Ghanbari Hamid, Feldman Dustin, Schmidt Martin, Ottino Jessica, Machado Christian, Akoum Nazem, Wall T Scott, Daccarett Marcos
Division of Cardiac Electrophysiology, Providence Hospital and Medical Centers/Wayne State University, Southfield, Michigan, USA.
Pacing Clin Electrophysiol. 2010 Apr;33(4):400-6. doi: 10.1111/j.1540-8159.2010.02703.x. Epub 2010 Feb 18.
Many patients who need cardiac resynchronization therapy (CRT) require chronic anticoagulation. Current guidelines recommend discontinuation of warfarin and the initiation of anticoagulant "bridging" therapy during these procedures. We evaluated the safety of CRT-device (CRT-D) implantation without interruption of warfarin therapy.
A total of 123 consecutive patients requiring CRT-D therapy were enrolled, 49 identified as high risk for thromboembolic events who received either intravenous heparin, low molecular weight heparin, or warfarin therapy. The control group comprised 74 patients with low risk of thromboembolic events who required only cessation of warfarin perioperatively. Patients were evaluated at discharge and 15 and 30 days postoperatively for pocket hematomas, thromboembolic events, and bleeding. Patients' length of stay was also catalogued.
Patients in the bridging arm had a significant increase in the rate of pocket hematomas (4.1%[control] vs 5.0%[warfarin] vs 20.7%[bridging], P = 0.03) and subsequent longer length of stay (1.6 +/- 1.6 [control] vs 2.9 +/- 2.7 [warfarin] vs 3.7 +/- 3.2 [bridging], P < 0.001). Hematoma formation postoperatively was not different among patients undergoing an upgrade procedure versus those without preexisting cardiac rhythm devices (12% vs 6.2%, P = NS). Patients with a prosthetic mechanical mitral valve had a higher incidence of pocket hematoma formation (1.8% vs 20%, P = 0.03).
Our findings suggest that implantation of CRT-Ds without interruption of warfarin therapy in patients at high risk of thromboembolic events is a safe alternative to routine bridging therapy. This strategy is associated with reduced risk of pocket hematomas and shorter length of hospital stay. (PACE 2010; 400-406).
许多需要心脏再同步治疗（CRT）的患者需要长期抗凝治疗。当前指南建议在这些操作过程中停用华法林并启动抗凝“桥接”治疗。我们评估了在不中断华法林治疗的情况下植入CRT设备（CRT-D）的安全性。
共纳入123例连续需要CRT-D治疗的患者，其中49例被确定为血栓栓塞事件高风险患者，接受了静脉肝素、低分子量肝素或华法林治疗。对照组包括74例血栓栓塞事件低风险患者，他们仅在围手术期停用华法林。在出院时以及术后15天和30天对患者进行评估，观察有无囊袋血肿、血栓栓塞事件和出血情况。还记录了患者的住院时间。
接受桥接治疗的患者囊袋血肿发生率显著增加（对照组为4.1%，华法林组为5.0%，桥接组为20.7%，P = 0.03），随后住院时间更长（对照组为1.6±1.6天，华法林组为2.9±2.7天，桥接组为3.7±3.2天，P < 0.001）。接受升级手术的患者与未植入心脏节律设备的患者术后血肿形成情况无差异（分别为12%和6.2%，P = 无显著性差异）。人工机械二尖瓣患者囊袋血肿形成的发生率更高（分别为1.8%和20%，P = 0.03）。
我们的研究结果表明，对于血栓栓塞事件高风险患者，在不中断华法林治疗的情况下植入CRT-D是常规桥接治疗的一种安全替代方法。该策略与降低囊袋血肿风险和缩短住院时间相关。（《PACE》2010年；400 - 406页）
