聚焦房颤导管消融围手术期,解析NOAC抗凝治疗价值

2020-11-30 心关注 心关注

对导管消融患者围术期,已经在使用抗凝治疗的患者不建议暂停抗凝治疗,那么对初诊为阵发性房颤、既往未曾接受抗凝治疗、要进行射频消融治疗的患者,是立刻开始抗凝治疗还是在手术后再开始抗凝治疗?

2020年11月26日,中国血管健康联盟CCA TV(心血管远程教育平台) “抗凝专线 言之有‘里’”栏目特邀中山大学附属第一医院杜志民教授担任主席,海军医科大学附属长征医院廖德宁教授担任主讲嘉宾,首先从循证证据方面详细介绍了房颤导管消融围手术期患者的抗凝治疗策略,随后针对阵发性房颤患者抗凝治疗与射频消融时机、成功消融后的抗凝治疗需求等进行了探讨。本文仅摘取部分讨论环节的精彩内容,欲知更多详情,请扫描文后海报内二维码观看视频回放。

杜志民教授:对导管消融患者围术期,已经在使用抗凝治疗的患者不建议暂停抗凝治疗,那么对初诊为阵发性房颤、既往未曾接受抗凝治疗、要进行射频消融治疗的患者,是立刻开始抗凝治疗还是在手术后再开始抗凝治疗?国内目前有一些医院对阵发性房颤患者,食道超声检测未发现血栓就直接进行射频消融,对这种做法您如何看待?抗凝策略又如何选择?

廖德宁教授:阵发性房颤患者仅通过食道超声检测未见血栓就直接进行导管消融,我认为不符合指南规范。第一,食道超声尽管能够发现很多左心耳血栓,但实际上也存在死角,因此不能够完全替代抗凝;第二,食道超声与导管消融存在时间差。在国内常常需要在特定的地方才能开展食道超声检查,之后再将患者转送导管室,这个过程中患者可能会发生房颤,会有血栓风险;第三,很多患者尽管房颤终止,但心房还处于电机械分离状态,风险更高。国内阵发性房颤未经正规抗凝仅根据食道超声就做导管消融有过一些患者发生卒中甚至大卒中的经验教训。所以根据指南,阵发性房颤尤其是CHA?DS?-VASc评分高的患者还是要经过系统的正规抗凝治疗,而后做食道超声,再选择射频消融。

抗凝药物选择方面,华法林还是NOAC?我个人认为,大多数房颤患者CHA?DS?-VASc评分并不是很高,选用NOAC起效快,准备时间较短,作用比较肯定;而选择华法林要达到有效的INR并维持,需要的时间比较长,且可靠性相对要差一些。因此对大多数普通患者,我都会推荐NOAC,但是对于一些血栓风险很高的患者,比如风湿性心脏瓣膜病患者要进行导管消融,以及房颤使用NOAC抗凝仍有左心耳血栓的患者等,我们要考虑用华法林抗凝。

杜志民教授:的确,阵发性房颤患者在食道超声检测后到导管消融的这段时间可能会有阵发性房颤,就有可能会出现血栓。事实上这种血栓形成可能只需要数分钟,阵发性房颤下,血流涡旋,1~2分钟可能就开始触发凝血,5分钟就可能形成比较明显的血栓,这种情况下进行导管消融,若器械靠近血栓形成部位,会进一步促进血栓形成或者触碰到血栓,都更容易导致事件发生。因此导管消融应该进行术前抗凝,有准备期可能会更好。

杜志民教授:另外一个临床有争议的问题是,成功房颤消融后窦性心律的患者,抗凝到底应该用多长时间?

廖德宁教授:一次成功的房颤消融并不意味着这例患者永远规避了房颤复发,这是我们为何对CHA?DS?-VASc评分高的患者,即便取得所谓的成功射频消融后也不能中断抗凝治疗的一个原因。第二,即使患者不再有房颤,也并不意味着不会形成血栓。现在越来越多的专家认为,房颤是心内膜损伤尤其是左房左心耳内膜损伤的一个标志物,提示高凝状态。大约5~10年前的研究发现,CHA?DS?-VASc评分高的患者射频消融后,植入式心电记录器观察显示:(1)患者发生房颤几分钟、几小时、十几个小时后发生卒中,卒中显然与房颤相关;(2)患者在完全窦性心律状态下发生卒中,提示卒中与房颤无关;(3)卒中发生后几分钟、几小时后出现房颤,研究者认为这种房颤由卒中引起。正是这些研究结果使得我们否定了房颤消融成功可以中断抗凝治疗的假设。所以目前无论国内外指南,CHA?DS?-VASc评分高的患者消融术后,无论是否成功都不应该轻易中断抗凝。若CHA?DS?-VASc评分高的患者是为了不进行抗凝治疗而寻求导管消融,临床不应接受。但是这也并不意味着房颤消融成功对房颤卒中预防没有效果,越来越多的证据显示房颤负荷低时,房颤卒中风险也低,负荷高时,房颤风险往往就高。消融成功显然可以大大减少房颤负荷,虽然不能杜绝卒中发生,但能够减少房颤卒中风险。

杜志民教授:我完全同意这个观点。事实上我们做房颤射频消融的目的之一就是减少房颤所导致的卒中发生,这种作用已经得到很多研究证实。但只是一定比例的减少,这种情况下加用抗凝药物会使卒中风险进一步减少,但也不会减至0。

杜志民教授:最后请廖教授分享一下贵院在房颤经导管射频消融方面开展的工作。

廖德宁教授:我们医院地处上海,是众多医学中心中的一个,手术总量不是很大。我们开展的工作:第一,我们采用的V6三维电磁标测系统对手术成功有很好帮助,应用Pentaray作为建模手段,并与心内超声相结合。建模方面是我们的特色和比较自豪的一点。第二,在消融能量掌握上,我们现在采用大功率短时间的方法即选择性阻抗热消融,避免或者减少对于临近部位的损伤,包括食道损伤。从2018年至今已经实施几百例患者,基本安全且效果很好,手术时间明显缩短,患者就医体验明显改善。第三,在上海一站式手术方兴未艾,我们也在尝试开展。因为很多患者一次甚至两次房颤消融并不能完全解决问题,加上更多地认识到CHA?DS?-VASc评分高的患者中房颤只是一种标志物,因此这方面的工作力度在提升。

抗凝治疗方面需要特别提到的是艾多沙班。上海是个老龄化城市,有很多超过85岁甚至90岁的老人。我们有高龄患者发生房颤后症状明显,乏力、食欲减退、浮肿等,要进行复律就要进行抗凝。我们通过检索发现,艾多沙班是目前循证医学中对超高龄老年人群数据最多、病例最多、结果也显示最安全的NOAC,因此我们在这种老老年患者中会较多使用艾多沙班。我个人认为艾多沙班在我国的应用有很大潜力,因为中国房颤老年患者很多,尤其高龄患者很多过去会选择中性治疗,不抗凝,患者卒中发生风险高,但实际上这类患者用艾多沙班是安全的。

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    2021-05-04 hongbochen
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  3. 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style='color:#2F92EE;'>#消融#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65819, encryptionId=4bc865819d2, topicName=消融)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=30bd35, createdName=一叶知秋, createdTime=Wed Dec 02 13:58:52 CST 2020, time=2020-12-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1507557, encodeId=72c8150e5578b, content=<a href='/topic/show?id=528b12904c3' target=_blank style='color:#2F92EE;'>#NOAC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=12904, encryptionId=528b12904c3, topicName=NOAC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=418f9911898, createdName=30397607, createdTime=Wed Dec 02 13:58:52 CST 2020, time=2020-12-02, status=1, ipAttribution=), 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  4. [GetPortalCommentsPageByObjectIdResponse(id=1672979, encodeId=25a116e2979bf, content=<a href='/topic/show?id=b79b910345c' target=_blank style='color:#2F92EE;'>#解析#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91034, encryptionId=b79b910345c, topicName=解析)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f42d26916490, createdName=hongbochen, createdTime=Tue May 04 05:58:52 CST 2021, time=2021-05-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2053903, encodeId=12c5205390378, content=<a href='/topic/show?id=8f5a54442a1' target=_blank style='color:#2F92EE;'>#手术期#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54442, encryptionId=8f5a54442a1, topicName=手术期)], attachment=null, authenticateStatus=null, 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style='color:#2F92EE;'>#消融#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65819, encryptionId=4bc865819d2, topicName=消融)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=30bd35, createdName=一叶知秋, createdTime=Wed Dec 02 13:58:52 CST 2020, time=2020-12-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1507557, encodeId=72c8150e5578b, content=<a href='/topic/show?id=528b12904c3' target=_blank style='color:#2F92EE;'>#NOAC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=12904, encryptionId=528b12904c3, topicName=NOAC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=418f9911898, createdName=30397607, createdTime=Wed Dec 02 13:58:52 CST 2020, time=2020-12-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=904126, encodeId=70599041266b, content=艾多沙班是目前循证医学中对超高龄老年人群数据最多、病例最多、结果也显示最安全的NOAC, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210325/2d9c955949df4b349a439f1a6773499e/b39f4845e869489d95bc545c79cf60fa.jpg, createdBy=303f5433779, createdName=Oranhyg, createdTime=Wed Dec 02 08:23:50 CST 2020, time=2020-12-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=904042, encodeId=6da190404233, content=无症状房颤可咋办, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210405/8cca360e910e4e4abbad67324b2cf9ef/37fef780c17a4da7b5506ea9971b725e.jpg, createdBy=91fa5404020, createdName=暂0e4516bm, createdTime=Tue Dec 01 22:02:06 CST 2020, time=2020-12-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=903909, encodeId=f852903909bc, content=真棒, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2a985341115, createdName=ms1000000377331048, createdTime=Tue Dec 01 16:19:54 CST 2020, time=2020-12-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1031323, encodeId=a841103132348, content=房颤,临床上碰到很多哦, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=心介, createdTime=Tue Dec 01 01:58:52 CST 2020, time=2020-12-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=903715, encodeId=52cb903e1568, content=文章写得不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201201/3eab7e21b5954f5298763b28d54ba44e/bef33baae8934f55be35737159093b51.jpg, createdBy=4adc1309571, createdName=trees8209, createdTime=Mon Nov 30 23:29:56 CST 2020, time=2020-11-30, status=1, ipAttribution=)]
  5. [GetPortalCommentsPageByObjectIdResponse(id=1672979, encodeId=25a116e2979bf, content=<a href='/topic/show?id=b79b910345c' target=_blank style='color:#2F92EE;'>#解析#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91034, encryptionId=b79b910345c, topicName=解析)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f42d26916490, createdName=hongbochen, createdTime=Tue May 04 05:58:52 CST 2021, time=2021-05-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2053903, encodeId=12c5205390378, content=<a href='/topic/show?id=8f5a54442a1' target=_blank style='color:#2F92EE;'>#手术期#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54442, encryptionId=8f5a54442a1, topicName=手术期)], attachment=null, authenticateStatus=null, 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style='color:#2F92EE;'>#消融#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65819, encryptionId=4bc865819d2, topicName=消融)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=30bd35, createdName=一叶知秋, createdTime=Wed Dec 02 13:58:52 CST 2020, time=2020-12-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1507557, encodeId=72c8150e5578b, content=<a href='/topic/show?id=528b12904c3' target=_blank style='color:#2F92EE;'>#NOAC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=12904, encryptionId=528b12904c3, topicName=NOAC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=418f9911898, createdName=30397607, createdTime=Wed Dec 02 13:58:52 CST 2020, time=2020-12-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=904126, encodeId=70599041266b, content=艾多沙班是目前循证医学中对超高龄老年人群数据最多、病例最多、结果也显示最安全的NOAC, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210325/2d9c955949df4b349a439f1a6773499e/b39f4845e869489d95bc545c79cf60fa.jpg, createdBy=303f5433779, createdName=Oranhyg, createdTime=Wed Dec 02 08:23:50 CST 2020, time=2020-12-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=904042, encodeId=6da190404233, content=无症状房颤可咋办, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210405/8cca360e910e4e4abbad67324b2cf9ef/37fef780c17a4da7b5506ea9971b725e.jpg, createdBy=91fa5404020, createdName=暂0e4516bm, createdTime=Tue Dec 01 22:02:06 CST 2020, time=2020-12-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=903909, encodeId=f852903909bc, content=真棒, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2a985341115, createdName=ms1000000377331048, createdTime=Tue Dec 01 16:19:54 CST 2020, time=2020-12-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1031323, encodeId=a841103132348, content=房颤,临床上碰到很多哦, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=心介, createdTime=Tue Dec 01 01:58:52 CST 2020, time=2020-12-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=903715, encodeId=52cb903e1568, content=文章写得不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201201/3eab7e21b5954f5298763b28d54ba44e/bef33baae8934f55be35737159093b51.jpg, createdBy=4adc1309571, createdName=trees8209, createdTime=Mon Nov 30 23:29:56 CST 2020, time=2020-11-30, status=1, ipAttribution=)]
    2020-12-02 30397607
  6. 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style='color:#2F92EE;'>#消融#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65819, encryptionId=4bc865819d2, topicName=消融)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=30bd35, createdName=一叶知秋, createdTime=Wed Dec 02 13:58:52 CST 2020, time=2020-12-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1507557, encodeId=72c8150e5578b, content=<a href='/topic/show?id=528b12904c3' target=_blank style='color:#2F92EE;'>#NOAC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=12904, encryptionId=528b12904c3, topicName=NOAC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=418f9911898, createdName=30397607, createdTime=Wed Dec 02 13:58:52 CST 2020, time=2020-12-02, status=1, ipAttribution=), 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Dec 01 22:02:06 CST 2020, time=2020-12-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=903909, encodeId=f852903909bc, content=真棒, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2a985341115, createdName=ms1000000377331048, createdTime=Tue Dec 01 16:19:54 CST 2020, time=2020-12-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1031323, encodeId=a841103132348, content=房颤,临床上碰到很多哦, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=心介, createdTime=Tue Dec 01 01:58:52 CST 2020, time=2020-12-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=903715, encodeId=52cb903e1568, content=文章写得不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201201/3eab7e21b5954f5298763b28d54ba44e/bef33baae8934f55be35737159093b51.jpg, createdBy=4adc1309571, createdName=trees8209, createdTime=Mon Nov 30 23:29:56 CST 2020, time=2020-11-30, status=1, ipAttribution=)]
    2020-12-02 Oranhyg

    艾多沙班是目前循证医学中对超高龄老年人群数据最多、病例最多、结果也显示最安全的NOAC

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=1672979, encodeId=25a116e2979bf, content=<a href='/topic/show?id=b79b910345c' target=_blank style='color:#2F92EE;'>#解析#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91034, encryptionId=b79b910345c, topicName=解析)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f42d26916490, createdName=hongbochen, createdTime=Tue May 04 05:58:52 CST 2021, time=2021-05-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2053903, encodeId=12c5205390378, content=<a href='/topic/show?id=8f5a54442a1' target=_blank style='color:#2F92EE;'>#手术期#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54442, encryptionId=8f5a54442a1, topicName=手术期)], attachment=null, authenticateStatus=null, 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style='color:#2F92EE;'>#消融#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65819, encryptionId=4bc865819d2, topicName=消融)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=30bd35, createdName=一叶知秋, createdTime=Wed Dec 02 13:58:52 CST 2020, time=2020-12-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1507557, encodeId=72c8150e5578b, content=<a href='/topic/show?id=528b12904c3' target=_blank style='color:#2F92EE;'>#NOAC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=12904, encryptionId=528b12904c3, topicName=NOAC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=418f9911898, createdName=30397607, createdTime=Wed Dec 02 13:58:52 CST 2020, time=2020-12-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=904126, encodeId=70599041266b, content=艾多沙班是目前循证医学中对超高龄老年人群数据最多、病例最多、结果也显示最安全的NOAC, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210325/2d9c955949df4b349a439f1a6773499e/b39f4845e869489d95bc545c79cf60fa.jpg, createdBy=303f5433779, createdName=Oranhyg, createdTime=Wed Dec 02 08:23:50 CST 2020, time=2020-12-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=904042, encodeId=6da190404233, content=无症状房颤可咋办, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210405/8cca360e910e4e4abbad67324b2cf9ef/37fef780c17a4da7b5506ea9971b725e.jpg, createdBy=91fa5404020, createdName=暂0e4516bm, createdTime=Tue Dec 01 22:02:06 CST 2020, time=2020-12-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=903909, encodeId=f852903909bc, content=真棒, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2a985341115, createdName=ms1000000377331048, createdTime=Tue Dec 01 16:19:54 CST 2020, time=2020-12-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1031323, encodeId=a841103132348, content=房颤,临床上碰到很多哦, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=心介, createdTime=Tue Dec 01 01:58:52 CST 2020, time=2020-12-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=903715, encodeId=52cb903e1568, content=文章写得不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201201/3eab7e21b5954f5298763b28d54ba44e/bef33baae8934f55be35737159093b51.jpg, createdBy=4adc1309571, createdName=trees8209, createdTime=Mon Nov 30 23:29:56 CST 2020, time=2020-11-30, status=1, ipAttribution=)]
    2020-12-01 暂0e4516bm

    无症状房颤可咋办

    0

  8. 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beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201201/3eab7e21b5954f5298763b28d54ba44e/bef33baae8934f55be35737159093b51.jpg, createdBy=4adc1309571, createdName=trees8209, createdTime=Mon Nov 30 23:29:56 CST 2020, time=2020-11-30, status=1, ipAttribution=)]
    2020-12-01 ms1000000377331048

    真棒

    0

  9. 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beContent=null, objectType=article, channel=null, level=null, likeNumber=69, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201201/3eab7e21b5954f5298763b28d54ba44e/bef33baae8934f55be35737159093b51.jpg, createdBy=4adc1309571, createdName=trees8209, createdTime=Mon Nov 30 23:29:56 CST 2020, time=2020-11-30, status=1, ipAttribution=)]
    2020-12-01 心介

    房颤,临床上碰到很多哦

    0

  10. 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    2020-11-30 trees8209

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