medicina60巻3号

2023年03月発行

特集 令和の脳卒中ディベート10番勝負—脳卒中治療ガイドライン2021とその先を識る ディベート・セクション　10番勝負 DOAC服用中に脳塞栓症を再発した心房細動患者に対する左心耳閉鎖術

Pro　出血ハイリスクがなくても積極的に実施する

著者： 福冨基城¹ 桃原哲也¹

所属機関： ¹川崎幸病院心臓病センター循環器内科

ページ範囲：P.537 - P.541

　本稿では，直接作用型経口抗凝固薬（direct oral anticoagulant：DOAC）内服中に脳塞栓を発症した心房細動（atrial fibrillation：AF）症例に対し，出血リスクが高くなくても経カテーテル左心耳閉鎖術（left atrial appendage closure：LAAC）を積極的に施行することについて，賛成の立場から述べさせていただく．

参考文献

1）Hindricks G, et al：2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery（EACTS）；The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology（ESC）Developed with the special contribution of the European Heart Rhythm Association（EHRA）of the ESC. Eur Heart J 42：373-498, 2021

2）Seiffge DJ, et al：Ischemic stroke despite oral anticoagulant therapy in patients with atrial fibrillation. Ann Neurol 87：677-687, 2020

3）Yao X, et al：Effect of adherence to oral anticoagulants on risk of stroke and major bleeding among patients with atrial fibrillation. J Am Heart Assoc 23：e003074, 2016

4）Jackson LR, et al：Discontinuation rates of warfarin versus direct acting oral anticoagulants in US clinical practice；Results from Outcomes Registry for Better Informed Treatment of Atrial Fibrillation Ⅱ（ORBIT-AF Ⅱ）. Am Heart J 226：85-93, 2020

5）Di Biase L, et al：Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? Results from a multicenter study. J Am Coll Cardiol 60：531-538, 2012

6）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 374：534-542, 2009

7）Reddy VY, et al：5-year outcomes after left atrial appendage closure；From the PREVAIL and PROTECT AF trials. J Am Coll Cardiol 70：2964-2975, 2017

8）January CT, et al：2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation：A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 74：104-132, 2019

9）Freixa X, et al：Left atrial appendage occlusion as adjunctive therapy to anticoagulation for stroke recurrence. J Invasive Cardiol 31：212-216, 2019

10）Masjuan J, et al：Oral anticoagulation and left atrial appendage closure；A new strategy for recurrent cardioembolic stroke. Eur J Neurol 26：816-820, 2019

11）Galloo X, et al：Left atrial appendage occlusion in recurrent ischaemic stroke, a multicentre experience. Acta clinica Belgica 77：255-260, 2022

12）Cruz-González I, et al：Left atrial appendage occlusion for stroke despite oral anticoagulation（resistant stroke）；Results from the Amplatzer Cardiac Plug registry. Rev Esp Cardiol（Engl Ed）73：28-34, 2020

13）Fukutomi M：Indications, current adoption and future perspectives for percutaneous left atrial appendage closure. EuroIntervention 14：1707-1709, 2019

14）Kar S, et al：Primary outcome evaluation of a next-generation left atrial appendage closure device；Results from the PINNACLE FLX Trial. Circulation 143：1754-1762, 2021