经皮导管射频消融治疗心房颤动时，围术期抗凝管理对应用开放灌流导管射频消融术患者中弥散张量磁共振成像检测到的无症状性血栓栓塞病变的发生率有影响吗？一项前瞻性多中心研究的结果。
Does periprocedural anticoagulation management of atrial fibrillation affect the prevalence of silent thromboembolic lesion detected by diffusion cerebral magnetic resonance imaging in patients undergoing radiofrequency atrial fibrillation ablation with open irrigated catheters? Results from a prospective multicenter study.
机构信息
Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas; Albert Einstein College of Medicine at Montefiore Hospital, New York, New York; Department of Biomedical Engineering, University of Texas, Austin, Texas; Department of Cardiology, University of Foggia, Foggia, Italy.
Department of Medical Sciences, University of Turin, Turin, Italy.
出版信息
Heart Rhythm. 2014 May;11(5):791-8. doi: 10.1016/j.hrthm.2014.03.003. Epub 2014 Mar 4.
BACKGROUND
Silent cerebral ischemia (SCI) has been reported in 14% of cases after catheter ablation of atrial fibrillation (AF) with radiofrequency (RF) energy and discontinuation of warfarin before AF ablation procedures.
OBJECTIVE
The purpose of this study was to determine whether periprocedural anticoagulation management affects the incidence of SCI after RF ablation using an open irrigated catheter.
METHODS
Consecutive patients undergoing RF ablation for AF without warfarin discontinuation and receiving heparin bolus before transseptal catheterization (group I, n = 146) were compared with a group of patients who had protocol deviation in terms of maintaining the therapeutic preprocedural international normalized ratio (patients with subtherapeutic INR) and/or failure to receive pretransseptal heparin bolus infusion and/or ≥2 consecutive ACT measurements <300 seconds (noncompliant population, group II, n = 134) and with a group of patients undergoing RF ablation with warfarin discontinuation bridged with low molecular weight heparin (group III, n = 148). All patients underwent preablation and postablation (within 48 hours) diffusion magnetic resonance imaging.
RESULTS
SCI was detected in 2% of patients (3/146) in group I, 7% (10/134) in group II, and 14% (21/148) in group III (P <.001). "Therapeutic INR" was strongly associated with a lower prevalence of postprocedural silent cerebral ischemia (SCI). Multivariable analysis demonstrated nonparoxysmal AF (odds ratio 3.8, 95% confidence interval 1.5-9.7, P = .005) and noncompliance to protocol (odds ratio 2.8, 95% confidence interval 1.5-5.1, P <.001] to be significant predictors of ischemic events.
CONCLUSION
Strict adherence to an anticoagulation protocol significantly reduces the prevalence of SCI after catheter ablation of AF with RF energy.
背景
据报道，在使用射频 (RF) 能量进行心房颤动 (AF) 导管消融并在消融前停止使用华法林的情况下，14%的病例会出现无症状性脑缺血 (SCI)。
目的
本研究旨在确定 RF 消融导管使用过程中的围手术期抗凝管理是否会影响使用开放式灌流导管消融后的 SCI 发生率。
方法
连续纳入未停用华法林且行经房间隔穿刺前给予肝素推注的 AF 患者（I 组，n=146），与因未遵循治疗前国际标准化比值（INR）方案（INR 低于治疗范围）和/或未接受经房间隔穿刺前肝素推注和/或连续 2 次 ACT 测量<300 秒（非依从人群，II 组，n=134）和因消融前行华法林停药桥接低分子肝素（III 组，n=148）的患者进行比较。所有患者均在消融前和消融后（48 小时内）行弥散磁共振成像。
结果
I 组患者 SCI 发生率为 2%（3/146），II 组为 7%（10/134），III 组为 14%（21/148）（P<.001）。“治疗性 INR”与较低的术后无症状性脑缺血（SCI）发生率密切相关。多变量分析显示，非阵发性 AF（优势比 3.8，95%置信区间 1.5-9.7，P=.005）和不遵守方案（优势比 2.8，95%置信区间 1.5-5.1，P<.001）是非缺血性事件的显著预测因子。
结论
严格遵循抗凝方案可显著降低 RF 能量导管消融治疗 AF 后 SCI 的发生率。
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