经皮左心耳封堵术在非瓣膜性心房颤动患者卒中预防中的应用

心房颤动(atrial fibrillation,AF)导致的卒中很常见,而且常常是灾难性的.尽管口服抗凝药是预防栓塞性卒中的基石,但它们也存在许多局限性,而且并非所有患者均能长期耐受.左心耳已被认定为非瓣膜性AF患者血栓形成的来源.目前已研发出多种左心耳封堵装置,并成功用于非瓣膜性AF患者的卒中预防,且围手术期并发症较少.文章对经皮左心耳封堵术在非瓣膜性AF患者卒中预防方面的应用进行了综述.     

Growth differentiation factor 15 is associated with left atrial/left atrial appendage thrombus in patients with nonvalvular atrial fibrillation

Background

There is evidence suggesting that growth differentiation factor 15 (GDF‐15) appears to be associated with stroke in patients with atrial fibrillation (AF). AF‐related thromboembolic stroke is predominantly attributed to the thrombus from the left atrium (LA) or left atrial appendage (LAA).

Hypothesis

GDF‐15 is related to LA/LAA thrombus in nonvalvular AF (NVAF) patients.

Methods

A total of 894 patients with NVAF without anticoagulation therapy were included in this study. All patients routinely underwent transesophageal echocardiography for detection of LA/LAA thrombus. GDF‐15 was measured by enzyme‐linked immunosorbent assay. Logistic regression models were used to test for association.

Results

LA/LAA thrombus was detected by transesophageal echocardiography in 69 (7.72%) patients with AF. The GDF‐15 levels in the patients with LA/LAA thrombus were significantly higher than those without LA/LAA thrombus (log₁₀ GDF‐15: 2.989 ± 0.023 ng/L vs 2.831 ± 0.007 ng/L; P < 0.001). Logistic regression analysis showed that GDF‐15 was an independent risk factor for LA/LAA thrombus (odds ratio [per quarter]: 1.799, 95% confidence interval: 1.381‐2.344, P < 0.001) after adjusting for potential clinical risk factors. The optimal cutoff point for GDF‐15 predicting LA/LAA thrombus was 809.9 ng/L (sensitivity, 75.3%; specificity, 61.5%), determined by ROC curve. The area under the curve was 0.709 (95% confidence interval: 0.644‐0.770, P < 0.001).

Conclusions

Elevated GDF‐15 indicated a significantly increased risk for LA/LAA thrombus in NVAF patients. Thus, GDF‐15 might be a potentially useful adjunct in discriminating LA/LAA thrombus in NVAF patients.     

非瓣膜性心房颤动患者卒中预防中的抗凝治疗

非瓣膜性心房颤动患者是缺血性卒中的高危人群,临床上主要采用抗凝治疗预防其卒中的发生.然而,常规口服抗凝药华法林因某些限制存在一定的困难.一些新型口服抗凝药,如直接凝血酶抑制药、凝血因子Xa抑制药在非瓣膜性心房颤动患者的卒中预防中显示了其前途.     

阿哌沙班在心房颤动患者卒中预防中的应用

心房颤动(atrial fibrillation,AF)是卒中的独立危险因素.AF患者的卒中转归较差,致死率和致残率也较高.对于卒中风险较高的AF患者,需要应用抗凝药.阿哌沙班是近年来新出现的一种口服直接Xa因子抑制药.与华法林等传统抗凝药相比,阿哌沙班在预防AF患者卒中和全身性栓塞方面展现出一定的优势.     

左心耳形态结构和功能与心房颤动相关性脑卒中的研究和展望

心房颤动（简称房颤）是临床最常见的持续性心律失常,房颤患者缺血性脑卒中的风险较非房颤患者明显增高,而其血栓主要来源于左心耳（LAA）。长期以来,非瓣膜性房颤患者的抗凝原则主要依据CHA2DS2-VASC评分,但是对于中低危患者存在局限性。随着医学影像学的发展,学者们发现左心耳形态结构特征和功能参数与血栓形成有关,可潜在地用于预测房颤脑卒中的发生。故本文拟对此进行综述,以期为下一步研究提供思路。     

不同起始剂量华法林在老年非瓣膜性房颤缺血性脑卒中预防中的应用

目的探讨老年非瓣膜性房颤患者应用华法林抗凝治疗的合适方案,以及影响治疗的因素。方法把96例65岁以上非瓣膜性房颤患者随机分为普通（3．0mg／d）、低（1．5mg／d）起始剂量组,抗凝强度的目标——国际标准化比值（INR）为1．5～3．0。随访2年。在治疗前、治疗期间查凝血酶原时间（PT）和INR。治疗前和治疗1、2年做头颅CT检查。比较两组全程缺血性脑卒中事件（“事件”）和出血的发生率,并对年龄、华法林起始用量等9个因素进行Logistic回归分析,找出血并发症的影响因素。结果96例患者平均年龄（74．5±6．8）岁,两组在随访期内均未发生“事件”;INRmax平均INR、PTmax以及出血发生率差异无统计学意义。并发出血16例（16．7％）,严重出血2例（2．1％）。所有患者平均INR为（1．9±1．4）～（2．1±0．8）,INRmax中位数2．4;第1个月平均实际检测次数为（4．1±1．1）次。Logistic回归分析显示,首月实际INR监测次数是出血发生的独立影响因素（OR 0．38,95％CI 0．20-0．75,P=0．006）,与出血并发症呈负相关。结论低抗凝强度华法林治疗对高龄、南方非瓣膜性房颤患者预防脑栓塞是可行的。避免出血并发症,增加患者治疗依从性的重要措施是在治疗的第1个月严密监测INR,并调整用药剂量。     

左心房增大与缺血性卒中

左心房增大是缺血性卒中及其他心血管不良事件的独立危险因素,可影响卒中严重程度并增高复发风险.左心房增大与缺血性卒中之间的相关机制目前仍未明确,可能与心房血栓形成或其共患病相关,例如心房颤动、高血压等.对于存在左心房增大的卒中患者如何实施一级和二级预防仍需要进一步临床试验来确定.     

左心耳封堵术在心房颤动患者中的应用价值

心房颤动是临床最常见的快速性心律失常。而血栓栓塞是心房颤动的主要危害之一,长期口服抗凝药物是预防栓塞的主要方法。但由于其存在较大的局限性,严重限制了其临床应用。     

心房颤动患者复发性缺血性卒中的危险因素

目的 探讨心房颤动患者复发性缺血性卒中的危险因素.方法 回顾性纳入合并心房颤动的缺血性卒中患者,收集其人口统计学和临床资料,对首发卒中组与复发性卒中组的卒中相关危险因素进行比较,采用多变量logistic回归分析确定心房颤动患者复发性缺血性卒中的独立危险因素.结果 共纳入504例合并心房颤动的缺血性卒中患者,其中男性245例(48.6%),女性259例(51.4%),平均年龄(76.67±8.26)岁;首发卒中组314例(62.3%),复发性卒中组190例(37.7%).复发卒中组高血压(78.9%对69.4%;χ2=5.446,P=0.020)、糖尿病(38.9%对26.8%;χ2=8.181,P=0.004)和年龄>75岁(68.9%对60.2%;χ2=3.915,P=0.048)的患者比例以及基线收缩压[(153.30±26.02)mmHg对(148.13±26.40)mmHg,1 mmHg=0.133 kPa;t=-2.141,P=0.033]均显著高于首发卒中组.多变量logistic回归分析表明,高血压[优势比(odds ratio, OR)1.734,95%可信区间(confidence interval, CI)1.121~2.682;P=0.013]、糖尿病(OR 1.757,95% CI 1.188~2.597;P=0.005)、年龄>75岁(OR 1.680,95% CI 1.132~2.494;P=0.010)是心房颤动患者复发性缺血性卒中的独立危险因素.结论 高血压、糖尿病和年龄>75岁是心房颤动患者复发缺血性卒中的独立危险因素.     

Detection and management of atrial fibrillation after cryptogenic stroke or embolic stroke of undetermined source

Cryptogenic stroke (CS) and embolic stroke of unknown source (ESUS) represent a major challenge to healthcare systems worldwide. Atrial fibrillation (AF) is commonly found after CS or ESUS. Independent of the mechanism of the index CS or ESUS, detection of AF in these patients offers the opportunity to reduce the risk of stroke recurrence by prescribing an anticoagulant instead of aspirin. The detection of AF may be pursued with different monitoring strategies. Comparison of monitoring strategies should take into account that AF detection rates reported in published studies, and then pooled in meta‐analyses, are not only a function of the monitoring strategy itself, but also depend on patient‐related, device‐related, and study design–related factors. Once AF is found, the decision to anticoagulate a patient should be made on the basis of AF burden and the baseline risk of the patient. Empirical anticoagulation in patients with ESUS and no evidence of AF is an intriguing but still‐unproven strategy and therefore should not be adopted outside of randomized clinical trials.     

Left atrial appendage occlusion: Initial experience with the Amplatzer™ Amulet™

Background

The Amplatzer™ Amulet™ (Amulet) is the evolution of the Amplatzer™ Cardiac Plug, a dedicated device for percutaneous left atrial appendage (LAA) occlusion. The new device has been designed to facilitate the implantation process, improve the sealing performance and further reduce the risk of complications. The objective of the study was to describe the initial experience with the Amplatzer Amulet for percutaneous LAA occlusion.

Methods

This was a prospective single-center study of patients undergoing percutaneous LAA occlusion. The indication for LAA closure was a formal contraindication for oral anticoagulation or previous history of stroke due to INR lability. All procedures were done under general anesthesia and transesophageal echocardiography (TEE) guidance. Transthoracic echocardiography was performed 24 h after the procedure in order to rule out procedural complications before discharge. Further follow-up was done with a clinical visit and TEE at 1–3 months.

Results

Between July-2012 and June-2013, 25 patients with a mean CHA₂DS₂-VASC of 4.3 ± 1.7 underwent LAA occlusion with the Amplatzer Amulet. The device was successfully implanted in 24 patients (96%) without any procedural stroke, pericardial effusion or device embolization. None of the patients presented any clinical event at follow-up. Follow-up TEE showed complete LAA sealing in all patients with no residual leaks > 3 mm and no device embolization. One patient (4.1%) presented a device thrombosis at follow-up without clinical expression.

Conclusion

In this initial series of patients, the Amulet showed a remarkable acute and short-term performance in terms of feasibility and safety as depicted by the high successful implantation rate and the low incidence of complications.     

闭塞左心耳在预防非风湿性心脏病房颤患者卒中中的作用

65岁以上人群房颤发生率为3％～5％，占缺血性卒中病因的15％～20％。每年约5％非风湿性房颤患者发生卒中。非风湿性心脏病房颤患者口服抗凝药（OAC）预防卒中的效果已被证实。但相当一部分栓塞事件的高危人群无法长期使用OAC。左心耳（LAA）是房颤患者血栓形成的最常见部位，在心脏外科手术中通过切除、结扎、缝合、固定等方法可以将LAA与体循环隔离。日前在二尖瓣手术中建议同时切除IAA以降低未来卒中风险。正在进行的LAA闭塞研究（LAAOS），主要对行选择性冠状动脉旁路移植的患者接受常规LAA闭塞的疗效进行评估。