心血管植入式电子装置导线相关静脉血栓形成的危险因素分析及治疗研究

发布时间：2018-05-28 16:53

本文选题：心血管植入式电子装置 + 深静脉血栓　；参考：《中国人民解放军医学院》2017年硕士论文

【摘要】：背景:心血管植入式电子装置(CIED)包括心脏永久性起搏器(PPM)、植入式心脏复律除颤器(ICD)及心脏再同步化治疗(CRT)等一系列植入装置,目前被广泛用于治疗严重缓慢型心律失常、持续快速型室性心律失常及心室收缩失同步心力衰竭的患者。经皮静脉内植入电极导线是CIED导线植入人体最常用的方法。近年来,许多文献报道植入电极导线可引起静脉血栓形成,而血栓脱落可导致肺栓塞(PE),血栓形成可导致管腔狭窄或闭塞,出现上腔静脉综合征(SVCS)等并发症,并且造成CIED系统更换或升级困难。目的:本研究以接受CIED治疗的患者为研究对象,拟探讨CIED导线相关静脉血栓形成的危险因素,比较CIED导线相关静脉血栓形成患者接受不同药物治疗后的差异,为临床预防和治疗提供依据。方法:连续入选中国人民解放军总医院心血管内科2013年9月至2015年12月入院首次行PPM植入术、ICD安置术及CRT (包括CRT-P及CRT-D)植入术的患者,分别于术前及术后1周、1个月、3个月、6个月行双侧上肢静脉、锁骨下静脉及上腔静脉血管超声检查,根据术后血管超声的结果进行分组:术后4次血管超声均无血栓形成的患者为非血栓组;术后任何1次血管超声提示有血栓形成的患者为血栓组。收集所有入选患者的临床资料,比较两组临床资料有无差异,对有差异的临床资料运用Logistic回归进行分析,评价各临床资料与静脉血栓形成之间的关系。血栓组患者随机分为两组接受不同的药物治疗:(1)华法林组:初始接受华法林联合低分子量肝素(LMWH)治疗3-5天,待国际标准化比率(INR)达到2.0后停用LMWH,单用华法林长期口服治疗,定期监测血凝,保证INR在2.0-3.0之间;(2)新型口服抗凝药(NOACs)组:接受达比加群酯胶囊110mg2/日长期口服治疗。分别于接受治疗前及接受治疗后1个月、3个月、6个月、1年来院行植入侧静脉数字减影血管造影术(DSA)。通过QAngioXA计算机软件测量得出血管狭窄处直径较其近心端正常血管管径减少的百分率得出血管狭窄程度,分为四个等级:≤50%为轻度狭窄,50%且≤70%为中度狭窄,70%且100%为重度狭窄,100%为完全闭塞。比较两组血栓形成的患者在治疗前后血管狭窄程度等级有无明显变化。接受治疗后,血管狭窄程度较治疗前减轻1个等级及以上为治疗有效,较治疗前无改善或加重1个等级及以上为治疗无效。结果:共入选首次接受CIED治疗的患者164例,发现CIED导线相关静脉血栓形成的患者56例,作为血栓组,未发现CIED导线相关静脉血栓形成的患者108例,作为非血栓组。结果发现:(1)两组患者的一般临床资料,如年龄、性别、身体质量指数(BMI)、吸烟、高血压病史、心肌梗死(MI)病史、卒中病史等无统计学差异(P0.05);(2)两组在心房颤动(AF)、植入除颤导线、服用抗凝药物的患者数百分比和糖化血红蛋白(HbAlc)、左室射血分数(LVEF)水平以及术中静脉穿刺次数、手术时间、导线数量相比较,差异均有统计学意义(P0.05); (3)运用Logistic回归对两组间有统计学差异的临床资料进行分析发现,AF(OR=15.816;P0.05)、HbAlc(OR=2.799;P=0.003)、术中静脉穿刺次数(OR=3.438;P0.05)及手术时间(OR=1.054;P0.05)是CIED导线相关静脉血栓形成的危险因素,服用抗凝药物(OR=0.016;P0.05)是其保护因素;(4)抗凝治疗能够显著减轻CIED导线相关静脉血栓形成所致的血管狭窄程度,且随着治疗时间的延长,治疗有效率逐渐增加。在接受药物治疗后1年,NOACs组的治疗有效率明显高于华法林组,差异有统计学意义(P0.05)。结论:AF、高血糖、术中静脉穿刺次数及手术时间是CIED导线相关静脉血栓形成的独立危险因素;抗凝药物对CIED导线相关静脉血栓形成的治疗作用显著,治疗有效性随着治疗时间延长而增加;NOACs的远期治疗有效性优于华法林。
[Abstract]:Background: the cardiovascular implantable electronic device (CIED), including a permanent cardiac pacemaker (PPM), implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT), is currently widely used in the treatment of severe bradyarrhythmia, sustained rapid ventricular arrhythmias and ventricular systolic dyssynchrony heart failure Patients. Implantation of electrode wires in the percutaneous vein is the most commonly used method of CIED wire implantation. In recent years, many reports have reported that implantation of electrode conductors can cause venous thrombosis, and thrombus abscission can lead to pulmonary embolism (PE). Thrombosis can lead to stenosis or occlusion of the lumen, occurrence of superior vena cava syndrome (SVCS) and other complications, and cause CI ED system replacement or upgrading difficulties. Objective: This study, taking patients receiving CIED treatment as the research object, intends to explore the risk factors of CIED traverse related venous thrombosis, compare the differences between the patients with CIED wire related venous thrombosis after the treatment of different drugs, and provide the basis for clinical prevention and treatment. PPM implantation, ICD placement and CRT (including CRT-P and CRT-D) implantation were performed for the first time from September 2013 to December 2015 in the General Hospital of the General Hospital of the people's Liberation Army. The bilateral upper extremity veins, subclavian veins and superior vena cava vessels were examined before and 1 weeks before and after operation, 3 months and 6 months respectively. The results were divided into groups: 4 times of postoperative vascular ultrasound without thrombus formation in the non thrombus group; the patients with thrombus formation at any 1 times of vascular ultrasound were thrombus group. The clinical data of all the selected patients were collected and the clinical data of the two groups were compared, and the different clinical data were analyzed by Logistic regression analysis. The relationship between the clinical data and venous thrombosis. The patients in the thrombus group were randomly divided into two groups to receive different medications: (1) the Hua Falin group was initially treated with Hua Falin combined with low molecular weight heparin (LMWH) for 3-5 days, and the international standardized ratio (INR) reached 2 after LMWH, and Hua Falin had been treated by Hua Falin for a long time, and the blood coagulation was monitored regularly. Guarantee INR between 2.0-3.0 and (2) the new oral anticoagulant group (NOACs) group: receive dabigan group 110mg2/ day long term oral treatment. After receiving treatment and receiving treatment, 1 months, 3 months, 6 months, and 1 years were implanted side vein digital subtraction angiography (DSA). The vascular stenosis was measured by the QAngioXA computer software. The degree of vascular stenosis was divided into four grades: less than 50% was mild stenosis, 50% and less than 70% were moderate stenosis, 70% and 100% were severe stenosis, 100% were completely obliterated. Compared with two groups of patients with thrombosis, there were no significant changes in the degree of vascular stenosis in the two groups. After treatment, the degree of vascular stenosis was less than 1 grades or more before treatment. No improvement or aggravation before treatment was not effective. Results: 164 patients received CIED treatment for the first time, and 56 cases of CIED traverse related venous thrombosis were found. As thrombus group, no CIED wire related static was found. 108 cases of vein thrombosis were found in the non thrombus group. The results were as follows: (1) the general clinical data of two groups of patients, such as age, sex, body mass index (BMI), smoking, hypertension history, MI history, and history of stroke, were not statistically different (P0.05); (2) the two groups were in atrial fibrillation (AF), implanted defibrillator traverse, taking anticoagulant drugs The percentage of patients with glycosylated hemoglobin (HbAlc), left ventricular ejection fraction (LVEF) and the number of intraoperative venipuncture, operation time and number of wires were statistically significant (P0.05); (3) the clinical data of two groups with statistical difference between groups were analyzed by Logistic regression, and AF (OR=15.816; P0.05), HbAlc (OR=2.79) 9; P=0.003), the number of intraoperative venipuncture (OR=3.438; P0.05) and operation time (OR=1.054; P0.05) are the risk factors for the formation of venous thrombosis in CIED wire, and the anticoagulant drugs (OR=0.016; P0.05) are the protective factors. (4) anticoagulant therapy can significantly reduce the degree of vascular stenosis caused by the formation of venous thrombosis in the CIED wire, and with the treatment. The effective rate of treatment increased gradually. The effective rate of treatment in group NOACs was significantly higher than that of warfarin group in 1 years after receiving the drug treatment. The difference was statistically significant (P0.05). Conclusion: AF, hyperglycemia, the number of intraoperative venipuncture and operation time are independent risk factors for the formation of CIED wire related vein thrombosis; anticoagulant drugs on CIED wire Associated venous thrombosis has significant therapeutic effect, and the effectiveness of treatment increases with the prolongation of treatment time. The long-term efficacy of NOACs is better than warfarin.
【学位授予单位】：中国人民解放军医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R541.7

【参考文献】