儿童起搏治疗、随访和并发症处理临床分析

Clinical analysis of pacing therapy and treatment of complications during follow-up in children

目的分析儿童永久起搏器治疗、随访情况，以及相关并发症处理及预后。方法2000年4月至2016年6月在上海交通大学医学院附属上海儿童医学中心、附属新华医院行永久起搏器治疗的患儿，分别安装心内膜或心外膜起搏器，术后5 d出院。随访行心电图、胸片、心脏超声及起搏器程控检查。回顾性分析治疗方案、并发症发生及相关处理和预后。数据分析采用均数、标准差以及方差分析。结果共193例，男106例，女87例，平均年龄（5.09±4.05）岁（0.4～16岁），平均体重（20.47±11.62） kg，心内膜起搏133例（68.9%），心外膜起搏60例（31.1%）；单腔起搏135例（69.9%），其中右室心尖部起搏87例，右室流出道起搏48例；双腔起搏58例（30.1%）。外科术后三度房室传导阻滞122例（63.2%），先天性完全性房室传导阻滞38例（19.7%），室间隔缺损介入术后房室传导阻滞3例（1.6%），病态窦房结综合征23例（11.9%），重症心肌炎后三度房室传导阻滞7例（3.6%）。137例（71%）随访，平均随访5.32年（0.3～10年），46例电池耗竭更换起搏器，平均5.4年（1～9年）。16例导线移位或脱落更换导线；1例完全性大动脉转位术后21 d恢复传导拔除导线；6例皮肤磨损、感染或囊袋裂开；2例心功能不全，分别随访6和8年出现，更改起搏模式或血管紧张素转换酶抑制剂治疗病情平稳；1例3年后导线断裂、起搏无效猝死；1例右房-右室双腔起搏，随访心房电极穿孔，起搏和感知正常未做处理。结论儿童永久起搏器安装路径和起搏模式有自身特点，随访可出现一些并发症，予恰当治疗预后较好。

ObjectiveTo analyze characteristics of permanent pacemaker implantation in children as well as treatment and prognosis of complications.MethodClinical data of children who underwent endocardial or epicardial permanent pacemaker implantation between April 2000 and June 2016 in Shanghai Xinhua Hospital and Shanghai Children′s Medical Center were analyzed retrospectively. These patients were discharged 5 days after implantation. Electrocardiogram, chest X ray, echocardiography and pacemaker programming were performed during follow-up. Treatment regimes, complication management and prognosis were analyzed retrospectively.ResultData of a total of 193 cases were collected. One hundred and six patients were male and 87 patients were female.The average age was （5.09±4.05） years（0.4-16 years）and the average weight was （20.47±11.62） kg.133（68.9%）; patients were implanted with endocardial pacemakers and 60（31.1%）patients were implanted with epicardial pacemakers; 135（69.9%）patients were single-chamber paced with 87 from RVA and 48 from RVOT. fifty-eight（30.1%）patients were dual chamber paced. These included 122（63.2%）postoperative third degree AV block（Ⅲ-AVB）, 38 （19.7%）congenital complete AV block （CCAVB）, 3（1.6%）post ventricular septal defect （VSD） interventional therapy AV block, 23 （11.9%）sick sinus syndrome （SSS） and 7（3.6%）Ⅲ-AVB after fulminant myocarditis. One hundred and thirty-seven（71%）patients were followed up for an average duration of 5.32 years（0.3-10 years）. Pacemaker exchange were performed in 46 patients due to battery exhaustion.The average life of battery was 5.4 years （1-9 years）. Sixteen patients underwent lead exchange due to dislocation or separation.One patient underwent lead extraction due to recovery of AV conduction 21 days after surgery for complete transposition of great arteries （D-TGA/VSD）. Skin abrasion, infection or dehiscence occured in 6 patients. Heart failure occurred in 2 patients at 6 and 8 years after implantation whose heart functions improved after switching from VVI to DDD or adding ACEI . One patient died suddenly due to ineffective pacing caused by lead fracture. Another patient under DDD pacing was found to have atrial myocardial perforation with normal sensing and pacing so that no intervention was performed.ConclusionThe pacing mode and path through which leads are implanted for permanent pacemaker implantation in children have their peculiar characteristics.Some complications might occur during follow-up with good prognosis if appropriately treated.