University of Utah Thrombosis Service, University of Utah, Department of Pharmacy Services, 675 Arapeen Drive, Suite 100, Salt Lake City, UT 84108, USA.
Thromb Res. 2010 Aug;126(2):e69-77. doi: 10.1016/j.thromres.2009.11.031. Epub 2010 Jan 6.
Radiofrequency catheter ablation is being used with increasing frequency as a strategy to manage atrial fibrillation. Patients undergoing this procedure are at increased short-term risk of thromboembolism for several days and up to 4 weeks or longer after their ablation, and anticoagulation management surrounding the ablation procedure remains controversial. Although no conclusive recommendations can be made, published guidelines and data support therapeutic anticoagulation with warfarin for 3 weeks prior and intravenous heparin during the ablation. Warfarin may either be continued through the ablation or stopped 2-5 days prior. If the latter approach is chosen, a pre-ablation bridging strategy of enoxaparin 1mg/kg twice daily is reasonable in selected patients unless the patient's bleeding risk dictates using a lower dose regimen (0.5mg/kg twice daily) or avoiding bridging altogether. Fewer data are available for post-ablation management strategies, and current practice patterns are based largely on single-center experiences in smaller, non-randomized studies. For lower risk patients (CHADS(2) 0-1), either warfarin or aspirin may be utilized without bridging. In higher thromboembolic risk patients (CHADS(2) >or=2), either enoxaparin (1mg/kg twice daily) or heparin may be started within the first 12-24h post-procedure. For patients with bleeding risk factors, enoxaparin may be subsequently reduced to 0.5mg/kg until the INR is therapeutic, although the efficacy of this lower dosing regimen has not been well studied. In accordance with national guidelines, warfarin should be continued post-ablation for a minimum of 2 months and then indefinitely in patients with a CHADS(2) score >or= 2.
射频导管消融术作为一种管理心房颤动的策略，其应用频率正在不断增加。接受该手术的患者在消融术后几天至 4 周或更长时间内，短期内心血栓栓塞风险增加，并且消融手术周围的抗凝管理仍然存在争议。虽然不能做出明确的建议，但已发表的指南和数据支持在消融前 3 周使用华法林进行治疗性抗凝，并在消融过程中使用静脉肝素。华法林可以在消融过程中继续使用，也可以在消融前 2-5 天停止使用。如果选择后者，在选择的患者中，使用依诺肝素 1mg/kg 每日两次进行预消融桥接策略是合理的，除非患者的出血风险需要使用较低剂量方案（0.5mg/kg 每日两次）或完全避免桥接。关于消融后管理策略的数据较少，目前的实践模式主要基于较小的、非随机研究中的单中心经验。对于低风险患者（CHADS(2) 0-1），可以不进行桥接而使用华法林或阿司匹林。对于高血栓栓塞风险患者（CHADS(2) >or=2），可以在术后 12-24 小时内开始使用依诺肝素（1mg/kg 每日两次）或肝素。对于有出血危险因素的患者，依诺肝素随后可减少至 0.5mg/kg，直到 INR 达到治疗范围，尽管尚未充分研究这种较低剂量方案的疗效。根据国家指南，对于 CHADS(2)评分>or=2 的患者，应在消融后至少继续使用华法林 2 个月，然后无限期使用。
