Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands.
Ann Thorac Surg. 2012 Oct;94(4):1143-9. doi: 10.1016/j.athoracsur.2012.04.038. Epub 2012 Jun 13.
Degenerative aortic valve stenosis (AS) is associated with conduction abnormalities. Pacemaker implantation is encountered after surgical aortic valve replacement (SAVR). Not much is known about the pacemaker implantation rate during midterm follow-up after SAVR. Our objectives were to determine the incidence of permanent pacemaker implantation (PPI) in the midterm after SAVR in a tertiary care facility.
We reviewed procedural data of 734 consecutive patients (56% men; mean age, 68.9±9.5 years) with degenerative severe AS who underwent SAVR between January 1, 2003, and December 31, 2008. Perioperative electrocardiograms were assessed for occurrence of conduction abnormalities, and we sought to determine the incidence and indication for PPI with a median follow-up of 3.76 years (interquartile range, 2.44 to 5.59 years). Univariate and multivariate logistic regression models were applied to identify predictors for early (≤30 days) and late (>30 days) PPI.
Isolated SAVR was performed in 56%, SAVR with coronary artery bypass grafting in 35%, and SAVR with any other valve therapy in 5.8%. Complete bundle branch block (BBB) was present in 7% and first-degree atrioventricular block in 11%. New BBBs were detected in 63 patients (8.6%). Fifteen patients (2.0%) required a PPI within 30 days after SAVR, and 28 (4.0%) underwent PPI more than 30 days after SAVR. The linearized rate of PPI after SAVR was 1.01%±0.37% per patient-year. Patients with BBB at baseline had a higher PPI incidence after SAVR than patients without BBB, both within 30 days (8% vs 1.5%, p=0.001) and after 30 days (10% vs 2.9%, p=0.006). PPI incidence after 30 days was also significantly higher in patients with a new BBB after SAVR (7.8% vs 2.9%, p=0.038). By multivariate logistic regression analysis, BBB and the combination of AS and regurgitation predicted PPI within 30 days after SAVR (hazard ratio [HR], 470; 95% confidence interval [CI], 1.55 to 14.27; and HR, 1.33; 95% CI, 0.03 to 1.73, respectively). BBB (HR, 3.26; 95% CI, 1.41 to 7.54), previous cardiac operation (HR, 3.40; 95% CI, 1.16 to 9.94), and severe left ventricular dysfunction (HR, 9.82; 95% CI, 2.90 to 33.26) were predictors for PPI after 30 days post-SAVR.
Patients with severe AS who underwent SAVR have a persistent 1% annual risk for PPI. Postoperative presence of BBB predicted the need for PPI both within 30 days and after 30 days after SAVR.
退行性主动脉瓣狭窄（AS）与传导异常有关。在主动脉瓣置换术后（SAVR）后需要植入起搏器。关于 SAVR 后中期随访期间起搏器植入率的信息并不多。我们的目的是确定在三级保健机构中 SAVR 后中期植入永久性起搏器（PPI）的发生率。
我们回顾了 2003 年 1 月 1 日至 2008 年 12 月 31 日期间接受 SAVR 的 734 例连续退行性重度 AS 患者的手术数据（56%为男性；平均年龄 68.9±9.5 岁）。术中心电图评估传导异常的发生情况，并寻求在中位数 3.76 年（四分位距 2.44 至 5.59 年）的随访中确定 PPI 的发生率和适应证。应用单变量和多变量逻辑回归模型来识别早期（≤30 天）和晚期（>30 天）PPI 的预测因素。
56%的患者接受了单纯 SAVR，35%的患者接受了 SAVR 加冠状动脉旁路移植术，5.8%的患者接受了任何其他瓣膜治疗。7%的患者存在完全性束支传导阻滞（BBB），11%的患者存在一度房室传导阻滞。63 例患者（8.6%）新出现 BBB。15 例（2.0%）患者在 SAVR 后 30 天内需要植入 PPI，28 例（4.0%）患者在 SAVR 后 30 天以上需要植入 PPI。SAVR 后 PPI 的线性发生率为 1.01%±0.37%/患者年。基线时存在 BBB 的患者在 SAVR 后 PPI 的发生率高于无 BBB 的患者，30 天内分别为 8%和 1.5%（p=0.001），30 天后分别为 10%和 2.9%（p=0.006）。SAVR 后新出现 BBB 的患者 30 天后 PPI 的发生率也明显更高（7.8%比 2.9%，p=0.038）。多变量逻辑回归分析显示，BBB 和 AS 与反流的组合预测了 SAVR 后 30 天内的 PPI（风险比 [HR]，470；95%置信区间 [CI]，1.55 至 14.27；HR，1.33；95%CI，0.03 至 1.73）。BBB（HR，3.26；95%CI，1.41 至 7.54）、既往心脏手术（HR，3.40；95%CI，1.16 至 9.94）和严重左心室功能障碍（HR，9.82；95%CI，2.90 至 33.26）是 SAVR 后 30 天内 PPI 的预测因素。
接受 SAVR 的严重 AS 患者每年有 1%的机会需要植入 PPI。术后存在 BBB 预测了 SAVR 后 30 天内和 30 天后需要植入 PPI。
