Sachweh J S, Vazquez-Jimenez J F, Schöndube F A, Daebritz S H, Dörge H, Mühler E G, Messmer B J
Department of Thoracic and Cardiovascular Surgery, University Hospital, Pauwelsstrasse 30, 52057, Aachen, Germany.
Eur J Cardiothorac Surg. 2000 Apr;17(4):455-61. doi: 10.1016/s1010-7940(00)00364-x.
Permanent cardiac pacing in children and adolescents is rare and often occurs by means of epicardial pacing. Based on two decades of experience, operative and postoperative data of patients with epicardial and transvenous pacing were analyzed retrospectively.
Between October 1979 and December 1998, 71 patients (mean age, 5.3+/-4.2, range, 1 day-16.2 years; mean body weight, 18+/-12; range, 8-56 kg) underwent permanent pacemaker implantation. Indications were sinus node dysfunction and atrio-ventricular block following surgery for congenital heart disease (69%), or congenital atrioventricular block (31%). Pacing was purely atrial (1.4%), purely ventricular (73%), ventricular with atrial synchronization (5. 6%), or atrioventricular synchronized (20%). Epicardial pacing was established in 49 (69%), transvenous in 22 (31%) patients. Follow-up was 3.4+/-3.8 years (epicardial) and 3.0+/-4.0 years (transvenous).
Epicardial leads were implanted in younger patients (mean age: 4.5 vs. 7.0 years, P<0.05) and preferably after surgery induced atrioventricular block (78 vs. 46%, P<0.05). The youngest patient with transvenous pacing was 1.3 years old (weight, 8.5 kg). At implantation epicardial ventricular stimulation threshold at 1.0 ms was 1.07+/-0.46 vs. 0.53+/-0.31 V (transvenous) (P<0.05). The age-adjusted rate of lead-related reoperations was significantly higher in patients with epicardial leads (P<0.05), mainly due to increasing chronic stimulation thresholds resulting in early battery depletion. In three patients who received steroid-eluting epicardial leads initial low thresholds persisted after five month to one years. In two patients with recurrent epicardial threshold increase, steroid-eluting epicardial leads led to good acute and chronic thresholds after nine to 15 month. Two post-operative death (2.8%) were probably due to a dysfunction of the (epicardial) pacing system.
Transvenous pacing in the pediatric population is associated with a lower acute stimulation threshold and a lower rate of lead-related complications. If epicardial pacing is necessary (e. g. small body weight, special intracardiac anatomy (e.g. Fontan), impossible access to superior caval vein), steroid-eluting leads may be considered.
儿童和青少年永久性心脏起搏很少见，且通常通过心外膜起搏实现。基于二十年的经验，对心外膜起搏和经静脉起搏患者的手术及术后数据进行回顾性分析。
1979年10月至1998年12月期间，71例患者（平均年龄5.3±4.2岁，范围1天至16.2岁；平均体重18±12 kg，范围8至56 kg）接受了永久性起搏器植入。适应证为先天性心脏病手术后的窦房结功能障碍和房室传导阻滞（69%），或先天性房室传导阻滞（31%）。起搏方式为单纯心房起搏（1.4%）、单纯心室起搏（73%）、心室与心房同步起搏（5.6%）或房室同步起搏（20%）。49例（69%）患者采用心外膜起搏，22例（31%）患者采用经静脉起搏。心外膜起搏患者的随访时间为3.4±3.8年，经静脉起搏患者的随访时间为3.0±4.0年。
心外膜导联植入于年龄较小的患者（平均年龄：4.5岁对7.0岁，P<0.05），且更倾向于在手术导致房室传导阻滞后植入（78%对46%，P<0.05）。经静脉起搏的最年轻患者为1.3岁（体重8.5 kg）。植入时，心外膜心室刺激阈值在1.0 ms时为1.07±0.46 V，而经静脉起搏为0.53±0.31 V（P<0.05）。心外膜导联患者与导联相关的再次手术的年龄校正率显著更高（P<0.05），主要是由于慢性刺激阈值增加导致电池过早耗尽。在3例接受类固醇洗脱心外膜导联的患者中，最初的低阈值在5个月至1年后持续存在。在2例心外膜阈值反复升高的患者中，类固醇洗脱心外膜导联在9至15个月后导致良好的急性和慢性阈值。2例术后死亡（2.8%）可能归因于（心外膜）起搏系统功能障碍。
儿科患者经静脉起搏的急性刺激阈值较低，与导联相关的并发症发生率也较低。如果有必要进行心外膜起搏（如体重小、特殊心脏内解剖结构（如Fontan手术）、无法进入上腔静脉），可考虑使用类固醇洗脱导联。
