婴儿及儿童房室阻滞的起搏治疗

Permanent endocardial pacing in infants and children with atrioventricular block

目的总结我院34例婴儿及儿童经心内膜方式永久起搏器植入术经验,探讨相关的方法学、参数设置及评价疗效。方法患儿34例,其中男性22例,女性12例,年龄自5个月至13岁,平均(5.26±3.92)岁,体重5～43(16.66±8.42)kg。其中:先天性心脏病术后三度房室阻滞18例;先天性心脏病术后高二度及三度房室阻滞3例;先天性三度房室阻滞8例;重度肺动脉瓣狭窄伴二度房室阻滞1例;窦性静止1例;心房静止l例;慢-快综合征1例;病毒性心肌炎后三度房室阻滞1例。起搏器植入技术、程控及随访等有一些与成人起搏不同的特殊性。结果选择插管的静脉途径为,经右头静脉10例,经右锁骨下静脉17例,经右颈内静脉6例(5例为1岁以下),心内膜电极行心外膜起搏1例。脉冲发生器的埋藏部位为,置于右侧胸大肌内16例,置于右胸前皮下18例。起搏方式为,VVIR 16例,VVI18例。起搏频率60～90(68.09±9.85)次/min,起搏阈值0.2～2.2(0.72±0.41)V,感知灵敏度3.6～29.0(8.97±4.87)mV,阻抗394～1000(652.06±140.72)Ω。所有患儿体动阈值均设置于低挡。18例术后首次植入起搏器的患儿,距植入术日13～300(67.17±90.25)d。巳随访1个月至7年。1例术后7个月发生电极导线头端移位至起搏功能丧失。2例随访中发生扩张性心肌病,经改变起搏参数后好转。2例先天性心脏病术后患者起搏器植入后恢复窦性心律。1例起搏器植入术后半年猝死,原因不明。结论我们的经验表明只要注意与婴儿及儿童有关的一些特点,并在植入、程控及随访中采取一些相应的对策,永久起搏器植入在婴儿及儿童的应用还是安全有效的。

Objective Thirty-four cases experience with permanent endocardial pacing in infants and children were summarized to the efficiency of permanent cardiac pacing. Methods Thirty-four patients [ male in 22,female in 12; mean age, （5.26 ±3.92） years,range 5 months -13 years; mean body weight, （ 16. 66 ± 8. 42） , range 5 - 43 kg-underwent permanent endocardial pacemaker implantation. Indications were advanced second-or third atrioventricular block after repair of congenital heart diseases （21 cases ）, congenital complete atrioventricular block （ 8 cases）, severe pulmonary stenosis and advanced second atrioventricular block （ 1 case）, sinus arrest （ 1 case）, silent atrium （ 1 case）, brady-tachycardia syndrome （ 1 case）, complete atrioventricular block post acute myocarditis （1 case）. There were some special skills in implant technique, program- ming and follow-up for infants and children. Results Venous access： via the right cephalic vein （ 10 cases）, via the right subclavian vein （ 17 cases） ,via the right internal jugular vein （6 cases ,5 cases under 1 year old） , epicardial pacin^g with endocardial lead （ 1 case）. The pulse generators were buried within the right pectoralis major muscle （16 cases and 18 cases respectively）. Pacing mode： VVIR 16 cases,VVI 18 cases. The range of pacing rate was 60-90 （68. 09 ± 9. 85 ） bpm. The range of pacing threshold at 0. 4 ms was 0. 2 - 2. 2 （0. 72 ± 0. 41 ） V. The range of sensitivity threshold was 3.6 - 29. 0 （8. 97 ± 4. 87） mV. The range of lead resistance was 394 - 1000（652.06 ± 140. 72） Ω. The rate response programmed to low. The range of the time from the operation day to the implantation day was 13 - 300 （67. 17 ±90.25 ）days. Follow-up time was 1 month - 7 years. Lead displacement in 1 case at 7 months post implantation. The dilated cardiomyopathy occurred in 2 cases and improved after reprogramming. The sinus rhythm recovered in 2 cases. The sudden death occurred in 1 case without the known etiology. Conclusion The results of this study showed that permanent endocardial pacing in infants and children is safe and efficient.