左心耳封堵术后器械相关血栓的单中心调查和病例分析

Single-center investigation and case series with device-related thrombus after left atrial appendage closure

目的探讨左心耳封堵术(left atrialappendage closure,LAAC)后器械相关血栓(device-related thrombus,DRT)的发生率、预测因子及其临床转归。方法回顾性分析2017年5月—2019年8月在上海长海医院因非瓣膜性心房颤动(简称房颤)应用Watchman封堵器完成LAAC的患者病史资料,重点分析所有发现DRT患者的基线资料、围术期和随访数据等。结果本研究共纳入203例患者,手术成功198例(97.5%)。随访时间为(12.2±7.1)个月,左心耳影像学随访82例(42.3%)。随访期间发现DRT 5例,总发病率为2.5%(5/198),占影像学随访的6.1%(5/82)。发生DRT者的共同特征包括持续性房颤、左心房容积增大、左心房内径增大、植入大尺寸的封堵器(4例33 mm,1例30 mm)。5例DRT患者中,4例患者年龄≥65岁,3例既往有脑梗死病史,3例房颤血栓危险度评分(CHA 2DS 2-VASc评分)≥3分,3例患者术前经食管超声心动图检查见左心耳内自发显影现象。发现DRT的时间为术后(5.4±2.0)个月。DRT确诊后,4例予利伐沙班治疗,1例予华法林治疗。随访中,2例DRT消失,1例DRT缩小,5例DRT患者均未发生血栓栓塞事件。结论LAAC术后DRT并不罕见,临床医师对高危患者应加强术后左心耳影像学随访,做到早发现、早诊断、早治疗。

Objective To investigate the incidence,predictive factors and clinical outcomes of device-related thrombus(DRT)after left atrial appendage closure(LAAC).Methods Clinical data of patients with nonvalvular atrial fibrillation who underwent the LAAC procedure with Watchman between May 2017 and August 2019 in Shanghai Changhai Hospital were retrospectively analyzed.The baseline,perioperative,and follow-up data of the patients with DRT were investigated.Results The LAAC procedure was performed in 203 consecutive patients with a procedural success rate of 97.5%(198/203).The follow-up duration was(12.2±7.1)months.A total of 82 patients(42.3%)underwent LAA imaging during follow-up.DRT was observed in 5 patients,accounting for 2.5%(5/198)of the whole patients with the Watchman device and 6.1%(5/82)of the patients receiving LAA imaging.Common features of these patients were persistent atrial fibrillation,enlarged left atrial volume,increased left atrial diameter,and larger occlude(4 cases of 33 Watchman and 1 case of 30 Watchman).Out of the 5 DRT patients,there were 4 with an age of≥65 years,3 with previous ischemic stroke,3 with CHA 2DS 2-VASc score≥3,and 3 with preoperative spontaneous transesophageal echocardiographic contrast in the left atrial appendage.The time of DRT was(5.4±2.0)months after surgery.Four patients were treated with rivaroxaban and one with warfarin.During follow-up,complete thrombus resolution was achieved in 2 patients and partial thrombus resolution in one.Fortunately,all the 5 DRTs survived without thromboembolism events.Conclusion DRT is a not rare complication after LAAC.Left atrial appendage imaging should be performed regularly in patients with high-risk DRT during follow-up,so as to achieve early detection and early treatment.