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非维生素 K 拮抗剂口服抗凝剂治疗的房颤患者行导管消融术时的术中抗凝管理:了解证据中的空白。

Management of Intraprocedural Anticoagulation in Patients on Non-Vitamin K Antagonist Oral Anticoagulants Undergoing Catheter Ablation for Atrial Fibrillation: Understanding the Gaps in Evidence.

机构信息

Hôpital d'Instruction des Armées Percy, Service de Cardiologie, Service de Santé des Armées, Clamart, France (A.-C.M.).

Institut National de la Santé et de la Recherche Medicale UMR-S1140, Faculté de Pharmacie, Université Paris Descartes, France (A.-C.M., A.G., D.M.S.).

出版信息

Circulation. 2018 Aug 7;138(6):627-633. doi: 10.1161/CIRCULATIONAHA.117.033326.

Abstract

Catheter ablation has gained a prominent role in the management of atrial fibrillation (AF), with recent data providing positive evidence on hard outcomes, including hospitalization and mortality. Ablation, however, exposes the patient to a rather unique situation, combining risks for both major bleeding and thromboembolic events. In this setting, the critical importance of rigorous anticoagulation during the procedure has been underlined, and the latest international guidelines now recommend performing AF catheter ablation with uninterrupted non-vitamin K antagonist oral anticoagulants (NOACs) and concomitant administration of unfractionated heparin adjusted to achieve and maintain a target activated clotting time of ≥300 seconds. Whereas observational studies and randomized controlled trials support the safety and efficacy of uninterrupted NOAC strategy for AF catheter ablation, recent experiences have questioned this point, showing a greater unfractionated heparin requirement in NOAC-treated patients compared with vitamin K antagonists-treated patients to achieve the target activated clotting time. Important gaps in evidence regarding optimal intraprocedural anticoagulation management need to be acknowledged. A thorough appreciation of the physiology of anticoagulation during AF catheter ablation and the relevant differences between vitamin K antagonists and NOACs is required, while also understanding the limitations of activated clotting time measurement with regard to accurate intraprocedural anticogulation monitoring. This review aims to provide a critical look at this relatively ignored aspect of AF catheter ablation, especially pitfalls in NOAC monitoring, and to identify gaps in knowledge that need to be addressed in the near future.

摘要

导管消融在心房颤动(AF)的治疗中发挥了重要作用,最近的数据提供了关于硬终点的积极证据,包括住院和死亡率。然而,消融使患者处于一种独特的情况,既存在大出血风险,也存在血栓栓塞事件风险。在这种情况下,强调了在手术过程中进行严格抗凝的重要性,最新的国际指南现在建议使用不间断的非维生素 K 拮抗剂口服抗凝剂(NOACs)进行 AF 导管消融,并同时给予未分级肝素,以达到并维持目标活化凝血时间≥300 秒。尽管观察性研究和随机对照试验支持不间断 NOAC 策略在 AF 导管消融中的安全性和有效性,但最近的经验对此提出了质疑,表明与维生素 K 拮抗剂治疗的患者相比,NOAC 治疗的患者需要更多的未分级肝素来达到目标活化凝血时间。需要承认关于最佳术中抗凝管理的证据存在重要差距。需要深入了解 AF 导管消融期间抗凝的生理学以及维生素 K 拮抗剂和 NOAC 之间的相关差异,同时还需要了解活化凝血时间测量在准确的术中抗凝监测方面的局限性。本综述旨在批判性地探讨 AF 导管消融中这一相对被忽视的方面,特别是在 NOAC 监测方面的陷阱,并确定需要在不久的将来解决的知识差距。

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