Niclauss Lars, Delay Dominique, Pfister Raymond, Colombier Sebastien, Kirsch Matthias, Prêtre René
Department of Cardiovascular Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
Asian Cardiovasc Thorac Ann. 2017 Jun;25(5):350-356. doi: 10.1177/0218492317712309. Epub 2017 May 22.
Background Permanent pacemaker implantation after surgical aortic valve replacement depends on patient selection and risk factors for conduction disorders. We aimed to identify risk criteria and obtain a selected group comparable to patients assigned to transcatheter aortic valve implantation. Methods Isolated sutured aortic valve replacements in 994 patients treated from 2007 to 2015 were reviewed. Demographics, hospital stay, preexisting conduction disorders, surgical technique, and etiology in patients with and without permanent pacemaker implantation were compared. Reported outcomes after transcatheter aortic valve implantation were compared with those of a subgroup including only degenerative valve disease and first redo. Results The incidence of permanent pacemaker implantation was 2.9%. Longer hospital stay ( p = 0.01), preexisting rhythm disorders ( p < 0.001), complex prosthetic endocarditis ( p = 0.01), and complex redo ( p < 0.001) were associated with permanent pacemaker implantation. Although prostheses were sutured with continuous monofilament in the majority of cases (86%), interrupted pledgetted sutures were used more often in the pacemaker group ( p = 0.002). In the subgroup analysis, the incidence of permanent pacemaker implantation was 2%; preexisting rhythm disorders and the suture technique were still major risk factors. Conclusion Permanent pacemaker implantation depends on etiology, preexisting rhythm disorders, and suture technique, and the 2% incidence compares favorably with the reported 5- to 10-fold higher incidence after transcatheter aortic valve implantation. Cost analysis should take this into account. Often dismissed as minor complication, permanent pacemaker implantation increases the risks of endocarditis, impaired myocardial recovery, and higher mortality if associated with prosthesis regurgitation.
背景 外科主动脉瓣置换术后永久性起搏器植入取决于患者选择及传导障碍的风险因素。我们旨在确定风险标准，并获得一组与接受经导管主动脉瓣植入术的患者相当的选定患者群体。方法 回顾了2007年至2015年治疗的994例孤立性缝合主动脉瓣置换患者。比较了植入和未植入永久性起搏器患者的人口统计学、住院时间、既往传导障碍、手术技术和病因。将经导管主动脉瓣植入术后报告的结果与仅包括退行性瓣膜疾病和首次再次手术的亚组结果进行比较。结果 永久性起搏器植入的发生率为2.9%。住院时间延长（p = 0.01）、既往存在心律失常（p < 0.001）、复杂性人工瓣膜心内膜炎（p = 0.01）和复杂性再次手术（p < 0.001）与永久性起搏器植入相关。尽管在大多数病例（86%）中假体采用连续单丝缝合，但在起搏器组中更常使用间断带垫片缝合（p = 0.002）。在亚组分析中，永久性起搏器植入的发生率为2%；既往心律失常和缝合技术仍然是主要风险因素。结论 永久性起搏器植入取决于病因、既往心律失常和缝合技术，2%的发生率与经导管主动脉瓣植入术后报告的高5至10倍的发生率相比更有利。成本分析应考虑到这一点。永久性起搏器植入常被视为轻微并发症，但如果与假体反流相关，会增加心内膜炎、心肌恢复受损和更高死亡率的风险。
