经导管主动脉瓣置换术术后抗栓仍靠经验

2019-12-07 佚名 中国循环杂志

目前,经导管主动脉瓣置换术(TAVR)已成为治疗重度、症状性主动脉瓣狭窄的一项重要治疗方法。脑卒中与出血作为TAVR术后常见并发症,如何制定兼顾二者风险的抗栓策略,具有重要的临床意义。

目前,经导管主动脉瓣置换术(TAVR)已成为治疗重度、症状性主动脉瓣狭窄的一项重要治疗方法。脑卒中与出血作为TAVR术后常见并发症,如何制定兼顾二者风险的抗栓策略,具有重要的临床意义。

近期,东南大学附属中大医院马根山、左文杰等对近年来的相关研究进展与指南建议进行了总结,认为TAVR 术后的抗栓治疗目前仍处于经验性选择阶段。

抗血小板治疗:单用阿司匹林与双联抗血小板治疗的效果仍需探索

作者指出,在绝大多数临床研究中,临床医生在TAVR术后普遍采用的是阿司匹林联合氯吡格雷的双联抗血小板治疗。最新的欧美指南和国内专家共识也建议,TAVR术后患者如无口服抗凝药物使用指征,应在术后6个月或3个月内进行双联抗血小板治疗。

但近年来陆续有研究表明,TAVR术后单用阿司匹林的效果不劣于DAPT,甚至在安全性上有优势。作者表示,关于这两种治疗方法的优劣还需要进一步讨论。

房颤患者;TAVR术后单用口服抗凝药或更安全、有效

作者表示,关于房颤患者TAVR 术后的抗栓治疗,目前缺乏足够临床证据以及明确的指南推荐。在TAVR 术后联合使用口服抗凝与抗血小板药物似乎更为合理,但至今并没有证据证实这一点。

专家共识指出,联用华法林和低剂量阿司匹林后,应避免再使用其他抗血小板药物。但最近的研究显示,房颤患者TAVR 术后单用口服抗凝药物可能更安全、有效。

生物瓣膜血栓预防:出血风险低者应口服抗凝3个月以上

近年来有研究表明术后生物瓣膜会产生亚临床血栓,在多排CT 下表现为瓣叶活动度下降等。研究表明,口服抗凝药物可能有较好的瓣膜血栓预防效果。

考虑到生物瓣膜血栓等因素,2017 年美国更新的瓣膜指南建议,出血风险较低的患者在TAVR 术后需要使用维生素K拮抗剂至少3 个月,使国际标准化比值(INR)达到2.5。

其他栓塞预防措施:栓塞保护装置、左心耳封堵

作者指出,为了保护大脑、降低栓塞风险,栓塞保护装置(EPD)在未来可能成为一种预防手段。关于未来TAVR手术中是否推广使用EPD,还需要进一步的上市后数据和反馈。

随着左心耳封堵术(LAAC)的不断发展,其也将成为房颤患者进行TAVR 术后抗栓治疗的有力替代,特别是适用于出血高危、不能耐受抗凝治疗的患者。

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    2020-07-23 yxch48
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    2019-12-09 lsj631
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JACC:低外科风险AS患者TAVR依旧是一个更好的选择

对于低外科手术风险的严重主动脉瓣狭窄(AS)患者,经导管主动脉瓣置换术(TAVR)较外科手术的术后1年死亡风险、卒中和再住院风险更低。然而,治疗策略对患者健康状态的影响尚不清楚。本研究的目的旨在比较和评估接受TAVR和外科手术治疗的低风险AS患者的术后健康状态。本研究纳入了PARTNER 3临床试验中的1000名低风险AS患者,并将其随机分成经股TAVR组和外科组,并在基线时、术后1月、6月和12

2019 CCS立场声明:经导管主动脉瓣置换术

2019年11月,加拿大心血管学会(CCS)发布了经导管主动脉瓣置换术的立场声明,经导管主动脉瓣植入(TAVI)或置换术迅速改变严重症状性主动脉狭窄患者的治疗。是不能进行手术以及手术风险较高患者的标准治疗方法。本文是对2012年CCS经导管主动脉瓣植入立场声明的更新。