Department of Cardiology, Columbia University Irving Medical Center, New York, New York.
Department of Cardiology, Columbia University Irving Medical Center, New York, New York.
Am J Cardiol. 2020 Apr 15;125(8):1263-1269. doi: 10.1016/j.amjcard.2020.01.026. Epub 2020 Feb 18.
Implantation of a permanent pacemaker is a negative prognostic marker in patients with Fontan palliation; however, data delineating outcomes in adult patients with pacemaker requirements are lacking. We hypothesize that high ventricular pacing burden is associated with adverse outcomes in adult Fontan patients. We performed a retrospective review comprising adult patients with history of Fontan repair. A high burden of ventricular pacing was defined as ≥40% pacing. Major adverse clinical events (MACE) were defined as all-cause mortality or need for advanced cardiac therapies (ventricular assist device or heart transplant). A total of 145 adult patients with Fontan were studied for a median of 3.1 years. Twenty (14%) patients had implanted pacemakers with ≥40% ventricular pacing. Twelve events occurred in those with ≥40% ventricular pacing (incidence 60.0%) versus 11 in those without (incidence 8.8%). In multivariable analysis, ≥40% ventricular-pacing (odds ratio 12.51, confidence interval [CI] 3.56 to 43.83, p <0.001) was associated with MACE independent of initial Fontan type, New York Heart Association functional class at baseline, or history of atrial tachyarrythmia. In survival analysis, patients with ≥40% ventricular pacing had nearly 8 times the risk of MACE compared with those with a lower ventricular pacing burden (hazard ratio 7.79, 95% CI 2.56 to 23.66, p <0.001), whereas patients with atrial-only or <40% ventricular pacing burden had a trend toward higher hazard of MACE compared with those without permanent pacemaker (hazard ratio 3.38, 95% CI 0.92 to 12.47, p = 0.07) that did not meet statistical significance. These findings suggest that high ventricular pacing burden contributes to poor outcomes in the adult Fontan patients and bear consideration when determining optimal treatment of tachyarrhythmias in this population.
植入永久性起搏器是 Fontan 姑息治疗患者的负面预后标志物；然而，缺乏关于起搏器需求的成年患者结果的数据。我们假设高心室起搏负担与成年 Fontan 患者的不良结局相关。我们进行了一项回顾性研究，包括有 Fontan 修复史的成年患者。高心室起搏负担定义为≥40%起搏。主要不良临床事件（MACE）定义为全因死亡率或需要先进的心脏治疗（心室辅助装置或心脏移植）。共有 145 名接受 Fontan 治疗的成年患者接受了中位时间为 3.1 年的研究。20 名（14%）患者植入了≥40%心室起搏的起搏器。≥40%心室起搏组发生 12 例事件（发生率 60.0%），而无≥40%心室起搏组发生 11 例事件（发生率 8.8%）。多变量分析显示，≥40%心室起搏（比值比 12.51，置信区间 [CI] 3.56 至 43.83，p<0.001）与 MACE 相关，独立于初始 Fontan 类型、基线纽约心脏协会功能分类或房性心动过速病史。在生存分析中，与起搏负担较低的患者相比，≥40%心室起搏的患者发生 MACE 的风险几乎高出 8 倍（风险比 7.79，95%CI 2.56 至 23.66，p<0.001），而只有心房起搏或<40%心室起搏负担的患者与无永久性起搏器的患者相比，发生 MACE 的风险有升高趋势（风险比 3.38，95%CI 0.92 至 12.47，p=0.07），但未达到统计学意义。这些发现表明，高心室起搏负担导致成年 Fontan 患者的预后不良，在确定该人群的心动过速最佳治疗方案时需要考虑这一点。
