冠状动脉支架植入术后不停用双联抗血小板药物植入心血管植入型电子器械

目的 观察冠状动脉（冠脉）支架植入术后在不停用双联抗血小板药物情况下心血管植入型电子器械（CIED）术后并发症发生情况.方法 将2008年3月至2013年3月在大连解放军第210医院心内科接受CIED植入的64例患者分为2组,双联抗血小板药物组32例,植入冠脉药物洗脱支架术后1年内持续使用双联抗血小板药物（阿司匹林100 mg＋氯吡格雷75 mg,每日1次口服）期间符合CIED适应证,在不停用的情况下植入CIED;对照组32例,采用随机数法抽取同期未使用或停用抗血小板药物情况下植入CIED患者.观察终点：术后30 d内囊袋血肿发生率.结果 2组患者术后30 d内均无囊袋血肿发生.结论 冠脉支架植入术后在不停用双联抗血小板药物情况下植入CIED未见囊袋血肿发病率增加,但需增加病例数、延长随访期进一步观察.     

高频电刀应用对心血管植入型电子器械囊袋血肿发生率的影响

目的探讨心血管植入型电子器械(CIED)植入术中应用高频电刀能否降低CIED囊袋血肿的发生率。方法回顾性分析在沈阳军区总医院接受新植入或更换CIED的患者3884例。CIED植入术中应用高频电刀的患者归为电刀组(3115例),而未应用高频电刀的患者归为对照组(769例)。两组患者各自又分为出血倾向亚组和无出血倾向亚组;出血倾向亚组再分为肝素桥接组和直接手术组。统计各组患者CIED囊袋血肿发生率。结果电刀组与对照组患者的基线资料均衡。CIED植入后1周共发生囊袋血肿86例(2.2%,86/3884),未发生CIED囊袋感染;而远期囊袋感染或破裂患者9例(10.5%,9/86)。电刀组囊袋血肿发生率显著低于对照组[1.5%(46/3115)比5.2%(40/769),P0.001];电刀组中出血倾向亚组[1.8%(4/218)比11.5%(6/52),P=0.004]、无出血倾向亚组[1.4%(42/2897)比4.7%(34/717),P0.001]和出血倾向亚组中的肝素桥接组[2.0%(2/100)比11.5%(6/52),P=0.020]CIED囊袋血肿发生率分别较对照组相应各亚组显著降低,差异均有统计学意义。对照组中出血倾向亚组CIED囊袋血肿发生率[11.5%(6/52)比4.7%(34/717),P=0.046]高于无出血倾向亚组,差异有统计学意义。而电刀组中出血倾向亚组与无出血倾向亚组的CIED囊袋血肿发生率比较,差异无统计学意义(P=0.560);电刀组出血倾向亚组中的肝素桥接组与直接手术亚组的CIED囊袋血肿发生率比较,差异亦无统计学意义(P=1.000)。结论CIED植入术中应用高频电刀能降低囊袋血肿的发生率,并降低口服抗凝或抗血小板药物对囊袋血肿发生率的影响。     

迟发性起搏器囊袋血肿13例分析

目的　观察植入或更换起搏器病人迟发性囊袋血肿的发生率 ,并探讨其发生的原因。方法　对从1995年 1月至 2 0 0 1年 12月植入或更换起搏器的 12 0 9例次病人的一般情况、临床资料、起搏器植入或更换手术的资料进行回顾性研究。结果　在 12 0 9例次植入或更换起搏器的病人中有 13例发生迟发性囊袋血肿 ,发生率1 0 % ,占整个急性期囊袋出血的 39 4%。结论　植入起搏器 3d后才出现的血肿称为迟发性起搏器囊袋血肿 ,其发生率较低 ,与手术操作和病人的一般情况有关。     

心脏永久起搏器安置术后囊袋血肿临床诊治

目的总结分析32例心脏永久起搏器安置术后患者囊袋血肿形成的原因及治疗。方法回顾性分析我院自2008年01月份开始至2012年06月份期间32例行心脏永久起搏器安置术后患者囊袋血肿形成的原因及其治疗,总结起搏器安置术后囊袋血肿的治疗经验。结果32例患者中早期囊袋血肿（起搏器植入术后1周内出现的囊袋内出血称为中早期囊袋血肿）22例,迟发性囊袋血肿10例,（起搏器植入术后1周以上出现的囊袋内出血称为迟发性囊袋血肿）,均取囊袋内液体行细菌培养结果为阴性。所有患者均予抗生素预防感染并积极治疗原发病,均未发生起搏器囊袋感染,32例患者术口均愈合出院。结论早期发现囊袋血肿,及时进行正确的治疗,有利于术口愈合。     

引流装置在心血管植入电子设备病人中的有效性分析

目的 评估自制引流装置在心血管植入电子设备(CIED)植入于应用抗血栓药物病人中的安全性和有效性。方法 将90例CIED植入于应用抗血栓药物的病人随机分为两组,试验组45例病人囊袋留置自制引流装置和常规盐袋加压16 h,对照组45例病人弹性胶带加压包扎和常规盐袋加压16 h。比较两组术后7 d内囊袋血肿情况、切口渗出情况及术后1年内囊袋感染情况。结果 试验组囊袋血肿发生率(0.0%)明显低于对照组(8.9%),差异有统计学意义(P<0.05)。试验组囊袋切口渗出发生率(2.2%)低于对照组(13.8%),差异有统计学意义(P<0.05)。两组囊袋感染率比较,差异无统计学意义(P>0.05)。结论 留置引流装置可明显降低CIED植入于应用抗血栓药物病人的血肿发生率、切口渗出发生率,且不增加感染的概率,在CIED植入病人中安全有效。     

老年患者永久起搏器植入术后囊袋血肿原因分析及处理

目的观察老年患者永久性心脏起搏器植入术后囊袋血肿的发生情况,并探讨其原因。方法对2006年8月—2011年10月植入起搏器的136例老年患者的临床资料进行回顾性分析。结果 136例中有8例发生囊袋血肿,发生率5.88%;其中发生在7d以内囊袋出血的患者5例,7d～14d囊袋出血的患者3例。8例患者中3例用注射器局部抽吸,1例抽吸效果欠佳后改为重新切开囊袋止血,3例切开囊袋,清创止血、并用立止血在囊袋内湿敷;2例芒硝外敷,盐袋压迫。无一例发生感染。结论老年患者起搏器囊袋内出血与起搏器手术操作、应用抗凝药物、患者的年龄、营养状况密切相关。高龄患者本身可能存在潜在的凝血功能障碍或因并存疾病需应用抗凝药物,囊袋血肿发生较高。局部处理主要依据囊肿大小、皮肤瘀斑色泽、出血速度和起搏器囊袋张力大小而定。     

不同压迫时间对起搏器植入术囊袋伤口愈合的影响

目的比较起搏器植入术后囊袋局部不同压迫时间对囊袋血肿发生和伤口愈合的影响,探讨缩短囊袋局部压迫时间的可能性及适宜的压迫时间。方法于本院行起搏器植入的患者,按围手术期有无使用抗凝抗血小板药物分为药物组和非药物常规组,每组分别随机分组至不同时间压迫,比较各组之间术后伤口渗血、囊袋血肿的发生及伤口愈合情况。结果 149例患者,常规组88例,分为3 h组(n=42)和6 h组(n=46);药物组61例,分为4 h组(n=30)和8 h组(n=31)。药物组共发生3例囊袋血肿,常规组无囊袋血肿发生;药物组术中电刀使用率、皮肤瘀斑以及伤口渗血发生率分别为100%、8.2%、14.8%,均明显高于常规组的75%、1.1%、1.1%,(P=0.000,0.042,0.001),而常规3 h、6 h组,药物4 h、8 h组间比较无显著性差异。结论围手术期抗凝抗血小板治疗是导致伤口出血和囊袋血肿的重要因素。起搏器术后囊袋压迫时间对伤口出血及囊袋血肿无影响。     

颅内血肿微创清除术后迟发性血肿23例

目的探讨颅内血肿微刨清除术后迟发性血肿的形成原因、发生机制及临床诊治。方法对术中发生急性脑水肿时，在对侧钻颅探查或术后患者病情恶化时及时行CT检查。结果治疗23例非术区迟发性血肿患者，其中死亡7例，病死率30.4％。结论在清除急性颅内血肿时发生急性脑水肿或术后病情恶化应想到迟发性血肿形成，宜尽早钻颅探查和（或）复查头颅CT，及时诊治可改善预后。     

青光眼滤过术后迟发性眼内炎临床分析

目的总结青光眼滤过术后迟发性眼内炎的病因、治疗方法及预后。方法对5例青光眼滤过术后迟发性眼内炎患者的临床资料作回顾性分析。结果 5例（5眼）迟发性眼内炎发生于青光眼滤过术后5个月～8 a,均发生于薄壁滤过泡患者。5例房水及结膜囊分泌物培养,发现金黄色葡萄球菌和表皮葡萄球菌各1例。均行局部广谱抗生素治疗,1例行玻璃体切割联合玻璃体腔注药治疗。眼内炎症均控制,但患者视力较差。结论青光眼滤过术后迟发性眼内炎的发生与薄壁滤过泡密切相关,有的脓液中可培养出致病菌。局部抗炎联合玻璃体切割治疗有效,但患者视力预后较差。     

含碘抗菌贴膜在预防心血管电子器械植入术切口感染中的效果

切口及囊袋感染是心血管植入型电子器械（CIED）患者最常见的手术并发症。随着CIED植入适应证的延伸,加上高龄患者日益增多、伴随疾病的增加均使感染风险增加。因此,预防CIED术后感染是围术期医疗安全的重点之一。手术野及周围皮肤污垢清除不彻底、切口出血及囊袋冲洗液外溢使切口周围的无菌布类浸湿而失去了保护作用,使细菌及污垢侵入,更易引起切口及囊袋感染。本文通过比较手术中使用含碘抗菌贴膜与未使用抗菌薄膜的患者术后切口及囊袋感染的发生率,探讨含碘抗菌贴膜在CIED植入术中预防感染的应用价值。     

抗凝抗血小板药物对起搏器植入术后囊袋出血的影响

目的研究围手术期应用抗凝及抗血小板药物对起搏器植入术后囊袋出血的影响。方法回顾3年来在本院行起搏器植入或更换的患者资料,对其中血栓高危患者在不停用抗凝或抗血小板药物的情况下,手术完成情况进行分析,了解围手术期抗凝和抗血小板药物的使用方法及术后囊袋出血情况。结果所有26例均顺利完成手术,15例术后起搏器囊袋正常,4例囊袋部位出现大于5cm×5cm瘀斑,7例发生囊袋血肿,其中严重出血5例,发生率为19.23%。严重出血见于围手术期用双重抗血小板药物或抗凝药物治疗。经适当处理,囊袋出血消失。随访3.0±2.6个月,无迟发囊袋出血发生。结论①围手术期使用单一抗血小板药物或短期应用低分子肝素替代双重抗血小板药物相对安全;②围手术使用双重抗血小板药物或单纯抗凝治疗发生囊袋出血的风险高,且抗凝治疗多为严重出血。     

永久性心脏起搏器植入术后并发症的分析

目的：比较＜70岁患者与≥70岁患者起搏器植入后并发症的发生率,评估起搏器植入术后的安全性。方法选择237例于2006年1月至2011年12月在我院行永久性心脏起搏器植入患者的临床资料,根据年龄分为＜70岁组178例,≥70岁组59例,随访2年比较两组并发症发生情况。结果发生起搏器并发症25例（10.55%）,其中囊袋出血/血肿11例,囊袋破溃/感染4例,起搏器介导心动过速5例,起搏综合征4例,电极脱位/断裂1例,两组并发症发生率差异无统计学意义。结论起搏器植入术后并发症并未随年龄增长而明显增加。     

心脏植入电子装置感染的治疗策略分析

目的：评估植入电子装置（CIED）感染的治疗策略。方法回顾性分析本心脏中心1817例植入起搏器和除颤仪患者中出现CIED感染的病例,分析其临床表现和预后,探讨治疗方法。结果发生CIED感染16例（0.88%）,其中起搏器囊袋感染15例（93.75%）。均进行起搏器囊袋清创聚维酮碘浸泡消毒。重置原起搏器于胸大小肌之间9例,复发6例（66.7%）,显著高于取出原起搏器患者（12例,复发率为0）。取出原起搏器和保留起搏导管8例,取出原起搏器和经皮拔除起搏导管4例。无感染和拔管相关的死亡。CIED感染者相关住院次数、住院治疗天数为（2.4＆#177;0.5）次、（41＆#177;18）d,非感染者为（1.0＆#177;0.1）次、（13＆#177;3）d。结论完全移除CIED是成功治疗CIED感染的关键。若无并发导管相关感染,保留导管并不影响患者的预后。     

起搏器植入术后囊袋并发症的临床分析及处理: 1368例报告

目的观察植入永久性心脏起搏器后的囊袋并发症,寻找其原因,探讨处理对策,以减少其发生率。方法系统性回顾总结白求恩国际和平医院心血管内科26年中1368例缓慢性或快速性心律失常患者囊袋并发症。结果1368例中,囊袋积血80例,发生率5．8％,抽吸或切开27例（2．0％）,囊袋积血与高龄、营养状况差、术前未停用抗凝药物、血小板低、分离制作囊袋术中解剖层次不对及操作不细致等因素有关,而与起搏器重量、起搏器类型等无明显关系;及时发现,延长压迫时间,根据情况抽吸积血往往奏效,个别需切开引流。囊袋破溃6例,发生率0．4％,囊袋破溃主要与起搏器重量较大、囊袋深浅和（或）位置和（或）大小与起搏器不匹配、多余的电极导线盘绕有张力和（或）在起搏器浅面等有关,个别与排斥有关。囊袋感染3例,发生率0．2％,均为囊袋破溃后起搏器外露继发感染;局部彻底清创消毒后囊袋易位,配合全身抗感染、加强营养等处理部分病例有效,最终解决感染问题需电极导线拔除。结论囊袋并发症与患者体质有关,术前准备不充分、术中操作不细致、术后压迫或处理不当等也会增加囊袋并发症;术前充分准备,术中规范操作,及时发现并恰当处理,囊袋并发症可降低。     

Periprocedural complications of cardiac implantable electronic device implantation in very elderly patients with cognitive impairment: A prospective study

Very elderly people (over 80 years) with cardiac implantable electronic devices (CIEDs) indications often have a higher prevalence of aging comorbidity, among which cognitive impairment is not uncommon. This study aimed to investigate periprocedural complications of CIED implantation among very elderly patients with and without cognitive impairment. One hundred eighty patients ≥80 years of age indicated for CIED implantation were included in our study. During hospitalization, the cognitive evaluation was performed according to the Diagnostic and Statistical Manual of Mental Disorders (fifth edition). According to the cognitive test results, patients were divided into 2 groups (90 patients with normal cognitive function and 90 patients with cognitive impairment). Meanwhile, their physical parameters and laboratory measurements were completed. The procedural data and periprocedural complications were collected from both groups. The association between cognitive impairment and periprocedural complications was analyzed using univariate and multiple logistic regression analyses. During a one-month follow-up, the most frequent periprocedural complications in very elderly patients were pocket hematoma and thrombosis events. Cognitively impaired patients had a higher incidence of complications than normal cognitive patients. Multivariate regression analysis showed that cognitive impairment was positively correlated with periprocedural complications in very elderly patients. Cognitive impairment is associated with increased periprocedural complications of CIED implantation in very elderly patients.     

A randomized trial comparing heparin initiation 6 h or 24 h after pacemaker or defibrillator implantation

OBJECTIVES

The purpose of this randomized study was to evaluate the prevalence of pocket hematomas in patients treated with heparin 6 h or 24 h after pacemaker or defibrillator implantation.

BACKGROUND

The risks of pocket hematoma and need for evacuation after device implantation have not been defined in patients who require anticoagulation.

METHODS

Forty-nine consecutive patients with an indication for anticoagulation with heparin after implantable defibrillator or pacemaker implantation were randomized to receive intravenous heparin either 6 h (n = 26) or 24 h (n = 23) postoperatively. Both groups also received warfarin on a daily basis starting the evening of surgery. Twenty-eight patients who received postoperative warfarin alone and 115 patients who did not receive anticoagulation were followed up in a study registry.

RESULTS

A pocket hematoma developed in 6 of 26 patients (22%) who were treated with intravenous heparin 6 h postoperatively, as compared with 4 of 23 patients (17%) who were treated with intravenous heparin 24 h postoperatively (p = 0.7). In total, a pocket hematoma developed in 10 of 49 patients (20%) treated with heparin, 1 of 28 patients (4%) treated with warfarin alone and 2 of 115 (2%) patients who received no anticoagulation (p < 0.001).

CONCLUSIONS

Intravenous heparin initiation 6 h or 24 h after pacemaker or defibrillator implantation is associated with a 20% prevalence of pocket hematoma formation. Warfarin therapy or no anticoagulation is associated with only a 2% to 4% risk of pocket hematoma formation.     

Pocket hematoma after pacemaker or implantable cardioverter defibrillator surgery: influence of patient morbidity, operation strategy, and perioperative antiplatelet/anticoagulation therapy

STUDY OBJECTIVES: Pocket hematoma is a common complication after pacemaker or implantable cardioverter defibrillator (ICD) implantation. Thus, we investigated the influence of patient comorbidity, implantation strategy, operator experience, antiplatelet therapy, and anticoagulation therapy on hematoma rate. DESIGN: Between 1990 and 2002, a total of 3,164 devices (pectoral pacemakers, 2,792; ICDs, 372) were implanted at our institution. Predictors of hematoma occurrence were determined prospectively and were analyzed by multivariate regression analysis. Operator experience was graded by individual implantation number, as follows: low, < 50; medium, 50 to 100; and high, > 100. RESULTS: The incidence of pocket hematoma was 4.9%, leading to prolonged hospitalization in 2.0% of all patients. Reoperation for pocket hematoma was required in 1.0% of patients. High-dose heparinization (hazard ratio [HR], 4.2), combined acetylsalicylic acid (ASA)/thienopyridine treatment after coronary stenting (HR, 5.2), and low operator experience (HR, 1.6) were independently predictive of hematoma development. Therapy with ASA alone did not increase the hematoma rate compared to patients who did receive antiplatelet or anticoagulation therapy (3.1% vs 2.5%, respectively; difference not significant). In patients with nonvalvular atrial fibrillation, postoperative high-dose heparinization substantially increased the hematoma rate (10.7% vs 2.9%, respectively; p < 0.001) without reducing the rate of arterial embolism within the first month after implantation (0.18% vs 0.21%, respectively; difference not significant). The infection rate (0.28% within 3 months after implantation) was not influenced by the presence of the pocket hematoma. CONCLUSIONS: The use of high-dose heparinization and combined ASA/thienopyridine treatment are highly predictive for the occurrence of intraoperative bleeding and pocket hematoma in patients who have undergone pacemaker and ICD surgery. We propose recommendations for the management of antiplatelet and anticoagulation therapy in patients undergoing these interventions.     

Subdural hematoma after open-heart surgery

Four cases are described of acute subdural hematoma that occurred after valve replacement in patients receiving anticoagulant therapy. All four patients experienced rapid deterioration of consciousness or neurological dysfunction, to varying degrees, between two and 42 days after valve replacement; emergency brain computed tomography scanning demonstrated the presence of subdural hematoma. The neurological problems were completely resolved by removal and drainage of the hematoma in three patients, while conservative management was performed with no aggravation of neurological symptoms in the fourth patient.