卵圆孔未闭(PFO)在患有隐源性缺血性卒中的年轻患者中经常被发现。潜在的卒中机制包括来自穿过PFO的静脉凝块的矛盾栓塞,PFO内的原位凝块形成,和由于电信号中断引起的房性心律失常。本指南的目的是提供诊断建议,治疗,以及长期管理缺血性卒中和PFO患者。相反,短暂性脑缺血发作(TIA)在这种情况下不被视为指示事件,因为只有一个RCT涉及TIA患者。然而,本亚组分析显示TIA和卒中结局无显著差异.工作组确定了问题和结果,分级证据,并在建议分级评估后制定了建议,发展,和评估(GRADE)方法和欧洲卒中组织(ESO)标准操作程序,以制定指南。该文件经过独立专家和ESO准则理事会和执行委员会成员的同行评审。工作组承认目前在描述用于检测PFO的明确诊断算法方面存在证据差距。尽管传统上经食管超声心动图被认为是诊断PFO最准确的工具,它作为“黄金标准”的地位仍然没有得到严格验证的证据。我们发现高质量的证据推荐PFO封堵加抗血小板治疗在选定的18-60岁的患者中,在这些患者中,除了PFO(即PFO相关的卒中)没有发现其他明显的卒中原因。PASCAL分类系统可用于选择PFO闭包的此类候选者。同时有大量右向左分流和房间隔动脉瘤的患者从PFO闭合中受益最多。没有足够的证据对60岁以上和18岁以下的患者进行PFO闭合的循证推荐。根据PASCAL分类,我们发现低质量的证据表明,不太可能出现PFO相关卒中的患者存在PFO封堵,除了在特定情况下(专家共识)。我们建议对PFO相关卒中患者进行长期抗凝治疗,除非其他医学原因表明抗凝治疗。关于PFO封堵后的长期房颤监测,工作组的结论是,与使用长期心脏监测相关的风险和收益仍然存在很大的不确定性,如植入式循环记录仪。本文件提供了额外的指导,以循证建议或专家共识声明的形式,关于PFO检测的诊断方法,PFO关闭后的医疗管理。
Patent foramen ovale (PFO) is frequently identified in young patients with cryptogenic ischaemic stroke. Potential stroke mechanisms include paradoxical embolism from a venous clot which traverses the PFO, in situ clot formation within the PFO, and atrial arrhythmias due to electrical signalling disruption. The purpose of this
guideline is to provide recommendations for diagnosing, treating, and long-term managing patients with ischaemic stroke and PFO. Conversely, Transient Ischaemic Attack (TIA) was not considered an index event in this context because only one RCT involved TIA patients. However, this subgroup analysis showed no significant differences between TIA and stroke outcomes. The working group identified questions and outcomes, graded evidence, and developed recommendations following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach and the European Stroke Organisation (ESO) standard operating procedure for
guideline development. This document underwent peer-review by independent experts and members of the ESO
Guideline Board and Executive Committee. The working group acknowledges the current evidentiary gap in delineating an unequivocal diagnostic algorithm for the detection of PFO. Although transoesophageal echocardiography is conventionally held as the most accurate diagnostic tool for PFO identification, its status as the \'gold standard\' remains unsubstantiated by rigorously validated evidence. We found high-quality evidence to recommend PFO closure plus antiplatelet therapy in selected patients aged 18-60 years in whom no other evident cause of stroke is found but a PFO (i.e. PFO-associated stroke). The PASCAL classification system can be used to select such candidates for PFO closure. Patients with both a large right-to-left shunt and an atrial septal aneurysm benefit most from PFO closure. There is insufficient evidence to make an evidence-based recommendation on PFO closure in patients older than 60 and younger than 18 years. We found low quality evidence to suggest against PFO closure in patients with unlikely PFO-related stroke according to the PASCAL classification, except in specific scenarios (Expert
Consensus). We suggest against long-term anticoagulation in patients with PFO-associated stroke unless anticoagulation is indicated for other medical reasons. Regarding the long-term AF monitoring after PFO closure, the working group concluded that there remains significant uncertainty regarding the risks and benefits associated with the use of long-term cardiac monitoring, such as implantable loop recorders. This document provides additional guidance, in the form of evidence-based recommendations or expert
consensus statements, on diagnostic methods for PFO detection, and medical management after PFO closure.