佟佳宾,施海峰,邹彤,陈浩,刘俊鹏,王华,李莹莹,吕游,种甲,董敏,杨杰孚

• 1:卫生部北京医院心内科

摘要(Abstract)：

目的观察大于75岁的高龄心房颤动(房颤)患者围导管消融期三种抗凝方案的安全有效性。方法选取2011年7月到2013年12月行房颤导管消融治疗的高龄(>75岁)房颤患者85例,术前常规华法林抗凝后经食管超声检查排除左心耳血栓,分为三组:传统抗凝组30例,消融前停用华法林,以低分子肝素桥接,术中用普通肝素抗凝,术后桥接低分子肝素联合华法林过渡到单用华法林;华法林持续使用组32例,围消融期正常使用华法林,术中使用普通肝素抗凝;新型口服抗凝药物组23例(达比加群组12例,利伐沙班组11例),术前、术中同传统抗凝组,术后4 h开始服用达比加群或利伐沙班抗凝。比较三组抗凝方案围术期到术后3个月的出血和栓塞事件发生率及其他并发症。结果传统抗凝组住院期间新发脑梗死1例,下肢血肿7例,假性动脉瘤1例,出院后3个月内内脏出血1例,小出血事件6例;华法林持续使用组院内下肢血肿4例,出院后3个月内小出血事件4例;新型口服抗凝药物院内下肢血肿2例,出院后无小出血事件。结论高龄房颤患者行导管消融治疗,总体安全有效。与传统抗凝治疗方案对比,持续使用华法林方案或采用新型口服抗凝药物能进一步降低出血并发症风险,并未增加血栓栓塞的风险。

关键词(KeyWords)： 心房颤动;导管消融;抗凝治疗;血栓栓塞

Abstract:

Keywords:

基金项目(Foundation):

作者(Author): 佟佳宾,施海峰,邹彤,陈浩,刘俊鹏,王华,李莹莹,吕游,种甲,董敏,杨杰孚

参考文献(References)：

• [1]Kopecky SL,Gersh BJ,McGoon MD,et al.The natural history,of lone atrial fibrillation.A population-based study over three decades.N Engl J Med,1987,317:669-674.
• [2]Haegeli LM,Duru F.Management of Patients with Atrial Fibrillation:Specific Considerations for the Old Age.Cardiol Res Pract,2011,2011:1-8.
• [3]王新华,刘旭,孙育民,等.环肺静脉消融电隔离治疗持续性心房颤动的疗效观察.中国介入心脏病学杂志,2006:147-151.
• [4]施海峰,刘旭,王新华,等.导管消融治疗慢性心房颤动两种消融策略的对比研究.中国介入心脏病学杂志,2007:133-138.
• [5]Gautam S,John RM,Stevenson WG,et al.Effect of therapeutic INR on activated clotting times,heparin dosage,and bleeding risk during ablation of atrial fibrillation.J Cardiovasc Electrophysiol,2011,22:248-254.
• [6]Benjamin EJ,Wolf PA,D’Agostino RB,et al.Impact of atrial fibrillation on the risk of death:the Framingham Heart Study.Circulation,1998,98:946-952.
• [7]Thrall G,Lane D,Carroll D,et al.Quality of life in patients with atrial fi brillation:a systematic review.Am J Med,2006,119:448,e1-9.
• [8]Noheria A,Kumar A,Wylie JV Jr,et al.Catheter ablation vs antiarrhythmic drug therapy for atrial fibrillation:a systematic review.Arch Intern Med,2008,168:581-586.
• [9]Oral H,Pappone C,Chugh A,et al.Circumferential pulmonary-vein ablation for chronic atrial fibrillation.N Engl J Med,2006,354:934-941.
• [10]Bunch TJ,May HT,Bair TL,et al.Atrial fibrillation ablation patients have long-term stroke rates similar to patients without atrial fi brillation regardless of CHADS2 score.Heart Rhythm,2013,10:1272-1277.
• [11]Tan HW,Wang XH,Shi HF,et al.Efficacy,safety and outcome of catheter ablation for atrial fi brillation in octogenarians.Int J Cardiol,2010,145:147-148.
• [12]Bunch TJ,Weiss JP,Crandall BG,et al.Long term clinical effi cacy and risk of catheter ablation for atrial fi brillation in octogenarians.Pacing Clin Electrophysiol,2010,33:146-152.
• [13]李世英,柳景华.欧美出血学术研究会(BARC)关于出血的统一定义.中国介入心脏病学杂志,2012,20:231-234.
• [14]Dagres N,Hindricks G,Kottkamp H,et al.Complications of atrial fi brillation ablation in a high-volume center in 1000 procedures:still cause for concern?J Cardiovasc Electrophysiol,2009,20:1014-1019.
• [15]Cappato R,Calkins H,Chen SA,et al.Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation.J Am Coll Cardiol,2009,53:1798-1803.
• [16]Wazni OM,Rossillo A,Marrouehe NF,et al.Embolic events and char formation during pulmonary vein isolation in patients with atrial fibrillation:impact of different anticoagulation regimens and importance of intracardiac echo imaging.J Cardiovasc Electrophysiol,2005,16:576-581.
• [17]Oral H,Chugh A,Ozaydin M,et al.Risk of thromboembolic events after percutaneous left atrial radiofrequency ablation of atrial fibrillation.Circulation,2006,114:759-765.
• [18]Pappone C,Santinelli V.How to perform encircling ablation of the left atrium.Heart Rhythm,2006,3:1105-1109.
• [19]Wazni OM,Beheiry S,Fahmy T,et al.Atrial fi brillation ablation in patients with therapeutic international normalized ratio:comparison of strategies of anticoagulation management in the periprocedural period.Circulation,2007,116:2531-2534.
• [20]Hussein AA,Martin DO,Saliba W,et al.Radiofrequency ablation of atrial fi brillation under therapeutic international normalized ratio:a safe and effi cacious periprocedural anticoagulation strategy.Heart Rhythm,2009,6:1425-1429.
• [21]Kaseno K,Naito S,Nakamura K,et al.Efficacy and safety of periprocedural dabigatran in patients undergoing catheter ablation of atrial fibrillation.Circ J,2012,76:2337-2342.
• [22]付坤,柳景华.维生素K拮抗剂与血管钙化.中国介入心脏病学杂志,2013,21:195-198.
• [23]Piccini JP,Stevens SR,Lokhnygina Y,et al.Outcomes after cardioversion and atrial fibrillation ablation in patients treated with rivaroxaban and warfarin in the ROCKET AF trial.JACC,2013,61:1998-2006.
• [24]马长生,高凌云.心房纤颤患者脑卒中的预防—抗凝与抗血小板治疗.心肺血管病杂志,2010,29:245-247.