双重抗血小板治疗患者不同时期进行永久起搏器植入的安全性观察

Safety of implantation permanent pacemaker at different times in patients with dual antiplatelet therapy

目的探讨冠心病药物洗脱支架植入后双重抗血小板治疗患者不同时期行永久起搏器植入的安全性，可行性。方法回顾性分析2009年1月至2015年1月在河北大学附属医院因冠心病植入药物洗脱支架并服用阿司匹林和氯吡格雷双重抗血小板治疗且安装永久起搏器的患者105例，分为3组：双抗组（n=25），桥接组（n=24），单抗组（n=56）。双抗组于支架植入后3个月内植入起搏器，持续双重抗血小板治疗；桥接组：冠脉支架术后3～6个月植入起搏器，术前5d停用双联抗血小板药物，应用依诺肝素钠注射液皮下注射（1mg／kg，1次／12h）；单抗组：冠脉支架6个月后植入起搏器，术前停用氯吡格雷5d。桥接组和单抗组均于术后12—24h恢复双抗治疗。观察围手术期心血管事件以及出血，感染情况。结果3组患者围手术期均无囊袋感染及心血管不良事件发生；桥接治疗组囊袋血肿及渗血的发生率为分别16．7％和29．2％，明显高于双抗组8．0％和12．0％以及单抗组的0．0％和7．1％（Х^2=10．431，P=0．005；Х^2=6．321，P=0．042）。桥接组有3例患者发生严重出血（12．5％，3／24），双抗组和单抗组没有严重出血事件（Х^2=9．161，P=0．010）。单抗组出血事件发生率最低。结论低分子肝素桥接治疗明显增加起搏器囊袋血肿、严重出血的风险；冠心病药物洗脱支架植入术后6个月行起搏器植入可能更安全。

Objective To investigate the safety of implantation permanent pacemaker （PM） at different times in patients with dual antiplatelet （DAPT） therapy after implantation of drug-eluting stent （DES）. Methods A total of 105 patients who implanted pacemakers with DAPT therapy （clopidogrel and aspirin） after implantation of DES admitted to our hospital from January 2009 to January 2015 were enrolled in the study. The patients were divided into 3 groups ： dual antiplatelet therapy （DAP） group ： implanting PM within 3 months after coronary stenting, continuous DAPT during perioperative period; low molecular weight heparin （LMWH） bridging group： implanting PM within 3 to 6 months after coronary stenting, DAPT interruption for 5 days replaced with subcutaneous injection of enoxaparin （ 1 mg/kg）, twice per day, enoxaparin was stopped 12 h before operation; asprin group, implanting PM after coronary stenting 6 months, clopidogrel interruption for 5 days. Oral DAPT was returned 12 -24 after operation according to the patients＇ condition. Peri-operative cardiovascular events and bleedings, infections were observed. Results There was no major adverse cardiac event （MACE） and pouch infection were observed among 3 groups in perioperation. The incidence of pocket hemorrhage and errhysis in bridging group was significantly higher than that of DAP group and asprin group （ 16.7%, 8.0% , 0.0% X^2 = 10. 431, P = 0. 005 and 29.2% , 12.0% , 7.1% X2 = 6. 321, P = 0. 042 respectively）. 3 patients had severe bleeding （ 12.5%, 3/24） in bridging group; compared with the other 2 groups, there were significant difference （X^2 = 9. 161, P = 0. 010）. The incidence of hematoma and hemorrhage of asprin group was lowest. Conclusions LMWH bridging therapy significantly increases the risk of pacemaker pocket hematoma and hemorrhage, and the pacemaker implantation may be safer after DES implantation 6 months.