Meincke F, Kuck K-H, Bergmann M W
Abteilung für Kardiologie, Asklepios Klinik St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Deutschland.
Herz. 2013 May;38(3):239-46. doi: 10.1007/s00059-013-3775-5.
Stroke prevention in patients with atrial fibrillation is one of the greatest challenges in modern cardiology. Interventional left atrial appendage occlusion is an alternative to oral anticoagulation in patients with non-valvular atrial fibrillation. This procedure is currently used mainly for patients with elevated risk for bleeding complications (HAS-BLED score ≥3) or other contraindications for oral anticoagulation. The novel anticoagulants dabigatran, rivaroxaban and apixaban carry a risk for major bleeding for 2-3% of patients per year. The indications for an interventional left atrial appendage closure are therefore not affected by these substances. Several devices have been developed for this purpose; however, currently only the WATCHMAN® and AMPLATZER® cardiac plug are used in the clinical routine in Germany. The WATCHMAN® device proved to be non-inferior to oral anticoagulation with warfarin in the PROTECT-AF trial in terms of safety and efficacy. These findings are supported by data from registries with up to 5 years follow-up. For the second device currently used in clinical practice, the AMPLATZER® cardiac plug, there is increasing data from registries suggesting comparable safety and efficacy. Both devices necessitate anticoagulation during the first 3-6 months after implantation until endothelialization is completed. Due to the anatomical complexity the implantation should be performed in experienced centers with reduction of the periprocedural risk to <1%. Thus, interventional left atrial appendage occlusion is a valid option to prevent stroke or other thromboembolic events in non-valvular atrial fibrillation especially for elderly patients or those with a history of bleeding complications.
心房颤动患者的卒中预防是现代心脏病学面临的最大挑战之一。对于非瓣膜性心房颤动患者，介入性左心耳封堵术是口服抗凝治疗的替代方法。目前，该手术主要用于出血并发症风险较高（HAS - BLED评分≥3）或有其他口服抗凝治疗禁忌证的患者。新型抗凝药物达比加群、利伐沙班和阿哌沙班每年有2% - 3%的患者发生大出血风险。因此，这些药物不影响介入性左心耳封堵术的适应证。为此已研发了多种装置；然而，目前在德国临床实践中仅使用WATCHMAN®和AMPLATZER®心脏封堵器。在PROTECT - AF试验中，WATCHMAN®装置在安全性和有效性方面被证明不劣于华法林口服抗凝治疗。长达5年随访的注册研究数据支持了这些发现。对于目前临床实践中使用的第二种装置AMPLATZER®心脏封堵器，注册研究的数据越来越多地表明其安全性和有效性相当。两种装置在植入后的前3 - 6个月都需要抗凝，直到内皮化完成。由于解剖结构复杂，植入手术应在经验丰富的中心进行，将围手术期风险降低至<1%。因此，介入性左心耳封堵术是预防非瓣膜性心房颤动患者发生卒中或其他血栓栓塞事件的有效选择，尤其适用于老年患者或有出血并发症病史的患者。
