Kawabata Mihoko, Goya Masahiko, Maeda Shingo, Yagishita Atsuhiko, Takahashi Yoshihide, Sasano Tetsuo, Hirao Kenzo
Arrhythmia Advanced Therapy Center, AOI Universal Hospital.
Department of Cardiovascular Medicine, Tokyo Medical and Dental University.
Int Heart J. 2020 Sep 29;61(5):905-912. doi: 10.1536/ihj.19-625. Epub 2020 Sep 12.
There is little data on management and outcomes of atrial fibrillation (AF) patients on direct oral anticoagulants (DOAC) undergoing general surgery.We retrospectively assessed 98 surgeries in 85 nonvalvular AF patients aged 73 ± 8 (59 men) receiving DOACs. Cardiac, emergency, and minimally invasive surgeries were excluded.The CHADS-VASc score ranged from 0 to 8. The DOACs being given were: dabigatran, 16; rivaroxaban, 25; apixaban, 28; and edoxaban, 16. While the DOACs were not suspended in 11 cases, they were interrupted for a median of 2.0 days before surgery and restarted at a median of 3.0 days after surgery. There were 9 complications (9.2%), 3 instances of thromboembolism and 6 bleeding. Thromboembolism occurred at a mean of 3.0 postoperative days, all of which occurred before resumption of DOACs, while bleeding events occurred at a mean of 4.0 postoperative days. Two of the 3 patients with thromboembolism went into cardiopulmonary arrest during the event, but were resuscitated. There were significantly more patients with congestive heart failure or combined antiplatelets in the patients with complications. The complication group had a significantly higher HAS-BLED score and lower preoperative hemoglobin level. There were no significant differences in the management of DOAC interruption between those with complications and without.The perioperative complication rate in nonvalvular AF patients undergoing elective surgery treating with DOACs was 9.2%. Patients with congestive heart failure, receiving combined therapy with antiplatelets, a higher HAS-BLED score, or lower preoperative hemoglobin level were at higher risk. Further studies evaluating the ideal perioperative DOAC protocol are warranted.
关于接受直接口服抗凝剂（DOAC）治疗的心房颤动（AF）患者进行普通外科手术的管理及预后的数据较少。我们回顾性评估了85例年龄为73±8岁（59例男性）接受DOAC治疗的非瓣膜性AF患者的98例手术。排除心脏手术、急诊手术和微创手术。CHADS-VASc评分范围为0至8分。所使用的DOAC包括：达比加群16例；利伐沙班25例；阿哌沙班28例；依度沙班16例。11例患者未停用DOAC，但在手术前中位中断2.0天，术后中位3.0天重新开始用药。发生9例并发症（9.2%），3例血栓栓塞和6例出血。血栓栓塞平均发生在术后3.0天，均发生在恢复使用DOAC之前，而出血事件平均发生在术后4.0天。3例血栓栓塞患者中有2例在事件发生期间发生心肺骤停，但均成功复苏。并发症患者中患有充血性心力衰竭或联合使用抗血小板药物的患者明显更多。并发症组的HAS-BLED评分明显更高，术前血红蛋白水平更低。有并发症和无并发症患者在DOAC中断管理方面无显著差异。接受DOAC治疗的非瓣膜性AF患者择期手术的围手术期并发症发生率为9.2%。患有充血性心力衰竭、接受抗血小板联合治疗、HAS-BLED评分较高或术前血红蛋白水平较低的患者风险更高。有必要进一步研究评估理想的围手术期DOAC方案。
