心房颤动左心耳封堵联合冷冻消融术后器械相关血栓发生及预后研究

Clinical characteristics of device-related thrombus after left atrial appendage closure combined with cryoballoon ablation in patients with atrial fibrillation

目的探讨非瓣膜性心房颤动(房颤)缺血性脑卒中高危患者左心耳封堵(1eft atrial appendage closure,LAAC)联合二代球囊冷冻消融术发生封堵器械相关血栓(device-related thrombus,DRT)的病例特点及药物调整后疗效。方法2018年1月—2019年6月期间上海健康医学院附属周浦医院接受房颤卒中及出血高危风险的LAAC联合球囊冷冻消融术患者130例[男性72例,平均年龄(71.5±8.9)岁,左房前后径(45.1±7.8)mm],阵发性房颤,持续性房颤,长程持续性房颤比例分别为63.8%、13.8%、22.3%;脑卒中高风险评分和出血风险评分分别为(5.0±1.7)分、(2.8±1.0)分;39例(占30.2%)患者有脑卒中或短暂性脑缺血发作病史,脑出血病史者未选入;23例(占17.7%)为冠脉经皮介入治疗术后病例;术后抗栓方案为常规华法林或非维生素K拮抗剂口服抗凝药。术后2~3个月完成经食道超声心动图(transesophageal echocardiography,TEE)复查。TEE复查诊断DRT病例分为为DRT组,TEE复查正常病例为对照组,分析DRT组患者临床特征,调整抗栓治疗方案,及随诊期间临床预后。结果130例房颤患者均完成LAAC联合球囊冷冻消融术,中位数随访时间为16(12,21)个月。所有病例术中TEE监测完成封堵,其中植入Watchman和LAmbre封堵器分别为106例和24例,术后2~3个月完成TEE复查病例90例(占69%),7例(占5.8%)诊断DRT,其中植入Watchman和LAmbre封堵器分别为5例和2例;3例封堵术上见低回声团块及1例细束条絮样低回声团块,3例微小血栓,局部毛糙伞面局部毛糙。随诊期间,DRT病例均维持窦律,2例发生短暂性脑缺血发作。结论心房颤动LAAC联合冷冻消融术后DRT发生率较高,TEE复查确诊患者需强化抗凝治疗方案。

Objective To explore the characteristics of device-related thrombus(DRT)after left atrial appendage closure(LAAC)combined with second-generation balloon cryoablation in high stroke-risk patients with non-valvular atrial fibrillation(AF).Methods From January 2018 to June 2019,a total of 130 high stroke-risk patients with non-valvular AF(72 males and 58 females,mean age 71.5±8.9,left atrial anteroposterior diameter 45.1±7.8 mm)whom underwent LAAC combined with second-generation balloon cryoablation were included.The proportions of paroxysmal AF,persistent AF and long-term persistent AF were 63.8%,13.8%and 22.3%,respectively.The CHA_(2)DS_(2)-VASc and HAS-BLED scores were 5.0±1.7 and 2.8±1.0 respectively.Thirty nine patients(30.2%)had a history of ischemic stroke or transient ischemic attacks(TIA);23 patients(17.7%)were post-PCI.Postoperative antithrombotic regimen was conventional warfarin or non-vitamin K antagonist oral anticoagulants(NOACs).Transesophageal echocardiography(TEE)review 2-3 months after operation,according to TEE results patients were classified as DRT group or non-DRT group(control group).Clinical characteristics of patients in DRT group were analyzed,and antithrombotic therapy regimen was adjusted,the clinical outcomes were analyzed during the follow-up.Results All 130 patients with AF completed LAAC combined with second-generation balloon cryoablation of pulmonary vein electrical isolation;and patients were followed up for a median of 16 months(12-21 months).In all cases,the LAAC was completed by TEE monitoring during the operation;106 cases were implanted with Watchman occluders and 24 cases with LAmbre occluders.Ninety cases(69%)completed TEE review,and 7 cases(5.4%)diagnosed with DRT,including 5 implanted Watchman and 2 implanted LAmbre review occluders.Three cases showed hypoechoic mass and 1 case showed fascicular floc-like hypoechoic mass,and 3 cases showed local roughness on the upper side of the umbrella surface.During follow-up,sinus rhythm was maintained in DRT patients;and transient ischemic attack(TIA)occurred in 2 cases.Conclusion The incidence of DRT after LAAC with cryoablation balloon is high in AF patients,once DRT is diagnosed,AF patients should intensify anticogulant treatment regimens.