1例左心耳封堵联合射频消融抗栓治疗病例分析及文献复习
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摘要
通过1例行左心耳封堵联合射频消融术患者的围术期及术后抗栓治疗方案调整情况,结合最新国际相关临床使用指南和治疗进展,总结、分析左心耳封堵联合射频消融术的围术期及术后抗栓治疗的选择。左心耳封堵联合射频消融手术适合高危房颤患者,既可以改善房颤症状,又能减少卒中和出血风险。使用新型口服抗凝药的患者术前一般需停药24 h以上,术中使用肝素,术后6 h以上即可恢复抗凝。使用华法林患者术前一般需停药3d以上,低分子肝素进行桥接。手术后抗凝6周可进行超声评估,内皮化完全后停止抗凝,之后使用双抗6个月,阿司匹林终身服用。患者在使用抗凝、双抗期间,如果出现出血事件,根据临床实际情况停用抗栓药物。医生和药师需权衡患者病情及出血风险决定术后的抗血小板治疗方案。
Based on the adjustment of antithrombotic therapy during and after operation in a patient undergoing left atrial appendage occlusion combined with radiofrequency ablation, combined with the latest international clinical guidelines and treatment progress, the perioperative and postoperative antithrombotic treatment options of left atrial appendage occlusion combined with radiofrequency ablation were summarized and analyzed. Left atrial appendage occlusion combined with radiofrequency ablation is suitable for patients with high-risk atrial fibrillation, which can not only relieve the symptoms of atrial fibrillation, but also reduce the risk of stroke and bleeding. Patients who use new oral anticoagulant generally need to stop taking drugs for more than 24 h before surgery. Heparin is used during surgery, and anticoagulation can be restored after more than 6 h after operation. Warfarin is usually discontinued for more than 3 days before operation and bridged with low molecular weight heparin. Ultrasound evaluation of anticoagulation was performed 6 weeks after operation. After endothelialization, anticoagulation was stopped. After that bi-anticoagulant was used for 6 months and aspirin was taken for life. During the period of using anticoagulant and bi-antibody, patients should stop using antithrombotic drugs according to the actual clinical situation if bleeding occurs. Doctors and pharmacists need to weigh the patient's condition and risk of bleeding to determine the antiplatelet regimen after surgery.
Based on the adjustment of antithrombotic therapy during and after operation in a patient undergoing left atrial appendage occlusion combined with radiofrequency ablation, combined with the latest international clinical guidelines and treatment progress, the perioperative and postoperative antithrombotic treatment options of left atrial appendage occlusion combined with radiofrequency ablation were summarized and analyzed. Left atrial appendage occlusion combined with radiofrequency ablation is suitable for patients with high-risk atrial fibrillation, which can not only relieve the symptoms of atrial fibrillation, but also reduce the risk of stroke and bleeding. Patients who use new oral anticoagulant generally need to stop taking drugs for more than 24 h before surgery. Heparin is used during surgery, and anticoagulation can be restored after more than 6 h after operation. Warfarin is usually discontinued for more than 3 days before operation and bridged with low molecular weight heparin. Ultrasound evaluation of anticoagulation was performed 6 weeks after operation. After endothelialization, anticoagulation was stopped. After that bi-anticoagulant was used for 6 months and aspirin was taken for life. During the period of using anticoagulant and bi-antibody, patients should stop using antithrombotic drugs according to the actual clinical situation if bleeding occurs. Doctors and pharmacists need to weigh the patient's condition and risk of bleeding to determine the antiplatelet regimen after surgery.
引文
[1]中国卒中学会.急性缺血性卒中血管内治疗中国指南(2018)[J].中国卒中杂志,2018,13(7):706-729.
[2] Patel M R,Mahaffey K W,Garg J,et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation[J]. N Engl J Med,2011,365(10):883-891.
[3] Wallentin L,Yusuf S,Ezekowitz M D,et al. Efficacy and safety of dabigatran compared with warfarin at different levels of international normalised ratio control for stroke prevention in atrial fibrillation:an analysis of the RE-LY trial[J]. Lancet,2010,376(9745):975-983.
[4]中华心血管病杂志血栓询证工作组.非瓣膜病心房颤动患者应用新型口服抗凝药物中国专家建议[J].中华心血管病杂志,2014,42(5):362-369.
[5] Heidbuchel H,Verhamme P,Alings M,et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular at-rial fibrillation[J]. Europace,2015,17(10):1467-1507.
[6] Swaans M J,Post M C,Rensing B J,et al. Ablation for atrial fibrillation in combination with left atrial appendage closure:first results of a feasibility study[J]. J Am Heart Assoc,2012,1(5):e002212.
[7] Wintgens L,Romanov A,Phillips K,et al. Combined atrial fibrillation ablation and left atrial appendage closure:long-term followup from a large multicentre registry[J]. Europace, 2018,20(11):1783-1789.
[8] Phillips K P,Walker D T,Humphries J A. Combined catheter ablation for atrial fibrillation and Watchman~(?)left atrial appendage occlusion procedures:Five-year experience[J]. J Arrhythm,2016,32(2):119-126.
[9] Walker D T,Humphries J A,Phillips K P. Combined catheter ablation for atrial fibrillation and Watchman~(?)left atrial appendage occlusion procedures:a single centre experience[J]. J Atr Fibrillation,2012,5(3):687.
[10] Fassini G, Conti S,Moltrasio M,et al. Concomitant cryoballoon ablation and percutaneous closure of left atrial appendage in patients with atrial fibrillation[J]. Europace, 2018, 18(11):1705-1710.
[11] Calvo N,Salterain N,Arguedas H,et al. Combined catheter ablation and left atrial appendage closure as a hybrid procedure for the treatment of atrial fibrillation[J]. Europace,2015,17(10):1533-1540.
[2] Patel M R,Mahaffey K W,Garg J,et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation[J]. N Engl J Med,2011,365(10):883-891.
[3] Wallentin L,Yusuf S,Ezekowitz M D,et al. Efficacy and safety of dabigatran compared with warfarin at different levels of international normalised ratio control for stroke prevention in atrial fibrillation:an analysis of the RE-LY trial[J]. Lancet,2010,376(9745):975-983.
[4]中华心血管病杂志血栓询证工作组.非瓣膜病心房颤动患者应用新型口服抗凝药物中国专家建议[J].中华心血管病杂志,2014,42(5):362-369.
[5] Heidbuchel H,Verhamme P,Alings M,et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular at-rial fibrillation[J]. Europace,2015,17(10):1467-1507.
[6] Swaans M J,Post M C,Rensing B J,et al. Ablation for atrial fibrillation in combination with left atrial appendage closure:first results of a feasibility study[J]. J Am Heart Assoc,2012,1(5):e002212.
[7] Wintgens L,Romanov A,Phillips K,et al. Combined atrial fibrillation ablation and left atrial appendage closure:long-term followup from a large multicentre registry[J]. Europace, 2018,20(11):1783-1789.
[8] Phillips K P,Walker D T,Humphries J A. Combined catheter ablation for atrial fibrillation and Watchman~(?)left atrial appendage occlusion procedures:Five-year experience[J]. J Arrhythm,2016,32(2):119-126.
[9] Walker D T,Humphries J A,Phillips K P. Combined catheter ablation for atrial fibrillation and Watchman~(?)left atrial appendage occlusion procedures:a single centre experience[J]. J Atr Fibrillation,2012,5(3):687.
[10] Fassini G, Conti S,Moltrasio M,et al. Concomitant cryoballoon ablation and percutaneous closure of left atrial appendage in patients with atrial fibrillation[J]. Europace, 2018, 18(11):1705-1710.
[11] Calvo N,Salterain N,Arguedas H,et al. Combined catheter ablation and left atrial appendage closure as a hybrid procedure for the treatment of atrial fibrillation[J]. Europace,2015,17(10):1533-1540.