Herring Neil, Page Stephen P, Ahmed Mohammed, Burg Melanie R, Hunter Ross J, Earley Mark J, Sporton Simon C, Newton James D, Sabharwal Nikant K, Myerson Saul G, Bashir Yaver, Betts Tim R, Schilling Richard J, Rajappan Kim
Oxford Heart Centre, John Radcliffe Hospital, Oxford, UK and.
Barts and the London Cardiovascular Biomedical Research Unit, London, UK.
J Atr Fibrillation. 2013 Apr 6;5(6):761. doi: 10.4022/jafib.761. eCollection 2013 Apr-May.
The 2012 HRS/EHRA/ECAS guidelines encourage pre-procedural transesophageal echocardiography (TEE) prior to ablation for atrial fibrillation (AF), but acknowledge a lack of consensus in patients maintained on therapeutic warfarin before, during and after the procedure. This is partly because the incidence of left atrial appendage (LAA) thrombus is so low, that it is hard to draw clear conclusion regarding the characteristics of patients who develop thrombus. We hypothesize that the presence of low LAA emptying velocities, which predisposes to thrombus, and/or thrombus itself can be predicted in patients undergoing ablation, based upon clinical characteristics and transthoracic echocardiography (TTE). In this multicentre study, we undertook TTE and transesophageal echocardiograms (TEE) in 586 patients (age 59.9±0.4 years old, 64.5% male) undergoing catheter ablation for AF who were anticoagulated on warfarin (target international normalized ratio 2-3.5) for ≥3 consecutive weeks prior to procedure and maintained on warfarin for the procedure. Low peak LAA emptying velocities (<40cm/s) were identified in 111 (24.7%) patients and LAA thrombus was identified in 3 patients (0.5%) despite having therapeutic INRs. The 3 patients with thrombus had LAA emptying velocities of 23, 29 and 31 cm/s. None of the remaining patients had a peri-procedural stroke. Patients with peak LAA emptying velocities <40cm/s or thrombus on TEE had significantly (p<0.05) higher CHADS-VASc scores (1.7± 0.1 v's 1.4±0.1), and were more likely to have impaired LVSF (odds ratio [95% CI]: 2.66 [1.52-4.66]), a LA diameter >4.6cm on TTE (2.40 [2.13-5.41]), or persistent AF (2.60 [1.63-4.14]) compared to those with a higher LAA velocity without thrombus. In patients on uninterrupted warfarin therapy, a CHADS-VASc score ≥1 or LA diameter >4.6cm on TTE identifies 91.5% of those at risk of developing thrombus with LAA emptying velocity of <40 cm/s and 100% of those with thrombus in our cohort.
2012年美国心律学会（HRS）/欧洲心律协会（EHRA）/欧洲心血管病预防与康复协会（ECAS）指南鼓励在房颤（AF）消融术前进行经食管超声心动图（TEE）检查，但也承认在手术前、手术期间和手术后接受治疗性华法林治疗的患者中缺乏共识。部分原因是左心耳（LAA）血栓的发生率很低，因此很难就发生血栓的患者特征得出明确结论。我们假设，根据临床特征和经胸超声心动图（TTE），可以预测接受消融治疗的患者中存在易导致血栓形成的LAA排空速度低和/或血栓本身。在这项多中心研究中，我们对586例接受房颤导管消融治疗的患者（年龄59.9±0.4岁，男性占64.5%）进行了TTE和经食管超声心动图（TEE）检查，这些患者在手术前连续3周以上接受华法林抗凝治疗（目标国际标准化比值为2 - 3.5），并在手术期间继续使用华法林。111例（24.7%）患者的LAA峰值排空速度低（<40cm/s），3例（0.5%）患者尽管国际标准化比值处于治疗范围仍发现有LAA血栓。3例有血栓的患者LAA排空速度分别为23、29和31cm/s。其余患者均未发生围手术期卒中。LAA峰值排空速度<40cm/s或TEE显示有血栓的患者，其CHADS - VASc评分显著更高（p<0.05）（1.7±0.1对1.4±0.1），与LAA速度较高且无血栓的患者相比，更有可能存在左心室射血分数受损（优势比[95%可信区间]：2.66[1.52 - 4.66]）、TTE显示左心房直径>4.6cm（2.40[2.13 - 5.41]）或持续性房颤（2.60[1.63 - 4.14]）。在接受不间断华法林治疗的患者中，CHADS - VASc评分≥1或TTE显示左心房直径>4.6cm可识别出本队列中91.5%的LAA排空速度<40cm/s有血栓形成风险的患者以及100%有血栓的患者。
