Okluzja uszka lewego przedsionka – przegląd stosowanych technik (część 2)

Kwiecień 26, 2013  |  Udostępnij  | 

W poprzednim artykule umieszczonym na naszym blogu omówiliśmy ciekawą alternatywę dla przewlekłego przyjmowania antykoagulantów w profilaktyce udaru u pacjentów z migotaniem przedsionków, jaką jest zamknięcie uszka lewego przedsionka (LAA). Nie omówiliśmy jednak wszystkich stosowanych w tym celu technik i zgodnie z zapowiedzią poniższy tekst poświęcimy najmniej inwazyjnej spośród nich – przezskórnej implantacji specjalnego okludera.

Pierwszym systemem dopuszczonym do użytku klinicznego było urządzenie PLAATO, obecnie już wycofane ze sprzedaży. Kolejnymi były Watchman i Amplatzer CP. Procedura ich wszczepienia wygląda następująco: po nakłuciu żyły udowej wprowadza się do jej światła koszulkę naczyniową rozmiaru 14 F, co odpowiada ok 4,6 mm średnicy. Następnie pod kontrolą skopii rentgenowskiej poprzez naczynia żylne, prawy przedsionek oraz nakłucie przegrody międzyprzedsionkowej, uzyskiwany jest dostęp do jamy lewego przedsionka, a konkretnie jego uszka, które jest właściwym celem interwencji. Do LAA wprowadzany jest okluder, który po rozprężeniu, dzięki systemowi specjalnych zaczepów, umocowuje się w uszku, szczelnie blokując dopływ krwi do jego wnętrza. Przed przystąpieniem do implantacji urządzenia konieczne jest wykonanie przezprzełykowego badania echokardiograficznego w celu oceny anatomii LAA, jego rozmiarów oraz wykluczenia obecności skrzeplin w jego świetle. Do niewątpliwych zalet procedury należy, wspomniana już na początku, minimalna inwazyjność. Wymagane jest jedynie nakłucie żyły, nie występuje natomiast konieczność otwarcia jamy osierdzia, co ogranicza zagrożenie szczególnie groźnymi powikłaniami zapalnymi. Podstawową wadą przezskórnej implantacji okludera do LAA jest natomiast sama istota procedury, czyli pozostawienie w jamach serca ciała obcego.

Spośród systemów stosowanych do zamykania uszka lewego przedsionka, najlepiej przebadanym urządzeniem jest Watchman. Pierwsze progresywne, randomizowane badanie oceniające to narzędzie określono akronimem PROTECT-AF [1]. Zostało ono przeprowadzone na grupie 707 chorych z migotaniem przedsionków, którzy spełniali kryteria włączenia (minimum 1 czynnik ryzyka udaru wg skali CHADS2 – udaru niedokrwienny/TIA w wywiadzie, niewydolność serca, cukrzyca, nadciśnienie, wiek powyżej 75 lat). Założono trzy pierwszorzędowe punkty końcowe badania – śmierć z przyczyn sercowo-naczyniowych, udar niedokrwienny oraz zatorowość systemową o innym umiejscowieniu. Pacjentów zrandomizowano w stosunku 2:1 do dwóch grup, u których odpowiednio: stosowano urządzenie Watchman do zamknięcia uszko lewego przedsionka lub stosowano doustne antykoagulanty (OAC) tak, by uzyskać INR w zakresie między 2 a 3. Chorych obserwowano średnio przez 18 miesięcy. Zabieg okluzji LAA powiódł się u 88% pacjentów, podczas gdy w grupie kontrolnej, stosującej OAC terapeutyczny poziom INR udało się utrzymać przez 66% okresu follow-up. Jak się okazało, pierwszorzędowe punkty końcowe występowały z porównywalną częstością w obu grupach: 3,0/100 pacjentów/rok wśród osób z wszczepionym urządzeniem Watchman oraz 4,9/100 pacjentów/rok w grupie przyjmującej doustne antykoagulanty. Jak można się było spodziewać, powikłania krwotoczne występowały częściej wśród chorych leczonych OAC, natomiast leczenie inwazyjne wiązało się z powikłaniami okołozabiegowymi, m.in. perforacjami i krwawieniami do worka osierdziowego (22 przypadki), z których większość wymagała interwencji chirurga.

Kolejny duży eksperyment mający ocenić efektywność systemu Watchman został nazwany PREVAIL. Jego wyniki, przedstawione prasie w ostatnich dniach, świadczą jeszcze bardziej dobitnie na korzyść badanej metody. Przy zachowaniu nie gorszej niż OAC skuteczności przeciwudarowej, udało się obniżyć ilość powikłań związanych z implantacją, a ogólny odsetek skuteczności zabiegów wyniósł w tym badaniu ponad 95%.

Jak widać wyniki przedstawionych badań pokazują, że system Watchman jest urządzeniem skutecznym, jeśli chodzi o profilaktykę powikłań zatorowych, na równi z klasycznymi doustnymi antykoagulantami. Bezpieczeństwo procedury, które budziło wątpliwości po opublikowaniu PROTECT-AF, zostało poprawione w badaniu PREVAIL. Jak pokazały oba te eksperymenty, bardzo ważne w tym zakresie jest doświadczenie operatora wszczepiającego okluder. Obecne wytyczne ESC rekomendują system Watchman, jako opcję do rozważenia (klasa IIb) jedynie u pacjentów z przeciwwskazaniami do OAC. Eksperci, którzy je opracowywali, nie znali jednak wyników badania PREVAIL, stąd być może zalecenia dotyczące mechanicznego zamknięcia LAA zostaną wzmocnione lub rozszerzone przy okazji następnej ich aktualizacji.

1. Holmes DR, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: A randomised non-inferiority trial. Lancet 2009; 374:534-542.



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