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依达赛珠单抗对口服达比加群的心房颤动患者导管消融围术期合并症的处理

Effectiveness and safety of idarucizumab in the management of perioperative complications of atrial fibrillation catheter ablation in atrial fibrillation patients under dabigatran therapy

摘要:

目的:探讨在心房颤动(房颤)导管消融围术期并发心脏压塞和血栓栓塞事件中应用依达赛珠单抗的有效性和安全性。方法:本研究为回顾性分析,入选2019年1月至2020年12月于北京安贞医院接受房颤导管消融术,围术期出现心脏压塞或急性缺血性卒中(AIS)并使用依达赛珠单抗逆转达比加群抗凝效应的房颤患者。收集患者的年龄、性别、肾功能、凝血指标及30 d随访的安全性事件,并对其临床表现及治疗转归进行分析。结果:共纳入7例患者,男性2例(2/7),年龄(66.3±11.2)岁,血肌酐水平为(66.3±13.6)μmol/L,肾小球滤过率为(89.4±11.2)ml·min -1·1.73 m -2,CHA 2DS 2-VASc与HAS-BLED评分分别为(3.2±1.9)和(1.3±1.3)分。5例(5/7)患者为心脏压塞,距最后一次服用达比加群的时间为(6.3±2.6)h,心脏压塞明确(36.4±16.7)min后给予依达赛珠单抗。依达赛珠单抗给药后5例患者的活化部分凝血活酶时间均有明显下降。5例心脏压塞患者均行心包穿刺引流,引流量为(1 037.0±846.9)ml,心包引流导管保留时间为(27.9±13.9)h,恢复抗凝时间为(28.4±13.2)h。1例(1/5)患者因出血量多,为确保彻底止血至外科接受开胸止血术;1例(1/5)患者第一次重启抗凝后发生出血。2例(2/7)患者为AIS,均发生于术后。1例(1/2)给予依达赛珠单抗5.0 g后行静脉溶栓,无出血转化,恢复良好。1例(1/2)予依达赛珠单抗5.0 g后行血管内取栓,未出现出血并发症,出院时意识无明显好转,右侧下肢肌力较术前有恢复。所有患者在使用依达赛珠单抗30 d内均未出现超敏反应和血栓形成事件。 结论:在房颤导管消融相关心脏压塞和血栓栓塞事件中,依达赛珠单抗可安全有效地迅速逆转达比加群的抗凝效应,为及时止血和改善大脑血液循环争取时间。

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abstracts:

Objective:To investigate the efficacy and safety of idarucizumab in the treatment of perioperative cardiac tamponade and thromboembolic events during catheter ablation in atrial fibrillation (AF) patients under dabigatran therapy.Methods:This study was a retrospective analysis enrolling patients under dabigatran therapy, who underwent catheter ablation for AF at Beijing Anzhen Hospital from January 2019 to December 2020 and developed perioperative cardiac tamponade or acute ischemic stroke (AIS) and received idarucizumab to reverse the anticoagulant effect of dabigatran. Patients′ age, sex, renal function, coagulation test and safety events at 30 d after idarucizumab administration were collected and analyzed. The clinical presentation and prognosis were also analyzed.Results:A total of 7 patients were included, 2 (2/7) were male, mean age was (66.3±11.2) years, serum creatinine level was (66.3±13.6) μmol/L, estimated glomerular filtration rate was (89.4±11.2) ml·min -1·1.73 m -2, CHA 2DS 2-VASc and HAS-BLED scores were (3.2±1.9) and (1.3±1.3), respectively. Five patients (5/7) developed cardiac tamponade during the perioperative period and the time interval to the last dose of dabigatran was (6.3±2.6) h. Idarucizumab was given at (36.4±16.7) min after the definitive diagnosis of cardiac tamponade. A significant decrease of activated partial thromboplastin time was achieved after idarucizumab administration in all five cases. Pericardial puncture and drainage were applied to all patients (5/5) with cardiac tamponade, the drainage volume was (1 037.0±846.9) ml, the retention time of pericardial drainage catheter was (27.9±13.9) h, and the recovery time of anticoagulation was (28.4±13.2) h. One patient (1/5) underwent thoracotomy for hemostasis due to excessive blood loss with the aim of ensuring complete hemostasis. Bleeding occurred in 1 patient (1/5) after the first restart of anticoagulation. AIS occurred in 2 patients (2/7) after operation. One case (1/2) received intravenous thrombolysis after receiving 5.0 g idarucizumab, no hemorrhagic transformation was observed, and the recovery process was satisfactory. Another patient in this group experienced significantly prolonged onset time and 5.0 g idarucizumab was applied before intravascular thrombectomy, there was no bleeding complication in this patient after thrombectomy. At the time of discharge, the consciousness was not significantly improved, and the muscle strength of the right lower limb was recovered somehow compared with that before operation. No hypersensitivity reactions or thrombotic events occurred in these patients within 30 days of the administration of idarucizumab. Conclusion:In AF catheter ablation-associated cardiac tamponade and AIS, idarucizumab is safe and effective in rapidly reversing the anticoagulant effect of dabigatran, use of thrombectomy saves valuable time for timely hemostasis and improvement of cerebral blood circulation.

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作者: 李松南 张景瑞 李昌义 戴雯莉 贾长琪 黎旭 宁曼 杜昕 董建增 马长生
期刊: 《中华心血管病杂志》2021年49卷3期 217-223页 MEDLINEISTICPKUCSCDCABP
栏目名称: 心房颤动
DOI: 10.3760/cma.j.cn112148-20201220-01002
发布时间: 2021-04-06
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