The peri-operative safety of maintaining the intra-procedural activated clotting time between 220 s and 270 s during catheter ablation in atrial fibrillation
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摘要: 目的 评估心房颤动(房颤)患者导管消融术中将活化凝血时间(ACT)维持于略低于指南建议范围的安全性。方法 连续纳入行房颤射频消融术的1065例患者，单次房间隔穿刺成功后根据体重给予100 U/kg的首剂肝素，之后每15~20 min测量1次ACT，根据ACT测值每次追加1000~2000 U肝素，ACT目标范围为220~270 s。应用冷盐水灌注消融导管进行肺静脉隔离和左房消融。结果 术中的ACT均值为(234.6±30.4) s，平均手术时间(145.8±36.7) min，术中平均肝素用量为(11 092.0±2297.6) U。在并发症方面，1例(0.09%)发生了围术期症状性脑栓塞，10例(0.9%)发生了急性心脏压塞。结论 在应用单次房间隔穿刺和冷盐水灌注消融导管的条件下，房颤射频消融术中ACT均值维持于低于指南建议的范围并不增加围术期血栓栓塞事件。Abstract: Objective To evaluate the perioperative safety of maintaining a lower active coagulation time (ACT) compared to the guidelines recommendation during the catheter ablation for patients with atrial fibrillation(AF).Methods The 1065 consecutive patients with AF underwent catheter ablation using an irrigatedtip catheter with a single left atrial long sheath. After an atrial septal puncture, a weight-based heparin bolus of 100 U/kg was given. Then, the ACT was checked every 15-20 min and additional 1000-2000 U heparin was infused if needed. The target ACT range was 220-270 s.Results he total heparin dose and the mean intra-procedural ACT were (11 092.0±2297.6) U and(234.6±30.4) s, respectively, with the mean procedure time of (145.8±36.7) min. Severe complications included 1(0.09%) symptomatic cerebral embolism and 10(0.9%) acute cardiac tamponades.Conclusion A intra procedural ACT target that is lower than the guidelines recommendation may not increase the peri-procedural thromboembolic events for patients who underwent catheter ablation in AF.
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Key words:
- atrial fibrillation /
- ablation /
- anticoagulation /
- activated clotting times /
- complication
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表 1 患者一般临床资料
Table 1. Clinical characteristics of the patients
例(%), X±S 项目 数值 项目 数值 年龄/岁 64.1±10.5 术前抗凝药物选择 女性 415(39.0) 低分子肝素 564(53.0) 体重/kg 73.6±12.3 华法林 59(5.5) BMI/(kg·m-2) 25.9±3.5 达比加群 160(15.0) 收缩压/mmHg 131.5±17.2 利伐沙班 282(26.5) 舒张压/mmHg 77.0±11.5 术后抗凝药物选择 房颤病史/月 49.8±59.2 华法林 143(13.4) 左房前后径/mm 40.4±5.7 达比加群 389(36.6) 左室射血分数/% 64.0±7.8 利伐沙班 533(50.0) CHA2DS2-VASc/分 2.2±1.6 抗心律失常药 HAS-BLED/分 1±1 未应用 213(20.0) 房颤类型 盐酸胺碘酮 728(68.4) 阵发性房颤 696(65.4) 盐酸普罗帕酮 108(10.1) 持续性房颤 369(34.6) 盐酸索他洛尔 4(0.4) 高血压 629(59.1) 决奈达隆 12(1.1) 2型糖尿病 214(20.1) β受体阻滞剂 424(39.8) 注：1 mmHg=0.133 kPa。 
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表 2 房颤射频消融术中低ACT组和高ACT组比较
Table 2. Differences between low mean ACT and high mean ACT in ablation of atrial fibrillation
X±S, 例(%) 项目 低ACT组
(266例)高ACT组
(266例)P 年龄/岁 62.8±10.9 64.8±10.3 0.037 女性 100(37.6) 110(41.4) 0.425 房颤病史/月 49.2±58.7 48.3±56.8 0.850 BMI/(kg·m-2) 26.2±3.7 25.8±3.5 0.136 左房前后径/mm 40.1±5.4 40.9±5.8 0.104 左室射血分数/% 64.1±7.5 63.6±8.5 0.426 CHA2DS2-VASc/分 1.9±1.4 2.5±1.7 < 0.001 HAS-BLED/分 0.9±0.9 1.1±1.1 0.015 PLT/(×109·L-1) 214.3±60.1 201.9±53.6 0.013 术前抗凝药物选择 低分子肝素 165(62.0) 114(42.9) < 0.001 华法林 8(3.0) 34(12.8) < 0.001 达比加群 29(10.9) 45(16.9) 0.045 利伐沙班 64(24.0) 73(27.4) 0.372 持续性房颤 76(28.6) 114(42.9) 0.001 高血压 141(53.0) 167(62.8) 0.022 糖尿病 52(19.5) 57(21.4) 0.591 卒中 13(4.9) 34(12.8) 0.001 手术时间/min 139.5±31.5 150.8±37.6 < 0.001 术中肝素用量/U 11 560.1±
2150.510 616.5± 2169.2 < 0.001 每分钟肝素用量/(U·min-1) 86.7±24.5 74.4±22.6 < 0.001 公斤体质量肝素/(U·kg-1) 156.5±27.8 149.2±32.7 < 0.001 并发症 3(1.1) 4(1.5) 0.704 心脏压塞 3(1.1) 0(0) 0.082 穿刺除血肿形成 0(0) 3(1.1) 0.082 下肢静脉血栓形成 0(0) 1(0.4) 0.317
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[1] Bencivenga L, Komici K, Nocella P, et al. Atrial fibrillation in the elderly: a risk factor beyond stroke[J]. Ageing Res Rev, 2020, 61: 101092. doi: 10.1016/j.arr.2020.101092
[2] Andrade JG, Aguilar M, Atzema C, et al. The 2020 canadian cardiovascular society/canadian heart rhythm society comprehensive guidelines for the management of atrial fibrillation[J]. Can J Cardiol, 2020, 36(12): 1847-948. doi: 10.1016/j.cjca.2020.09.001
[3] Kirchhof P, Camm AJ, Goette A, et al. Early rhythm-control therapy in patients with atrial fibrillation[J]. N Engl J Med, 2020, 383(14): 1305-16. doi: 10.1056/NEJMoa2019422
[4] 朱文青, 陈庆兴. 《2020ESC/EACTS心房颤动诊断与管理指南》更新解读[J]. 临床心血管病杂志, 2020, 36(11): 975-977 https://www.cnki.com.cn/Article/CJFDTOTAL-LCXB202011001.htm
[5] Calkins H, Hindricks G, Cappato R, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: Executive summary[J]. Europace, 2018, 20(1): 157-208. doi: 10.1093/europace/eux275
[6] 黄从新, 张澍, 黄德嘉, 等. 心房颤动: 目前的认识和治疗的建议-2018[J]. 中国心脏起搏与心电生理杂志, 2018, 32(4): 315-368. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGXZ201804002.htm
[7] He SN, Tian Y, Shi L, et al. Identification of circumferential pulmonary vein isolation responders among patients with persistent atrial fibrillation: clinical value of the sequential low-dose ibutilide test[J]. Europace, 2020, 22(8): 1197-1205. doi: 10.1093/europace/euaa095
[8] Aagaard P, Briceno D, Csanadi Z, et al. Atrial Fibrillation Ablation and Stroke[J]. Cardiol Clin, 2016, 34(2): 307-316. doi: 10.1016/j.ccl.2015.12.012
[9] Jame S, Barnes G. Stroke and thromboembolism prevention in atrial fibrillation[J]. Heart, 2020, 106(1): 10-7. doi: 10.1136/heartjnl-2019-314898
[10] Weitz JI, Healey JS, Skanes AC, et al. Periprocedural management of new oral anticoagulants in patients undergoing atrial fibrillation ablation[J]. Circulation, 2014, 129(16): 1688-94. doi: 10.1161/CIRCULATIONAHA.113.005376
[11] Bruce CJ, Friedman PA, Narayan O, et al. Early heparinization decreases the incidence of left atrial thrombi detected by intracardiac echocardiography during radiofrequency ablation for atrial fibrillation[J]. J Interv Card Electrophysiol, 2008, 22(3): 211-219. doi: 10.1007/s10840-008-9270-x
[12] 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, 2021, 42(5): 373-498.
[13] Briceno DF, Villablanca PA, Lupercio F, et al. Clinical Impact of Heparin Kinetics During Catheter Ablation of Atrial Fibrillation: Meta-Analysis and Meta-Regression[J]. J Cardiovasc Electrophysiol, 2016, 27(6): 683-693. doi: 10.1111/jce.12975
[14] Winkle RA, Mead RH, Engel G, et al. Safety of lower activated clotting times during atrial fibrillation ablation using open irrigated tip catheters and a single transseptal puncture[J]. Am J Cardiol, 2011, 107(5): 704-708. doi: 10.1016/j.amjcard.2010.10.048
[15] Winkle RA, Mead RH, Engel G, et al. Atrial fibrillation ablation using open-irrigated tip radiofrequency: experience with intraprocedural activated clotting times ≤210 seconds[J]. Heart Rhythm, 2014, 11(6): 963-968. doi: 10.1016/j.hrthm.2014.03.013
[16] 陈丽竹, 梁拓, 陈小路, 等. 消融指数在射频消融治疗阵发性心房颤动中的作用研究[J]. 临床心血管病杂志, 2021, 37(3): 259-262. https://www.cnki.com.cn/Article/CJFDTOTAL-LCXB202103015.htm
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