JAMA:预防心源性卒中的新方法-左心耳夹闭术

2018-06-08 杨中华 脑血管病及重症文献导读

心脏外科手术是最常见的手术之一,在美国每年超过30万例冠脉搭桥手术(CABG)和瓣膜手术。许多心外科手术的患者,既往房颤病史会增加卒中的风险。在房颤患者中,左心耳血栓是心源性卒中的主要栓子来源,有时候外科手术中闭塞左心耳(occlusion of the left atrial appendage,LAAO)能够降低卒中的长期风险


心脏外科手术是最常见的手术之一,在美国每年超过30万例冠脉搭桥手术(CABG)和瓣膜手术。许多心外科手术的患者,既往房颤病史会增加卒中的风险。在房颤患者中,左心耳血栓是心源性卒中的主要栓子来源,有时候外科手术中闭塞左心耳(occlusion of the left atrial appendage,LAAO)能够降低卒中的长期风险。

目前尚缺乏LAAO的有效性证据,限制了决策的制定。最近的观察性研究显示在房颤患者中LAAO与较低血栓栓塞风险有关。不过,无房颤的患者不能从LAAO中获益。但是在另外一项最近的观察性研究中,超过一半的患者不合并房颤,结果显示在发生房颤高风险的患者中采用LAAO是一种常见的临床策略。只是,目前尚不清楚这种方法的裨益。

2018年5月来自美国的Xiaoxi Yao等在JAMA上公布了他们的研究结果,目的在于评价心脏外科手术期间外科LAAO与卒中风险、死亡率和随后发展为房颤之间的关系。

本回顾性研究利用了美国大型管理数据库,包含了2009年年1月到2017年3月间进行了CABG或瓣膜手术的个人保险或医疗保险的成人患者。按照一对一倾向得分匹配的方法对76项指标进行了平衡,以比较LAAO和无LAAO。主要终点为卒中(缺血性卒中或全身性栓塞)和全因死亡。二级终点为手术后房颤(无房颤者手术后30天内新发房颤)以及长期房颤相关门诊就诊率和住院率。

共75782例患者进行了心脏外科手术(平均年龄66[SD 11.2];22091例[29.2%]为女性;25721例[33.9%]以前存在房颤),4374例[5.8%]同时进行了LAAO,平均随访2.1年(SD 1.9)。在8590例倾向得分匹配患者中,LAAO与卒中((1.14 vs 1.59 events per 100 person-years; hazard ratio [HR], 0.73 [95%CI, 0.56-0.96]; P = 0.03)和死亡(3.01 vs 4.30 events per 100 person-years; HR, 0.71 [95%CI, 0.60-0.84]; P < 0.001)风险下降有关。LAAO与较高的房颤相关门诊就诊(11.96 vs 10.26 events per person-year; absolute difference, 1.70 [95%CI, 1.60-1.80] events per person-year; rate ratio, 1.17 [95%CI, 1.10-1.24]; P < 0.001)和住院治疗(0.36 vs 0.32 event per person-year; absolute difference, 0.04 [95%CI, 0.02-0.06] event per person-year; rate ratio, 1.13 [95%CI, 1.05-1.21]; P = 0.002)有关。对于以前有房颤的患者(6438/8590 [74.9%]),LAAO和无LAAO的卒中风险分别为1.11 vs 1.71 events per 100 person-years (HR, 0.68 [95%CI, 0.50-0.92]; P = 0.01),死亡风险分别为3.22 vs 4.93 events per 100 person-years (HR, 0.67 [95%CI, 0.56-0.80]; P < 0.001)。对于以前无房颤的患者(2152/8590 [25.1%]),LAAO和无LAAO的卒中风险分别为1.23 vs 1.26 events per 100 person-years (HR, 0.95 [95%CI, 0.54-1.68],死亡风险分别为2.30 vs 2.49 events per 100 person-years (HR, 0.92 [95%CI, 0.61-1.37],手术后房颤风险分别为27.7% vs 20.2% events per 100 person-years (HR, 1.46 [95%CI, 1.22-1.73]; P < 0.001)。既往房颤和LAAO无明显交互(P = 0.29 for stroke and P = 0.16 for mortality)。

最终作者认为对于心脏外科手术的患者,同时外科LAAO(vs 无LAAO)与随后的卒中和全因死亡的风险降低有关。需要进一步随机试验验证外科LAAO的作用。

原始出处:

Xiaoxi Yao,et al.Association of Surgical Left Atrial Appendage Occlusion With Subsequent Stroke and Mortality Among Patients Undergoing Cardiac.JAMA. 2018 May 22;319(20):2116-2126. doi: 10.1001/jama.2018.6024. Surgery.

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    2018-06-10 jxrzshh
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    2018-06-10 mhm295
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    2018-06-08 医者仁心5538

    学习了

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1903332, encodeId=ffc5190333245, content=<a href='/topic/show?id=e1b0583884b' target=_blank style='color:#2F92EE;'>#新方法#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=58388, encryptionId=e1b0583884b, topicName=新方法)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c22f171, createdName=kord1982, createdTime=Thu Mar 14 05:18:00 CST 2019, time=2019-03-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1647871, encodeId=a8b4164e8715b, content=<a href='/topic/show?id=7c8448084d3' target=_blank style='color:#2F92EE;'>#左心耳夹闭术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=48084, encryptionId=7c8448084d3, topicName=左心耳夹闭术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=36f023527799, createdName=july_983, createdTime=Fri Sep 21 01:18:00 CST 2018, time=2018-09-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1455603, encodeId=c0d8145560312, content=<a href='/topic/show?id=d15a4808371' target=_blank style='color:#2F92EE;'>#左心耳#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=48083, encryptionId=d15a4808371, topicName=左心耳)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=386b5684768, createdName=jxrzshh, createdTime=Sun Jun 10 08:18:00 CST 2018, time=2018-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1593478, encodeId=78c715934e842, content=<a href='/topic/show?id=9850510e9a3' target=_blank style='color:#2F92EE;'>#心源性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=51079, encryptionId=9850510e9a3, topicName=心源性)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=955718147815, createdName=mhm295, createdTime=Sun Jun 10 08:18:00 CST 2018, time=2018-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322582, encodeId=5ec9322582dd, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Fri Jun 08 20:44:33 CST 2018, time=2018-06-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1026070, encodeId=917310260e0a6, content=卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=健健, createdTime=Fri Jun 08 20:18:00 CST 2018, time=2018-06-08, status=1, ipAttribution=)]
    2018-06-08 健健

    卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!

    0

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