Peri-procedural anticoagulation management of mechanical prosthetic heart valve patients
Peri-procedural anticoagulation management of mechanical prosthetic heart valve patients
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DOI：
10.1016/j.thromres.2009.01.011
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发表时间：
2009-07-01
影响因子：
7.5
通讯作者：
Heit, John A.
中科院分区：
文献类型：
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作者：
Daniels, Paul R.;McBane, Robert D.;Heit, John A.
为了评估机械心脏瓣膜(MHV)患者围手术期抗凝治疗后3个月血栓栓塞和出血的累积发生率，对1997-2003年间连续7年到梅奥临床血栓形成中心接受围手术期抗凝治疗的MHV患者进行了为期3个月的血栓栓塞症、出血和生命状态的跟踪调查。材料和方法：术前4-5天停用华法林，术中止血后立即重新使用华法林。结果：556例MHV患者(单纯主动脉372例，单纯二尖瓣136例，多瓣膜48例)共接受了580次手术。血栓栓塞率为0.9%，其中脑缺血3例，不稳定型心绞痛1例，急性心肌梗死1例。没有一人死亡。大出血累积发生率为3.6%，死亡率为0.2%。无论使用低分子肝素(3.7%)、超低分子肝素(6.1%)或不使用肝素(2.4%)，术后主要出血事件的发生率均无差异(p=0.26)。结论：因有创而暂时中断抗凝的MHV患者血栓栓塞症的三个月累积发生率较低。虽然出血超过血栓栓塞性并发症，但我们目前的做法是在手术后尽快重新启动华法林。术后肝素用于血栓栓塞症风险最高的患者(二尖瓣MHV、多发性MHV、MHV既往中风或心房颤动)，在开始治疗前至少等待48小时。(C)2009爱思唯尔有限公司。保留所有权利。
Introduction: To estimate the three-month cumulative incidence of thromboembolism and bleeding among mechanical heart valve (MHV) patients receiving peri-procedural anticoagulation management, consecutive MHV patients referred to the Mayo Clinic Thrombophilia Center for peri-procedural anticoagulation management over the seven-year period, 1997-2003, were followed for three months for thromboembolism, bleeding and vital status.Materials and Methods: Warfarin was stopped 4-5 days prior to the procedure, and re-started after the procedure as soon as hemostasis was assured. The decision to provide bridging therapy with low molecular weight (LMWH) or unfractionated (UFH) heparin was individualized and based on the estimated risks of TE and bleeding.Results: 556 MHV patients (372 aortic only, 136 mitral only, 48 with multiple valves) underwent 580 procedures. The three-month cumulative incidence of thromboembolism was 0.9% which included: cerebral ischemia (n = 3), unstable angina (n = 1), acute myocardial infarction (n = 1). None were fatal. The cumulative incidence of major bleeding was 3.6% and fatal in 0.2%. The incidence of major bleeding events did not differ by postoperative anticoagulant strategy whether LMWH (3.7%), UFH (6.1%), or no heparin (2.4%) was used (p = 0.26).Conclusions: The three-month cumulative incidence of thromboembolism among MHV patients in whom anticoagulation is temporarily interrupted for an invasive procedure is low. Whereas bleeding exceeds thromboembolic complications, our current practice is to restart warfarin as soon as possible post-procedure. Post-procedural heparin use is reserved for patients with the highest thromboembolic risk (mitral MHV, multiple MHVs, MHV with prior stroke or atrial fibrillation) waiting at least 48 hours before initiating. (c) 2009 Elsevier Ltd. All rights reserved.