Proietti R, Porto I, Levi M, Leo A, Russo V, Kalfon E, Biondi-Zoccai G, Roux J-F, Birnie D H, Essebag V
Cardiology Department, Luigi Sacco Hospital, Milan, Italy.
Eur Rev Med Pharmacol Sci. 2015 Apr;19(8):1461-79.
Periprocedural management of warfarin remains challenging in patients requiring electrophysiological device surgery. For patients at high risk of thromboembolic events, guidelines recommend bridging therapy with heparin; however, this strategy is associated with a high risk of pocket hematoma. This paper systematically reviews studies appraising the risk of pocket hematoma with different perioperative anticoagulation strategies.
All relevant studies identified in MEDLINE/PubMed, The Cochrane Collaboration CENTRAL, clinicaltrials.org and in bibliographies of key articles. Estimates were combined using a fixed effects model. Heterogeneity was assessed by p values of χ2 statistics and I2. Publication bias was assessed by visual examination of funnel plots and by Egger test. Fifteen studies enrolling 5911 patients met all inclusion criteria and were included in this review.
Heparin bridging compared with no heparin was associated with increased risk of pocket hematoma (OR = 4.47, 95% CI 3.21-6.23, p < 0.00001), and prolonged hospital stay (9.13 ± 1.9 days vs. 5.11 ± 1 .39 days, p < 0.00001). Warfarin continuation was not associated with increased pocket hematoma compared to warfarin discontinuation (p = 0.38), but was associated with reduced risk of pocket hematoma compared with heparin bridging (OR = 0.37, 95% CI 0.2-0.69, p = 0.002). Thromboembolic complications were reduced with heparin bridging vs. no heparin (0.50% vs.1.07%, p = 0.02), and no significant differences were reported between heparin bridging vs. warfarin continuation (p = 0.83).
Heparin bridging is associated with a higher risk of pocket hematoma and a prolonged hospital stay. Perioperative continuation of warfarin reduces the occurrence of pocket hematoma compared with heparin bridging without any significant differences in thromboembolic complications.
对于需要进行电生理设备手术的患者，华法林的围手术期管理仍然具有挑战性。对于血栓栓塞事件高危患者，指南推荐使用肝素进行桥接治疗；然而，该策略与较高的囊袋血肿风险相关。本文系统回顾了评估不同围手术期抗凝策略下囊袋血肿风险的研究。
检索MEDLINE/PubMed、Cochrane协作网CENTRAL、clinicaltrials.org以及关键文章的参考文献中所有相关研究。采用固定效应模型合并估计值。通过χ2统计量的p值和I2评估异质性。通过漏斗图的视觉检查和Egger检验评估发表偏倚。15项纳入5911例患者的研究符合所有纳入标准并被纳入本综述。
与不使用肝素相比，肝素桥接与囊袋血肿风险增加相关（OR = 4.47，95%CI 3.21 - 6.23，p < 0.00001），且住院时间延长（9.13 ± 1.9天 vs. 5.11 ± 1.39天，p < 0.00001）。与停用华法林相比，继续使用华法林与囊袋血肿增加无关（p = 0.38），但与肝素桥接相比，囊袋血肿风险降低（OR = 0.37，95%CI 0.2 - 0.69，p = 0.002）。与不使用肝素相比，肝素桥接可降低血栓栓塞并发症（0.50% vs. 1.07%，p = 0.02），肝素桥接与继续使用华法林之间未报告显著差异（p = 0.83）。
肝素桥接与较高的囊袋血肿风险和延长的住院时间相关。与肝素桥接相比，围手术期继续使用华法林可减少囊袋血肿的发生，且血栓栓塞并发症无显著差异。
