Implantation of cardiac rhythm devices without interruption of oral anticoagulation compared with perioperative bridging with low-molecular weight heparin
Implantation of cardiac rhythm devices without interruption of oral anticoagulation compared with perioperative bridging with low-molecular weight heparin
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DOI：
10.1016/j.ahj.2009.06.005
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发表时间：
2009-08-01
影响因子：
4.8
通讯作者：
Kraho, Andrew D.
中科院分区：
文献类型：
--
作者：
Tischenko, Alex;Gula, Lorne J.;Kraho, Andrew D.
越来越多需要植入心律失常装置的患者正在服用华法林。华法林中断和围手术期肝素桥接的常见做法与术后出血并发症的发生率高相关。我们评估了装置植入的安全性，而不中断华法林therapeutic.Methods三个患者组进行了研究：第1组包括117例连续的长期华法林治疗的患者，具有显著的血栓栓塞风险（房颤与CHADS（2）评分>= 2，机械心脏瓣膜，最近静脉血栓栓塞），他们接受了心律失常装置植入而不中断华法林。第2组为117例患者，作为年龄和性别匹配的对照组，与未服用华法林的手术类型匹配。第3组包括38例相似血栓栓塞风险历史对照患者，这些患者在术前和术后24小时中断华法林治疗并使用达肝素桥接。锁骨下或腋静脉穿刺使用主动固定电极导线，56%的患者在心室中进行间隔固定。在出院时以及手术后7天和30天评估出血和血栓栓塞并发症。结果在18个月的时间内，连续1，562名成年患者接受了心律装置植入或更换。447例接受华法林治疗的患者中有117例被认为是高风险患者，并在手术中继续接受华法林治疗。第1组患者的平均国际标准化比值为2.2 ± 0.4（年龄79 ± 11岁，73例男性）。在9例患者（7.7%）中观察到严重血肿，1例需要手术翻修（0.9%）。第2组5例患者（对照组）出现严重血肿（4.3%），均无需翻修（P = 0.41）。在第3组中，9例患者发生严重血肿（23.7%，P = 0.012），其中3例需要再次手术（7.9%，P = 0.046）。所有患者均未发生死亡、血栓栓塞事件、心包填塞或血胸。华法林患者血肿的唯一危险因素是植入的导线数量。结论心律失常装置可以安全地植入在患者的高血栓栓塞风险，而不中断华法林。与达肝素桥接相比，该策略可能与显著囊袋血肿风险降低相关。(Am Heart J 2009; 158：252-6.）
Background Increasing numbers of patients requiring arrhythmia device implantation are taking warfarin. The common practice of warfarin interruption and perioperative bridging with heparin is associated with a high rate of postoperative hemorrhagic complications. We assessed the safety of device implantation without interruption of warfarin therapy.Methods Three patient groups were studied: Group 1 consisted of 117 consecutive patients on long-term warfarin therapy with significant risk of thromboembolism (atrial fibrillation with CHADS(2) score >= 2, mechanical heart valve, recent venous thromboembolism) who underwent arrhythmia device implantation without interruption of warfarin. Group 2 was 117 patients who served as age- and sex-matched controls matched to procedure type not taking warfarin. Group 3 consisted of 38 similar thromboembolic risk historical control patients who underwent interruption of warfarin therapy and bridging with dalteparin before and 24 hours after surgery. Active fixation leads were used by subclavian or axillary vein puncture, with septal fixation in the ventricle in 56% of patients. Hemorrhagic and thromboembolic complications were assessed at discharge and at 7 and 30 days after surgery.Results During an 18-month period, 1,562 consecutive adult patients underwent heart rhythm device implantation or replacement. One hundred seventeen of the 447 patients on warfarin were considered high risk and remained on warfarin for their procedure. The mean international normalized ratio in group 1 patients was 2.2 +/- 0.4 (age 79 11 years, 73 male). Significant hematoma was noted in 9 patients (7.7%), and one required surgical revision (0.9%). Five group 2 patients (control) had significant hematomas (4.3%), none of which required revision (P =.41). In group 3, 9 patients developed significant hematomas (23.7%, P = .012), 3 of whom required reoperation (7.9%, P = .046). There were no deaths, thromboembolic events, cardiac tamponade, or hemothorax in any patient. The only risk factor for hematoma in the warfarin patients was the number of leads implanted.Conclusions Arrhythmia devices can be implanted safely in patients with high thromboembolic risk without interruption of warfarin. This strategy may be associated with reduced risk of significant pocket hematoma compared with dalteparin bridging. (Am Heart J 2009; 158:252-6.)