Bonatti V, Agnetti A, Squarcia U
U.O. Cardiologia--U.T.I.C., Ospedale SS. Giacomo e Cristoforo, Massa, Italia.
Pediatr Med Chir. 1998 May-Jun;20(3):181-6.
The incidence of complete heart block (CHB) following open-heart surgery for congenital heart disease is about 1%. Most of postoperative CHBs are the consequence of procedures involving the closure of ventricular septal defect; they usually occur immediately after surgery or early in the postoperative period; in few cases they also may occur many months or years after surgery. Early postoperative CHB can be transient or permanent. Permanent pacing is generally not recommended in the former. On the contrary, if CHB persists after at least two weeks of temporary pacing, permanent pacing is needed because the block is usually due to His bundle damage or to trifascicular damage and this is associated with excessive bradycardia and risk of asystole. Late postoperative CHB can be due to the recurrence of previous transient early postoperative CHB or to the progression of postoperative His-Purkinje conduction troubles suggesting trifascicular damage. Permanent pacing is obviously needed in case of documented late postoperative CHB. The prophylactic use of permanent pacing in patients at risk of late postoperative CHB is still a controversial point. Electrophysiologic studies should be performed in such patients. The occurrence of second degree AV block within or below the bundle of His during atrial pacing at rate lower than 200/min can be considered a good marker of impending CHB. In this case prophylactic permanent pacing should be recommended, especially in patients with coexisting problems of troublesome or malignant tachyarrhythmias who have to be treated with antiarrhythmic drug therapy that may favour the progression to CHB.
先天性心脏病心脏直视手术后完全性心脏传导阻滞（CHB）的发生率约为1%。术后大多数CHB是室间隔缺损修补手术的结果；通常在手术后即刻或术后早期发生；少数情况下也可能在术后数月或数年出现。术后早期CHB可为暂时性或永久性。对于前者一般不建议植入永久性起搏器。相反，如果在临时起搏至少两周后CHB仍持续存在，则需要植入永久性起搏器，因为这种阻滞通常是由于希氏束损伤或三分支损伤所致，且与严重心动过缓和心脏停搏风险相关。术后晚期CHB可能是先前术后早期暂时性CHB复发，或术后希氏 - 浦肯野传导障碍进展提示三分支损伤所致。对于有记录的术后晚期CHB，显然需要植入永久性起搏器。对于有术后晚期CHB风险的患者预防性使用永久性起搏器仍是一个有争议的问题。对此类患者应进行电生理检查。在心房起搏频率低于200次/分钟时，希氏束内或希氏束以下出现二度房室传导阻滞可被视为即将发生CHB的良好指标。在这种情况下，应建议预防性植入永久性起搏器，尤其是对于同时存在麻烦的或恶性快速心律失常问题且必须接受抗心律失常药物治疗的患者，因为这类药物治疗可能会促使病情进展为CHB。
