlispach, MD TIAs, migraine with aura Pre Man 46 years, MI Out of the Blue Post Courtesy Ahmed Khattab, MD 25 mm Amplatzer PFO Occluder Kohler Walter 27.09.1968 13.05.2014 Khattab PA Thrombus aspirated through guiding catheter PFO looked for and found while abciximab running LAO PFO Causing MI Woman 46 y, chest pain 1 week after swollen and tender calf (courtesy Aris Moschovitis, MD) Züttel Franziska 19.02.1967 18.07.2013 Moschovitis LAO, end-systole Long thrombus in RCA Waffling of territory of dominant RCA PFO Causing MI Woman 46 y, chest pain 1 week after swollen and tender calf (courtesy Aris Moschovitis, MD) < 1 cm Züttel Franziska 19.02.1967 18.07.2013 Moschovitis > Thrombus extracted RCA ted sten PFO Causing MI Woman 46 y, chest pain 1 week after swollen and tender calf (courtesy Aris Moschovitis, MD) Züttel Franziska 19.02.1967 18.07.2013 Moschovitis PFO looked for and found Amplatzer 25 mm Cribriform Occluder LA SS SS LA RA RA PFO / MI • 46-year-old man • Anterior ST↑ • Normal coronary arteries except for proximal LAD occlusion • Severe LV impairment • Orsiro Stent • Amplatzer 25 mm PFO Occluder Mehri Stefan 28.04.1969 18.01.2015 Pilgrim Courtesy Thomas Pilgrim, MD PFO / MI End-systole • 48-year-old man • 1:30 a.m. admission • Chest pain for several hours • Anterior ST↑ • Normal coronary arteries except for proximal LAD occlusion • Severe LV impairment LAD occluded by embolus Schelker Beat, 17.09.1961, 22.11.2009 Khattab Reopened by wire • Stent • Amplatzer 25 mm PFO Occluder PFO probed for, found, and occluded LA RA LAD recanalized and stented PFO / MI • 45-year-old man • Acute anterior MI with schock Embolus Embolus Carvalho Pereira Adao Joaquim 03.09.1965, 17.06.2010 Wenaweser Embolus PFO closure with 25 mm Amplatzer Occluder Post removal with basket • Frau, 57 Jahre • Malaise and Präsynkope während Wanderung • Mit Helikopter in die Klinik geflogen Briessinck Marie Jeanne, 18.12.1953, 20.08.2010 Dr. Aris MoschoviPs Paradoxe Embolie mit floIerendem Thrombus im proximalen RCX und funkPonellem Verschluss der distalen RCX-‐Aeste Resultat nach mehreren AspiraPonen mit Export 6F und (bei proximal persisPerendem Thrombus) mit dem 6F-‐Führungskatheter selber Dr. Aris MoschoviPs LA Nachweis des PFOs Verschluss mibels Amplatzer PFO Occluder Device 25 mm. Frühe und späte Phase nach KM Gabe mit Darstellung von RA und LA RA • 53-year-old man • Lingering chest pain for 3 days • No prior history of CAD • LV: anterior akinesia PFO and multiple MIs • Old recanalized (embolic?) occlusion of RCA • Embolic occlusion of LAD extending into diagonal Courtesy: Aris Moschovitis, MD • Stent for LAD • Amplatzer 25 mm PFO Occluder LAO LA SS NUNES JOAQUIM 03.10.1960, 07.04.2013, Moschovitis PFO Occluder RA RA Akinesia in LAD territory PFO looked for and found Embolic LAD occlusion with thrombus in diagonal Long recanalized (embolic?) RCA occlusion Stented LAD PFO and MI in Elderly • 86-year-old woman • Acute anterior MI at 10 pm • Concurrent pulmonary embolism Pre Aspiration Aspirated Thrombus Sahli Bethli 24.06.1928 25.08.2014 Wenaweser PFO Courtesy Peter Wenaweser, MD Post Aspiration 25 mm Amplatzer PFO Occluder PFO —> LM Embolization in Newborn • • • Boy, 4 days 18-hour delivery Born in cardiogenic shock Thrombus Lötscher Nathan, 14.12.2014, 18.12.2014 Pfammatter Thrombus Thrombus PFO Causes Anterior MI Perrone Michele 13.05.1954 21.03.2014 16.04.2014 Räber PFO looked for, found, and closed 1 month after primary PCI: partial recovery of anterior wall function PFO-Near-Death in Healthy 26-Year-Old Ice-Hockey Player Sudden severe angina and hypotension at 2 a.m. Courtesy A. Khattab, MD PFO in TEE Bärtschi André, 11.05.1988, 15.12.2014 Longish thrombus in LAD 25 mm Amplatzer PFO Occluder After stent PFO-Death in Healthy 34-Year-Old Man, 1 Day after a Soccer Bruise to the Thigh Sudden collapse: cardiogenic shock --> catheterization under cardiac massage Di Giorgio Roberto, 30.05.1977, 24.07.2011 Pilgrim Pilgrim T, J Invasive Cardiol 25:162-164, 2013 Autopsy Huge infarction Femoral vein thrombus at bruise Culprit PFO Pulmonary embolus also found Eur Heart J 2014;35:2971 (fatal outcome) Abecasis Joao ECM O PFO-Death in Healthy 46-Year-Old Woman after Face Lifting LA Wiestner Marianne 31.01.1967 01.05.2013 Diehm, Nietlispach, Kadner PFO RA Multiple coronary artery occlusions (under ECMO support) PFO Cardiogenic shock and death 4 days after emergency heart surgery Multiple pulmonary embolisms and Death Pavoni D, J. Am. Coll. Cardiol. 2012;59;1329 PFO!? • 26-year-old man • Occasional smoker, recently cannabis • Lysis failed • Nice therapy • Wrong diagnosis Sürder D, Kucher N, Eberli FR, Roffi M EHJ 27:2631, 2006 After extraction Mobile Mass in the Left Main Coronary Artery Baris Ikitimur, MD, Tevfik Gurmen, MD, Ali Tabakan, MD, Kaya Suzer, MD Istanbul, Turkey (Ikitimur B, J. Am. Coll. Cardiol. 2010;55;e131) PFO!? Ikitimur B PFO not mentioned! Multivessel Spontaneous Coronary Artery Dissection!? 35-year-old woman, 12 days post-partum PFO!? PFO not mentioned! Survived on anticoagulants only Sardar MR, JINT 2014;7:e161-162 Eur Heart J. 2014;35:2046 Zimmermann FM 45-year-old woman with two previous embolic brain events and PFO Courtesy: Luiz Carlos Simões, MD Embolic Occlusion of Internal Cerebral Artery with PFO • 58-year-old man with mild stroke • 25 mm PFO occluder Alshahumi Mufta 01.01.1950 13.05.2009 Pulmonary Embolism and Simultaneous Silent Embolic Occlusion of Left Carotid Artery (Woman, 56 y, --> PFO closure and oral anticoagulation) CT done for suspected pulmonary embolism PFO looked for and found at TEE Clot in left carotid artery Clot in right pulmonary artery Zwahlen Inge, 15.12.195408.03.2010 PFO closed with 25 mm Amplatzer PFO occluder Simultaneous Embolic Occlusion of Left Carotid Artery and Multiple Coronary Arteries (Woman, 63 y, intubated because of cardiogenic shock out of well-being, hemiplegic when waking up) ASA Anselmo Andrea Gabriela Pilgrim 29.08.1961 04.12.2014 30.03.2015 Multiple coronary “lesions”, EF 20% TEE 3 months later after multiple PCIs in 2 sessions, EF 30% Bubbles crossing PFO Occluder 25 mm 40-year-old man with massive pulmonary embolism, died 2 hours after emergency surgery from acute stroke PFO Barz Olaf 22.07.1970 01.06.2010 Kucher Courtesy: Nils Kucher, MD Simultaneous Embolic Occlusion of • • • • Left Vertebral Artery (plus Embolically Stenosed Right Carotid Artery) Dominant Left Circumflex Coronary Artery (LCX) Celiac Trunk and Superior Mesenteric Artery Left Iliac artery (plus Embolically Stenosed Aorta at Bifurcation) (Woman, 49 y, sudden shock after several days of not feeling well) Pre Hauri Patrizia 05.04.1965 28.03.2015 29.03.2015 death Moschovitis Post LCX Pre Mesenteric Pre Post Celiac Post Pre Post Iliac Died the following day (after additional abdominal vascular surgery) because of cerebral hemorrhage, autopsy refused Stortecky S, J. Am. Coll. Cardiol. 2011;58;1923 Pulmonary Embolism and Simultaneous Paradoxical Embolism to Dominant LCX with Inferior MI (Woman, 69 y, 8-hour train ride with pre-syncope, severe dyspnea at rest, and inferior ST-elevation the next morning) Schwartz Nanna 26.09.1941, 10.06.2010 Togni Good course after additional systemic thrombolysis Venous Thromboembolism (VTE) and Stroke/MI Relative Risk of MI or Stroke Provoked VTE • 20-year population-based cohort study • Danish medical databases • No known cardiovascular disease • 25 199 patients with deep venous thrombosis • 16 925 patients with pulmonary embolism • 163 566 population controls No con side rati on o f PF O !! Paper First year hazard ratio MI 1.60 (95% CI 1.35–1.91) Stroke 2.19 (1.85-2.60) Sørensen HT, Lancet 2007; 370: 1773–9 (Denmark, Italy, US) Editorial Lowe GDO, Lancet 2007; 370: 1743-4 (Glasgow) 20 PFO and D-Dimer Stroke 570 patients with • cryptogenic stroke • TEE: PFO (42%) Pulmonary Embolism Kim YD, Thromb Haemost 2015 l o C Vorkommen von PFO gemäss Alter PFO in 263/965 Autopsien (Durchschnitt 27%) Se 38 36 34 32 % lek Y = 34.613 - .121 * X; R^2 = .603 tiv 30 eS 28 ter 26 24 bli ch 22 20 0 10 20 Hagen PT, Mayo Clin Proc 1984; 59: 17-20 30 40 50 60 70 Column 133 Alter (Jahre) 80 ke it? 90 100 110 Events per Year PFO with Closure PFO device PFO without device Medical Treatment (≥ 10 years of FU) P=0.03 P=0.09 P=0.001 1,872 patient-years 1,394 patient-years Wahl A, Circulation 2012, 125:803-812 P<0.001 Cost for Year of Life Saved (US$) PFO closure at 30 years 0 • Bypass surgery for left main stem disease 7,000 • Betablocker after infarction 10,000 • Invasive strategy for coronary artery disease 10,000 • Cervical cancer screening 12,000 • Treatment of hypertension 13,000 • Statin therapy, secondary prevention 24,000 • TPA instead of streptokinase for infarction 33,000 PFO closu • Hemodialysis 35,000 re at 2.6 y ears 50,000 • Percutaneous aortic valve replacement • PTCA for acute myocardial infarction 52,000 • Heart transplantation 54,000 • Fourth day of monitoring for acute infarction 105,000 • Statin therapy, primary prevention 150,000 • Seat belt 150,000 • Smoke detector 239,000 • Radiation control 834,000 Pickett CA, AJC 2014: $20,000.00 per case • Air bag 1,500,000 *Frei A, Kardiovask Med 7:174-180, 2004
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