加拿大汉密尔顿综合医院Richard P. Whitlock团队研究了心脏手术中封堵左心耳预防中风的效果。2021年5月15日，《新英格兰医学杂志》发表了该成果。

外科封堵左心耳可以预防房颤患者的缺血性中风，但这一点尚未得到证实。这一过程可以在因其他原因进行的心脏手术中进行。

研究组进行了一项多中心、随机试验，招募患有房颤、CHA2DS2 VASc评分至少为2分（0-9分，评分越高，中风风险越大）、计划接受心脏手术的患者。将受试者随机分组，分别接受术中左心耳封堵术和不封堵术，所有参与者在随访期间都接受常规护理，包括口服抗凝剂。主要结局是发生缺血性中风（包括神经影像学阳性的短暂性脑缺血发作）或全身性栓塞。

主要分析人群包括封堵术组的2379名参与者和非封堵术组的2391名参与者，平均年龄为71岁，平均CHA2DS2 VASc评分为4.2分。参与者平均随访3.8年。92.1%的受试者接受了指定的程序治疗，3年后，76.8%的受试者继续接受口服抗凝治疗。封堵术组中有114例（4.8%）参与者发生中风或全身性栓塞，非封堵术组中有168例（7.0%），风险比为0.67。两组患者围手术期出血、心力衰竭或死亡的发生率无显著差异。

研究结果表明，在接受过心脏手术的房颤患者中，大多数患者继续接受抗血栓治疗，术中进行左心耳封堵术后缺血性中风或系统性栓塞的风险显著低于未经治疗的患者。

附：英文原文

Title: Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke | NEJM

Author: Richard P. Whitlock, M.D., Ph.D.,, Emilie P. Belley-Cote, M.D., Ph.D.,, Domenico Paparella, M.D.,, Jeff S. Healey, M.D.,, Katheryn Brady, B.Sc.,, Mukul Sharma, M.D.,, Wilko Reents, M.D.,, Petr Budera, M.D., Ph.D.,, Andony J. Baddour, M.D., Ph.D.,, Petr Fila, M.D., Ph.D.,, P.J. Devereaux, M.D., Ph.D.,, Alexander Bogachev-Prokophiev, M.D., Ph.D.,, Andreas Boening, M.D.,, Kevin H.T. Teoh, M.D.,, Georgios I. Tagarakis, M.D., Ph.D.,, Mark S. Slaughter, M.D.,, Alistair G. Royse, M.D.,, Shay McGuinness, M.B., Ch.B.,, Marco Alings, M.D., Ph.D.,, Prakash P. Punjabi, F.R.C.S.,, C. David Mazer, M.D.,, Richard J. Folkeringa, M.D., Ph.D.,, Andrea Colli, M.D.,, álvaro Avezum, M.D., Ph.D.,, Juliet Nakamya, Ph.D.,, Kumar Balasubramanian, M.Sc.,, Jessica Vincent, M.Sc.,, Pierre Voisine, M.D.,, Andre Lamy, M.D.,, Salim Yusuf, F.R.S.C., D.Phil.,, and Stuart J. Connolly, M.D.

Issue&Volume: 2021-05-15

Abstract:

Background

Surgical occlusion of the left atrial appendage has been hypothesized to prevent ischemic stroke in patients with atrial fibrillation, but this has not been proved. The procedure can be performed during cardiac surgery undertaken for other reasons.

Methods

We conducted a multicenter, randomized trial involving participants with atrial fibrillation and a CHA2DS2-VASc score of at least 2 (on a scale from 0 to 9, with higher scores indicating greater risk of stroke) who were scheduled to undergo cardiac surgery for another indication. The participants were randomly assigned to undergo or not undergo occlusion of the left atrial appendage during surgery; all the participants were expected to receive usual care, including oral anticoagulation, during follow-up. The primary outcome was the occurrence of ischemic stroke (including transient ischemic attack with positive neuroimaging) or systemic embolism. The participants, research personnel, and primary care physicians (other than the surgeons) were unaware of the trial-group assignments.

Results

The primary analysis population included 2379 participants in the occlusion group and 2391 in the no-occlusion group, with a mean age of 71 years and a mean CHA2DS2-VASc score of 4.2. The participants were followed for a mean of 3.8 years. A total of 92.1% of the participants received the assigned procedure, and at 3 years, 76.8% of the participants continued to receive oral anticoagulation. Stroke or systemic embolism occurred in 114 participants (4.8%) in the occlusion group and in 168 (7.0%) in the no-occlusion group (hazard ratio, 0.67; 95% confidence interval, 0.53 to 0.85; P=0.001). The incidence of perioperative bleeding, heart failure, or death did not differ significantly between the trial groups.

Conclusions

Among participants with atrial fibrillation who had undergone cardiac surgery, most of whom continued to receive ongoing antithrombotic therapy, the risk of ischemic stroke or systemic embolism was lower with concomitant left atrial appendage occlusion performed during the surgery than without it.

DOI: 10.1056/NEJMoa2101897

Source: https://www.nejm.org/doi/full/10.1056/NEJMoa2101897