Sakamoto Toshihito, Kano Hiroya, Miyahara Shunsuke, Inoue Takeshi, Izawa Naoto, Gotake Yasuko, Matsumori Masamichi, Okada Kenji, Okita Yutaka
J Heart Valve Dis. 2014 Nov;23(6):744-51.
Recent brain complications (e.g., bleeding or infarction) in patients with active infective endocarditis (AIE) are recognized as a contraindication for early surgery. Nafamostat mesilate (NM) is a synthetic protease-inhibiting agent that has not only potent inhibitory activity against coagulation factors (Xlla, Xa) but also an anti-inflammatory action. Herein is reported the authors' successful surgical experience using NM with low-dose heparinization in patients with AIE complicated by recent cerebral complications.
Twenty-eight patients (mean age 54.9 +/- 18.7 years) who had undergone surgery for AIE of the native valve (n = 21) or prosthetic valve (n = 7) were reviewed retrospectively. AIE was present in the aortic (n = 8), mitral (n = 16), aortic/mitral (n = 4) and tricuspid (n = 1) valves. Twenty-two of 28 patients had preoperative stroke, and six had active brain bleeding. Surgery was performed at a mean of 2.4 +/- 2.1 days after the onset of stroke. NM (209 +/- 152 mg) with low-dose heparin (3796 +/- 1218 IU; 67.4 +/- 20.3 IU/kg) was used for anticoagulation during cardiopulmonary bypass (CPB). The activated clotting time (ACT) was maintained at 350-450 s by the precise administration of NM into a cardiotomy reservoir (0.5 mg/kg/h) and a venous reservoir (sliding controlled dose at 1.5 mg/kg/h).
The CPB time was 181.3 +/- 92.6 min. Five patients (17.8%) died during hospitalization due to persistent sepsis (n = 3), brain death caused by massive brain embolism before CPB establishment (n = 1), and pneumonia (n = 1). There was no further aggravation of intracranial bleeding, and no new hemorrhagic stroke.
Nafamostat mesilate, administered in conjunction with low-dose heparinization, served as an effective anticoagulant for early surgery in patients with AIE complicated by stroke, and caused no further deterioration of the cerebral lesions.
活动性感染性心内膜炎（AIE）患者近期出现的脑部并发症（如出血或梗死）被视为早期手术的禁忌证。甲磺酸萘莫司他（NM）是一种合成的蛋白酶抑制剂，不仅对凝血因子（Xlla、Xa）具有强大的抑制活性，还具有抗炎作用。本文报道了作者在AIE合并近期脑部并发症患者中使用NM联合小剂量肝素化进行手术的成功经验。
回顾性分析28例接受自体瓣膜（n = 21）或人工瓣膜（n = 7）AIE手术的患者（平均年龄54.9±18.7岁）。AIE累及主动脉瓣（n = 8）、二尖瓣（n = 16）、主动脉瓣/二尖瓣（n = 4）和三尖瓣（n = 1）。28例患者中有22例术前发生卒中，6例有活动性脑出血。卒中发生后平均2.4±2.1天进行手术。在体外循环（CPB）期间，使用NM（209±152 mg）联合小剂量肝素（3796±1218 IU；67.4±20.3 IU/kg）进行抗凝。通过精确地将NM注入心内吸引器（0.5 mg/kg/h）和静脉储血器（滑动控制剂量为1.5 mg/kg/h），使活化凝血时间（ACT）维持在350 - 450秒。
CPB时间为181.3±92.6分钟。5例患者（17.8%）在住院期间死亡，原因包括持续性脓毒症（n = 3）、CPB建立前因大量脑栓塞导致的脑死亡（n = 1）和肺炎（n = 1）。颅内出血未进一步加重，也未出现新的出血性卒中。
甲磺酸萘莫司他联合小剂量肝素化，可作为AIE合并卒中患者早期手术的有效抗凝剂，且不会导致脑部病变进一步恶化。
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