人工心脏瓣膜置换术后患者的抗凝治疗

Aniticoagulation in patients following prosthetic heart valve replacement.

作者信息

Akhtar Raja Parvez, Abid Abdul Rehman, Zafar Hasnain, Khan Jawad Sajid

机构信息

Department of Cardiac Surgery, Punjab Institute of Cardiology, Lahore, Pakistan.

出版信息

Ann Thorac Cardiovasc Surg. 2009 Feb;15(1):10-7.

PMID:19262444

Abstract

PURPOSE

To identify optimum international normalized ratio (INR) levels and required warfarin doses and anticoagulation-related complications in patients following mechanical prosthetic valve replacement.

MATERIALS AND METHODS

Five hundred and seven patients were prospectively followed up for 10 years (2008.5 patient-years). Anticoagulation-related complications were classified into hemorrhage and thromboembolism.

RESULTS

Two hundred and ninety-two (57.6%) were males and 215 (42.4%) were females with a mean age of 29.5 +/- 11.32 years. A total of 268 (52.9%) patients had mitral, 96 (18.9%) had aortic and mitral, and 76 (15%) had aortic valve replacement (AVR). Valves implanted totaled 345 (68%) ball and cage, 126 (24.9%) bileaflet, and 36 (7.1%) single disc. There were 10,669 total visits, with mean INR 2.6 +/- 0.59 and mean warfarin 5.17 +/- 1.6 mg. Sixty-four (3.2% per patient-years) events occurred during follow-up, of which 23 (1.13% per patient-years) events were due to thromboembolism and 41 (2.04% per patient-years) to bleeding. Atrial fibrillation occurred in 12 (52.4%) patients having thromboembolic events and in 24 (58.5%) suffering from bleeding complications. Among thromboembolic events, valve thrombosis occurred in 9 patients (0.44% per patient-years) and cerebrovascular accidents (CVAs) in 14 (0.69% per patient-years). Atrial fibrillation was present in 7 (77.8%) patients in the valve thrombosis group and in 5 (35.7%) in the CVA group. Of 41 bleeding events, 8 (0.39% per patient-years) were minor episodes, 20 (0.99% per patient-years) were major episodes, and severe hemorrhage occurred in 5 (0.34% per patient-years). Intracranial hemorrhage leading to CVA was seen in 8 patients (0.34% per patient-years). There were 22 (1.1% per patient-years) fatal hemorrhages and 15 (0.74% per patient-years) fatal thromboembolic events. In-hospital mortality was 25 (4.9%), and 62 (12.2%) were late deaths; of these, 37 (7.3%) were anticoagulation related.

CONCLUSIONS

Anticoagulation for mechanical heart valve replacement can be managed with INR levels of 2-2.5 with acceptable hemorrhagic and thromboembolic events.

摘要

目的

确定机械瓣膜置换术后患者的最佳国际标准化比值（INR）水平、所需华法林剂量及抗凝相关并发症。

材料与方法

对507例患者进行了为期10年（2008.5患者年）的前瞻性随访。抗凝相关并发症分为出血和血栓栓塞。

结果

男性292例（57.6%），女性215例（42.4%），平均年龄29.5±11.32岁。共有268例（52.9%）患者进行了二尖瓣置换，96例（18.9%）进行了主动脉瓣和二尖瓣置换，76例（15%）进行了主动脉瓣置换（AVR）。植入的瓣膜中，球笼瓣345个（68%），双叶瓣126个（24.9%），单盘瓣36个（7.1%）。总共进行了10669次随访，平均INR为2.6±0.59，平均华法林剂量为5.17±1.6mg。随访期间发生64例事件（每患者年3.2%），其中23例事件（每患者年1.13%）为血栓栓塞所致，41例事件（每患者年2.04%）为出血所致。12例（52.4%）发生血栓栓塞事件的患者和24例（58.5%）发生出血并发症的患者出现房颤。在血栓栓塞事件中，9例患者（每患者年0.44%）发生瓣膜血栓形成，14例患者（每患者年0.69%）发生脑血管意外（CVA）。瓣膜血栓形成组7例（77.8%）患者出现房颤，CVA组5例（35.7%）患者出现房颤。在41例出血事件中，8例（每患者年0.39%）为轻微出血，20例（每患者年0.99%）为大出血，5例（每患者年0.34%）发生严重出血。8例患者（每患者年0.34%）发生导致CVA的颅内出血。有22例（每患者年1.1%）致命性出血和15例（每患者年0.74%）致命性血栓栓塞事件。住院死亡率为25例（4.9%），62例（12.2%）为晚期死亡；其中37例（7.3%）与抗凝有关。