Zhang Wen, Gauvreau Kimberlee, DeWitt Elizabeth S, Lee Ji M, Liu Hua, Feins Eric N, Kaza Aditya K, Del Nido Pedro J, Nathan Meena
Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China.
Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Biostatistics, Harvard School of Public Health, Boston, Mass.
J Thorac Cardiovasc Surg. 2025 Feb;169(2):411-419.e5. doi: 10.1016/j.jtcvs.2024.08.026. Epub 2024 Aug 23.
The need for permanent pacemaker (PPM) for iatrogenic atrioventricular block (AVB) after congenital heart surgery is approximately 1%. We aimed to evaluate the long-term outcomes of patients with PPM for iatrogenic AVB and compare them with patients with an optimal repair (trivial/no residual) Residual Lesion Score (RLS) Class 1 repair without PPM need.
We reviewed 183 patients discharged with PPM for iatrogenic AVB from 2011 to 2022. Patients who survived to discharge with >30 days of follow-up were matched 1:1 with a cohort of patients categorized as RLS Class 1 on the basis of fundamental diagnosis and primary procedure.
Median age at PPM placement was 1.4 years (interquartile range, 4.3 months to 3.9 years). The cumulative incidence of moderate or greater ventricular dysfunction at 1 year and 5 years was 11% and 18% in patients with PPM, respectively, compared with 3% and 7% in patients categorized as RLS Class 1 (subdistribution hazard ratio, 2.6; 95% confidence interval, 1.2-6.1; P = .022). Independently, patients with PPM with hypoplastic left heart syndrome (P = .027) and who had undergone Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 5 procedures (P = .033) were at greater risk of ventricular dysfunction. Transplant-free survival at 1 year and 5 years was 94% and 89% in patients with PPM, respectively, compared with 98% and 97% in patients categorized as RLS Class 1 (P = .044). In addition, patients with PPM with palliated circulation had significantly lower transplant-free survival (P < .001).
Compared with patients with an optimal repair without PPM, patients with PPM for iatrogenic AVB are at greater risk of developing moderate or greater ventricular dysfunction and have lower transplant-free survival.
先天性心脏手术后因医源性房室传导阻滞（AVB）而需要永久起搏器（PPM）的比例约为1%。我们旨在评估因医源性AVB而使用PPM的患者的长期预后，并将其与接受最佳修复（轻微/无残留）、残留病变评分（RLS）为1级且无需PPM的修复患者进行比较。
我们回顾了2011年至2022年因医源性AVB而携带PPM出院的183例患者。存活至出院且随访超过30天的患者与根据基本诊断和主要手术归类为RLS 1级的一组患者进行1:1匹配。
植入PPM时的中位年龄为1.4岁（四分位间距，4.3个月至3.9岁）。使用PPM的患者在1年和5年时中度或更严重心室功能障碍的累积发生率分别为11%和18%，而归类为RLS 1级的患者分别为3%和7%（亚分布风险比，2.6；95%置信区间，1.2 - 6.1；P = 0.022）。单独来看，患有左心发育不全综合征的PPM患者（P = 0.027）以及接受胸外科医师协会 - 欧洲心胸外科协会死亡率分类为5类手术的患者（P = 0.033）发生心室功能障碍的风险更高。使用PPM的患者1年和5年的无移植生存率分别为94%和89%，而归类为RLS 1级的患者分别为98%和97%（P = 0.044）。此外，循环系统姑息治疗的PPM患者的无移植生存率显著较低（P < 0.001）。
与无需PPM的最佳修复患者相比，因医源性AVB而使用PPM的患者发生中度或更严重心室功能障碍的风险更高，且无移植生存率更低。
