本文選題：心血管植入式電子裝置 + 深靜脈血栓�。� 參考：《中國(guó)人民解放軍醫(yī)學(xué)院》2017年碩士論文

【摘要】：背景:心血管植入式電子裝置(CIED)包括心臟永久性起搏器(PPM)、植入式心臟復(fù)律除顫器(ICD)及心臟再同步化治療(CRT)等一系列植入裝置,目前被廣泛用于治療嚴(yán)重緩慢型心律失常、持續(xù)快速型室性心律失常及心室收縮失同步心力衰竭的患者。經(jīng)皮靜脈內(nèi)植入電極導(dǎo)線是CIED導(dǎo)線植入人體最常用的方法。近年來,許多文獻(xiàn)報(bào)道植入電極導(dǎo)線可引起靜脈血栓形成,而血栓脫落可導(dǎo)致肺栓塞(PE),血栓形成可導(dǎo)致管腔狹窄或閉塞,出現(xiàn)上腔靜脈綜合征(SVCS)等并發(fā)癥,并且造成CIED系統(tǒng)更換或升級(jí)困難。目的:本研究以接受CIED治療的患者為研究對(duì)象,擬探討CIED導(dǎo)線相關(guān)靜脈血栓形成的危險(xiǎn)因素,比較CIED導(dǎo)線相關(guān)靜脈血栓形成患者接受不同藥物治療后的差異,為臨床預(yù)防和治療提供依據(jù)。方法:連續(xù)入選中國(guó)人民解放軍總醫(yī)院心血管內(nèi)科2013年9月至2015年12月入院首次行PPM植入術(shù)、ICD安置術(shù)及CRT (包括CRT-P及CRT-D)植入術(shù)的患者,分別于術(shù)前及術(shù)后1周、1個(gè)月、3個(gè)月、6個(gè)月行雙側(cè)上肢靜脈、鎖骨下靜脈及上腔靜脈血管超聲檢查,根據(jù)術(shù)后血管超聲的結(jié)果進(jìn)行分組:術(shù)后4次血管超聲均無血栓形成的患者為非血栓組;術(shù)后任何1次血管超聲提示有血栓形成的患者為血栓組。收集所有入選患者的臨床資料,比較兩組臨床資料有無差異,對(duì)有差異的臨床資料運(yùn)用Logistic回歸進(jìn)行分析,評(píng)價(jià)各臨床資料與靜脈血栓形成之間的關(guān)系。血栓組患者隨機(jī)分為兩組接受不同的藥物治療:(1)華法林組:初始接受華法林聯(lián)合低分子量肝素(LMWH)治療3-5天,待國(guó)際標(biāo)準(zhǔn)化比率(INR)達(dá)到2.0后停用LMWH,單用華法林長(zhǎng)期口服治療,定期監(jiān)測(cè)血凝,保證INR在2.0-3.0之間;(2)新型口服抗凝藥(NOACs)組:接受達(dá)比加群酯膠囊110mg2/日長(zhǎng)期口服治療。分別于接受治療前及接受治療后1個(gè)月、3個(gè)月、6個(gè)月、1年來院行植入側(cè)靜脈數(shù)字減影血管造影術(shù)(DSA)。通過QAngioXA計(jì)算機(jī)軟件測(cè)量得出血管狹窄處直徑較其近心端正常血管管徑減少的百分率得出血管狹窄程度,分為四個(gè)等級(jí):≤50%為輕度狹窄,50%且≤70%為中度狹窄,70%且100%為重度狹窄,100%為完全閉塞。比較兩組血栓形成的患者在治療前后血管狹窄程度等級(jí)有無明顯變化。接受治療后,血管狹窄程度較治療前減輕1個(gè)等級(jí)及以上為治療有效,較治療前無改善或加重1個(gè)等級(jí)及以上為治療無效。結(jié)果:共入選首次接受CIED治療的患者164例,發(fā)現(xiàn)CIED導(dǎo)線相關(guān)靜脈血栓形成的患者56例,作為血栓組,未發(fā)現(xiàn)CIED導(dǎo)線相關(guān)靜脈血栓形成的患者108例,作為非血栓組。結(jié)果發(fā)現(xiàn):(1)兩組患者的一般臨床資料,如年齡、性別、身體質(zhì)量指數(shù)(BMI)、吸煙、高血壓病史、心肌梗死(MI)病史、卒中病史等無統(tǒng)計(jì)學(xué)差異(P0.05);(2)兩組在心房顫動(dòng)(AF)、植入除顫導(dǎo)線、服用抗凝藥物的患者數(shù)百分比和糖化血紅蛋白(HbAlc)、左室射血分?jǐn)?shù)(LVEF)水平以及術(shù)中靜脈穿刺次數(shù)、手術(shù)時(shí)間、導(dǎo)線數(shù)量相比較,差異均有統(tǒng)計(jì)學(xué)意義(P0.05); (3)運(yùn)用Logistic回歸對(duì)兩組間有統(tǒng)計(jì)學(xué)差異的臨床資料進(jìn)行分析發(fā)現(xiàn),AF(OR=15.816;P0.05)、HbAlc(OR=2.799;P=0.003)、術(shù)中靜脈穿刺次數(shù)(OR=3.438;P0.05)及手術(shù)時(shí)間(OR=1.054;P0.05)是CIED導(dǎo)線相關(guān)靜脈血栓形成的危險(xiǎn)因素,服用抗凝藥物(OR=0.016;P0.05)是其保護(hù)因素;(4)抗凝治療能夠顯著減輕CIED導(dǎo)線相關(guān)靜脈血栓形成所致的血管狹窄程度,且隨著治療時(shí)間的延長(zhǎng),治療有效率逐漸增加。在接受藥物治療后1年,NOACs組的治療有效率明顯高于華法林組,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論:AF、高血糖、術(shù)中靜脈穿刺次數(shù)及手術(shù)時(shí)間是CIED導(dǎo)線相關(guān)靜脈血栓形成的獨(dú)立危險(xiǎn)因素;抗凝藥物對(duì)CIED導(dǎo)線相關(guān)靜脈血栓形成的治療作用顯著,治療有效性隨著治療時(shí)間延長(zhǎng)而增加;NOACs的遠(yuǎn)期治療有效性優(yōu)于華法林。
[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.
【學(xué)位授予單位】：中國(guó)人民解放軍醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R541.7

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