Sugrue Alan, DeSimone Christopher V, Lenz Charles J, Packer Douglas L, Asirvatham Samuel J
Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
J Interv Card Electrophysiol. 2016 Aug;46(2):115-20. doi: 10.1007/s10840-015-0085-2. Epub 2015 Dec 9.
The rates of cardiovascular implantable electronic device (CIED) implantations and cardiac ablation procedures are increasing worldwide. To date, the management of CIED lead thrombi in the peri-ablation period remains undefined and key clinical management questions remained unanswered. We sought to describe the clinical course and management strategies of patients with a CIED lead thrombus detected in the peri-ablative setting.
We performed a retrospective analysis of all patients who underwent a cardiac ablation procedure at Mayo Clinic Rochester from 2000 to 2014. Patients were included in our study cohort if they had documented CIED lead thrombus noted on peri-ablation imaging studies. Electronic medical records were reviewed to determine the overall management strategy, outcomes, and embolic complications in these patients.
Our overall cohort included 1833 patients, with 27 (1.4 %) having both cardiac ablation procedures as well as CIED lead thrombus detected on imaging. Of these 27 patients, 21 were male (77 %), and the mean age was 59.2 years. The mean duration of follow-up was 16.5 months (range 3 days-48.3 months). Anticoagulation was an effective therapeutic strategy, with 11/14 (78.6 %) patients experiencing either resolution of the thrombus or reduction in size on re-imaging. For atrial fibrillation ablation, the most common management strategy was a deferment in ablation with initiation/intensification of anticoagulation medication. For ventricular tachycardia ablations, most procedures involved a modified approach with the use of a retrograde aortic approach to access the left ventricle. No patient had any documented embolic complications.
The incidence of lead thrombi in patients undergoing an ablation was small in our study cohort (1.4 %). Anticoagulation and deferral of ablation represented successful management strategies for atrial fibrillation ablation. For patients undergoing ventricular tachycardia ablation, a modified approach using retrograde aortic access to the ventricle was successful. In patients who are not on warfarin anticoagulation at the time of thrombus detection, we recommend initiation of this medication, with a goal INR of 2-3. For patients on warfarin at the time of thrombus detection, we recommend an intensification of anticoagulation with a goal INR of 3.0.
心血管植入式电子设备（CIED）植入率和心脏消融手术率在全球范围内均呈上升趋势。迄今为止，CIED导线血栓在消融围术期的管理仍不明确，关键的临床管理问题也未得到解答。我们试图描述在消融背景下检测到CIED导线血栓的患者的临床病程及管理策略。
我们对2000年至2014年在罗切斯特梅奥诊所接受心脏消融手术的所有患者进行了回顾性分析。如果患者在消融围术期影像学检查中记录有CIED导线血栓，则纳入我们的研究队列。查阅电子病历以确定这些患者的总体管理策略、结局及栓塞并发症情况。
我们的总体队列包括1833例患者，其中27例（1.4%）既接受了心脏消融手术，又在影像学检查中检测到CIED导线血栓。在这27例患者中，21例为男性（77%），平均年龄为59.2岁。平均随访时间为16.5个月（范围3天至48.3个月）。抗凝是一种有效的治疗策略，14例患者中有11例（78.6%）在再次成像时血栓溶解或体积缩小。对于房颤消融，最常见的管理策略是推迟消融并启动/强化抗凝药物治疗。对于室性心动过速消融，大多数手术采用改良方法，即使用逆行主动脉途径进入左心室。没有患者有任何记录在案的栓塞并发症。
在我们的研究队列中，接受消融的患者中导线血栓的发生率较低（1.4%）。抗凝和推迟消融是房颤消融成功的管理策略。对于接受室性心动过速消融的患者，使用逆行主动脉进入心室的改良方法是成功的。对于在检测到血栓时未接受华法林抗凝治疗的患者，我们建议启动该药物治疗，目标国际标准化比值（INR）为2 - 3。对于在检测到血栓时正在接受华法林治疗的患者，我们建议强化抗凝，目标INR为3.0。
