杜方,姜程,余阳阳,赵锋,胡浩

• 1:兰州大学第二医院(第二临床医学院)心血管内科

摘要(Abstract)：

目的 回顾性分析心房颤动合并左心耳血栓持续存在患者行左心耳封堵术的可行性。方法 计算机检索2000年1月1日至2023年6月1日，PubMed、EBSCO、知网、万方等电子数据库中所有关于左心耳血栓患者行左心耳封堵术的摘要或全文。收集了所有患者基线的临床特点、手术相关资料和围术期并发症、随访时的临床结局，对数据汇总进行分析。结果 回顾性纳入了心房颤动合并左心耳血栓持续存在的278例患者，平均年龄为73.2岁，男性占58.6%，平均CHA_2DS_2-VASc和HAS-BLED评分分别为（4.62±1.23）分和（3.28±0.94）分，既往发生脑卒中的患者中，缺血性脑卒中/短暂性脑缺血发作（TIA）的患者占74.8%，绝大部分左心耳血栓位于左心耳远端（72.7%）。所有患者均成功置入了左心耳封堵器，Amulet是最常用的左心耳封堵器类型（65%）。术中有118例（42.4%）患者使用了脑保护装置。大多数左心耳封堵术在标准左心耳封堵术的基础上进行了改良。术后1例患者发生TIA,3例（1.08%）患者出现了少量心包积液，但无需引流，主要出血事件3例，其中2例需要输血。纳入研究平均随访时间（6.2±7.1）个月，随访238例，随访期间全因死亡率为1.68%(4/238)，发生4例缺血性脑卒中，器械相关血栓12例（12/238,5.04%）。结论 由经验丰富的术者，结合左心耳内血栓位置，采用改良的手术技术和合适的封堵器类型，左心耳血栓持续存在患者行左心耳封堵术是可行的。

关键词(KeyWords)： 心房颤动;左心耳血栓;抗凝;左心耳封堵术;系统性分析

Abstract:

Keywords:

基金项目(Foundation): 甘肃省自然科学基金项目（22JR5RA1001）

作者(Author): 杜方,姜程,余阳阳,赵锋,胡浩

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].J Am Coll Cardiol,2017,70(24):2964-2975.DOI:10.1016/j.j acc.2017.10.021.
• [2]Brouwer TF,Whang W,Kuroki K,et al.Net clinical benefit of left atrial appendage clo sure versus warfarin in patients with atrial fibrillation:a pooled analysis of the randomized PROTECTAF and PREVAIL studies[J].J Am Heart Assoc,2019,8(23):e013525.DOI:10.1161/JAHA.119.013525.
• [3]Osmancik P,Herman D,Neuzil P,et al.4-year outcomes after left atrial appendage closure versus nonwarfarin oral anticoagulation for atrial fibrillation[J].J Am Coll Cardiol,2022,79(1):1-14.DOI:10.1016/j.jacc.2021.10.023.
• [4]Lip GY,Hammerstingl C,Marin F,et al.Left atrial thrombus resolution in atrial fibrillation or flutter:results of a prospective study with rivaroxaban(X-TRA)and a retrospective observational registry providing baseline data(CLOT-AF)[J].Am Heart J,2016,178:126-134.DOI:10.1016/j.ahj.2016.05.007.
• [5]Marroquin L,Tirado-Conte G,Pracon R,et al.Management and outcomes of patients with left atrial appendage thrombus prior to percutaneous closure[J].Heart,2022,108(14):1098-1106.DOI:10.1136/heartjnl-2021-319811.
• [6]Pak HN,Shim CY,Kim JS,et al.Self-expandable device for percutaneous closing of left atrial appendage with organized thrombus in a patient with permanent atrial fibrillation[J].Can J Cardiol,2013,29(10):1329.e1-1329.e3.DOI:10.1016/j.cjca.2012.09.016.
• [7] Lange M,Bültel H,Lffeld P,et al.Successful LAA-closures despite persistent distal thrombus[C].EuroPCR,2017.
• [8]Aytemir K,Aminian A,Asil S,et al.First case of percutaneous left atrial appendage closure by Amulet~(TM)device in a patient with left atrial appendage thrombus[J].Int J Cardiol,2016,223:28-30.DOI:10.1016/j.ijcard.2016.08.171.
• [9]Cammalleri V,Ussia GP,Muscoli S,et al.Transcatheter occlusion of left atrial appendage with persistent thrombus using a trans-radial embolic protection device[J].J Cardiovasc Med(Hagerstown),2016,17 Suppl 2:e224.DOI:10.2459/jcm.0000000000000323.
• [10]Dugo D,Bordignon S,Konstantinou A,et al.Locked away:percutaneous closure of a malignant left atrial appendage to constrain an unresolvable thrombus[J].Circ Arrhythm Electrophysiol,2016,9(8):e004127.DOI:10.1161/circep.116.004127.
• [11]Jalal Z,Iriart X,Dinet ML,et al.Extending percutaneous left atrial appendage closure indications using the AMPLATZER~(TM)Cardiac Plug device in patients with persistent left atrial appendage thrombus:the thrombus trapping technique[J].Arch Cardiovasc Dis,2016,109(12):659-666.DOI:10.1016/j.acvd.2016.02.012.
• [12]Lange M,Bültel H,Weglage H,et al.Closure of left atrial appendage with persistent distal thrombus using an amplatzer amulet occluder[J].J Invasive Cardiol,2016,28(9):E75-E76.
• [13] Bellmann B,Rillig A,Leistner DM,et al.Left atrial appendage closure in a patient with left atrial appendage thrombus using a novel fish ball technique[J].Int J Cardiol,2017,234:146-149.DOI:10.1016/j.ij card.2016.12.141.
• [14]Cruz-Gonzalez I,Fuertes Barahona M,Moreno-Samos JC,et al.Left atrial appendage occlusion in the presence of thrombus with a lamb re device[J].JACC Cardiovasc Interv,2017,10(21):2224-2226.DOI:10.1016/j.jcin.2017.05.036.
• [15]Del Furia F,Ancona MB,Giannini F,et al.First-in-man percutaneous LAA clo sure with an amplatzer amulet and TriGuard embolic protection device in a patient with LAA thrombus[J].J Invasive Cardiol,2017,29(4):E51-E52.
• [16] Sacca S,Ferro J,Umemoto T,et al.A new strategy for transcatheter left atrial appendage closure with cerebral embolic protection in patient with left auricular thrombosis and total contraindication to long-term anticoagulation[J].J Invasive Cardiol,2017,29(3):E37-E38.
• [17]Lee OH,Kim JS,Pak HN,et al.Feasibility of left atrial appendage occlusion for left atrial appendage thrombus in patients with persistent atrial fibrillation[J].Am J Cardiol,2018,121(12):1534-1539.DOI:10.1016/j.amjcard.2018.02.045.
• [18] Martins JL,Paiva L,Costa M,et al.Thrombus in left atrial appendage-Overcoming percutaneous closure limitations[J].Rev Port Cardiol(Engl Ed),2018,37(3):269-270.DOI:10.1016/j.repc.2017.04.006.
• [19] Tarantini G,D'Amico G,Latib A,et al.Percutaneous left atrial appendage occlusion in patients with atrial fibrillation and left appendage thrombus:feasibility,safety and clinical efficacy[J].EuroIntervention,2018,13(13):1595-1602.DOI:10.4244/eij-d-17-00777.
• [20]Yadav PK,Wang DD,Eng MH,et al.Watchman in ascending aorta for systemic protection(WAASP):novel use of Watchman in ascending aorta for embolic protection-first in man[J].Catheter Cardiovasc Interv,2018,92(2):433-436.DOI:10.1002/ccd.27117.
• [21] Beneduce A,Ancona F,Marzi A,et al.Percutaneous treatment of persistent left atrial appendage thrombus using Watchman FLX no-touch implantation technique and cerebral protection system[J].JACC Clin Electrophysiol,2019,5(10):1231-1232.DOI:10.1016/j.jacep.2019.06.015.
• [22]Bordignon S,Bologna F,Chen S,et al.Percutaneous left atrial appendage closure in the presence of thrombus:a feasibility report[J].J Cardiovasc Electrophysiol,2019,30(12):2858-2863.DOI:10.1111/jce.14246.
• [23]高建斌,张戈军,潘家华,等.预置脑血管保护装置下的左心耳封堵术1例[J].中国介入心脏病学杂志,2019,27(11):659-660.DOI:10.3969/j.issn.1004-8812.2019.11.013.
• [24]Mohandes M,Pernigotti A,Morr CI,et al.Percutaneous left atrial appendage closure in the presence of thrombus using lambre device and cerebral protection system[J].Korean Circ J,2020,50(3):281-283.DOI:10.4070/kcj.2019.0305.
• [25]Sahiner L,Coteli C,Kay a EB,et al.Left atrial appendage occlusion in patients with thrombus in left atrial appendage[J].J Invasive Cardiol,2020,32(6):222-227.
• [26]Boccuzzi GG,Montabone A,D'Ascenzo F,et al.Cerebral protection in left atrial appendage closure in the presence of appendage thrombosis[J].Catheter Cardiovasc Interv,2021,97(3):511-515.DOI:10.1002/ccd.29161.
• [27]Briosa E Gala A,Pope MTB,Newton JD,et al.Caged-in:successful percutaneous closure of left atrial appendage with Watchman-FLX in the presence of proximal thrombus[J].J Cardiovasc Electrophysiol,2021,32(6):1655-1657.DOI:10.1111/jce.15068.
• [28]Streb W,Mitrega K,Podolecki T,et al.Rationale for cerebral protection in patients with left atrial appendage thrombus during percutaneous left atrial appendage closure:a single-center initial experience[J].Pol Arch Intern Med,2021,131(2):202-204.DOI:10.20452/pamw.15711.
• [29] Tan BE,Depta JP.Trans catheter cerebral embolic protection during WATCHMAN procedure in two patients with persistent left atrial appendage thrombus:case report with review of the literature[J].Catheter Cardiovasc Interv,2021,97(2):365-368.DOI:10.1002/ccd.29060.
• [30]杨明,郝应禄,梁梅,等.存在左心耳血栓的左心耳封堵一例[J].中国心脏起搏与心电生理杂志,2021,35(6):612-613.DOI:10.13333/j.cnki.cj cpe.2021.06.025.
• [31]赵志宏,罗俊,武英彪,等.心房颤动合并左心耳血栓行左心耳封堵术疗效分析:单中心经验[J].中国介入心脏病学杂志,2021,29(10):570-575.DOI:10.3969/j.issn.1004-8812.2021.10.006.
• [32]Jin LS,Ke JY,Lin YN,et al.Percutaneous left atrial appendage clo sure using the LAmbre device in patients with atrial fibrillation and left atrial appendage thrombus[J].Front Cardiovasc Med,2022,9:1071119.DOI:10.3389/fcvm.2022.1071119.
• [33]Popescu SS,Heeger CH,Keelani A,et al.Percutaneous left atrial appendage closure with the LAmbre device protected by a cerebral protection system in a 76-year-old man with persistent left atrial appendage thrombus[J].Am J Case Rep,2022,23:e937063.DOI:10.12659/AJCR.937063.
• [34] Sebag FA,Garot P,Galea R,et al.Left atrial appendage closure for thrombus trapping:the international,multicentre TRAPEUR registry[J].EuroIntervention,2022,18(1):50-57.DOI:10.4244/EIJ-D-21-00713.
• [35]Marschall A,Rodriguez Torres D,Rueda Li?ares A,et al.Recurrent embolisms despite adequate anticoagulant therapy in a patient with prosthetic heart valves and atrial fibrillation:a case report[J].Eur Heart J Case Rep,2021,5(7):ytab263.DOI:10.1093/ehjcr/ytab263.
• [36] Limite LR,Radinovic A,Cianfanelli L,et al.Outcome of left atrial appendage closure using cerebral protection system for thrombosis:no patient left behind[J].Pacing Clin Electrophysiol,2022,45(1):23-34.DOI:10.1111/pace.14398.
• [37] Torres-Saura F,Cruz-González I,Perez-Berbel P,et al.Left atrial appendage closure with the use of a WATCHMAN FLX device in a patient with persistent left atrial appendage thrombus[J].Can J Cardiol,2020,36(6):968.e5-968.e7.DOI:10.1016/j.cjca.2019.12.031.
• [38]Lange M,Bültel H,Lffeld P,et al.Successful LAA-closures despite persistent distal thrombus[C].EuroPCR,2017.
• [39]Marcon L,Sicuso R,Galli S,et al.TriGuard embolic protection device in percutaneous cardiac interventions with intracavitary cardiac thrombosis:a case series[J].Pacing Clin Electrophysiol,2024,47(1):106-112.DOI:10.1111/pace.14712.
• [40] Fukuda S,Watanabe H,Shimada K,et al.Left atrial thrombusand prognosis after anticoagulation therapy in patients with atrial fibrillation[J].J Cardiol,2011,58(3):266-277.DOI:10.1016/j.jjcc.2011.06.009.
• [41]Murtaza G,Turagam MK,Atti V,et al.Warfarin vs.nonvitamin K oral anticoagulants for left atrial appendage thrombus:a meta-analysis[J].J Cardiovasc Electrophysiol,2020,31(7):1822-1827.DOI:10.1111/jce.14502.
• [42]Joglar JA,Chung MK,Armbruster AL,et al.2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation:a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines[J].Circulation,2024,149(1):e1-e156.DOI:10.1161/cir.0000000000001193.
• [43]中国医师协会心血管内科医师分会结构性心脏病专业委员会.中国经导管左心耳封堵术临床路径专家共识[J].中国介入心脏病学杂志,2019,27(12):661-672.DOI:10.3969/j.issn.1004-8812.2019.12.001.
• [44]何长健,谢瑞芹.心腔内超声在左心耳封堵术中的应用研究进展[J].中国介入心脏病学杂志,2021,29(12):704-707.DOI:10.3969/j.issn.1004-8812.2021.12.010.
• [45]Cruz-Gonzalez I,Korsholm K,Trejo-Velasco B,et al.Procedural and short-term results with the new Watchman FLX left atrial appendage occlusion device[J].JACC Cardiovasc Interv,2020,13(23):2732-2741.DOI:10.1016/j.jcin.2020.06.056.
• [46]Turagam MK,Osmancik P,Neuzil P,et al.Left atrial appendage clo sure versus oral anticoagulants in atrial fibrillation:a meta-analysis of randomized trials[J].J Am Coll Cardiol,2020,76(23):2795-2797.DOI:10.1016/j.jacc.2020.08.089.
• [47]Kar S,Doshi SK,Sadhu A,et al.Primary outcome evaluation of a next-generation left atrial appendage closure device:results from the PINNACLE FLX trial[J].Circulation,2021,143(18):1754-1762.DOI:10.1161/circulationaha.120.050117.
• [48]Schmidt B,Nielsen-Kudsk JE,Ellis CR,et al.Incidence,predictors,and clinical outcomes of device-related thrombus in the Amulet IDE trial[J].JACC Clin Electrophysiol,2023,9(1):96-107.DOI:10.1016/j.jacep.2022.07.014.
• [49]Dukkipati SR,Kar S,Holmes DR,et al.Devicerelated thrombus after left atrial appendage closure:incidence,predictors,and outcomes[J].Circulation,2018,138(9):874-885.DOI:10.1161/circulationaha.118.035090.
• [50]Seeger J,Kapadia SR,Kodali S,et al.Rate of peri-procedural stroke observed with cerebral embolic protection during transcatheter aortic valve replacement:a patient-level propensitymatched analysis[J].Eur Heart J,2019,40(17):1334-1340.DOI:10.1093/eurheartj/ehy847.
• [51]Isogai T,Vanguru HR,Krishnaswamy A,et al.Cerebral embolic protection and severity of stroke following transcatheter aortic valve replacement[J].Catheter Cardiovasc Interv,2022,100(5):810-820.DOI:10.1002/ccd.30340.
• [52] Streb W,Lasek-Bal A,Mitrega K,et al.Rationale and design of a randomized clinical trial evaluating the efficacy of mechanical neuroprotection in reducing the risk of silent brain infarcts associated with percutaneous left atrial appendage closure:study protocol for a LAAC-SBI trial[J].Trials,2023,24(1):749.DOI:10.1186/s 13063-023-07766-3.
• [53] Meincke F,Spangenberg T,Kreidel F,et al.Rationale of cerebral protection devices in left atrial appendage occlusion[J].Catheter Cardiovasc Interv,2017,89(1):154-158.DOI:10.1002/ccd.26677.