Department of Medicine, Regions Hospital and the University of Minnesota Medical School, Saint Paul, Minnesota 55101, USA.
Heart Rhythm. 2010 Jun;7(6):745-9. doi: 10.1016/j.hrthm.2010.02.018. Epub 2010 Feb 20.
Current guidelines recommend stopping oral anticoagulation and starting bridging anticoagulation with intravenous heparin or subcutaneous enoxaparin when implanting a pacemaker or defibrillator in patients at moderate or high risk for thromboembolic events. A limited body of literature suggests that device surgery without cessation of oral anticoagulation may be feasible.
The purpose of this study was to evaluate the safety of device surgery in orally anticoagulated patients without interrupting warfarin therapy.
We performed a retrospective study of 459 consecutive patients on chronic warfarin therapy who underwent device surgery from April 2004 to September 2008. Warfarin was continued in 222 patients during the perioperative period. Warfarin was temporarily held and bridging therapy administered in 123 patients. Warfarin was temporarily held without bridging therapy in 114 patients.
There were no significant differences with regard to age, sex, or risk factors for thromboembolism in the three groups. Patients who continued taking warfarin had a lower incidence of pocket hematoma (P = .004) and a shorter hospital stay (P <.0001) than did patients in the bridging group. Holding warfarin without bridging is associated with a higher incidence of transient ischemic attacks (P = .01).
Temporarily interrupting anticoagulation is associated with increased thromboembolic events, whereas cessation of warfarin with bridging anticoagulation is associated with a higher rate of pocket hematoma and a longer hospital stay. Continuing warfarin with a therapeutic international normalized ratio appears to be a safe and cost-effective approach when implanting a pacemaker or defibrillator in patients with moderate to high thromboembolic risk.
目前的指南建议，对于有中度或高度血栓栓塞事件风险的患者，在植入起搏器或除颤器时，应停止口服抗凝治疗并开始静脉肝素或皮下依诺肝素桥接抗凝治疗。有限的文献表明，不停用口服抗凝药物进行器械手术可能是可行的。
本研究旨在评估不停用华法林治疗的情况下，接受口服抗凝药物治疗的患者进行器械手术的安全性。
我们对 2004 年 4 月至 2008 年 9 月期间连续 459 例接受慢性华法林治疗的患者进行了回顾性研究，这些患者接受了器械手术。在围手术期，有 222 例患者继续服用华法林，123 例患者暂时停止服用华法林并进行桥接治疗，114 例患者暂时停止服用华法林但不进行桥接治疗。
三组患者在年龄、性别或血栓栓塞风险因素方面无显著差异。继续服用华法林的患者发生囊袋血肿的发生率较低（P =.004），住院时间较短（P <.0001），而桥接组患者的发生率较高。不进行桥接而暂时停止华法林治疗与一过性脑缺血发作发生率升高有关（P =.01）。
暂时中断抗凝治疗与血栓栓塞事件增加有关，而桥接抗凝治疗停止华法林与囊袋血肿发生率较高和住院时间延长有关。在中高危血栓栓塞风险的患者中植入起搏器或除颤器时，继续使用华法林并维持治疗国际标准化比值可能是一种安全且具有成本效益的方法。
