Cui J, Du X, Wu J H, Jia C Q, Li X, Ning M, Lyu J, Yang Y, Liu X H, Dong J Z, Ma C S
Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China.
Zhonghua Xin Xue Guan Bing Za Zhi. 2018 Aug 24;46(8):606-610. doi: 10.3760/cma.j.issn.0253-3758.2018.08.006.
To investigate the effect of non-vitamin K antagonist oral anticoagulants (NOAC) on left atrial or atrial appendage (LA/LAA) thrombi in patients with nonvalvular atrial fibrillation (NVAF). Data from 3 042 patients with atrial fibrillation(AF), who underwent transesophageal echocardiography (TEE) examination before cardioversion or catheter ablation for the detection of LA/LAA thrombus in our department from March 2016 to January 2018 were prospectively analyzed. Among these patients, LA/LAA thrombus was detected by TEE in 57 patients. A total of 19 patients who received dabigatran or rivaroxaban for ≥3 weeks and underwent repeated TEE were included, 38 patients were excluded (7 patients with rheumatic heart disease, 1 patient treated with pericardial decortication, 1 patient treated with surgical repair of endocardial cushion defect, 1 patient with LA thrombus associated with the atrial septal occluder device, 14 patients received warfarin therapy, 14 patients did not receive repeated TEE). First repeated TEE results showed that LA/LAA thrombus was not completely resolved in 4 out of 4 patients treated with dabigatran (110 mg bid) for a median time of 119 (47, 258) days, whereas LA/LAA thrombus was completely resolved in 5 out of 11 patients treated with dabigatran (150 mg bid) for a median time of 80 (58, 147) days. Thrombus was completely resolved in 2 out of 2 patients treated with rivaroxaban (15 mg qd) for 110 days and 95 days respectively, and in 1 out of 2 patients treated with rivaroxaban (20 mg qd) for 91 days. Second repeated TEE was performed in 8 patients. Thrombus was resolved completely in 2 out of 3 patients with undissolved thrombus treated by dabigatran (110 mg bid) after increasing the dabigatran dosage (150 mg bid). Thrombus was resolved in 3 (1 patient prolonged treatment with dabigatran 150 mg bid and 2 patients switched to rivaroxaban 20 mg qd) out of 4 patients with undissolved thrombus under the dabigatran 150 mg bid regimen, whereas the thrombus remained unresolved in 1 patient switched to rivaroxaban (15 mg qd). After receiving rivaroxaban 15 mg bid treatment, the thrombus was finally resolved in 1 patient with undissolved thrombus treated by rivaroxaban 20 mg qd. There was no clinical thromboembolism or major bleeding events during the median follow up time of 462 (305, 558) days. Our data show that NOAC is an effective therapeutic option for the treatment of LA/LAA thrombi. When eligible, a higher NOAC dosage may be preferred due to the higher efficacy on thrombus resolvement.
研究非维生素K拮抗剂口服抗凝药（NOAC）对非瓣膜性心房颤动（NVAF）患者左心房或心耳（LA/LAA）血栓的影响。对2016年3月至2018年1月在我科接受转复或导管消融术前经食管超声心动图（TEE）检查以检测LA/LAA血栓的3042例心房颤动（AF）患者的数据进行前瞻性分析。在这些患者中，TEE检测到57例LA/LAA血栓。共纳入19例接受达比加群或利伐沙班治疗≥3周并接受重复TEE检查的患者，排除38例患者（7例风湿性心脏病患者、1例接受心包剥脱术治疗的患者、1例接受心内膜垫缺损手术修复的患者、1例与房间隔封堵器相关的LA血栓患者、14例接受华法林治疗的患者、14例未接受重复TEE检查的患者）。首次重复TEE结果显示，4例接受达比加群（110 mg bid）治疗中位时间为119（47，258）天的患者中，有4例LA/LAA血栓未完全溶解，而11例接受达比加群（150 mg bid）治疗中位时间为80（58，147）天的患者中有5例LA/LAA血栓完全溶解。2例分别接受利伐沙班（15 mg qd）治疗110天和95天的患者以及2例接受利伐沙班（20 mg qd）治疗91天的患者中有1例血栓完全溶解。8例患者进行了第二次重复TEE检查。3例达比加群（110 mg bid）治疗后血栓未溶解的患者中，2例在增加达比加群剂量（150 mg bid）后血栓完全溶解。在达比加群150 mg bid方案下，4例血栓未溶解的患者中有3例血栓溶解（1例延长达比加群150 mg bid治疗时间，2例换用利伐沙班20 mg qd），而1例换用利伐沙班（15 mg qd）的患者血栓仍未溶解。1例接受利伐沙班20 mg qd治疗后血栓未溶解的患者在接受利伐沙班15 mg bid治疗后血栓最终溶解。在462（305，558）天的中位随访时间内未发生临床血栓栓塞或大出血事件。我们的数据表明，NOAC是治疗LA/LAA血栓的有效治疗选择。在符合条件时，由于对血栓溶解效果更高，可能更倾向于使用较高剂量的NOAC。
