不间断抗凝方案在经皮左心耳封堵围术期的临床应用研究

Continuous anticoagulation regimen in the perioperative period of percutaneous left atrial appendage closure

目的探讨不间断抗凝方案在经皮左心耳封堵术(LAAC)围术期抗凝治疗中的临床应用特点及安全性和有效性。方法连续纳入2018年1月至2020年12月南京医科大学鼓楼临床医学院心内科收治的非瓣膜性心房颤动(房颤)行经皮LAAC的患者共62例,根据术前是否停用原口服抗凝药将患者分为不间断抗凝组(26例)和间断抗凝组(36例)。分析和比较两组患者术中抗凝特点,包括基础活化凝血时间(ACT),肝素化后最大ACT值,平均ACT值;围术期出血事件和栓塞事件以及出血导致血红蛋白下降>20 g/L的发生率,其中出血事件包括严重出血事件(脑出血、心脏压塞)和其他出血包括消化道和泌尿道出血、穿刺部位血肿、口腔和鼻出血等;栓塞事件包括脑卒中、颅外循环栓塞。结果不间断抗凝组与间断抗凝组患者基础ACT值为[146.50(131.00,171.25)s对134.00(121.00,169.50)s,P=0.380];术中最大的ACT值为[300.00(277.00,366.25)s对309.00(286.50,329.75)s,P=0.926];ACT值为[(251.63±39.07)s对(241.74±34.37)s,P=0.295];围术期不间断抗凝组与间断抗凝组出血事件总数分别为5例和6例(19.2%对16.7%,P=0.794),血红蛋白下降>20 g/L的人数分别为8例和7例(30.8%对19.4%,P=0.304),差异无统计学意义(P>0.05)。均无栓塞事件发生。结论不间断抗凝治疗在房颤患者LAAC围术期抗凝治疗中的安全性和有效性均不劣于间断抗凝治疗,可以作为LAAC围术期新的抗凝治疗策略。

Objective To investigate the clinical characteristics,safety and efficacy of an uninterrupted anticoagulation protocol for the perioperative anticoagulation treatment of patients undergoing percutaneous left atrial appendage closure(LAAC).Methods A total of 62 patients who underwent percutaneous LAAC for nonvalvular atrial fibrillation(AF)admitted to Department of Cardiology,Nanjing Drum Tower Hospital,Clinical College of Nanjing Medical University between January 2018 and December 2020 were consecutively enrolled,and the patients were divided into uninterrupted anticoagulation group(26 patients)and interrupted anticoagulation group(36 patients)according to whether the original oral anticoagulant was uninterrupted on the day of surgery.The characteristics of intraoperative anticoagulation,perioperative bleeding events and embolic events were analyzed and compared between the two groups,including basal activated clotting time(ACT),maximum ACT value after heparinization and mean ACT value,in which bleeding events included severe bleeding events(cerebral hemorrhage,pericardial tamponade),bleeding resulting in a drop in hemoglobin greater than 20 g/L,and other bleeding including gastrointestinal and urinary urethral hemorrhage,hematoma at the puncture site,oral and nasal hemorrhage.Embolic events include stroke,embolism in the extracranial circulation.Results The baseline ACT value were[146.50(131.00,171.25)s vs.134.00(121.00,169.50)s]respectively between patients on uninterrupted versus interrupted anticoagulation(P=0.380).The intraoperative maximum ACT values were[300.00(277.00,366.25)s vs.309.00(286.50,329.75)s,P=0.926].The mean ACT values were[(251.6±39.07)s vs.(241.74±34.37)s,P=0.295],and the total number of bleeding events was 5 and 6 in the uninterrupted versus interrupted anticoagulation groups during the periprocedural period(19.2%vs.16.7%,P=0.794),and the number of persons with a hemoglobin drop>20 g/L was 8 and 7(30.8%vs.19.4%,P=0.304),respectively(all P>0.05).The total number of embolic events was all 0.Conclusion Both safety and efficacy of uninterrupted anticoagulation in the setting of LAAC perioperative anticoagulation in patients with AF were noninferior to those of interrupted anticoagulation perioperative.