左心耳封堵术联合经皮冠状动脉介入术“一站式”手术的有效性及安全性

徐敏敏; 王健; 袁康正; 何胜虎; 柳芳美; 廖清池; 王大新; 邓敏

doi:10.7619/jcmp.20221817

左心耳封堵术联合经皮冠状动脉介入术“一站式”手术的有效性及安全性

1.
大连医科大学临床医学院, 辽宁大连, 116000
2.
江苏省泰州市人民医院心内科, 江苏泰州, 225300
3.
江苏省苏北人民医院心内科, 江苏扬州, 225009
4.
扬州大学临床医学院, 江苏扬州, 225009

详细信息

通讯作者:
邓敏, E-mail: dengmin2046@sina.com

中图分类号: R541.4;R541.7
计量
- 文章访问数: 144
- HTML全文浏览量: 63
- PDF下载量: 7
出版历程
- 收稿日期: 2022-06-09
- 网络出版日期: 2022-11-03

Effectiveness and safety of “one-stop” surgery of left atrial appendage closure and percutaneous coronary intervention

1.
Clinical Medical College of Dalian Medical University, Dalian, Liaoning, 116000
2.
Department of Cardiology, Taizhou People's Hospital of Jiangsu Province, Taizhou, Jiangsu, 225300
3.
Department of Cardiology, Northern Jiangsu People's Hospital of Jiangsu Province, Yangzhou, Jiangsu, 225009
4.
Clinical Medical College of Yangzhou University, Yangzhou, Jiangsu, 225009

摘要

摘要:
目的
评估冠心病(CAD)合并心房颤动(AF)患者行左心耳封堵术(LAAC)联合经皮冠状动脉介入术(PCI)的有效性及安全性。
方法
回顾性选取接受LAAC联合PCI“一站式”手术的10例CAD合并AF患者作为研究对象, 记录患者的基线资料、围术期治疗情况、严重并发症发生情况和术后抗栓方案，比较患者术前和术后1个月、1年时的超声心动图相关参数和加拿大心血管学会(CCS)心绞痛分级。术后开展电话随访或门诊随访，记录患者用药情况、生存情况和血栓栓塞、大出血事件发生情况。
结果
10例患者房颤脑卒中风险评分(CHA2DS2-VASc评分)为(4.8±1.1)分，出血风险评分(HAS-BLED评分)为(3.8±1.0)分; 左心耳开口直径为(24.6±4.3) mm, 左心耳锚定区直径为(22.8±2.8) mm, 左心耳深度为(32.2±4.4) mm。10例患者术中均成功置入Lambre封堵器，并对病变血管进行支架植入，围术期均未发生血栓栓塞、出血等严重并发症。10例患者平均随访(18.7±3.9)个月，均存活，未发生心肌梗死、缺血性卒中、出血性卒中、血栓栓塞事件，1例患者发生大出血事件, 2例患者发生小出血事件。术后1个月时，患者左心房内径、左心室射血分数、肺动脉压力和二尖瓣反流、三尖瓣反流、主动脉瓣反流情况与术前比较，差异无统计学意义(P>0.05); 术后1个月时，患者CCS心绞痛分级与术前比较，差异有统计学意义(P < 0.05)。术后1年时，患者左心房内径、肺动脉压力和二尖瓣反流、三尖瓣反流、主动脉瓣反流情况与术前比较，差异无统计学意义(P>0.05); 术后1年时，患者左心室射血分数、心绞痛CCS分级与术前比较，差异有统计学意义(P < 0.05)。
结论
LAAC(Lambre封堵器)联合PCI“一站式”手术应用于CAD合并AF患者中安全、可行且有效。
- 心房颤动 /
- 冠心病 /
- 左心耳封堵术 /
- 经皮冠状动脉介入术 /
- Lambre 封堵器
Abstract:
Objective
To evaluate the effectiveness and safety of percutaneous left atrial appendage closure (LAAC) combined with percutaneous coronary intervention (PCI) in patients with coronary heart disease (CAD) and atrial fibrillation (AF).
Methods
A retrospective study was performed in 10 patients with CAD and AF who underwent "one-stop procedure" of LAAC combined with PCI. Baseline data, perioperativetreatment, occurrence of serious complications and postoperative antithrombotic regiments were recorded. Echocardiographic parameters and Canadian Cardiovascular Society (CCS) angina classification were compared before operation and at 1 month and 1 year after operation. Routine postoperative telephone or outpatient follow-up was performed, and the medications, thromboembolism, major bleeding events, and survival of patients were recorded.
Results
The atrial fibrillation stroke risk score (CHA2DS2-VASc score) and bleeding risk score were (4.8±1.1) and (3.8±1.0); the diameter of left atrial appendage opening was (24.6±4.3) mm, the diameter of left atrial appendage anchoring area was (22.8±2.8) mm, and the depth of left atrial appendage was (32.2±4.4) mm. Lambre devices were successfully placed in all 10 patients, and stent implantation was performed in the diseased culprit vessel. No patient had severe complications such as thromboembolism or bleeding during the perioperative period. During follow-up of (18.7±3.9) months, all patients survived, no patient had myocardial infarction, ischemic stroke, hemorrhagic stroke, or thromboembolic events. One patient had massive bleeding and 2 patients had minor bleeding. There were no significant differences in left atrial internal diameter, left ventricular ejection fraction, pulmonary artery pressure, mitral regurgitation, tricuspid regurgitation, and aortic regurgitation of patients 1 month after operation compared with pre-operation (P>0.05). At 1 month after operation, the CCS angina grade showed a significant difference compared with that before operation (P < 0.05). There were no significant differences in left atrial internal diameter, pulmonary artery pressure, mitral regurgitation, tricuspid regurgitation, and aortic regurgitation of patients 1 year after operation compared with pre-operation (P>0.05). There were statistically significant differences in left ventricular ejection fraction and angina pectoris CCS classification of patients 1 year after operation compared with pre-operation(P < 0.05).
Conclusion
The "one-stop" procedure of LAAC (Lambre closure) combined with PCI in patients with CAD and AF is feasible, safe, and effective.
- atrial fibrillation /
- coronary heart disease /
- left atrial appendage closure /
- percutaneous coronary intervention /
- Lambre closure

HTML全文

表 1 10例患者具体手术情况

序号	麻醉方式	左心耳封堵术						术中肝素使用量/U	经皮冠状动脉介入术
序号	麻醉方式	左心耳形态	左心耳开口直径/mm	左心耳锚定区直径/mm	左心耳深度/mm	封堵器型号	残余漏/mm	术中肝素使用量/U	病变血管	支架尺寸
1	全身麻醉	鸡翅型	24.3	23.8	32.1	24-30	1	7 000	LAD	2.5 mm×29 mm, 2.75 mm×33 mm
2	深度镇静	菜花型	20.1	22.5	21.8	24-30	0	7 000	LAD	2.5 mm×24 mm
3	深度镇静	鸡翅型	25.1	27.0	33.5	28-34	0	6 000	LAD	2.75 mm×23 mm
4	深度镇静	菜花型	31.0	23.8	32.3	26-38	1	11 000	LAD	2.0 mm×38 mm
5	全身麻醉	鸡翅型	19.0	17.0	30.0	18-24	0	10 000	LAD	3.0 mm×23 mm
6	全身麻醉	鸡翅型	29.0	20.0	36.5	22-34	0	8 000	RCA, LCX	3.0 mm×18 mm, 2.5 mm×29 mm
7	深度镇静	鸡翅型	22.0	23.0	29.8	24-30	1	8 000	LCX	2.5 mm×18 mm, 2.5 mm×18 mm, 2.5 mm×15 mm
8	全身麻醉	鸡翅型	21.8	22.0	33.6	24-30	0	6 000	LAD	4.0 mm×15 mm
9	全身麻醉	鸡翅型	22.6	26.0	34.0	28-34	0	12 000	RCA	3.0 mm×30 mm, 3.0 mm×24 mm
10	全身麻醉	鸡翅型	30.7	23.0	37.5	24-30	0	9 000	LAD	3.0 mm×33 mm
LAD: 左前降支; RCA: 右冠状动脉; LCX: 左回旋动脉。

下载: 导出CSV

表 2 患者手术前后超声心动图相关参数和CCS心绞痛分级比较(x±s)[n(%)]

指标	分类	术前(n=10)	术后1个月(n=10)	术后1年(n=8)
左心房内径/mm		40.9±4.5	41.5±4.7	42.6±4.0
左心室射血分数/%		56.4±7.5	56.6±4.8	54.8±4.9^*
肺动脉压力/mmHg		36.2±8.4	36.0±8.5	34.7±7.5
二尖瓣反流	无	3(30.0)	1(10.0)	0
	轻	6(60.0)	7(70.0)	6(75.0)
	中	1(10.0)	2(20.0)	2(25.0)
	重	0	0	0
三尖瓣反流	无	1(10.0)	1(10.0)	1(12.5)
	轻	6(60.0)	6(60.0)	4(50.0)
	中	3(30.0)	3(30.0)	3(37.5)
	重	0	0	0
主动脉瓣反流	无	6(60.0)	6(60.0)	3(37.5)
	轻	4(40.0)	4(40.0)	5(62.5)
	中	0	0	0
	重	0	0	0
CCS心绞痛分级/级		2.3±0.6	0.9±0.3^*	1.1±0.3^*
CCS: 加拿大心血管学会。与术前比较, *P < 0.05。

下载: 导出CSV

参考文献(17)

[1]	HINDRICKS G, POTPARA T, DAGRES N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC[J]. Eur Heart J, 2020, 42(5): 373-498.
[2]	MICHNIEWICZ E, MLODAWSKA E, LOPATOWSKA P, et al. Patients with atrial fibrillation and coronary artery disease-Double trouble[J]. Adv Med Sci, 2018, 63(1): 30-35. doi: 10.1016/j.advms.2017.06.005
[3]	LOPES R D, HEIZER G, ARONSON R, et al. Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation[J]. N Engl J Med, 2019, 380(16): 1509-1524. doi: 10.1056/NEJMoa1817083
[4]	于凯, 张珍侠, 王媛. 心房颤动合并冠心病患者行经皮冠状动脉介入术后3种抗栓治疗疗效比较[J]. 实用临床医药杂志, 2020, 24(12): 39-41. doi: 10.7619/jcmp.202012011
[5]	VRANCKX P, VALGIMIGLI M, ECKARDT L, et al. Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST-AF PCI): a randomised, open-label, phase 3b trial[J]. Lancet, 2019, 394(10206): 1335-1343. doi: 10.1016/S0140-6736(19)31872-0
[6]	OSMANCIK P, HERMAN D, NEUZIL P, et al. Left atrial appendage closure versus direct oral anticoagulants in high-risk patients with atrial fibrillation[J]. J Am Coll Cardiol, 2020, 75(25): 3122-3135. doi: 10.1016/j.jacc.2020.04.067
[7]	WANG Y, WU D, MA J, et al. The feasibility and safety of "one-stop" left atrial appendage closure and percutaneous coronary intervention in atrial fibrillation patients with significant coronary artery disease (PCI-LAAC study)[J]. Am J Cardiovasc Dis, 2021, 11(5): 679-687.
[8]	戴雯莉, 姚可欣, 蒋超, 等. 长期透析的终末期肾病合并心房颤动患者行左心耳封堵术的安全性与有效性初探[J]. 中华心血管病杂志, 2021, 49(9): 880-885. doi: 10.3760/cma.j.cn112148-20210608-00487
[9]	中华医学会心血管病学分会, 中华心血管病杂志编辑委员会. 中国左心耳封堵预防心房颤动卒中专家共识(2019)[J]. 中华心血管病杂志, 2019, 47(12): 937-955. doi: 10.3760/cma.j.issn.0253-3758.2019.12.002
[10]	JANUARY C T, WANN L S, CALKINS H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American college of cardiology/American heart association task force on clinical practice guidelines and the heart rhythm society in collaboration with the society of thoracic surgeons[J]. Circulation, 2019, 140(2): e125-e151.
[11]	GLIKSON M, WOLFF R, HINDRICKS G, et al. EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion-an update[J]. Europace, 2020, 22(2): 184. doi: 10.1093/europace/euz258
[12]	CHEN S, CHUN K R J, BORDIGNON S, et al. Left atrial appendage occlusion using LAmbre amulet and watchman in atrial fibrillation[J]. J Cardiol, 2019, 73(4): 299-306. doi: 10.1016/j.jjcc.2018.10.010
[13]	HUANG H, LIU Y, XU Y, et al. Percutaneous left atrial appendage closure with the LAmbre device for stroke prevention in atrial fibrillation: a prospective, multicenter clinical study[J]. JACC Cardiovasc Interv, 2017, 10(21): 2188-2194. doi: 10.1016/j.jcin.2017.06.072
[14]	KUMAR S, LIM E, COVIC A, et al. Anticoagulation in concomitant chronic kidney disease and atrial fibrillation: JACC review topic of the week[J]. J Am Coll Cardiol, 2019, 74(17): 2204-2215. doi: 10.1016/j.jacc.2019.08.1031
[15]	LIU B, LUO J, GONG M, et al. Five-year outcomes and cardiac remodeling following left atrial appendage occlusion[J]. Clin Interv Aging, 2021, 16: 655-663. doi: 10.2147/CIA.S296639
[16]	KOOK H, YU C W, JEONG H S, et al. P1668Comparison of clinical outcomes between left atrial appendage occlusion with dual antiplatelet therapy versus conventional antithrombotic therapy in patients with atrial fibrillation undergoing PCI[J]. Eur Heart J, 2018, 39(suppl_1): ehy565. P1668.
[17]	KÖRMENDY D, PILGRIM T, PULVER C, et al. Outcome after simultaneous PCI and left atrial appendage occlusion[J]. Cardiovascular Medicine, 2015, 18(3): 96-102. doi: 10.4414/cvm.2015.00300

施引文献(18)

期刊类型引用(16)

1.	郭兴，刘宝. 左西孟旦联合双联抗血小板对急性心肌梗死介入后心力衰竭患者心肌损伤及血清Periostin、sST2水平的影响. 医药论坛杂志. 2024(04): 419-423 . 百度学术
2.	吴晶晶，赵妍妍，王燕，陈蝶，胡杨，秦闻. 基于心力衰竭超声指数及血清学指标构建急性失代偿性心力衰竭患者短期主要不良心血管事件发生风险的预测模型. 心脑血管病防治. 2024(01): 4-8 . 百度学术
3.	郭双，苏丽萍，胡丽君. 血清VS-2、CTRP9水平对急性心肌梗死患者PCI术后心力衰竭的预测价值. 热带医学杂志. 2024(06): 872-875+883+916 . 百度学术
4.	安然，韩建妙，张倩，朱娜娜，闫士然. 血尿酸、肠道菌群、miR-25水平与老年慢性心力衰竭患者心功能的相关性及对诊断的价值. 疑难病杂志. 2024(10): 1198-1202 . 百度学术
5.	杨漫，刘连庚，姚林，冒小红. 心衰患者不同心功能分级与血尿酸水平的相关性. 智慧健康. 2024(26): 32-34 . 百度学术
6.	权党军，张明卜，赵向利. 米力农联合rhBNP治疗慢性心力衰竭的疗效及其对患者心、肺功能的影响. 医学临床研究. 2024(05): 736-738+742 . 百度学术
7.	冯玲华. 不同剂量呋塞米注射液对慢性心力衰竭患者 NT-proBNP、VS-2水平的影响. 医学理论与实践. 2023(07): 1124-1126 . 百度学术
8.	张海洋，冯静茹，李凡，王静，赵娜，毕胜利，李新军. 绝经后慢性心力衰竭患者内源性性激素水平与左心室射血分数的相关性研究. 中国医药导报. 2023(13): 96-99 . 百度学术
9.	孙利敏，张培勇，杨冰冰. 高血压合并HHCY伴HFPEF患者的血清因子与NYHA分级的相关性分析. 江西医药. 2022(06): 631-633+636 . 百度学术
10.	王颂，王辉，郭清晓. 不同NYHA分级慢性心力衰竭患者血清SIRT1、VS-2水平变化及其与疾病转归的关系. 河南医学研究. 2022(17): 3143-3146 . 百度学术
11.	王静，亓民，常珍珍，乔俭，张卓，卜巧云，费睿成，丁珊珊. Fibrosis-4指数、NFS联合血清DBIL、尿酸对老年CHF患者全因死亡风险的评价研究. 中国卫生工程学. 2022(04): 630-633+638 . 百度学术
12.	陈建南，吴进盛，于莉，余华军. 冻干重组人脑利钠肽联合参脉注射液对慢性肺源性心脏合并心力衰竭患者的临床疗效. 临床和实验医学杂志. 2022(17): 1825-1829 . 百度学术
13.	万超. CHF患者血清UA、D-D、和肽素、HGF与NYHA心功能分级和心血管事件的关系. 中国卫生工程学. 2022(05): 799-802 . 百度学术
14.	黎叶飞，钱烨晟，郑扣龙，盛臻强，卢辉和. 窦性心率震荡与射血分数保留的心力衰竭患者预后的相关性研究. 实用临床医药杂志. 2022(24): 107-111 . 本站查看
15.	郜旌宏，秦小飞. 沙库巴曲缬沙坦钠辅助治疗在慢性心力衰竭患者中的应用价值. 医药论坛杂志. 2021(09): 123-126 . 百度学术
16.	刘兴超. 急性失代偿期心力衰竭患者不良心血管事件发生的影响因素. 河南医学研究. 2021(34): 6450-6453 . 百度学术