经导管主动脉瓣置换术后永久起搏器植入预测因子及预后分析  

Analysis on predictive factors of permanent pacemaker implantation after transcatheter aortic valve replacement and its prognosis

作　　者：张佳琪 池程伟 刘吉义[2] 赵维龙[2] 孟庆涛 王丽丹[2] 孙凤志 张树龙[2] 刘继红 ZHANG Jiaqi;CHI Chengwei;LIU Jiyi;ZHAO Weilong;MENG Qingtao;WANG Lidan;SUN Fengzhi;ZHANG Shulong;LIU Jihong(Graduate School,Dalian Medical University,Dalian Liaoning 116000;Heart Center,Affiliated Zhongshan Hospital of Dalian University,Dalian Liaoning 116001,China)

机构地区：[1]大连医科大学研究生院,辽宁大连116000 [2]大连大学附属中山医院心脏中心,辽宁大连116001

出　　处：《实用心电学杂志》2021年第6期412-418,431,共8页Journal of Practical Electrocardiology

基　　金：国家自然科学基金资助项目(81370307)。

摘　　要：目的分析接受经导管主动脉瓣置换术(transcatheter aortic valve replacement,TAVR)的患者术后永久起搏器(permanent pacemaker,PPM)植入的发生率、预测因子以及TAVR的预后。方法纳入38例在我院行TAVR的严重主动脉瓣狭窄的患者,根据术后1个月内是否植入PPM,将其分为起搏器组(8例)与非起搏器组(30例),并分析PPM植入的预测因子。根据左室收缩功能是否降低,将患者分为左室射血分数(left ventricular ejection fraction,LVEF)<50%组(15例)和LVEF≥50%组(23例),并分析2组TAVR的预后。结果TAVR术后PPM植入的发生率21.1%。如果肌酐清除率较低、存在血脂异常、美国胸外科医师协会发病率及死亡率评分较高、Ⅰ导联T波振幅较大,则TAVR术后PPM植入风险较高。PPM植入的主要预测因子是新发左束支阻滞(Coef 3.170,95%CI 0.853~7.447,P=0.005)和术前Ⅰ导联T波振幅较大(Coef 10.894,95%CI 1.478~28.012,P=0.018)。在术后及术后1个月随访时,平均主动脉压差、主动脉瓣瓣口面积、主动脉瓣瓣口面积/体表面积均显著改善,左室后壁厚度明显改善。LVEF、左室舒张末期内径与左室间隔厚度在术后1个月明显改善(P<0.05),而术后较术前改善不显著(P>0.05)。结论TAVR术后新发左束支阻滞及术前较大的Ⅰ导联T波振幅是术后PPM植入的预测因子。TAVR术后早期发生心脏逆重构,心功能及射血分数均有不同程度的改善。Objective To analyze the incidence rate and predictive factors of permanent pacemaker( PPM) implantation in patients undergoing transcatheter aortic valve replacement( TAVR),and the prognosis of TAVR.Methods Thirty-eight patients with severe aortic valve stenosis were enrolled in our study who had undergone TAVR in our hospital. According to the implantation of PPM one month after operation,they were divided into pacemaker group( 8 cases) and non-pacemaker group( 30 cases);predictive factors of PPM implantation were analyzed. By the increase or decrease of left ventricular systolic function,they were classified into left ventricular ejection fraction( LVEF) < 50% group( 15 cases) and LVEF≥50% group( 23 cases);the prognosis of the two groups after TAVR was analyzed. Results The incidence rate of PPM implantation after TAVR is 21. 1%. Patients with low creatinine clearance,dyslipidemia,high STS morbimortality score,and large T-wave amplitude in lead Ⅰ are at high risk of PPM implantation after TAVR. The main predictors of PPM implantation are new-onset left bundle branch block( Coef 3. 170,95% CI 0. 853-7. 447,P = 0. 005) and preoperative large T-wave amplitude in lead Ⅰ( Coef 10. 894,95% CI 1. 478-28. 012,P = 0. 018). Mean pressure gradient,aortic valve area and aortic valve area/body surface area are all significantly improved after surgery and during one-month follow-up,and so is the left ventricular posterior wall thickness. LVEF,left ventricular end-diastolic diameter and left ventricular septal thickness are significantly improved during the one-month follow-up( P < 0. 05),however,there is no statistically significant difference after surgery( P > 0. 05). Conclusion New-onset left bundle branch block after TAVR and preoperative large T-wave amplitude in lead Ⅰ are predictive factors of PPM implantation after surgery.Inverse cardiac remo-deling occurs in the early phase after TAVR,and heart function and ejection fraction both improve to varying degrees.

关 键 词：主动脉瓣狭窄 经导管主动脉瓣置换术 永久起搏器 心电图 超声心动图 心脏彩超 

分 类 号：R542.52[医药卫生—心血管疾病] R540.4[医药卫生—内科学]