陈莎莎,潘文志,金沁纯,张晓春,周达新

• 1:复旦大学附属中山医院心内科上海市心血管病研究所

摘要(Abstract)：

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。

关键词(KeyWords)： 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

Abstract:

Keywords:

基金项目(Foundation):

作者(Author): 陈莎莎,潘文志,金沁纯,张晓春,周达新

参考文献(References)：

• [1] Reddy VY, Doshi SK, Kar S, et al. 5-Year outcomes after left atrial appendage closure:from the PREVAIL and PROTECT AF Trials. J Am Coll Cardiol,2017, 70(24):2964-2975.
• [2] Boersma LV, Ince H, Kische S, et al. EWOLUTION Investigators.Efficacy and safety of left atrial appendage closure with WATCHMAN in patients with or without contraindication to oral anticoagulation:1-Year follow-up outcome data of the EWOLUTION trial. Heart Rhythm,2017, 14(9):1302-1308.
• [3] Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J,2016,37(38):2893-2962.
• [4] January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. J Am Coll Cardiol,2019,pii:S0735-1097(19)30209-30218.
• [5] Fauchier L, Cinaud A, Brigadeau F, et al. Device-related thrombosis after percutaneous left atrial appendage occlusion for atrial fibrillation. J Am Coll Cardiol,2018, 71(14):1528-1536.
• [6] Holmes DR Jr, Kar S, Price MJ, et al. Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy:the PREVAIL trial. J Am Coll Cardiol,2014, 64(1):1-12.
• [7] Holmes DR, Reddy VY, Turi ZG, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation:a randomised noninferiority trial. Lancet,2009, 374(9689):534-542.
• [8] Reddy VY, Doshi SK, Sievert H, et al. Percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation:2.3-year follow-up of the PROTECT AF(Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation)trial. Circulation,2013, 127(6):720-729.
• [9] Reddy VY, M?bius-Winkler S, Miller MA, et al. Left atrial appendage closure with the Watchman device in patients with a contraindication for oral anticoagulation:the ASAP study(ASA Plavix Feasibility Study with Watchman Left Atrial Appendage Closure Technology). J Am Coll Cardiol,2013, 61(25):2551-2556.
• [10] Kar S, Hou D, Jones R, et al. Impact of Watchman and Amplatzer devices on left atrial appendage adjacent structures and healing response in a canine model. JACC Cardiovasc Interv,2014, 7(7):801-809.
• [11]陈雨意,陈艳红,张勇华,等。新型口服抗凝药物用于经皮左心耳封堵术术中、术后抗凝的初步临床随访结果.中国介入心脏病学杂志, 2018,26(10):547-552.
• [12] Daniel WG, Nellessen U, Schr?der E, et al. Left atrial spontaneous echo contrast in mitral valve disease:an indicator for an increased thromboembolic risk. J Am Coll Cardiol,1988, 11(6):1204-1211.
• [13] Jones EF, Calafiore P, McNeil JJ, et al. Atrial fibrillation with left atrial spontaneous contrast detected by transesophageal echocardiography is a potent risk factor for stroke. Am J Cardiol,1996, 78(4):425-429.
• [14] Chimowitz MI, DeGeorgia MA, Poole RM, et al. Left atrial spontaneous echo contrast is highly associated with previous stroke in patients with atrial fibrillation or mitral stenosis. Stroke,1993, 24(7):1015-1019.