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

Safety and feasibility of left atrial appendage occlusion in atrial fibrillation patients with thrombus in left atrial appendage:single-center experience

目的分析心房颤动合并左心耳血栓行左心耳封堵术的安全性和有效性。方法连续入选上海健康医学院附属周浦医院11例经冠状动脉计算机断层扫描血管成像(CTA)和经食管超声心动图(TEE)确诊左心耳血栓,抗凝方案治疗,但不能耐受长期抗凝及抗凝无效时,行左心耳封堵治疗的心房颤动患者纳入研究。结果心房颤动患者包括阵发性、持续性和长程持续性心房颤动,平均年龄为78岁(57~93岁),CHA2DS2-VASc评分平均值为6.2(4~8)分,HAS-BLED评分平均值为3.6(2~6)分。左心耳血栓2型(近端至中端)和3型(远端)分别有2例和9例。3例患者抗凝治疗左心耳血栓消失后行左心耳封堵术,8例患者左心耳血栓存在情况下行左心耳封堵术(1例为2型血栓,7例为3型血栓)。2例患者左心耳血栓消失病例采用Watchman封堵器,其他患者均用LAmbre封堵器完成左心耳封堵术。1例患者左心耳LAmbre封堵术后住院期间发生短暂性脑缺血发作,出院后随诊未再发生;其他病例未发生任何明显的围术期不良事件。术后8~12周TEE复查,3例发生左心耳器械相关血栓,继续抗血小板药物联合华法林或非维生素K口服抗凝药(NOACs)抗凝方案。中位随访时间为6(6,13)个月,随访期间未发生心血管和全因死亡、重大缺血性脑血管事件、心力衰竭恶化和重大出血事件。结论对于心房颤动合并左心耳血栓患者首选华法林或NOACs抗凝方案,抗凝无效或不能耐受、适宜左心耳封堵术的左心耳血栓患者,可选择左心耳封堵术作为替代治疗方案。

Objective To analyze the safety and effectiveness of left atrial appendage occlusion for atrial fibrillation complicated with left atrial appendage thrombosis.Methods A total of 11 patients with AF in our hospital,whom were diagnosed of LAA thrombus by cardiac CT angiography and transesophageal echocardiography(TEE)were enrolled.LAAC were performed because of intolerance or ineffective of anticoagulation.Results Paroxysmal,persistent and longterm persistent AF were all included,with mean age of 78 years(57-93),mean CHA2DS2-VASC score of 6.2(4-8),mean HAD-BLED score of 3.6(2-6).LAA thrombus including type 2(proximal to middle)and type 3(distal)were found in 2 and 9 cases,respectively.LAAC were performed in 3 patients with LAA thrombus disappeared after warfarin or NOACs treatment,and in 8 patients with the presence of LAA thrombus(1 patient with type 2 thrombus and 7 patients with type 3 thrombus).Watchman occlude was implanted in 1 patient whom LAA thrombus disappeared,all others underwent Lambre occluder.Transient ischemic attack occurred in 1 patient during hospitalization after LAAC,without reoccurrence after discharge.During perioperative period,no significant cardiac and cerebral vascular events occurred in other cases.According to TEE examination in 8-12 weeks after LAAC,device related thrombus was found in 3 cases,whom continued with antiplatelet drugs with warfarin or NOACs.The median follow-up time was 6 months(6,13),and no cardiovascular and cerebrovascular events or all-cause deaths,worsening heart failure,or major bleeding events occurred during the follow-up period.Conclusions For AF patients complicated with LAA thrombus,the first choice was anticoagulant with warfarin or NOACs.For those ineffective or intolerance with anticoagulation and suitable for LAAC,LAAC is an alternative treatment option.