Tanaka-Esposito Christine C, Chung Mina K, Abraham Joellyn M, Cantillon Daniel J, Abi-Saleh Bernard, Tchou Patrick J
Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue J2-2, Cleveland, OH 44195, USA.
J Interv Card Electrophysiol. 2013 Aug;37(2):163-8. doi: 10.1007/s10840-013-9796-4. Epub 2013 Apr 14.
Vascular complications are a known risk of catheter-based pulmonary vein antral isolation (PVAI). Procedure-related thromboembolic events necessitate full-dose anticoagulation, which worsens outcomes in the event of vascular access injury.
Real-time ultrasound allows direct visualization of vascular structures. We hypothesized that ultrasound use with venipuncture reduces vascular complications associated with PVAI.
Retrospective analysis of all adverse events occurring with PVAI was performed during two periods: 2005-2006 when ultrasound was not used and 2008-2010 when ultrasound was routinely employed. All patients received full-dose IV heparin during PVAI. In the no ultrasound cohort, only 14 % underwent PVAI without stopping warfarin, while 91 % of patients in the ultrasound cohort were on continued warfarin. Only patients deemed at high risk for thromboembolism with a periprocedural international normalized ratio (INR) less than 2 were bridged with subcutaneous low-molecular-weight heparin.
Ultrasound reduced total vascular complications (1.7 vs. 0.5 %, p < 0.01) and decreased the incidence of major vascular complications by sevenfold. Warfarin with INR ≥ 1.2 on the day of PVAI was associated with more vascular complications (4.3 vs. 1.2 %, p < 0.01). Ultrasound guidance overcame the risk associated with warfarin therapy. Vascular complications in anticoagulated patients with INR ≥ 1.2 using ultrasound guidance were two- and ninefold lower than those in patients not using ultrasound with an INR < 1.2 (0.5 vs. 1.2 %, p < 0.05) and INR ≥ 1.2 (0.5 vs. 4.3 %, p < 0.01), respectively.
Ultrasound-guided venipuncture improves the safety profile of PVAI, reducing vascular complications in patients on warfarin to levels below those with no ultrasound and off warfarin.
血管并发症是基于导管的肺静脉前庭隔离术（PVAI）已知的风险。与手术相关的血栓栓塞事件需要全剂量抗凝，而这在发生血管通路损伤时会使预后恶化。
实时超声可直接观察血管结构。我们推测在静脉穿刺时使用超声可减少与PVAI相关的血管并发症。
对PVAI期间发生的所有不良事件进行回顾性分析，分为两个时期：2005 - 2006年未使用超声时期和2008 - 2010年常规使用超声时期。所有患者在PVAI期间均接受全剂量静脉注射肝素。在未使用超声的队列中，只有14%的患者在不停用华法林的情况下接受PVAI，而在使用超声的队列中，91%的患者继续服用华法林。只有那些围手术期国际标准化比值（INR）小于2且被认为有高血栓栓塞风险的患者才采用皮下注射低分子量肝素进行桥接抗凝。
超声降低了总的血管并发症发生率（1.7%对0.5%，p < 0.01），并使主要血管并发症的发生率降低了7倍。PVAI当天INR≥1.2的华法林治疗与更多的血管并发症相关（4.3%对1.2%，p < 0.01）。超声引导克服了与华法林治疗相关的风险。使用超声引导的INR≥1.2的抗凝患者的血管并发症比未使用超声且INR < 1.2（0.5%对1.2%，p < 0.05）以及INR≥1.2（0.5%对4.3%，p < 0.01）的患者分别低2倍和9倍。
超声引导下的静脉穿刺改善了PVAI的安全性，将服用华法林患者的血管并发症降低到未使用超声且未服用华法林患者的水平以下。
