Allen M R, Hayes D L, Warnes C A, Danielson G K
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA.
Pacing Clin Electrophysiol. 1997 May;20(5 Pt 1):1243-6. doi: 10.1111/j.1540-8159.1997.tb06776.x.
Patients with Ebstein's anomaly present unique challenges to permanent pacing due to anatomical variations and tricuspid valve replacement. We retrospectively reviewed our experience with permanent pacing in patients with Ebstein's anomaly between 1976 and 1993. We identified 401 patients with Ebstein's anomaly, of whom 15 (3.7%) required permanent pacing (1 of the 15 was implanted elsewhere). Of the 15, there were 8 females and 7 males (mean age 32 years [range 7-74]); the indications for pacing were AV block in 11 and sinus node dysfunction in 4. Eight patients were programmed with VVI and seven with DDD. All VVI patients were paced epicardially. Two patients with DDD pacemakers had transvenous atrial and ventricular leads, 4 DDD patients had transvenous atrial leads and epicardial ventricular leads, and 1 patient had both epicardial and transvenous systems. Associated surgical procedures included tricuspid valve replacement in 14 of 15, atrial septal defect repair in 10 of 15, atrioplasty in 7 of 15, prior tricuspid annuloplasty in 4 of 15, pulmonary vein dilation in 1 of 15, and conduction system ablation in 2 of 15. Patients had a mean follow-up of 35 months (range 1-168 months). Complications requiring operative intervention occurred in four patients. One patient had displacement of a transvenous ventricular lead. A second patient had an epicardial lead failure. A third patient had a nonfunctioning atrial lead that displaced across the tricuspid valve, causing severe tricuspid regurgitation. The fourth patient had multiple epicardial and endocardial leads exit block with secondary diaphragmatic stimulation. Permanent pacemakers were required in 3.7% of patients with Ebstein's anomaly, with the indication being intrinsic conduction disease in the majority of patients. Ninety-three percent of patients required tricuspid valve replacement, suggesting more severe manifestation of Ebstein's anomaly. Twenty-seven percent had complications requiring surgical intervention. Thus, permanent pacing in patients with Ebstein's anomaly can be challenging and should be approached by an experienced physician.
由于解剖结构变异和三尖瓣置换,埃布斯坦畸形患者在永久性起搏方面面临独特挑战。我们回顾性分析了1976年至1993年间对埃布斯坦畸形患者进行永久性起搏的经验。我们确定了401例埃布斯坦畸形患者,其中15例(3.7%)需要永久性起搏(15例中有1例在其他地方植入)。15例中,女性8例,男性7例(平均年龄32岁[范围7 - 74岁]);起搏指征为11例房室传导阻滞和4例窦房结功能障碍。8例患者采用VVI程控,7例采用DDD程控。所有VVI患者均采用心外膜起搏。2例DDD起搏器患者有经静脉心房和心室导线,4例DDD患者有经静脉心房导线和心外膜心室导线,1例患者同时有心外膜和经静脉系统。相关外科手术包括15例中的14例三尖瓣置换、15例中的10例房间隔缺损修补、15例中的7例心房成形术、15例中的4例既往三尖瓣环成形术、15例中的1例肺静脉扩张以及15例中的2例传导系统消融。患者平均随访35个月(范围1 - 168个月)。4例患者出现需要手术干预的并发症。1例患者经静脉心室导线移位。第2例患者心外膜导线故障。第3例患者心房导线失灵并穿过三尖瓣移位,导致严重三尖瓣反流。第4例患者有多根心外膜和心内膜导线出口阻滞并伴有继发性膈肌刺激。3.7%的埃布斯坦畸形患者需要永久性起搏器,大多数患者的指征为内在传导疾病。93%的患者需要三尖瓣置换,提示埃布斯坦畸形表现更为严重。27%的患者出现需要手术干预的并发症。因此,埃布斯坦畸形患者的永久性起搏具有挑战性,应由经验丰富的医生进行。