室间隔肌切除术后永久起搏器置入风险因素及相关预后分析  

Analysis of risk factors and prognosis of permanent pacemaker implantation after septal myectomy

作　　者：吴子宁 朱昌盛[1] 聂长荣 蒙延海[2] 杨秋蓝[2] 刘小希[1] 王水云[1] WU Zi-ning;ZHU Chang-sheng;NIE Chang-rong;MENG Yan-hai;YANG Qiu-lan;LIU Xiao-xi;WANG Shui-yun(Department of Cardiac Surgery,Fuwai Hospital,National Center for Cardiovascular Diseases,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100037,China;Department of Intensive Care Unit,Fuwai Hospital,National Center for Cardiovascular Diseases,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100037,China,Fuwai Hospital,National Center for Cardiovascular Diseases,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100037,China)

机构地区：[1]中国医学科学院北京协和医学院国家心血管病中心阜外医院成人外科中心,北京市100037 [2]中国医学科学院北京协和医学院国家心血管病中心阜外医院重症监护室,北京市100037

出　　处：《中国心血管病研究》2023年第5期413-421,共9页Chinese Journal of Cardiovascular Research

摘　　要：目的评估肥厚性梗阻型心肌病(HOCM)患者外科手术后置入新置入永久性起搏器(PPM)的风险因素及相关患者的结局。方法回顾性收集2016年至2021年于阜外医院接受室间隔肌切除术的HOCM患者连续数据,并根据基线倾向性评分匹配建立匹配队列。在整体和匹配队列中比较术后是否置入PPM两组围术期和随访终点预后。并通过Cox回归建立术后置入PPM风险预测模型。结果共1070例患者纳入研究,中位随访时间2.2(1.4,3.3)年。在研究终点,共有39例(3.64%)患者接受了PPM置入。通过1∶3比例倾向性评分建立39对(n=156)术后置入或非置入PPM匹配队列。术后置入PPM组基线糖尿病、房颤、右束支阻滞和既往酒精消融的比例更高。在匹配队列中,两组远期病死率、不良事件发生率、纽约心功能分级(NYHA)未见明显差异。而在置入PPM组,远期左心室舒张末内径更大,二尖瓣和三尖瓣返流程度更重。高龄(HR=1.07)、术前束支传导阻滞(HR=13.20)、既往酒精室间隔消融手术史(HR=6.39)和本次同时合并Maze手术(HR=4.99)为术后置入PPM的独立危险因素,而女性为术后置入PPM的保护因素(HR=0.38),模型预测术后PPM发生的曲线下面积为0.854。结论肥厚性梗阻型心肌病患者在外科治疗术后PPM置入率为3.64%。在长期随访中,与无PPM患者相比,PPM患者的生存率和不良事件发生率未见明显差异。对基线束支传导阻滞和酒精消融术后等高危人群的识别和关注有助于术后起搏器置入的策略选择。Objective To assess the risk factors and outcomes of permanent pacemaker implantation(PPM)in patients with hypertrophic obstructive cardiomyopathy(HOCM)after surgery.Method Consecutive HOCM patients underwent septal myectomy in Fuwai Hospital from 2016 to 2021 were collected,and the matched PPM and non-PPM groups were establish based on baseline propensity score matching.The perioperative and follow-up outcomes were compared between the two groups.A risk prediction model for postoperative PPM implantation was established through Cox regression.Result A total of 1070 patients were included in the study,with a median follow-up of 2.2 years.A total of 39 patients(3.64%)underwent PPM implantation at the end point of the study.A matched cohort of 39 pairs(n=156)of PPM and non-PPM groups was established using a 1∶3 proportional propensity score.The proportion of baseline diabetes,atrial fibrillation,right bundle branch block and previous alcohol septal ablation was higher in the PPM group.In the matched cohort,there was no significant difference between the two groups in long-term mortality,incidence of adverse events and NYHA cardiac function grade.In the PPM group,the long-term left ventricular end diastolic diameter was larger,and the degree of mitral and tricuspid regurgitation was more severe.Elderly age(HR=1.07),preoperative bundle branch block(HR=13.20),previous history of alcohol septal ablation(HR=6.39)and combined Maze procedure(HR=4.99)were the independent risk factors for PPM implantation,while female were the protective factor(HR=0.38).The area under the curve of the predict model was 0.854.Conclusion During the long-term follow-up,there was no significant difference in survival and adverse event rates between PPM and non-PPM groups.Identification and attention to high-risk populations can help for strategy in PPM implantation.

关 键 词：永久起搏器置入 肥厚型梗阻性心肌病 室间隔肌切除术 

分 类 号：R541[医药卫生—心血管疾病]