Asmarats Lluis, O'Hara Gilles, Champagne Jean, Paradis Jean-Michel, Bernier Mathieu, O'Connor Kim, Beaudoin Jonathan, Junquera Lucia, Del Val David, Muntané-Carol Guillem, Côté Mélanie, Rodés-Cabau Josep
Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada.
Circ Cardiovasc Interv. 2020 Aug;13(8):e009039. doi: 10.1161/CIRCINTERVENTIONS.120.009039. Epub 2020 Aug 10.
The impact of antithrombotic therapy on coagulation system activation after left atrial appendage closure (LAAC) remains unknown. This study sought to compare changes in coagulation markers associated with short-term oral anticoagulation (OAC) versus antiplatelet therapy (APT) following LAAC.
Prospective study including 78 atrial fibrillation patients undergoing LAAC with the Watchman device. F1+2 (prothrombin fragment 1+2) and TAT (thrombin-antithrombin III) were assessed immediately before the procedure, and at 7, 30, and 180 days after LAAC.
Forty-eight patients were discharged on APT (dual: 31, single: 17) and 30 on OAC (direct anticoagulants: 26, vitamin K antagonists: 4), with no differences in baseline-procedural characteristics between groups except for higher spontaneous echocardiography contrast in the OAC group. OAC significantly reduced coagulation activation within 7 days post-LAAC compared with APT (23% [95% CI, 5%-41%] versus 82% [95% CI, 54%-111%] increase for F1+2, =0.007; 52% [95% CI, 15%-89%] versus 183% [95% CI, 118%-248%] increase for TAT, =0.048), with all patients in both groups progressively returning to baseline values at 30 and 180 days. Spontaneous echocardiography contrast pre-LAAC was associated with an enhanced activation of the coagulation system post-LAAC (144 [48-192] versus 52 [24-111] nmol/L, =0.062 for F1+2; 299 [254-390] versus 78 [19-240] ng/mL, =0.002 for TAT). Device-related thrombosis occurred in 5 patients (6.4%), and all of them were receiving APT at the time of transesophageal echocardiography (10.2% versus 0% if OAC at the time of transesophageal echocardiography, =0.151). Patients with device thrombosis exhibited a greater coagulation activation 7 days post-LAAC (=0.038 and =0.108 for F1+2 and TAT, respectively).
OAC (versus APT) was associated with a significant attenuation of coagulation system activation post-LAAC. Spontaneous echocardiography contrast pre-LAAC associated with enhanced coagulation activation post-LAAC, which in turn increased the risk of device thrombosis. These results highlight the urgent need for randomized trials comparing OAC versus APT post-LAAC.
抗栓治疗对左心耳封堵术（LAAC）后凝血系统激活的影响尚不清楚。本研究旨在比较LAAC后短期口服抗凝药（OAC）与抗血小板治疗（APT）相关的凝血标志物变化。
前瞻性研究纳入78例使用Watchman装置行LAAC的房颤患者。在手术前、LAAC后7天、30天和180天评估F1+2（凝血酶原片段1+2）和TAT（凝血酶-抗凝血酶III）。
48例患者出院时接受APT（双联：31例，单药：17例），30例接受OAC（直接抗凝剂：26例，维生素K拮抗剂：4例），除OAC组自发超声心动图造影较高外，两组间基线手术特征无差异。与APT相比，OAC在LAAC后7天内显著降低了凝血激活（F1+2升高23%[95%CI，5%-41%] vs 82%[95%CI，54%-111%]，P=0.007；TAT升高52%[95%CI，15%-89%] vs 183%[95%CI，118%-248%]，P=0.048），两组所有患者在30天和180天时逐渐恢复至基线值。LAAC前的自发超声心动图造影与LAAC后凝血系统激活增强相关（F1+2为144[48-192] vs 52[24-111]nmol/L，P=0.062；TAT为299[254-390] vs 78[19-240]ng/mL，P=0.002）。5例患者（6.4%）发生器械相关血栓形成，所有患者在经食管超声心动图检查时均接受APT（经食管超声心动图检查时接受OAC者为10.2% vs 0%，P=0.151）。器械血栓形成患者在LAAC后7天表现出更大的凝血激活（F1+2和TAT分别为P=0.038和P=0.108）。
OAC（与APT相比）与LAAC后凝血系统激活的显著减弱相关。LAAC前的自发超声心动图造影与LAAC后凝血激活增强相关，这反过来增加了器械血栓形成的风险。这些结果凸显了迫切需要进行随机试验比较LAAC后OAC与APT。
