摘要
目的探讨经皮左心耳封堵术术后早期(60 d)的最佳抗血栓方案,为抗血栓的选择提供依据。方法回顾性观察2017年6月至2018年6月于复旦大学附属中山医院心内科成功进行经皮左心耳封堵术(Watchman封堵器)的221例患者术后早期(60 d)不同抗血栓方案治疗下的器械相关血栓(DRT)形成、器械相关栓塞事件发生率和大出血发生率,并分析相关危险因素。结果本研究共入选了221例患者,其中男性82例,女性139例,平均年龄(69.3±8.9)岁,平均CHA2DS2-VASc评分为(3.7±1.4)分,平均HAS-BLED评分为(3.1±1.1)分。所有患者均按医嘱进行了术后早期抗血栓药物治疗,术后60 d经食管超声心动图(TEE)检查,发生DRT患者为DRT组有8例(3.6%)患者,其中1例(0.5%)发生缺血性卒中,其余血栓栓塞事件发生率为0。未发生DRT为无DRT组有213例患者,无短暂性脑缺血发作(TIA)、缺血性卒中和动脉系统栓塞发生。随访期间所有患者均未发生大出血和死亡事件。DRT组患者CHA2DS2-VASc评分较无DRT组患者高[(4.0±1.1)分比(3.7±1.5)分,P=0.551],但差异无统计学意义。所有患者术后均进行了抗血栓治疗,达比加群组78例(35.3%),利伐沙班组50例(22.6%),华法林组42例(19.0%),双联抗血小板组51例(23.1%)。术后60 d,达比加群组DRT发生率最高6例(7.7%),其中1例于术后48 d时发生了缺血性卒中。华法林组和双联抗血小板组分别有1例患者发生DRT,发生率分别为2.4%和2.0%,利伐沙班组未发生DRT。Cox多因素回归模型分析显示,术前TEE提示左心房自发显影与术后DRT形成相关(HR 4.76,95%CI 1.36~16.28,P=0.023),而年龄、男性、CHA2DS2-VASc评分和既往TIA/脑梗死病史并非术后DRT形成的预测因素。结论利伐沙班可能是经皮左心耳封堵术术后最佳的早期抗血栓治疗方案,尤其对于术前存在左心房自发显影的患者。华法林或双联抗血小板治疗也可考虑选择,但达比加群(110 mg、每日2次)抗凝效果不佳。
Objective This study aimed to determine the optimal antithrombotic therapy in the early stage of 60 days after percutaneous left atrial appendage closure. Methods A total of 221 patients with di erent early stage antithrombotic therapies enrolled in this study,who underwent a successful percutaneous left atrial appendage closure in Zhongshan Hospital,Fudan University from Jun 2017 to Jun 2018. The study retrospective observed their incidence of device-related thrombus,thromboembolism and bleeding events. We also analyzed the risk factors of these adverse events. Results A total of 221 patients were consecutively enrolled, including 82 male and 139 female,with a mean age of(69.3±8.9)years old,a mean CHA2DS2-VASc score of(3.7±1.4) and a mean HAS-BLED score o(3.1±1.1). All patients were received early stage of antithrombotic therapy and followed-up at the 60 day after procedure. Based on transesophageal echocardiogram(TEE),there were 8 cases of device-related thrombus(DRT)(3.6%),including 1 case of ischemia stroke(0.5%). No major bleeding event happened in all patients. The CHA2DS2-VASc score was higher in DRT patients,but whit no statistical signifi cance[(4.0±1.07)vs.(3.7±1.45),P=0.551]. All patients received antithrombotic therapies,including 78 cases(35.3%)of dabigatran,50 cases(22.6%)of rivaroxaban,42 cases(19.0%)of warfarin and 51 cases (23.1%)of dual antiplatelet. Left atrial spontaneous echo contrast detected by TEE before the procedure, rather than old age,male,thrombosis score or prior TIA, was the independent predictor of DRT (HR 4.76, 95%CI 1.36 –16.28,P=0.02). Conclusions Rivaroxaban may be the optimal antithrombotic therapy in early stage after percutaneous left atrial appendage closure,especially for patients with left atrial spontaneous echo contrast before the procedure. Warfarin and dual antiplatelet therapy also could be considered, but Dabigatran(110 mg bid) may have bad performance in this kind of patients.
作者
陈莎莎
潘文志
金沁纯
张晓春
周达新
CHEN Sha-sha;PAN Wen-zhi;JIN Qin-chun;ZHANG Xiao-chun;ZHOU Da-xin(Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai 200032, China)
出处
《中国介入心脏病学杂志》
2019年第8期428-432,共5页
Chinese Journal of Interventional Cardiology
关键词
经皮左心耳封堵术
器械相关性血栓
缺血性卒中
抗血栓治疗
Percutaneous left atrial appendage closure
Device-related thrombus
Ischemia stroke
Antithrombotic therapy
作者简介
通信作者:周达新,Email:zhou.daxin@zs-hospital.sh.cn.
