左心耳封堵之并发症——不可回避的风险

心房颤动为临床最常见的心律失常,血栓的形成及脱落导致的缺血性脑卒中是房颤患者致残的主要原因。近年来左心耳封堵术已逐渐成为非瓣膜性房颤患者卒中预防中不可缺少的手段,有望发展成为抗凝治疗的合理替代方案。然而左心耳封堵术合并相关的并发症,如心包积液、残余漏、器械相关血栓及栓塞并发症等。如何保证操作安全,降低相关的并发症,一直是临床关注和需要亟待解决的热点问题。本文就左心耳封堵术相关的并发症作一综述。     

经皮左心耳封堵术临床研究进展

心房颤动 ( 简称房颤 ) 患者具有更高的卒中风险。左心耳被证实是房颤患者血栓形成的主要部位。经皮左心 耳封堵术是近年来发展的通过微创导管术封堵左心耳以达到预防房颤患者血栓栓塞的新技术。许多左心耳封堵器 已经正式上市或者进入临床研究阶段。Watchman 是当前使用最广、循证医学证据最多的封堵器。Protect-AF 研究 是第一个头对头对比华法林预防卒中的随机对照研究。目前,Watchman 成为目前第一个经过美国 FDA 批准的左 心耳封堵器。与此同时,国产左心耳封堵器 LAmbre 及 Lefort 也崭露头角并相继进入临床研究。左心耳封堵术开启 了全球预防房颤患者卒中治疗的新模式,即由“局部封堵、单次手术”替代传统的“全身抗凝、终生服药”。     

老年心房颤动左心耳血流淤滞介入治疗一例

正目前研究的热点是非瓣膜性心房颤动(房颤)的治疗。对栓塞并发症的主要预防措施为口服抗凝药物和左心耳封堵术。大量的研究证实,左心耳封堵术在预防栓塞方面的有效性不劣于口服抗凝药。但是,围术期的手术相关并发症导致左心耳封堵术临床应用受限,故左心耳封堵术主要用于出血风险较高不能耐受抗凝治疗或抗凝治疗情况下仍存在栓塞高风险的患者。现报道1例服用新型口服抗凝治疗情况下,左心耳局部仍存在血流淤滞现象,经左心耳封堵术成功隔离左心耳的房颤患者。     

左心耳封堵联合房颤导管射频消融的进展

房颤导管射频消融主要目的是改善患者症状，提高患者生活质量，但不能替代抗凝治疗。而左心耳封堵术可替代抗凝治疗，成为房颤卒中预防的重要治疗手段，但不能改善房颤患者症状。因此左心耳封堵联合射频消融术是不适合口服抗凝药的症状性房颤患者的最佳治疗选择。本文针对联合术式的安全性、有效性以及相互间的影响进行综述。     

左心-耳封堵术预防心房颤动患者血栓栓塞的研究进展

研究表明左心耳有不同的形态和结构,具有独立的舒缩功能,心房颤动（简称房颤）时,这种舒缩功能消失,成为血栓形成的场所。因此,干预（封堵）左心耳可预防房颤患者脑卒中。目前封堵左心耳手术器械有PLAA．TO、WATCHMAN、Amplatzer,以及国产Lambre系统封堵器,在临床上均有应用,并能降低房颤患者的脑卒中。此外,左心耳也是一种分泌器官、封堵术有创,并会造成相应的有关并发症。因此,仍需大规模前瞻性临床试验证实其利弊。     

心内超声指导下经皮左心耳封堵技术及其应用进展

经皮左心耳介入封堵术已经成为脑卒中与出血均高危的房颤患者的重要处理方法之一。传统手术模式是在全麻+食管超声指导下完成,而采用心内超声技术则可以在局麻下完成。临床研究证实采用心内超声指导下进行左心耳介入封堵不仅安全有效,还能大大降低并发症风险。在心内超声指导下左心耳封堵术中心脏CT图像起到非常重要的作用。术前CT测量左心耳相关参数对于选择合适的封堵器非常重要。     

心房颤动患者行左心耳封堵术的护理体会

目的观察左心耳封堵治疗心房颤动患者进行综合护理的效果。方法 6例心房颤动患者进行左心耳封堵术,治疗过程均给予术前、术中、术后护理、出院指导及随访等综合护理措施干预。结果经过综合护理措施干预后,所有患者均成功行左心耳封堵术,术后恢复良好,无并发症发生。结论对左心耳封堵患者进行综合护理,护理疗效显著。     

房间隔缺损或卵圆孔未闭联合左心耳一站式封堵治疗的安全及有效性

目的评估先天性房间隔缺损或卵圆孔未闭并发心房颤动(房颤)患者同时行房间隔缺损或卵圆孔未闭联合左心耳封堵术的安全性、疗效及预后。方法回顾性分析珠海市人民医院2017年10月至2019年6月收治的10例先天性房间隔缺损或卵圆孔未闭并发房颤的患者的术前、术中及术后临床资料,评估术中安全性及即刻手术疗效,并于术后的第45天、90天、180天及360天对患者进行随访观察,了解患者临床表现,并确认房间隔缺损或卵圆孔未闭和左心耳封堵器的位置,评估残余分流及血栓形成情况。结果成功对10例患者植入双盘式房间隔缺损或卵圆孔未闭封堵器及左心耳封堵器(均为WATCHMANTM),其中5例为房间隔缺损联合左心耳封堵患者,5例为卵圆孔未闭联合左心耳封堵患者(其中3例患者进行了射频消融联合卵圆孔未闭封堵及左心耳封堵术治疗)。患者术后即刻封堵效果满意,房间隔缺损或卵圆孔未闭封堵器位置固定且无残余分流,WATCHMANTM左心耳封堵器符合PASS原则。术中未发现器械相关性血栓,无心包填塞及血管并发症。随访结果显示,10例患者均未发现新发脑卒中,无心绞痛、心肌梗死以及心功能恶化,且未出现器械相关性血栓及封堵器移位和左心耳封堵器残余分流加重等不良事件。3例同期接受射频消融的患者维持窦性心律,1例房间隔缺损患者自行转为窦性心律。结论对先天性房间隔缺损或卵圆孔未闭并发房颤患者同期实施房间隔缺损或卵圆孔未闭联合左心耳封堵术,操作安全简便,手术效果及随访结果满意。     

左心耳封堵预防心房颤动患者血栓栓塞：进展与展望

血栓栓塞是心房颤动（房颤）最严重的并发症之一。长期以来,口服抗凝药物一直是房颤患者预防血栓栓塞的主要方法。然而,口服抗凝药物的诸多弊端导致真实世界中房颤患者规范化抗凝治疗严重不足。左心耳是房颤患者发生血栓栓塞事件的重要起源部位,近年来左心耳封堵术已成为房颤患者预防血栓栓塞的新方法,本文就相关内容做一综述。     

左心耳封堵术和口服抗凝药在非瓣膜性心房颤动中的有效性和安全性的Meta分析

目的 评估左心耳封堵术和口服抗凝药在非瓣膜性心房颤动(房颤)患者中的有效性和安全性.方法 通过检索Pubmed、EMBASE、Cochrane数据库中关于左心耳封堵术治疗房颤的相关文献,时间截止为2021年6月,检索关键词为:"Nonvalvular atrial fibrillation"、"Left atrial ...     

左心耳封堵器在非瓣膜性心房颤动患者中应用新进展

心房颤动（AF）是最常见、最普遍的心律失常,被称为21世纪的心血管流行病,目前没有治愈AF的方法。AF的最大风险是血栓形成并脱落,造成人体重要部位,特别是脑部血管的堵塞,引发脑卒中。缺血性脑卒中是AF的主要严重并发症,与其他类型的脑卒中相比,心源性脑卒中发病更急、瘫痪的程度更重、住院治疗的周期更长、复发率和病死率更高,造成患者生活质量差,经济负担重。研究表明90 %以上的非瓣膜性心房颤动（NVAF）患者缺血性脑卒中的栓子来源于左心耳。随着现代生物医学技术的创新发展,经皮左心耳封堵术的获益得到肯定,作为一种可替代的,特别是对于不适合口服抗凝药物治疗患者有了非药物性介入的治疗方法。本文对左心耳封堵术在AF的现代化应用进行阐述,详细介绍用左心耳封堵器的发展、国内外各类封堵器的优劣及其创新应用,为AF的临床治疗选择提供科学依据,为推动AF患者治疗提供参考。     

One-stop procedure of “Atrial fibrillation radiofrequency ablation + left atrial appendage closure” guided by 3D printing technology: A case report

Left atrial appendage occlusion (LAAO) in the treatment of atrial fibrillation (AF) has become a hot topic in clinical research in recent years. We report a 68-year-old female with a 3-year history of paroxysmal atrial fibrillation refractory to antiarrhythmic therapy and unable to tolerate anticoagulation therapy who underwent successful atrial fibrillation radiofrequency ablation combined with left atrial appendage occlusion guided by 3D printing technology. There was no recurrence of her atrial fibrillation and there was continued complete occlusion of her left atrial appendage at 3-month and 1-year follow-ups.This case supports the potential advantage of 3D printing technology to guide a “one-stop combined AF radiofrequency ablation and left atrial appendage occlusion procedure.” But whether it can improve the prognosis and quality of life of patients, further multi-center research and large data statistics are required.     

左心耳封堵术对于房颤患者防治卒中的作用

心房颤动（Atrial fibrillation,AF),简称房颤,是最常见的持续性心律失常。随着人口的普遍老龄化,人群中房颤患病率呈显著上升趋势。预计到2050年房颤患病人口将在目前患病人数水平上增加一倍。而对于房颤患者,卒中的预防是房颤治疗的首要目标。据统计,房颤患者发生卒中的风险约为窦性心律失常人群的5倍。目前,对于房颤患者的卒中治疗预防主要是应用口服抗凝药物。最新研究表明,左心耳封堵术对于房颤患者的卒中预防有着显著疗效。本文将综述左心耳封堵术对于房颤患者防治卒中的作用,为临床应用提供依据。     

Evidence-based percutaneous closure of the left atrial appendage in patients with atrial fibrillation

Atrial fibrillation is the most common cardiac arrhythmia, and its prevalence is increasing. Cardioembolic stroke, most of the times secondary to thrombus formation in the left atrial appendage, is its most feared and life threatening consequence. Oral anticoagulation with vitamin-K-antagonists is currently the most used prophylaxis for stroke in patients with atrial fibrillation; unfortunately, its benefits are limited by a narrow therapeutic window and an increased risk for bleeding, making it often undesired. Percutaneous occlusion of the left atrial appendage is a novel alternative strategy for cardioembolic stroke prophylaxis in patients with atrial fibrillation at a high risk of stroke but with contraindication for long-term oral anticoagulation therapy. At present, several devices have been developed specifically for percutaneous occlusion of the left atrial appendage. Current results show good feasibility and efficacy for these devices, with a high rate of successful implantation, although also associated with the inherent potential periprocedural complications. This work reviews the current state of the art of percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation.     

Is left atrial appendage occlusion useful for prevention of stroke or embolism in atrial fibrillation?

Since in atrial fibrillation more than 90% of the thrombi are located in the left atrial appendage, an “elimination” of the left atrial appendage, either by resection or occlusion, seems an attractive alternative to oral anticoagulation. Although frequently regarded as an useless appendage, data from animal and human investigations show that the left atrial appendage may play an important role in the maintenance and regulation of the cardiac function, especially in arterial hypertension, atrial fibrillation, coronary heart disease, valvular heart disease and heart failure. Elimination of the left atrial appendage may impede thirst in hypovolemia, deteriorate hemodynamic responses to volume or pressure overload, decrease cardiac output and promote heart failure. Instead of preventing stroke, the consequences of left atrial appendage elimination may create new risk factors for stroke and thus might induce more harm than benefit to patients with atrial fibrillation. As long as the physiologic and pathophysiologic role of the left atrial appendage is not fully understood, left atrial appendage elimination should not be an alternative to oral anticoagulation.     

左心耳封堵治疗的现状和进展

左心耳（LAA）封堵术是新近发展起来的预防房颤并发卒中的一种有效方法，特别是为华法林治疗禁忌的患者提供了一种可选的治疗手段。本文就LAA封堵术适应证、循证医学证据、存在问题及展望做一综述。     

Percutaneous exclusion of the left atrial appendage in prevention of systemic embolism

Left atrial appendage is the most frequent place of blood clot formation in heart cavities. The thrombus formation increases a risk of a systemic embolism especially in patients with a permanent atrial fibrillation. The standard preventive treatment is the oral anticoagulation therapy. Another possible a treatment is an exclusion of a left atrial appendage. We present current overview a risks and benefits of surgical and percutaneous elimination of a left atrial appendage. We present the first experience with Amplatzer Cardiac Plug system in an elimination of a left atrial appendage. We concluded that an exclusion of left atrial appendage could become a useful possibility of prevention of systemic embolization in patients with an atrial fibrillation, but is not still an alternative therapy for anticoagulation therapy at present.     

Left atrial appendage function in patients with atrial flutter.

OBJECTIVE: To determine whether echocardiographic markers thromboembolic risk differ between patients with pure atrial flutter and patients with atrial flutter and intermittent atrial fibrillation. DESIGN: Patients with atrial flutter were followed up prospectively for 12 months to identify intermittent atrial fibrillation. After the follow up period, transthoracic and multiplane transoesophageal echocardiography were performed to assess left atrial chamber and appendage size, peak emptying velocities, and emptying fraction of the left atrial appendage. The presence of spontaneous echo contrast was also determined. SETTING: Tertiary cardiac care centre. PATIENTS: 20 consecutive patients with atrial flutter; 11 healthy subjects in sinus rhythm served as controls. RESULTS: Intermittent atrial fibrillation was documented in 11 patients by Holter monitoring or surface ECG; atrial fibrillation was not found in the other nine patients. Compared with the patients with pure atrial flutter, patients with atrial flutter and intermittent atrial fibrillation had larger left atrial chamber (mean (SD) 4.5 (0.6) v 3.8 (0.5) cm; 95% confidence interval 0.2 to 1.2; P = 0.01) and appendage areas (6.7 (2.2) v 4.8 (4.9) cm; 95% CI 0.4 to 3.5; P = 0.02), lower left atrial appendage emptying fractions (33 (11)% v 52 (11)%; 95% CI 8 to 29; P = 0.008), and also lower left atrial appendage emptying velocities (0.44 (0.21) v 0.79 (0.27) m/s; 95% CI 0.13 to 0.56; P = 0.005). In addition, a higher incidence of spontaneous echo contrast (11% v 36%) was observed in patients with atrial flutter and intermittent atrial fibrillation. CONCLUSIONS: Left atrial appendage function is depressed and spontaneous echo contrast more frequent in patients with atrial flutter and intermittent atrial fibrillation, as opposed to patients with pure atrial flutter. These data support the concept that patients with atrial flutter and intermittent atrial fibrillation have an increased risk of thromboembolic events and should therefore receive adequate anticoagulant treatment.     

经皮左心耳封堵联合冠脉介入“一站式”治疗对房颤合并冠心病患者的安全性及疗效初探

目的 探讨对非瓣膜性房颤合并冠心病的患者，同期进行经皮左心耳封堵术联合冠脉介入一站式治疗的可行性、安全性及疗效。方法 回顾性分析珠海市人民医院2017年4月-2018年6月收治的5例房颤合并冠心病的患者的临床资料。所有患者术后采用阿司匹林100mg Qd+氯吡格雷75mg Qd双抗1年，阿司匹林/波立维单抗长期使用的方案。术后即刻评价左心耳封堵及冠脉介入疗效，并于术后45天，90天随访观察左心耳封堵器的位置、血栓形成以及残余分流情况及患者临床表现。结果 5例患者均成功植入WATCHMAN左心耳封堵器及冠脉支架。术后即刻封堵效果满意，WATCHMAN封堵器符合PASS原则，冠脉介入治疗效果满意。术中无器械表面血栓，无心包填塞及血管并发症。随访结果显示，5例患者无出现脑卒中、心功能恶化者、封堵器移位、封堵器残余分流加重及器械表面血栓、心绞痛或心梗事件，且亦未发现皮肤瘀斑、消化道出血、脑出血等出血事件。结论 对非瓣膜性房颤合并冠心病患者，同期实施左心耳封堵术联合冠脉介入一站式治疗的安全性可，有一定的可行性，近、中期的随访效果良好。