Schulman Jacqueline M, Majeed Ammar, Mattsson Eva, Schulman Sam, Holmström Margareta, Ågren Anna
Department of Medicine, Coagulation Unit, Hematology Center, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.
Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
J Thromb Thrombolysis. 2015 Nov;40(4):430-6. doi: 10.1007/s11239-015-1216-4.
Patients with mechanical heart valves (MHV) undergoing invasive procedures often receive periprocedural bridging with low-molecular-weight heparin (LMWH). The bridging strategies used in real-life and the predictors for bleeding and thrombosis are not well studied. We retrospectively assessed patients with MHV that underwent invasive procedures requiring vitamin K antagonist interruption and LMWH bridging. Thromboembolic and bleeding events occurring up to 30 days after the procedures were recorded. Predictors of major bleeding events (MBEs) were analyzed with logistic regression. We evaluated 547 patients with MHV who underwent 275 procedures during a 6.5-year period. Bridging with LMWH was used in 185 procedures in a total of 117 patients. Combined pre- and post-operative bridging was the most frequently employed (63 %). Doses of LMWH were prophylactic in 96 (52 %) of the procedures and therapeutic in 89 (48 %). The procedure-related bleeding risk was evaluated as high in 70 (38 %) and low in 115 (62 %) of the procedures. There was a trend to more frequent use of prophylactic doses (61 %) in high-risk surgery, and more therapeutic doses (53 %) in low-risk ones. There were 36 bleeding episodes, 21 (11 % of procedures) of which were classified as MBEs, but there were no thromboembolic events. Most MBEs (n = 14; 67 %) occurred in surgeries with high bleeding risk. In the multivariate analysis, the bleeding risk of the surgery itself was the only independent predictor for MBEs. For patients with MHV receiving perioperative bridging with LMWH, the major predictor for MBE is the bleeding risk of the surgery.
接受侵入性手术的机械心脏瓣膜（MHV）患者通常在围手术期使用低分子量肝素（LMWH）进行桥接抗凝。现实生活中使用的桥接策略以及出血和血栓形成的预测因素尚未得到充分研究。我们回顾性评估了接受需要中断维生素K拮抗剂并使用LMWH桥接的侵入性手术的MHV患者。记录了手术后30天内发生的血栓栓塞和出血事件。采用逻辑回归分析主要出血事件（MBE）的预测因素。我们评估了547例MHV患者，他们在6.5年期间接受了275例手术。共有117例患者的185例手术中使用了LMWH桥接。术前和术后联合桥接是最常用的方法（63%）。96例（52%）手术中LMWH剂量为预防性，89例（48%）为治疗性。70例（38%）手术的与手术相关的出血风险被评估为高，115例（62%）为低。高危手术中预防性剂量的使用频率更高（61%），低危手术中治疗性剂量的使用频率更高（53%）。共有36例出血事件，其中21例（占手术的11%）被归类为MBE，但没有血栓栓塞事件。大多数MBE（n = 14；67%）发生在出血风险高的手术中。在多变量分析中，手术本身的出血风险是MBE的唯一独立预测因素。对于接受LMWH围手术期桥接的MHV患者，MBE的主要预测因素是手术的出血风险。
