Professor Zheng Jingang: Director of the Department of Cardiology of China-Japan Friendship Hospital, Head of the Catheter Room of the Heart Center, Chief Physician, Professor of Peking University Medical Department. Doctoral supervisor at Peking Union Medical College and Beijing Medical University. Member of the Expert Group of the American Coronary Intervention Association, International Cooperation Review Expert of the Ministry of Science and Technology, Communication Editorial Board Member of the Chinese Journal of Cardiovascular Disease, and Guidance Mentor for Coronary Intervention Training Base.
Percutaneous left atrial appendage occlusion - a blessing for high-risk atrial fibrillation patients with bleeding
A 68 year old man suffered a cerebral infarction due to years of atrial fibrillation
Ms. Zhang, who is 68 years old this year, was diagnosed with atrial fibrillation during a physical examination 7 years ago and did not receive regular diagnosis and treatment. 7 days ago, Ms. Zhang suddenly experienced left limb weakness and unstable standing while walking, accompanied by left eyelid droop. When visiting the emergency department of a Sino Japanese hospital, the left upper limb muscle strength was found to be level 2, the left lower limb muscle strength was level 2, and the corners of the mouth were skewed. The head CT scan showed no bleeding lesions, suggesting cerebral infarction. The patient was treated with alteplase thrombolysis. After treatment, the patient's left limb activity slightly improved. Ms. Zhang has a history of hypertension for 10 years. She usually takes 30 mg nifedipine controlled-release tablets once a day. Her blood pressure is still stable and she has a history of diabetes. After admission, the electrocardiogram showed that Ms. Zhang had atrial fibrillation rhythm.
Based on Ms. Zhang's symptoms and medical history, we consider her cerebral thrombosis to be a cardioembolic thrombus, which means that it is caused by atrial fibrillation leading to the formation and detachment of atrial thrombus, ultimately causing cerebral artery embolism.
I had this surgery! The old man recovered quickly and was discharged from the hospital
Patients like Ms. Zhang are at high risk of thromboembolism. According to the CHA2DS2 VASc score for atrial fibrillation thromboembolism, which is 6 points, the risk of peripheral vascular embolism is extremely high (greater than 2 points is considered high risk), and anticoagulant therapy is needed to further prevent peripheral thromboembolism (such as secondary cerebral embolism, renal artery embolism, mesenteric artery embolism, etc.).
Just as we were preparing to give Ms. Zhang formal anticoagulant treatment, she experienced a situation: she had a black stool. Black stool in medicine means there may be gastrointestinal bleeding. The clinical examination confirmed our hypothesis with positive occult blood. At this point, the treatment of patients is facing a dilemma: atrial fibrillation and cerebral embolism require sufficient anticoagulation. If anticoagulation is not performed, cerebral embolism may occur again, and even disability or death may occur as a result; However, the coexistence of gastrointestinal bleeding makes it impossible to carry out urgent anticoagulant therapy. If anticoagulant therapy is used, gastrointestinal bleeding may worsen and even lead to fatal gastrointestinal bleeding.
So how should we treat it next? After discussion, several experts in the cardiology department have decided to perform "radiofrequency ablation+left atrial appendage occlusion" on the patient.
Ms. Zhang's condition remained stable during the surgery, and she was able to move around on the ground 10 hours after the operation. On the third day after the surgery, Ms. Zhang was transferred to a rehabilitation hospital for further treatment. During postoperative follow-up, Ms. Zhang did not experience any further cerebral embolism or other peripheral embolic events, nor did she experience any gastrointestinal or other bleeding.
The hazards and treatment challenges of atrial fibrillation have been overcome, with over 90% of blood clots in atrial fibrillation patients originating from the left atrial appendage
Atrial fibrillation (AF) is one of the most common rapid arrhythmias in clinical practice, usually caused by diseases such as hypertension, coronary heart disease, myocardial ischemia, and heart failure. During atrial fibrillation, the ventricular rate is fast and irregular, sometimes reaching 100-160 beats per minute. Patients may experience palpitations, chest tightness, and difficulty breathing, which can cause or worsen heart failure.
The left atrial appendage is an ear shaped sac that extends from the left atrium and is part of the left atrium. Its inner wall is rich in comb like muscles. Due to the loss of effective contraction and relaxation function in the atrium, the blood flow velocity in the atrium is significantly slowed down, making it highly susceptible to thrombus formation in the left atrial appendage during atrial fibrillation. More than 90% of blood clots in atrial fibrillation patients originate from the left atrial appendage.
The risk of thrombotic events caused by thrombus detachment in the left atrium is extremely high. Embolic events can cause peripheral organ embolism, such as cerebral embolism (stroke), splenic infarction, mesenteric artery embolism, renal infarction, coronary artery embolism, etc., especially fatal and disabling stroke. However, patients often lack sufficient awareness of the severity of embolic events, and it is extremely common for them to regret it too late after the occurrence of embolic events.
Bleeding in atrial fibrillation patients has become a treatment contradiction that cannot be resolved by medication
In the prevention of thromboembolism, oral anticoagulants (warfarin, new oral anticoagulants) are currently commonly used. However, patients with atrial fibrillation and high risk of embolism are also at high risk of bleeding. A large proportion of atrial fibrillation patients are unable to fully anticoagulate due to their high risk of bleeding, and the incidence of embolism (especially fatal or disabling stroke) is high, which is currently the biggest limitation of drug anticoagulation therapy.
China is the "hardest hit area" for anticoagulant therapy for atrial fibrillation worldwide. Multiple epidemiological studies suggest that as a major country in atrial fibrillation, the usage rate of oral anticoagulants in China is only about 10%, significantly lower than the global and even Asian average levels; After one year of initial anticoagulation, 44.4% of patients with non valvular atrial fibrillation stopped taking the medication, and the 2-year discontinuation rate was as high as 57.6%. The main reason for stopping medication is bleeding. Discontinuing anticoagulants due to bleeding exposes atrial fibrillation patients to a high risk of embolism, which is a treatment contradiction that cannot be resolved by medication!
Left atrial appendage occlusion is the safest and most effective treatment option
In this situation, the "percutaneous left atrial appendage occlusion surgery" emerged!
Left atrial appendage occlusion (LAAC) is performed using percutaneous intervention therapy. The left atrial appendage occluder is inserted through the femoral vein into the atrial septum and into the left atrium to the opening of the left atrial appendage. During the operation, X-ray imaging and transesophageal echocardiography are used to monitor the position and release timing of the occluder. After successful release, the opening of the left atrial appendage is occluded. After 45 days, the occluder can be completely endothelialized.
LAfter AAC surgery, only oral warfarin or a new type of oral anticoagulant is needed for 45 days. After 45 days, a follow-up transesophageal echocardiogram is required. If there is no residual shunt, dual antiplatelet therapy can be switched to single antiplatelet therapy. After 6 months, single antiplatelet therapy can be switched to. This greatly shortens the time for patients to take oral anticoagulants and reduces the risk of bleeding.
At present, in the 2016 guidelines of the European Society of Cardiology (ESC) and the guidelines of the Chinese Medical Association's Electrophysiology and Pacing Branch, left atrial appendage occlusion surgery is recommended for the following patients: not suitable for long-term standardized anticoagulant therapy (high risk of bleeding); On the basis of long-term standardized anticoagulant therapy, stroke or embolism events still occur; HAS-BLED score ≥ 3.
For atrial fibrillation patients with high risk of embolism and high risk of bleeding who cannot fully anticoagulate, left atrial appendage occlusion is currently the safest and most effective treatment option.
Tip: What should I do if I have atrial fibrillation?
What should I do if I have atrial fibrillation? Here are a few issues that atrial fibrillation patients need to pay attention to.
1. Atrial fibrillation is not just "palpitations"
The harm of atrial fibrillation lies not only in the palpitations caused by rapid ventricular rate, but more importantly, in the occurrence of peripheral organ embolism events caused by thrombus detachment in the left atrial appendage, especially disabling or fatal cerebral embolism. Therefore, once you discover that you have atrial fibrillation, you should seek medical attention promptly and have a professional cardiologist assess your risk of thromboembolism and determine how to prevent the occurrence of embolic events.
2. Cerebral infarction also depends on the heart
Patients who seek treatment in the neurology department for cerebral infarction should also seek treatment in the cardiology department to assess the presence of asymptomatic atrial fibrillation and determine whether the cerebral infarction is a cerebral embolism caused by atrial fibrillation.
3. Countermeasures for high-risk bleeding
If atrial fibrillation patients experience bleeding during anticoagulant therapy (common bleeding in the digestive tract, skin and mucous membranes, respiratory tract, etc.), do not be nervous. They should seek timely medical attention from a cardiologist to assess the risk of bleeding, determine whether anticoagulant therapy needs to be discontinued, and whether left atrial appendage occlusion surgery can be used to prevent embolism after discontinuation of anticoagulant therapy.