心脏起搏装置感染拔除后未再植入新起搏装置的安全性分析

Safety of Non-reimplantation of a New Pacing Device After Removal of the Infected Cardiac Pacing Device

目的:评价心脏起搏装置感染拔除后未再植入新起搏装置的安全性。方法:回顾性分析2014年1月至2020年1月于北京大学人民医院因起搏器感染行电极拔除术患者共825例,根据是否植入新起搏装置分为再植入组(n=640)和未再植入组(n=185)。收集患者的临床资料,随访拔除后未再植入新起搏装置的患者,分析其安全性。随访的研究终点是患者死亡以及再次植入新起搏装置。结果:185例(22.4%)患者感染装置拔除后未再植入新起搏装置。未再植入组与再植入组的年龄、男性、起搏器植入时间、窦性心动过缓或停搏患者比例差异均无统计学意义(P均>0.05)。与再植入组相比,未再植入组的高度或完全性房室阻滞患者比例较低(45.6%vs.1.1%,P<0.05),而心房颤动伴长R-R间期患者比例较高(18.4%vs.62.3%,P<0.05)。未再植入组患者中,单纯囊袋感染155例(83.8%),菌血症20例(10.8%),感染性心内膜炎10例(5.4%)。未再植入新起搏装置的最常见原因是患者为非起搏依赖且电极拔除后未见长R-R间期(128例,69.2%;其中包括12例已行心房颤动射频导管消融治疗且术后未再出现长R-R间期的患者),其次为自主心率<50次/min但无心动过缓相关症状(55例,29.7%),2例(1.1%)患者伴高度房室阻滞但电极拔除后不愿意再次植入。电极拔除过程中最常用的工具是经股静脉抓捕器(50.3%),其次是锁定钢丝(28.7%)。对未再植入组患者中位随访40.6(12.5,52.8)个月,36例(19.5%)患者达到研究终点,包括24例(12.9%)因症状性心动过缓再次植入起搏装置的患者和12例(6.5%)死亡患者,所有死亡患者均无症状性心动过缓,均与慢心率无关。结论:心脏起搏装置感染拔除后,22.4%的患者不需要再植入新起搏装置,最常见的为心房颤动伴长R-R间期患者,密切随访证实未再植入新起搏装置的患者是安全的。

Objectives:To evaluate the safety of non-reimplantation of a new pacing device after removal of the infected cardiac pacing device.Methods:A retrospective analysis was conducted on 825 patients who underwent electrode extraction surgery for pacemaker infection in the Peking University People’s Hospital from January 2014 to January 2020.Patients were divided into reimplantation group(n=185)and non-reimplantation group(n=640)based on whether a new pacing device was implanted or not.Clinical data were collected and patients were closely followed up.Results:A total of 185 patients(22.4%)did not receive a new pacing device after the removal of infected device.There were no significant difference in age,sex,pacemaker implantation time,sinus bradycardia or cardiac arrest between the non-reimplantation group and the reimplantation group(all P>0.05).For patients with high or complete atrioventricular block,the proportion of patients was significantly higher in the reimplantation group than that in the non-reimplantation group(P<0.05),while the proportion of patients with atrial fibrillation and long R-R interval was higher in the non-reimplantation group(P<0.05).In the non-reimplantation group,155 patients(83.8%)had simple pocket infection,20 patients(10.8%)had bacteremia,and 10 patients(5.4%)had infective endocarditis.The most common reason for non-reimplantation was independent of pacing and no long R-R interval after electrode removal(n=128,69.2%),including 12 patients who had undergone radiofrequency ablation of atrial fibrillation without long R-R interval after surgery,55 asymptomatic patients(29.7%)with an autonomous heart rate of less than 50 beats per minute,and 2 patients(1.1%)with high degree atrioventricular block,who were unwilling to receive new device implantation.The most commonly used tool for electrode removal was the femoral vein trapper(50.3%),followed by the locking wire(28.7%).The median follow-up time for patients in the non-implantation group was 40.6(12.5,52.8)months,and 36 patients(19.5%)reached the study endpoint,including 24 patients(12.9%)who were reimplanted with pacing devices due to symptomatic bradycardia in the second,third,and later years after devices removal.Twelve patients(6.5%)dead,and all deaths occurred in patients with asymptomatic bradycardia.Conclusions:After the removal of infected cardiac pacing device,considerable patients(22.4%)do not receive new device implantation in this cohort,they are more likely to be atrial fibrillation patients with long R-R interval.Watchful monitoring is needed to these patients,especially those with bradycardia and atrioventricular block.