心房颤动患者左心耳Watchman封堵器相关血栓的发生及转归

Incidence,predictors and outcomes of device-related thrombus after left atrial appendage closure with the Watchman device

目的 分析心房颤动(简称房颤)患者左心耳置入Watchman封堵器后封堵器相关血栓(DRT)的发生率、危险因素及其转归。方法 连续入选2016年8月—2021年6月于上海健康医学院附属周浦医院就诊的585例应用Watchman封堵器行左心耳封堵的房颤患者,其中75.04%(439/585)患者完成经食道超声心动图(TEE)复查,完成随访患者419例。收集患者的基线资料和临床资料,记录左心耳封堵术中参数、术后DRT的发生情况,DRT组患者的抗栓方案和预后。采用Cox回归分析左心耳封堵术后发生DRT的危险因素。结果 419例患者中,男222例、女197例,年龄为(73.2±9.2)岁,房颤脑卒中危险评分(CHA_(2)DS_(2)-VASc评分)为(5.1±1.7)分,房颤出血风险评估(HAS-BLED评分)为(2.9±1.2)分。左心耳封堵术后DRT发生率为4.3%(18/419)。根据TEE诊断结果将患者分为无DRT组(401例)和DRT组(18例)。DRT组患者的CHA_(2)DS_(2)-VASc评分和有缺血性脑卒中史的比例显著高于无DRT组(P值均<0.05)。两组间左心耳口直径、置入Watchman封堵器直径、封堵器压缩比、左心耳完全封堵状态、封堵器周边漏为1~3 mm或≥3 mm、术中更换封堵器占比的差异均无统计学意义(P值均>0.05)。Cox回归分析结果显示,高CHA_(2)DS_(2)-VASc评分(RR=3.468,95%CI为2.189~7.786,P=0.001)和缺血性脑卒中病史(RR=1.494,95%CI为1.020~2.189,P=0.003)是应用Watchman封堵器行左心耳封堵术后发生DRT的独立危险因素。DRT组患者均继续抗凝治疗,包括华法林或非维生素K拮抗剂(NOACs)方案,随访期间均未发生急性缺血性脑卒中或系统性栓塞,1例发生脑出血,1例因恶性肿瘤死亡。结论 应用Watchman封堵器行左心耳封堵的房颤患者术后DRT发生率为4.3%,高CHA_(2)DS_(2)-VASc评分和缺血性脑卒中病史是DRT发生的主要危险因素。

Objective To analyze the incidence,risk factors and outcomes of device-related thrombus(DRT)after left atrial appendage closure(LAAC)with the Watchman device in patients with atrial fibrillation(AF).Methods A total of 585 AF patients who underwent LAAC with the Watchman device at Zhoupu Hospital from August 2016 to June 2021 were enrolled in this study.Of these,75.04%(439/585)completed transesophageal echocardiography(TEE)review,and follow-up was completed in 419 patients.The baseline and clinical data of the patients were collected.Intraoperative parameters of LAAC,the occurrence of DRT,antithrombotic regimen,and prognosis were recorded.Cox regression was used to analyze risk factors for the occurrence of DRT after LAAC.Results There were 222 males and 197 females with an average age of(73.2±9.2)years.The CHA_(2) DS_(2)-VASc score was 5.1±1.7,and the HAS-BLED score was 2.9±1.2.The incidence of DRT after LAAC was 4.3%(18/419).Based on the TEE results,the patients were categorized into DRT-free group(n=401)and DRT group(n=18).The DRT group had a significantly higher CHA_(2) DS_(2)-VASc score and a higher proportion of patients with the history of ischemic stroke than DRT-free group(P<0.05).No significant differences were found between the two groups in LAA orifice diameter,Watchman size,compression ratio,plugged state,peri-device leakage 1-3 mm or≥3 mm,or the percentage of intraoperative replacement of Watchman(P>0.05).The Cox regression analysis revealed that a high CHA_(2) DS_(2)-VASc score(RR=3.468,95%CI:2.189-7.786,P=0.001)and ischemic stroke(RR=1.494,95%CI:1.020-2.189,P=0.003)were risk factors for the development of DRT after LAAC.In the DRT group,patients continued anticoagulant therapy(warfarin or NOACs regimens).None of the patients experienced acute ischemic stroke or systemic embolism,but there was one case of cerebral hemorrhage and one case of death due to malignancy.Conclusion The incidence of DRT after LAAC with the Watchman device is 4.3%.A high CHA_(2) DS_(2)-VASc score and a history of ischemic stroke are the major risk factors for DRT.