心脏术后永久性起搏器植入64例临床分析

Permanent pacemaker implantation after cardiac surgery:analysis of 64 cases

目的探讨心脏术后永久性起搏器植入的病因、预防措施及预后。方法回顾性分析2000年1月-2008年12月64例心脏术后行永久性起搏器植入患者的临床资料。64例患者中,风湿性心脏瓣膜病46例(同时合并冠心病1例),退行性主动脉瓣病变5例,感染性心内膜炎3例,先天性心脏病6例(主动脉瓣二叶畸形2例、部分房室管畸形2例、法洛四联症1例、Ebstein畸形1例),冠心病2例,二尖瓣脱垂及肥厚梗阻性心肌病各1例。行双瓣置换(DVR+TVP)22例,主动脉瓣置换(AVR)9例,二尖瓣置换(MVR)25例(其中同期行CABG术1例),部分房室管畸形矫治术2例,单纯行CABG术2例,Bentall术1例,左室流出道疏通及二尖瓣置换1例,法洛四联症根治术1例,Ebstein畸形矫治术1例。结果本组64例患者中,术后出现房颤伴心室长间歇者31例,三度房室传导阻滞11例,病态窦房结综合征(SSS)19例,二度Ⅱ型房室传导阻滞2例,双结病变1例。出现心脏传导系统功能障碍后采用VVI起搏器者41例,DDD起搏器者23例。无晚期死亡。结论心脏术后出现传导功能障碍主要表现为房颤伴心室长间歇、病窦综合征及三度房室传导阻滞。前两者主要发生于术后远期,一旦出现且伴有明显的临床症状均需行永久性起搏器植入;后者多发生于术后早期,与手术部位有一定关系,术中注重心脏瓣膜结构与房室结及传导束的解剖关系是预防的关键。三度房室传导阻滞持续时间超过2～3周者需行永久性起搏器植入术。

Objective To explore the eitology, prevention and prognosis of ailment demanding permanent pacemaker implantation after cardiac surgery. Methods The clinical data of 64 patients receiving permanent pacemaker implantation after cardiac surgery from Jan. 2000 to Dec. 2008 were retrospectively analyzed. Forty-six out of the 64 cases were suffering from rheumatic valvular heart disease （one of them with complication of coronary heart disease）, 5 with degenerative aortic valvular disease, 3 with infective endocarditis, 6 with congenital heart disease （2 of bicuspid aortic vane, 2 of incomplete atrioventricular septal defect, 1 of Fallot tetralogy, and 1 of Ebstein＇s anomaly）, 2 with coronary heart disease, 1 with mitral valve prolapse, and 1 with hypertrophic obstructive cardiomyopathy. Twenty two out of the 64 cases received double valve replacement （DVR＋TVP）, 9 received aortic valve replacement （AVR）, 25 received mitral valve replacement （MVR, one of them simultaneously received coronary artery bypass grafting）, 2 received rectification of incomplete atrioventricular septal defect, 2 received coronary artery bypass grafting, 1 received Bentall procedure, 1 received left ventricular outflow tract resection and mitral valve replacement, 1 received rectification of Fallot tetralogy, and 1 received rectification of Ebstein＇s anomaly. Results Thirty-one out of 64 cases patients suffered from atrial fibrillation with ventricular prolonged pause, 11 with 3rd-degree atrioventricular block, 19 with sick sinus syndrome, 2 with 2nd-degree of type II atrioventricular block, and 1 with binodal disease after cardiac surgery. Forty-one patients received VVI pacemaker implantation and 23 received DDD pacemaker without late death. Conclusion The main functional disturbances after cardiac surgery are atrial fibrillation with ventricular prologed pause, sick sinus syndrome and 3rd- degree atrioventricular block. The former two occur mainly in late postoperative period, and permanent pacemaker implantation is necessary because of complications with obvious symptoms. The latter occurs mainly in early postoperative period, and is related to the surgical site. The permanent pacemaker implantation is necessary when 3rd-degree atrioventricular block continues for longer than 2-3 weeks.