Arizona State University, Edson College, Phoenix, AZ, United States of America.
Brigham and Women's Heart & Vascular Center and Harvard Medical School, Boston, MA, United States of America.
Prog Cardiovasc Dis. 2020 May-Jun;63(3):210-218. doi: 10.1016/j.pcad.2020.02.002. Epub 2020 Feb 5.
Anticoagulation before, during, and after heart transplantation (HT) presents unique challenges to clinicians. Bleeding and thrombotic morbidity continues to affect this patient population throughout all phases of the HT journey. Reversal is commonly required since patients are commonly bridged to HT with left ventricular assist devices, which require chronic anti platelet and anticoagulation. Caution must be exercised in patients requiring cardiopulmonary bypass during surgery who are at risk of complications from heparin induced thrombocytopenia. The reported incidence of venous thromboembolism following HT is high, particularly during the first post-HT year, most likely due to surgery, biopsies, specific immunosuppression (mTOR inhibitors) and immobilization. It is crucial to maintain long-term oral anticoagulation after the first venous thromboembolism event, especially when risk factors exist. A major issue, and one for which there remains considerable debate, is the optimal treatment of such complications, particularly upper extremity venous thrombosis. For both warfarin and the thrombin inhibitors or Factor Xa inhibitors, the clinician must determine potential drug interactions based on the HT drug regimen, and then develop a patient-specific management strategy.
在心脏移植（HT）之前、期间和之后，抗凝治疗对临床医生提出了独特的挑战。在 HT 治疗的所有阶段，出血和血栓形成的发病率仍然会影响到这一患者群体。由于患者通常需要通过左心室辅助装置进行桥接治疗，而这些装置需要长期抗血小板和抗凝治疗，因此经常需要进行逆转。对于在手术过程中需要体外循环的患者，必须谨慎操作，因为他们存在肝素诱导的血小板减少症并发症的风险。报告的 HT 后静脉血栓栓塞发生率较高，尤其是在 HT 后第一年，这很可能是由于手术、活检、特定免疫抑制（mTOR 抑制剂）和固定导致的。在首次发生静脉血栓栓塞事件后，尤其是存在危险因素时，维持长期口服抗凝治疗至关重要。一个主要问题，也是一个仍存在相当大争议的问题，是此类并发症的最佳治疗方法，特别是上肢静脉血栓形成。对于华法林和凝血酶抑制剂或 Xa 因子抑制剂，临床医生必须根据 HT 药物方案确定潜在的药物相互作用，然后制定患者特异性管理策略。
