Perioperative application of epicardial temporary pacemaker in patients with heart valve replacement
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摘要:
目的探讨心外膜临时起搏器在单纯的心脏瓣膜替换手术中的安放指征与临床应用。 方法回顾性分析2013年1月~2017年12月723例患者的临床数据。根据术中起搏器安置与术后依赖性应用情况对术前及术中相应的指标参数进行对比及相关性分析。 结果接受单纯的心脏瓣膜替换手术患者723例。全组患者术后发生死亡20例(2.77%),其中安置组发生死亡1例(5%),未安置组发生死亡19例(2.70%)。未安置组中依赖性应用2例(0.28%),安置组中依赖性应用17例(85.00%)。临时心脏起搏的高危因素(优势比; 95%置信区间):年龄>60岁(1.009;1.003,1.015;P=0.002),纽约心脏协会心功能分级Ⅲ-Ⅳ级(4.5;1.4,16.7;P=0.014),I°房室传导阻滞病史(5;1.01,34.8;P=0.042),主动脉阻断时间>60 min(6.1;1.4,29.2;P=0.027),肺动脉压>50 mmHg(14.0;5.2,109.7;P=0.032)。 结论将停体外循环前作为起搏器是否置入的评估时间点,以Ⅱ°-Ⅲ°AVB;室上性心动过缓,使用异丙肾上腺素后反应较差,心率仍低于100次/min者;快慢综合征且药物治疗无效作为起搏器置入指征,对减少和避免不必要的起搏器应用具有较好地临床指导意义。以年龄>60岁或I°房室传导阻滞病史,纽约心脏协会心功能分级Ⅲ-Ⅳ级、肺动脉压>50 mmHg、主动脉阻断时间>60 min等高危因素,联合指导临时起搏器安置,可能会更好地保证患者起搏器的应用安全。 Abstract:ObjectiveTo determine the clinical application of temporary epicardial pacing wires placed in patients undergoing surgery for cardiac valve replacement. MethodsA retrospective observational study was performed on 723 consecutive heart valve replacement surgery patients between January 2013 and December 2017. Logistic regression analysis was performed to identify independent predictors of temporary cardiac pacing. ResultsTemporary epicardial pacing wires were placed in 20 of 723 (2.77%) patients undergoing surgery for cardiac valve replacement. Only 1 patient (5%) required temporary pacing died who were compared with the 19 (2.70%) died in patients did not have insertion of temporary pacing wires. Two (0.28%) required temporary pacing who did not have insertion of temporary pacing wires, 17 (85.00%) required temporary pacing who had insertion of temporary pacing wires. The determinants of temporary cardiac pacing (adjusted odds ratios; 95% confidence interval) were : age over 60 (1.009;1.003,1.015;P=0.002), NYHA III- IV (4.5;1.4,16.7;P=0.014), I° AVB (5;1.01,34.8;P=0.042), aorta cross clamp time greater than 60 min (6.1;1.4,29.2;P=0.027), PAP greater than 50 mmHg (14.0;5.2,109.7;P=0.032). ConclusionThe routine use of temporary epicardial pacing wires after valve replacement surgery is necessary for high risk patients including II-III° atrioventricular block, supraventricular bradycardia, heart rate still less than 100 beats、min after using atropine or isoproterenol is poor, fast and slow syndrome. Furthermore, the determinants of temporary cardiac pacing: age greater than 60 years, I°AVB, and NYHA class III-IV, or PAP greater than 50 mmHg, or aortic block time greater than 60 min. -
表 1 安置组与未安置组患者的基线临床资料比较[n(%)]
项目 总人数(n=723) 未安置组(n=703) 安置组(n=20) χ2 P 年龄(岁) 7.813 0.005 18~59 496(68.60) 488(69.42) 8(40.00) ≥60 227(31.40) 215(30.58) 12(60.00) 性别 0.282 0.595 女 439(60.72) 428(60.88) 11(55.00) 男 284(39.28) 275(39.12) 9(45.00) 合并症 房颤 236(32.64) 227(32.29) 9(45.00) 1.429 0.232 Ⅰ°AVB 76(10.51) 71(10.10) 5(25.00) 4.590 0.049 糖尿病 60(8.30) 58(8.25) 2(10.00) 0.078 0.678 高血压 126(17.43) 123(17.50) 3(15.00) 0.084 1.000 慢性阻塞性肺病 25(3.46) 24(3.41) 1(5.00) 0.147 0.510 NYHA分级 1.323 0.250 I - II 230(31.81) 226(32.14) 4(20.00) III - IV 493(68.19) 477(67.86) 16(80.00) 左心室射血分数(%) 0.315 0.575 >50 501(69.29) 486(69.13) 15(75.00) ≤50 222(30.71) 217(30.87) 5(25.00) PAP(mmHg) 5.094 0.024 <50 462(63.90) 454(64.58) 8(40.00) ≥50 261(36.10) 249(35.42) 12(60.00) 术前用药 β受体阻滞剂 56(7.75) 54(7.68) 2(10.00) 0.146 0.663 胺碘酮 33(3.06) 32(4.55) 1(5.00) 0.009 0.612 地高辛 289(39.97) 277(39.40) 12(60.00) 3.438 0.064 左心房内径(mm) 3.071 0.080 <34 240(33.20) 237(33.71) 3(15.00) ≥34 483(66.80) 466(66.29) 17(85.00) 左心室内径(mm) 0.575 0.448 <55 456(63.07) 445(63.30) 11(45.00) ≥55 267(36.93) 258(36.70) 9(55.00) 病程(年) 2.120 0.145 <10 472(65.28) 462(65.72) 10(50.00) ≥10 251(34.72) 241(34.28) 10(50.00) 手术类型 二尖瓣置换 387(53.53) 381(54.20) 6(30.00) 0.736a 0.415a 主动脉瓣置换 107(14.80) 104(14.79) 3(15.00) 0.730b 0.561b 多瓣膜置换 229(31.67) 218(31.01) 11(55.00) 5.673c 0.017c 体循时间(min) 2.117 0.146 <100 369(51.04) 362(51.49) 7(35.00) ≥100 354(48.96) 341(48.51) 13(65.00) 阻断时间(min) 4.513 0.034 <60 350(48.41) 345(49.08) 5(25.00) ≥60 373(51.59) 358(50.92) 15(75.00) PAP:肺动脉压;AVB:房室传导阻滞;NYHA:纽约心脏协会心功能分级;a二尖瓣vs主为动脉瓣;b主动脉瓣vs多瓣膜;c二尖瓣vs多瓣膜. 表 2 安置组与未安置组患者的死亡率与死亡原因比较[n(%)]
项目 总人数(n =723) 未安置组(n = 703) 安置组(n = 20) χ2 P 预后 0.382 0.434 痊愈 703(97.23) 684(97.30) 19(95.00) 早期死亡 20(2.77) 19(2.70) 1(5.00) 早期死亡原因 0.382 0.434 呼吸衰竭和多器官功能衰竭 8(1.11) 8(1.14) 0(0.00) 低心排综合征 7(0.97) 6(0.85) 1(5.00) 心室颤动和心脏骤停 4(0.55) 4(0.57) 0(0.00) 术后出血 1(0.14) 1(0.14) 0(0.00) 表 3 起搏器依赖性应用多因素分析
项目 优势比(OR) 95%置信区间(CI) P 下限 上限 年龄≥60岁 1.009 1.003 1.015 0.002 Ⅰ°AVB病史 5 1.01 34.8 0.042 NYHA分级(III - IV) 4.5 1.4 16.7 0.014 PAP≥50 mmHg 14.0 5.2 109.7 0.032 阻断时间≥60 min 6.1 1.4 29.2 0.027 -
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