心脏机械瓣膜置换术后抗凝治疗中的消化道出血

目的：探讨心脏机械瓣膜置换术后抗凝治疗中，消化道出血发生的危险因素及防治措施。方法：回顾性研究2001年3月至2008年7月我院16例机械瓣膜置换术后抗凝治疗中消化道出血患者的临床资料，分析发生的危险因素，并总结其诊治经验。结果：心脏机械瓣膜置换术后患者抗凝治疗中消化道出血发生在服用华法令后3天～5年，平均147．53±136．71天。其中，上消化道出血12例，下消化道出血4例；保守治疗11例，内窥镜治疗4例；死亡2例（DIC及多器官功能衰竭各1例），病死率12．5％（2／16）。出血组患者术中转流时间（142．73min±49．81min）明显长于对照组（98．27min±39．52min）（P〈0．05），华法令平均用药量（2．46±0．53mg／d）与对照组（2．38±0．69mg／d）无明显差异（P〉0．05），国际标准比值（INR）均值（2．79±0．57））明显大于对照组（1．49±0．58）（P〈0．05）。消化道出血治疗期间停用华法令5～19天，平均13±2天，所有痊愈患者消化道出血治疗期间及出院后随访3月内均无栓塞及消化道再出血事件发生。结论：（1）、心脏机械瓣膜置换术后早期（3月内）抗凝治疗发生消化道出血的危险因素包括术中转流时间过长和抗凝强度过大（INR〉2．0），晚期则可能与合并使用非甾体类抗炎药有关；（2）、消化道出血治疗期间，华法林停用2周较为安全。

The Gastrointestinal Hemorrhage during Anticoagulation Therapy Following Mechanical Heart Valve Replacement

Objective：To evaluated the risk factors of gastrointestinal（GI）hemorrhage during anticoagulation therapy following mechanical heart valve replacement. Methods： Between March 2001 and July 2008,16 cases of gastrointestinal hemorrhage during anticoagulation therapy following mechanical heart valve replacement were analyzed retrospectively. Results ： Sixteen GI hemorrhage occurred 3d -5 y（ 147.53 ± 136.71 d） after anticoagulation therapy（warfarin）. There were twelve cases located in the upper GI tract, and four cases in the lower GI tract. Eleven cases underwent conservative therapy, five eases were treated by endoscope therapy. Two cases died of DIC and multi-organ failure respectively, and mortality was 12.5%（2/16）. The bypass time of hemorrhage group（142.73 min±49.81 min） was longer than that of control group（（98.27 min±39.52 rain） （P 〈0.05）significantly,Mean INR value of hemorrhage group（2.79±0.57） was longer than that of control group （ 1.49 ± 0. 58） （ P 〈 0.05 ） significantly; The mean duration of anticoagulation withholding during GI hemorrhage treatment was（13 ±2 d）,There were no recurrent hemorrhage and bolthromboemic complications within 3 months. Conclusion： （1）The risk factors of GI hemorrhage during antieoagulation therapy following mechanical heart valve replacement included the following：longer bypass time,higher anticoagulation intensity （INR〉2.0） ,and use of combination warfarin with no steroidal anti-inflammatory drugs. （2）Thromboembolic risk is low when anticoagulation therapy is withheld for two weeks.