Sick Peter B
Hospital Barmherzige Brueder Regensburg.
J Atr Fibrillation. 2013 Oct 31;6(3):923. doi: 10.4022/jafib.923. eCollection 2013 Oct-Nov.
Atrial fibrillation is a common rhythm disorder, which is related to a higher risk of thrombembolism resulting in a high rate of cerebral stroke or transient ischemic attacks. According to the CHADS- or CHADSVasc-Score there is an indication for oral anticoagulation to prevent patients from mostly disabling strokes. However, more than 50% of patients are not adequately treated with oral anticoagulation due to different reasons, especially contraindications. More than 90% of thrombi develop in the left atrial appendage (LAA), which lead to the idea of developing devices to exclude the LAA from the systemic circulation to prevent patients from embolisations. Another approach is surgical ligation or removal of the LAA during operation procedures. Different devices and their clinical data are discussed in this review. Available literature for most of the devices is evaluated and last but not least some surgical results are discussed at the end. Existing data of randomized and non-randomized studies show that the concept of LAA-occlusion instead of anticoagulation therapy works. However, complication rates during intervention have to be kept in mind, but with adequate training also new and inexperienced operators can do the procedure safely. Most data and the only randomized studies are available for the Watchman Device. Despite some few complications like pericardial effusions, bleeding complications and thrombus formation on the devices, the data showed a non inferiority of device-implantation in comparison with anticoagulation therapy in the first few years. In long term follow up more than 4 years after implantation, there is even a superiority of the device compared with anticoagulation therapy, safety issues are no longer significantly different despite some periprocedural complications. This has to be reflected with the background, that operators could treat 3 patients with a totally new method, thereafter all patients had to be randomized into the study. So experience was limited in the first phase of this trial. Surgical data vary much due to different techniques of LAA-occlusion. With newer devices results are also promising. LAA-occlusion is a developing field of interventional and surgical techniques. The concept of LAA-occlusion could be proved in one randomized trial. At least for patients contraindicated for anticoagulation therapy, LAA-occlusion is a real alternative to only aspirin therapy or doing nothing. With emerging techniques and lower complication rates, LAA-occlusion might develop to a real alternative to anticoagulation therapy, at least for vitamin-K-antagonists. There are no data available so far in comparison with new oral anticoagulants. Further studies are needed to compare device therapy with new oral anticoagulants.
心房颤动是一种常见的节律紊乱，与血栓栓塞风险较高相关，会导致较高的脑卒中和短暂性脑缺血发作发生率。根据CHADS或CHADSVasc评分，有口服抗凝治疗的指征，以预防患者发生致残性中风。然而，超过50%的患者因各种原因，尤其是禁忌症，未得到充分的口服抗凝治疗。超过90%的血栓形成于左心耳（LAA），这促使人们研发将左心耳排除在体循环之外的装置，以防止患者发生栓塞。另一种方法是在手术过程中对左心耳进行结扎或切除。本综述讨论了不同的装置及其临床数据。评估了大多数装置的现有文献，最后还讨论了一些手术结果。随机和非随机研究的现有数据表明，左心耳封堵而非抗凝治疗的概念是可行的。然而，必须牢记干预期间的并发症发生率，但经过充分培训，新的和经验不足的操作者也能安全地进行该操作。关于Watchman装置有最多的数据和唯一的随机研究。尽管存在一些并发症，如心包积液、出血并发症和装置上的血栓形成，但数据显示在最初几年，与抗凝治疗相比，装置植入并不逊色。在植入后超过4年的长期随访中，与抗凝治疗相比，该装置甚至具有优势，尽管存在一些围手术期并发症，但安全问题不再有显著差异。这必须结合这样的背景来考虑，即操作者可以用一种全新的方法治疗3名患者，此后所有患者都必须随机分组进入研究。因此，在该试验的第一阶段经验有限。由于左心耳封堵技术不同，手术数据差异很大。使用更新的装置结果也很有前景。左心耳封堵是介入和手术技术不断发展的领域。左心耳封堵的概念已在一项随机试验中得到证实。至少对于抗凝治疗禁忌的患者，左心耳封堵是仅用阿司匹林治疗或不采取任何措施之外的一种切实可行的选择。随着技术的不断涌现和并发症发生率的降低，左心耳封堵可能会成为抗凝治疗的一种切实可行的替代方法，至少对于维生素K拮抗剂而言。与新型口服抗凝药相比，目前尚无相关数据。需要进一步研究来比较装置治疗与新型口服抗凝药。
