Sant'anna Roberto T, Leiria Tiago L, Nascimento Thais, Sant'anna João Ricardo M, Kalil Renato A K, Lima Gustavo G, Verma Atul, Healey Jeff S, Birnie David H, Essebag Vidal
Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, Brazil.
Pacing Clin Electrophysiol. 2015 Apr;38(4):417-23. doi: 10.1111/pace.12557. Epub 2014 Dec 26.
Management of patients treated with oral anticoagulation (OAC) requiring a cardiovascular implantable electronic device (CIED) surgery is a challenge that requires balancing the risk of bleeding complications with the risk of thromboembolic events. Recently the approach of performing these procedures while the patient remains with a therapeutic international normalized ratio has gained interest due to several publications showing its relative safety.
To evaluate the safety and effectiveness of continuous use of OAC compared with heparin bridging in the perioperative setting of CIED surgery using a meta-analysis.
A systematic review of PubMed/MEDLINE, Ovid, and Elsevier databases was performed. Eligible randomized controlled trials and cohort studies were included. The outcomes studied were risk of clinically significant bleeding and of thromboembolic events. Our analysis was restricted to OAC with vitamin K antagonists.
Of 560 manuscripts initially considered relevant, seven were included in the meta-analysis, totaling 2,191 patients. Data are reported as odds ratios (ORs) with confidence interval (CI) of 95%. Maintenance of OAC was associated with a significantly lower risk of postoperative bleeding compared with heparin bridge (OR = 0.25, 95% CI 0.17-0.36, P < 0.00001). There was no difference noted in the risk of thromboembolic events between the two strategies (OR = 1.86, 95% CI 0.29-12.17, P = 0.57).
Uninterrupted use of OAC in the perioperative of CIED surgery was associated with a reduced risk of bleeding. This strategy should be considered the preferred one in patients at moderate-to-high risk of thromboembolic events.
对于接受口服抗凝治疗（OAC）且需要进行心血管植入式电子设备（CIED）手术的患者，其管理是一项挑战，需要平衡出血并发症风险与血栓栓塞事件风险。最近，由于一些出版物表明在患者国际标准化比值处于治疗水平时进行这些手术的方法具有相对安全性，这种方法受到了关注。
通过荟萃分析评估在CIED手术围手术期持续使用OAC与肝素桥接相比的安全性和有效性。
对PubMed/MEDLINE、Ovid和Elsevier数据库进行系统评价。纳入符合条件的随机对照试验和队列研究。研究的结局是具有临床意义的出血风险和血栓栓塞事件风险。我们的分析仅限于使用维生素K拮抗剂的OAC。
在最初认为相关的560篇手稿中，7篇被纳入荟萃分析，共2191例患者。数据以比值比（OR）及95%置信区间（CI）报告。与肝素桥接相比，持续使用OAC与术后出血风险显著降低相关（OR = 0.25，95%CI 0.17 - 0.36，P < 0.00001）。两种策略在血栓栓塞事件风险方面未发现差异（OR = 1.86，95%CI 0.29 - 12.17，P = 0.57）。
在CIED手术围手术期不间断使用OAC与出血风险降低相关。对于中高血栓栓塞事件风险的患者，应考虑将该策略作为首选。
