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目的:探讨消融技术后血栓栓塞的机制和预防的方法,为临床提供血栓栓塞并发症的防治方法。方法:在我科行射频消融术的室上速患者158名,年龄15～61岁,其中右侧旁道12例,双径路62例,左侧旁道84例。随机分为五组,组Ⅰ(n=31)术前未服抗血小板制剂,术后立即服用阿斯匹林0.3g,1/日;组Ⅱ(n=32)术前3天始服用阿斯匹林0.3g,1/日;组Ⅲ(n=30)术前3天始服用氯吡格雷75mg1/日;组Ⅳ(n=32)术前3天服用阿斯匹林0.3g+氯吡格雷75mg1/日;组V(n=33)术前3天始服用阿斯匹林0.3g,1/日,术后皮下注射速避凝0.4ml1/日。分别于入院后、电生理检查前即成功放置鞘管后、消融前即静推肝素前、消融后即刻、消融后24h采血。测定血浆血小板α颗粒膜蛋白(GMP-140)水平、D-二聚体、血管性假血友病因子(vWF)。结果:①组ⅠGMP-140水平自穿刺后即开始上升,射频消融术后24小时仍处于较高水平,血管穿刺后电生理检查前明显升高为30.41±5.67ng/m(lP<0.05),而射频消融术后升高为60.4±12.79ng/m(lP<0.05),但组Ⅱ、Ⅲ、Ⅳ、V尤其是组ⅣGMP-140水平始终处于相对较低的水平(P<0.05)。②组ⅠD-二聚体水平自穿刺后即开始上升,射频消融术后24小时仍处于较高水平,血管穿刺后电生理检查前明显升高为0.58±0.22mg/L(P<0.05),而射频消融术后升高为1.50±0.56mg/L(P<0.05)。组Ⅱ、Ⅲ、Ⅳ、V尤其是组ⅣD-二聚体水平与组Ⅰ相比始终处于较低水平(P<0.05)。③血浆vWF的水平:各组vWF水平自血管穿刺结束后即明显升高(P<0.05),射频消融术后组Ⅰ、Ⅲ升高明显,而组Ⅱ、Ⅳ、VvWF水平只有轻度升高(P<0.05),各组vWF水平在术后24小时仍维持相对较高的水平。④血浆GMP-140、D-二聚体、vWF在射频消融前后的改变与累及放电量、放电时间、放电次数、消融时间及肌钙蛋白I等无关(P<0.05)。结论:射频消融对内皮细胞有损伤作用,可导致GMP-140、D-二聚体的明显升高呈血栓前状态。不同的抗血小板制剂对其有改善作用。阿斯匹林可能降低血浆中vWF水平。
Objective: To investigate the mechanism and prevention of thromboembolism after ablation, and to provide the prevention and treatment of thromboembolic complications for clinical use. Methods: In our department of radiofrequency ablation of 158 patients with supraventricular tachycardia, aged 15 to 61 years, of which 12 cases of right bypass, double path 62 cases, 84 cases of left bypass. Randomly divided into five groups, group Ⅰ (n = 31) did not take preoperative antiplatelet agents, immediately after taking aspirin 0.3g, 1 / day; group Ⅱ (n = 32) (N = 30) taking clopidogrel 75mg / day 3 days before the operation; group IV (n = 32) taking aspirin 0.3g + clopidol 3 days before the operation Gray 75mg1 / day; group V (n = 33) 3 days before taking aspirin 0.3g, 1 / day, postoperative subcutaneous injection rate of 0.4ml1 / day. Respectively after admission, electrophysiological examination before the successful placement of the sheath, before the ablation of heparin before injection, immediately after ablation, ablation after 24h blood. Plasma platelet α-granule membrane protein (GMP-140) levels, D-dimer, and von Willebrand factor (vWF) were measured. Results: ① The level of GMP-140 began to increase from the point of puncture, and remained high at 24 hours after radiofrequency ablation. The level of GMP-140 was significantly increased to 30.41 ± 5.67ng / m (lP <0.05) However, the levels of GMP-140 in group Ⅱ, Ⅲ, Ⅳ and especially in group Ⅳ were all kept at a relatively low level (P <0.05) after radiofrequency ablation was 60.4 ± 12.79ng / m (lP <0.05). ② The level of ID-dimer began to increase after puncture. The level of D-dimer was still high at 24 hours after radiofrequency ablation and was significantly increased to 0.58 ± 0.22 mg / L (P <0.05) before electrophysiological examination after vascular puncture. After radiofrequency ablation, the elevation was 1.50 ± 0.56 mg / L (P <0.05). Group Ⅱ, Ⅲ, Ⅳ, V especially group Ⅳ D-dimer level was always lower than group Ⅰ (P <0.05). Plasma vWF levels: The levels of vWF in each group increased significantly (P <0.05) after the end of vascular puncture. The levels of group Ⅰ and Ⅲ increased significantly after radiofrequency catheter ablation, while those of group Ⅱ, Ⅳ and VvWF increased only slightly (P <0.05). The vWF levels in all groups remained relatively high at 24 hours after operation. ④ The changes of plasma GMP-140, D-dimer and vWF before and after radiofrequency ablation were not related to the discharge, discharge time, discharge times, ablation time and troponin I (P <0.05). Conclusion: Radiofrequency ablation of endothelial cells have an injury effect, can lead to GMP-140, D-dimer was significantly increased prethrombotic state. Different antiplatelet agents have an effect on it. Aspirin may reduce plasma vWF levels.