起搏器植入术后对三尖瓣反流的远期影响

Long-term effects of permanent pacemaker implantation on tricuspid valve regurgitation

目的分析永久心脏起搏器植入术后三尖瓣反流（TR）的远期发生率及影响因素，研究其对心脏结构及功能的影响，探讨其发生机制。方法选取解放军总医院心血管外科2000年1月至2011年6月为行永久心脏起搏器更换手术住院的患者共430例，共筛选出心脏超声等资料完整的108例患者资料进行回顾性分析。根据术后随访心脏超声检查确定的TR的程度将所有患者分为三尖瓣正常组（79例）和三尖瓣异常组（29例），对两组患者临床及超声资料进行比较及多因素回归分析。结果平均随访时间（距首次起搏器植入手术时间）4-34（13±6）年。术前三尖瓣功能正常的108例患者在植入永久心脏起搏器术后远期随访共有29例（26．9％）发现有意义的Try（1．5-3级）。与三尖瓣正常组比较，在起搏器植入术后三尖瓣异常组中，距首次植入起搏器的时间（年）更长（16±7比12±5，P=0．003）；跨三尖瓣口电极数（根）更多（1．31±0．66比1．10±0．30，P=0．026）；术前右房径（mm）更大（38±7比35±4，P=0．028）；术前轻度三尖瓣及二尖瓣反流（MR）率更高（TR：21％比4％、P=0．015，MR：28％比5％、P=0．003）。在起搏器植入术后三尖瓣异常组的随访超声数据右房径、右室径、左房径及二尖瓣异常反流率均明显高于三尖瓣正常组，而左室射血分数明显低于三尖瓣正常组。结论心脏起搏器植入术后远期有意义的TR并不少见，起搏器植入时间、跨三尖瓣口电极数、术前右房大小及术前存在轻度的MR、TR是影响起搏器植入术后远期TR的相关因素。

Objective To explore the long-term effects of permanent pacemaker implantation （PPI）on tricuspid valve regurgitation （TR） in Chinese patients so as to determine the incidence and related factors, evaluate its effects on heart structure and function and ascertain the exact mechanism of TR after PPI. Methods A total of 430 patients undergoing permanent pacemaker replacement at our hospital between January 2000 and June 2011 were recruited. The patients with isolated atrial lead implantation procedures, significant heart valve disease or chronic obstructive pulmonary disease were excluded. The data of 108 patients who had Doppler echocardiograms performed before the first pacemaker implantation procedure and this pacemaker replacement procedure were obtained and retrospectively analyzed. According to the postimplant grade of TR, the patients were divided into two groups ： normal tricuspid （ n =79 ） and abnormal tricuspid（n = 29 ）. Their clinical characteristics and echocardiographic data between two groups were analyzed and compared. Results The mean follow-up time （from the first pacemaker implantation） was （ 13 ± 6） years（ range ： 4 - 34）. Among 108 patients with initially normal tricuspid post-implant, 29 patients （26. 9% ） developed significant TR during the follow-up. In comparison to those in normal tricuspid group, the patients in abnormal tricuspid group had a longer time from the first pacemaker implantation （ （ 16 ±7 ） vs （ 12 ± 5 ） years, P = 0. 003 ）, more transtricuspid leads （ 1.31 ±0. 66 vs 1.10 ± 0. 30, P = 0. 026 ）, larger right atrial size （ （38±7） vs （35 ±4） mm, P =0. 028） and higher prevalence of mild TR and mitral valve regurgitation （MR） pre-implantation（TR： 21% vs 4%, P =0. 015 ,MR： 28% vs 5% , P =0. 003）. The size of right atrium, right ventricle and left atrium in abnormal tricuspid group were more than those in normal tricuspid group. The prevalence of significant MR post-implantation in abnormal tricuspid group was higher than that in normal tricuspid group. The ejection fraction in abnormal tricuspid group was lower than that in normal tricuspid group during the follow-up. Conclusions Abnormal TR after PPI during a long-term follow-up is quite common. The related factors include the time interval from the first pacemaker implantation, number of transtricuspid lead, right atrial size, mild TR and MR pre-implantation.