Tischenko Alex, Gula Lorne J, Yee Raymond, Klein George J, Skanes Allan C, Krahn Andrew D
Division of Cardiology, University of Western Ontario, London, Ontario, Canada.
Am Heart J. 2009 Aug;158(2):252-6. doi: 10.1016/j.ahj.2009.06.005.
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.
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 > or =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.
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.
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.
需要植入心律失常装置的患者中，服用华法林的人数日益增多。华法林中断及围手术期使用肝素桥接的常规做法与术后出血并发症的高发生率相关。我们评估了在不中断华法林治疗的情况下进行装置植入的安全性。
研究了三组患者：第1组由117例长期接受华法林治疗且有显著血栓栓塞风险（CHADS(2)评分≥2的房颤、机械心脏瓣膜、近期静脉血栓栓塞）的连续患者组成，他们在不中断华法林治疗的情况下接受了心律失常装置植入。第2组为117例年龄和性别匹配、未服用华法林且手术类型匹配的对照患者。第3组由38例有类似血栓栓塞风险的历史对照患者组成，他们在手术前和术后24小时中断华法林治疗并使用达肝素桥接。通过锁骨下或腋静脉穿刺使用主动固定导线，56%的患者在心室进行间隔固定。在出院时以及术后7天和30天评估出血和血栓栓塞并发症。
在18个月期间，1562例连续成年患者接受了心律装置植入或更换。447例服用华法林的患者中有117例被认为是高风险患者，手术时继续服用华法林。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，男性73例）。9例患者（7.7%）出现明显血肿，1例需要手术修复（0.9%）。第2组（对照）有5例患者出现明显血肿（4.3%），均无需修复（P = 0.41）。第3组有9例患者出现明显血肿（23.7%，P = 0.012），其中3例需要再次手术（7.9%，P = 0.046）。所有患者均无死亡、血栓栓塞事件、心脏压塞或血胸。华法林治疗患者发生血肿的唯一危险因素是植入的导线数量。
对于高血栓栓塞风险的患者，在不中断华法林治疗的情况下可以安全地植入心律失常装置。与达肝素桥接相比，这种策略可能与显著减少囊袋血肿的风险相关。
