| 摘要: |
| 目的 分析心脏外科手术后植入永久起搏器的影响因素以及早期起搏器植入时机和途径。方法 回顾性纳入2007年1月至2016年12月于我院行心脏外科手术后植入永久起搏器（不包括植入埋入式除颤器和心脏再同步化治疗）的患者。收集植入永久起搏器患者的性别、年龄、临床诊断、术前心律情况、心脏外科手术类型、起搏器植入适应证、心脏外科手术距离起搏器植入的时间、植入永久起搏器的类型等资料。并根据心脏外科手术距离起搏器植入的时间将患者分为早期（术后≤1个月）组、中期（术后1个月～1年）组和远期（术后>1年）组。比较3组患者心脏外科手术类型和起搏器植入适应证的差异。结果 共纳入103例患者，其中瓣膜病手术86例、先天性心脏病手术9例、冠状动脉旁路移植（CABG）术8例；病态窦房结综合征患者22例（21.36%），房室传导阻滞患者81例（78.64%）。房室传导阻滞包括Ⅲ度或高度房室传导阻滞患者68例[66.02%，其中心房颤动伴长RR间期29例（28.16%）]和慢心室率心房颤动13例（12.62%）。早期组27例（26.21%），中期组16例（15.53%），远期组60例（58.25%）。3组心脏外科手术后植入永久起搏器患者的主动脉瓣手术和双瓣及更复杂手术（包含瓣膜置换或成形术）占比的差异均无统计学意义（P均>0.05）。在起搏器植入适应证中房室传导阻滞比例较高，且在3组间差异有统计学意义（χ2=6.089，P=0.048）。早期组患者的心脏外科手术距离起搏器植入的平均时间为（13.43±7.24）d，择期经皮介入心内膜植入起搏电极导线25例，术中植入心内膜、心外膜起搏电极导线各1例。结论 房室传导阻滞为心脏外科手术后植入永久起搏器最常见的适应证。早期植入前需留出合理的时间供房室传导或窦房结功能恢复，起搏导线植入途径以择期经皮介入心内膜植入为主，但必要时可在术中植入起搏电极导线（心内膜或心外膜）。 |
| 关键词: 心脏外科手术 房室传导阻滞 冠状动脉旁路移植术 人工心脏起搏器 |
| DOI：10.16781/j.0258-879x.2018.07.0758 |
| 投稿时间：2018-03-10修订日期：2018-05-14 |
| 基金项目:国家重点研发计划（2016YFC1100900）. |
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| Permanent pacemaker implantation after cardiac surgery: an analysis of 103 cases |
| PAN Jia-jun,ZHOU Guang-wei,LI Li,XU Zhi-yun,LI Bai-ling* |
(Department of Cardiovascular Surgery, Changhai Hospital, Navy Medical University(Second Military Medical University), Shanghai 200433, China
*Corresponding author) |
| Abstract: |
| Objective To explore the factors influencing the implantation of permanent pacemaker in patients after cardiac surgery, and the timing and approach of pacemaker for early implantation. Methods Patients undergoing permanent pacemaker implantation (excluding implanted defibrillators and cardiac resynchronization therapy) after cardiac surgery between Jan. 2007 and Dec. 2016 were retrospectively enrolled, and their clinical data were collected, including gender, age, clinical diagnosis, preoperative heart rhythm, type of cardiac surgery, indication of pacemaker implantation, duration from cardiac surgery to pacemaker implantation, and type of permanent pacemaker. According to the time between cardiac surgery and pacemaker implantation, the patients were divided into three groups:early group (≤ 1 month), mid-term group (1 month to 1 year) and long-term group (>1 year). The type of cardiac surgery and the indication of pacemaker implantation were compared between the three groups. Results A total of 103 patients were included in this study, among which 86 cases received valvular surgery, 9 received surgery for congenital heart disease, and 8 received coronary artery bypass grafting (CABG). Twenty-two patients (21.36%) had sick sinus atrial node syndrome, and 81 patients (78.64%) had atrioventricular block. Sixty-eight cases (66.02%) had grade Ⅲ or advanced atrioventricular block, including 29 (28.16%) atrial fibrillation with long RR interval, and 13 cases (12.62%) had atrial fibrillation with slow ventricular rate. Twenty-seven patients (26.21%) were included in the early group, 16 patients (15.53%) in the mid-term group, and 60 patients (58.25%) in the long-term group. There were no significant differences in the proportions of aortic valve surgery, double valve surgery or more complex surgery (including valve replacement or valve plasty) between the three groups (all P>0.05). The proportion of atrioventricular block was higher among the pacemaker implantation indications, and the difference in the proportion of atrioventricular block among the three groups was statistically significant (χ2=6.089, P=0.048). The average time between surgery and implantation of patients in the early group was (13.43±7.24) d, and the major approach for implanting electrode leads was elective percutaneous endocardial implantation after surgery (25 cases), occasionally the electrode leads was implanted during the surgery (one case of endocardial leads and one case of epicardial leads). Conclusion Atrioventricular block is the most common indication of permanent pacemaker implantation after cardiac surgery. Reasonable time is required for recovery of atrioventricular conduction or sinus node function before early implantation. Major approach for implanting endocardial leads is elective percutaneous endocardial implantation; if necessary, endocardial or epicardial leads can be implanted during surgery. |
| Key words: cardiac surgical procedures atrioventricular block coronary artery bypass artificial pacemaker |
