Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA.
J Cardiovasc Electrophysiol. 2024 Jun;35(6):1212-1216. doi: 10.1111/jce.16284. Epub 2024 Apr 23.
Early guidance recommended a bolus of intravenous heparin at the beginning of leadless pacemaker (LP) implantation procedures. However, due to concern about bleeding complications, more recent practice has tended toward omitting the bolus and only running a continuous heparin infusion through the introducer sheath. The impact of omitting the heparin bolus on procedural outcomes is not clear.
We reviewed all Medtronic Micra LP implants at our institution from 9/2014 to 9/2022. The decision to bolus with heparin was at operator discretion.
Among 621 LP implants, 326 received an intravenous heparin bolus, 243 did not, and 52 patients were excluded because heparin bolus status could not be confirmed. There was a trend toward more frequent omission of the heparin bolus with more recent implants. Median follow-up after LP implant was 14.3 (interquartile range [IQR]: 8.4-27.9) months. There was no difference between heparin bolus and no bolus groups in the number of device deployments/recaptures (1.42 ± 0.81 vs. 1.31 ± 0.66, p = .15). Implant-related adverse events were also similar between heparin bolus and no bolus groups: access-site hematoma requiring intervention (7 vs. 5, p = .99), pseudoaneurysm (1 vs. 1, p = .99), cardiac perforation (1 vs. 1, p = .99), intraprocedural device thrombus formation (2 vs. 4, p = .41), 30-day rehospitalization (21 vs. 15, p = .98), and 30-day all-cause mortality (16 vs. 14, p = .70). There was one additional nonfatal cardiac perforation in a patient who was excluded due to unknown heparin bolus status. Regarding device electrical parameters between heparin bolus and no bolus groups, there were no significant differences at the time of implant: pacing capture threshold 0.5 ± 0.4 vs. 0.5 ± 0.3, p = .10; pacing impedance 739.9 ± 226.4 vs. 719.1 ± 215.4, p = .52; R wave sensing 11.7 ± 5.7 vs. 12.0 ± 5.4, p = .34). Long-term device performance was also similar between groups.
Omission of the systemic heparin bolus at the time of LP implantation appears safe in appropriately selected patients. Heparin bolus may still be considered in long cases requiring multiple device deployments or in patients at high risk for thrombotic complications.
早期指南建议在植入无导线起搏器（LP）时给予静脉肝素推注。然而，由于担心出血并发症，最近的做法倾向于省略推注肝素，而仅通过引导鞘管持续输注肝素。省略肝素推注对程序结果的影响尚不清楚。
我们回顾了我院 2014 年 9 月至 2022 年 9 月期间所有 Medtronic Micra LP 植入术。给予肝素推注的决定由操作者自行决定。
在 621 例 LP 植入术中，326 例给予静脉肝素推注，243 例未给予肝素推注，52 例因无法确认肝素推注状态而被排除。最近植入的 LP 更倾向于省略肝素推注。LP 植入后中位随访时间为 14.3（四分位距 [IQR]：8.4-27.9）个月。肝素推注组和未推注组在器械展开/回收次数方面无差异（1.42±0.81 次比 1.31±0.66 次，p=0.15）。肝素推注组和未推注组的植入相关不良事件也相似：介入治疗的穿刺部位血肿（7 例比 5 例，p=0.99）、假性动脉瘤（1 例比 1 例，p=0.99）、心脏穿孔（1 例比 1 例，p=0.99）、术中器械血栓形成（2 例比 4 例，p=0.41）、30 天再入院（21 例比 15 例，p=0.98）和 30 天全因死亡率（16 例比 14 例，p=0.70）。由于肝素推注状态未知而被排除的患者中，还有 1 例额外的非致命性心脏穿孔。关于肝素推注组和未推注组之间的设备电参数，植入时无显著差异：起搏捕获阈值 0.5±0.4 比 0.5±0.3，p=0.10；起搏阻抗 739.9±226.4 比 719.1±215.4，p=0.52；R 波感知 11.7±5.7 比 12.0±5.4，p=0.34）。两组的长期设备性能也相似。
在适当选择的患者中，在 LP 植入时省略全身肝素推注似乎是安全的。对于需要多次器械展开或有血栓形成并发症高风险的患者，肝素推注仍可考虑。
