Оптимальная гипокоагуляция в интраоперационном периоде при радиочастотной катетерной изоляции легочных вен у больных с фибрилляцией предсердий

Abstract

Освещены актуальные вопросы гипокоагуляции в интраоперационном периоде при радиочастотной катетерной изоляции легочных вен у больных с фибрилляцией предсердий. Адекватная антикоагуляция является важным аспектом для профилактики тромбоэмболических и геморрагических осложнений. Несмотря на большое количество исследований в этой области и широкое применение катетерных методов лечения, не существует единых стандартизованных схем антикоагуляции, и риск тромбоэмболических и геморрагических осложнений радиочастотной изоляции легочных вен у больных с фибрилляцией предсердий остается высоким. Разработаны оптимальные схемы интраоперационных режимов гипокоагуляции на основе определения времени активации свертывания крови и международного нормализационного отношения.

An important aspect of the intra-operative management of patients with atrial fibrillation (AF) is adequate anticoagulation to prevent thromboembolic complications. The most frequent complications of the so-called “silent” strokes up to 10% of the total number of complications. Excessive anticoagulation, in turn, can lead to hemorrhagic complications including hemopericardium and cardiac tamponade, hematoma after puncture site vessels. The aim of our research is to develop optimal perioperative anticoagulation regimes during catheter interventions for atrial fibrillation, based on the determination of the time of activation of coagulation (active clotting time, ACT) and the international normalizing ratio (INR) for the prevention of stroke, systemic embolism and bleeding complications. The study included 70 patients with paroxysmal AF, aged between 45 and 75 years who underwent radiofrequency catheter isolation of the pulmonary veins. There were 42 (64.3%) men and 28 (35.7%) women. The first group (I) included 30 patients who underwent bridging-therapy. Warfarin abolished in 2–3 days prior to the procedure and resumed at 4 h after surgery. The second group (II) included 40 patients who received warfarin dose 2.5–7.5 mg per day prior to surgery. In the perioperative period, warfarin was not canceled. In the perioperative period, heparin was administered intravenously at a dose of 130–150 IU/kg body weight bolus, depending on the initial levels of INR and ACT and their ratio. Subsequently, heparin was administered intravenously according to the ACT indicator. ACT levels were significantly higher in group II, wherein INR level was on average 2.3±0.8 (r=0.7; p<0.001). The initial dose of heparin in this group was significantly lower than in group I and was (10.234±543.000) IU (8.000–12.000) IU compared with group I — (12.600±550.000) IU. After the first injection of heparin in the perioperative period, ACT were significantly higher in patients in the second group who received warfarin entire perioperative period compared with patients who observed bridging-therapy (p<0.001). Each subsequent measurement of ACT showed significantly higher levels of ACT in the second group at lower injected heparin. Hemorrhagic complications, such as small bleeding (hematoma puncture site) were observed in 7 (23%) patients in bridging-therapy group and the 2nd group — 4 patients (10%). So, it was found an association between the level of INR, an indicator of the ACT and the total dose of heparin, which must be taken into account during the interventional treatment of AF in the prevention of thromboembolic complications in order to reduce the risk of hemorrhagic complications.