Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia.
Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia.
Ann Thorac Surg. 2018 Aug;106(2):460-465. doi: 10.1016/j.athoracsur.2018.02.041. Epub 2018 Mar 22.
Permanent pacemaker (PPM) implantation has been touted as an inconsequential complication after transcatheter aortic valve replacement. As transcatheter aortic valve replacement moves to lower risk patients, the long-term implications remain poorly understood; therefore, we evaluated the long-term outcomes of pacemaker for surgical aortic valve replacement patients.
A total of 2,600 consecutive patients undergoing surgical aortic valve replacement over the past 15 years were reviewed using The Society of Thoracic Surgeons (STS) institutional database and Social Security death records. Patients were stratified by placement of a PPM within 30 days of surgery. The impact of PPM placement on long-term survival was assessed by Kaplan-Meier analysis and risk-adjusted survival by Cox proportional hazards modeling.
A total of 72 patients (2.7%) required PPM placement postoperatively. Patients requiring PPM had more postoperative complications, including atrial fibrillation (43.1% versus 27.0%, p = 0.003), prolonged ventilation (16.7% versus 5.7%, p < 0.0001), and renal failure (12.5% versus 4.6%, p = 0.002). These led to greater resource utilization including longer intensive care unit stay (89 versus 44 hours, p < 0.0001) and hospital length of stay (9 versus 6 days, p < 0.0001), and higher inflation-adjusted hospital cost ($81,000 versus $47,000, p < 0.0001). Median follow-up was 7.5 years, and patients requiring PPM had significantly worse long-term survival (p = 0.02), even after risk adjustment with STS predicted risk of mortality (hazard ratio 1.48, p = 0.02).
The need for PPM after aortic valve replacement independently reduces long-term survival. The rate of PPM placement after surgical aortic valve replacement remains very low but dramatically increases resource utilization. As transcatheter aortic valve replacement expands to low-risk patients, the impact of PPM placement on long-term survival warrants close monitoring.
经导管主动脉瓣置换术后，永久性起搏器（PPM）植入被认为是一种无关紧要的并发症。随着经导管主动脉瓣置换术向低危患者推进，其长期影响仍知之甚少；因此，我们评估了外科主动脉瓣置换患者起搏器的长期结果。
在过去 15 年中，使用胸外科医师学会（STS）机构数据库和社会保障死亡记录对 2600 例连续接受外科主动脉瓣置换术的患者进行了回顾。根据术后 30 天内是否植入 PPM 将患者分层。通过 Kaplan-Meier 分析评估 PPM 植入对长期生存率的影响，并通过 Cox 比例风险模型评估风险调整后的生存率。
共有 72 例（2.7%）患者术后需要植入 PPM。需要 PPM 的患者术后并发症更多，包括心房颤动（43.1%比 27.0%，p=0.003）、通气时间延长（16.7%比 5.7%，p<0.0001）和肾功能衰竭（12.5%比 4.6%，p=0.002）。这导致了更多的资源利用，包括更长的重症监护病房住院时间（89 比 44 小时，p<0.0001）和住院时间（9 比 6 天，p<0.0001），以及更高的通胀调整后住院费用（81000 美元比 47000 美元，p<0.0001）。中位随访时间为 7.5 年，需要 PPM 的患者长期生存率明显较差（p=0.02），即使在使用 STS 预测死亡率风险进行风险调整后也是如此（风险比 1.48，p=0.02）。
主动脉瓣置换术后需要 PPM 会独立降低长期生存率。外科主动脉瓣置换术后 PPM 植入率仍然很低，但显着增加了资源利用。随着经导管主动脉瓣置换术向低危患者扩展，PPM 植入对长期生存率的影响值得密切监测。
