Thromboembolic events during the perioperative period in patients undergoing permanent pacemaker implantation

Background:

Thromboembolism (TE) is one of the most serious complications after pacemaker implantation. It has been demonstrated that several patient characteristics and different pacing modes are related to an increased risk of TE events during long‐term follow‐up.

Hypothesis:

We propose that TE events occurring during the perioperative period of pacemaker implantation may be associated with certain clinical characteristics.

Methods:

The potential risk factors of TE events were analyzed in 406 consecutive patients who underwent pacemaker implantation.

Results:

We identified TE events in 11 patients (2.7%) within 7 days after pacemaker implantation. Four of the 11 (36.4%) patients died of complications of TE. Univariate analysis revealed that an age of >75 years (4.56 odds ratio [OR], P = 0.031), hypertension (3.59 OR, P = 0.028), diabetes (8.89 OR, P < 0.001), coronary heart disease (4.8 OR, P = 0.005), atrial fibrillation (AF) (5.68 OR, P = 0.006), persistent AF (10.36 OR, P < 0.001), and a history of stroke or transient ischemic attack (5.62 OR, P = 0.002) were associated with an increased risk of TE events. Multivariate logistic analysis showed that persistent AF (9.8 OR, P < 0.001) was independently associated with TE. The incidence of perioperative TE was not significantly different between patients with single‐ and dual‐chamber pacemakers.

Conclusions:

We found TE events during the perioperative period in patients undergoing pacemaker implantation were not uncommon. Because persistent AF during the perioperative period was the only independent risk factor for perioperative TE, appropriate anticoagulation therapy may be necessary in those patients. © 2012 Wiley Periodicals, Inc. J. Liu, MD, is co‐first author. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

起搏器置入后新出现起搏器依赖及右室起搏相关心室不同步研究

目的:研究置入起搏器5年以上患者新出现起搏器依赖及右室起搏相关心室不同步的情况。方法:选取置入时为非起搏器依赖且置入起搏器已超过5年患者272例进行随访,测量自身心率,记录心室起搏比例;将起搏器心室频率逐渐降至30次/min,观察30s,无患者自身心律出现,判定为起搏器依赖;将自身心率<50次/min且心室起搏比例>90%者判定为右室起搏相关心室不同步患者,对起搏器依赖及右室起搏相关心室不同步患者提出个别随访方案和更换建议。结果:136例病窦综合征患者中有4例(2.9%)进展为起搏器依赖;116例房室传导阻滞患者中有10例(8.6%)进展为起搏器依赖;全部病例有15例(5.5%)进展为起搏器依赖;有43例自身心率<50次/min且心室起搏比例>90%,占全部病例的15.8%。结论:房室传导阻滞患者较之病窦综合征患者,更容易进展为起搏器依赖患者;置入起搏器5年以上患者中约有5.5%进展为起搏器依赖;置入起搏器5年以上患者中右室起搏相关心室不同步人群比例约15.8%。     

Pacemaker stress echocardiography predicts cardiac events in patients with permanent pacemaker

Purpose

Noninvasive pacemaker stress echocardiography is a newly introduced method for the diagnosis of coronary artery disease in patients with a permanent pacemaker. The prognostic value of pacemaker stress echocardiography has not been studied.

Subjects and methods

We studied 136 patients (mean age 64 ± 12 years) with a permanent pacemaker who underwent pacemaker stress echocardiography for evaluation of coronary artery disease. All patients underwent pacemaker stress echocardiography by external programming (pacing heart rate up to ischemia or target heart rate).

Results

Thirty-one patients (23%) had normal study results. Ischemia was detected in 75 patients (55%). During a mean follow-up of 3.5 ± 2.4 years, 35 deaths (26%) (20 the result of cardiac causes) and 2 nonfatal myocardial infarctions (1%) occurred. The annual cardiac death rate was 1.3% in patients without ischemia and 4.6% in patients with ischemia (P = .01). The annual all-cause mortality rate was 3.1% in patients without ischemia and 7% in patients with ischemia (P = .004). The presence of ischemia during pacemaker stress echocardiography was the strongest independent predictor of cardiac death (hazard ratio 4.1, confidence interval 1.2-14.5) and all-cause mortality (hazard ratio 2.7, confidence interval 1.2-6.0) in a multivariable model.

Conclusion

Myocardial ischemia during pacemaker stress echocardiography is an independent predictor of cardiac death and all-cause mortality in patients with a permanent pacemaker.     

永久性心脏起搏器植入术护理干预体会

目的分析永久性心脏起搏器植入术患者采用护理干预的方法与体会。方法护理对象118例,皆为我院1998年~2013年接诊的永久性起搏器植入术患者,回顾性分析他们的临床资料,总结分析临床护理干预的方法与体会。结果 118例患者经过永久性心脏起搏器植入术治疗与护理干预后,手术成功率为99.15%(117/118),并发症发生率仅为3.39%(4/118)。结论永久性心脏起搏器植入术患者临床护理中采用护理干预策略可以提高手术成功率,同时也能减少并发症的发生,值得临床借鉴。     

Prevalence of regurgitant murmurs in patients with valvular regurgitation detected by Doppler echocardiography

STUDY OBJECTIVE: To determine the relation between heart valve regurgitation detected by Doppler echocardiography and audible regurgitant murmurs. DESIGN: Consecutive sample. SETTING: Adult echocardiography laboratory in a tertiary care university hospital. PATIENTS: Sequential sample of 408 patients presenting for clinical echocardiographic studies who had technically satisfactory studies and were available for auscultation. MEASUREMENT AND MAIN RESULTS: Valvular regurgitation occurred in 43% of patients at the mitral valve, 39% of patients at the tricuspid valve, 33% of patients at the aortic valve, and 15% of patients at the pulmonic valve. Corresponding regurgitant murmurs were frequently absent. A murmur corresponding to Doppler-detected regurgitation was detected in 56% of patients with mitral regurgitation, 61% of patients with aortic regurgitation, 28% of patients with tricuspid regurgitation, and 15% of patients with pulmonic regurgitation. There was a highly significant positive correlation of audibility with severity of valve regurgitation for the aortic, tricuspid, and mitral valves. Audibility ranged from 10% to 40% for mild regurgitation to 86% to 100% for severe regurgitation. Murmur audibility was not related to the type of valvular disease present. CONCLUSIONS: Doppler echocardiography is a sensitive method for detecting valve regurgitation. Corresponding regurgitant murmurs are frequently not present. The audibility of regurgitant murmur is highly dependent on the severity of valve regurgitant and has little relation to the type of valve disease present.     

Characteristics of patients with cervical spinal injury requiring permanent pacemaker implantation

Acute cervical spinal cord injury frequently results in bradydysrhythmia, which may lead to hypotension and asystole. Such symptoms are more common in the first 2 weeks after the injury. Treatment modalities include atropine, epinephrine, aminophylline, and pacemaker insertion. The criteria for pacemaker use in this population are not well defined. We describe characteristics of 3 patients who required permanent, transvenous pacemaker implantation for recurrent symptoms. In 2 of the 3 patients, transcutaneous pacing failed to provide adequate protection. Transcutaneous pacemakers are not reliable, as was the case of these patients, and early consideration for transvenous pacemaker insertion may be indicated, especially in hemodynamically unstable patients. In this report, all 3 patients required permanent pacemaker implantation.     

Left ventricular systolic dyssynchrony index by three-dimensional echocardiography in patients with decreased left ventricular function: comparison with tissue Doppler echocardiography

Background: Three‐dimensional echocardiography (3DE) can simultaneously assess left ventricular (LV) regional systolic motion and global LV mechanical dyssynchrony. Methods: We used 3DE to measure systolic dyssynchrony index (SDI) (standard deviation of the time from cardiac cycle onset to minimum systolic volume in 17 LV segments) in 100 patients and analyzed the association of SDI with other parameters for LV systolic function or dyssynchrony. Eighteen patients who underwent cardiac resynchronization therapy (CRT) were also evaluated at 6 months after CRT, and the association of baseline SDI and tissue Doppler imaging (TDI) dyssynchrony index (Ts‐SD) with the change of LV end‐systolic volume (ESV) analyzed. Ts‐SD was calculated using the standard deviation of the time from the QRS complex to peak systolic velocity. Results: There was a significant inverse correlation between LVEF and SDI (r =?0.686, P < 0.0001). QRS duration was also significantly correlated to SDI (r = 0.407, P < 0.0001). There was a significant positive correlation between baseline SDI and the decrease in LVESV after CRT (r = 0.42). Baseline SDI was significantly greater in responders (10 patients) than in nonresponders (16.4 ± 5.1 vs. 7.9 ± 2.4%, P < 0.01), but there was no significant difference in Ts‐SD. SDI > 11.9% predicted CRT response with a sensitivity of 90% and a specificity of 75%. Conclusions: SDI derived from 3DE is a useful parameter to assess global LV systolic dyssynchrony and predict responses to CRT. (Echocardiography 2012;29:346‐352)     

Coexistent coronary artery disease in Indian patients undergoing permanent pacemaker implantation (PPI) for symptomatic bradyarrhythmia

BackgroundThe cause-effect of conduction disturbance in chronic lesion of coronary arteries is complicated. This study was designed to evaluate coexistent CAD in patients with symptomatic bradyarrhythmia to find common anatomic basis for conduction disturbances and its relationship to conventional coronary risk factors.MethodsIn this prospective observational study, 929 patients who admitted for symptomatic bradyarrhythmia requiring permanent pacemaker implantation were included. All included patients underwent coronary angiography and were divided into groups based on angiographic findings. Association between conduction disturbances and these groups were analyzed.ResultsA total of 929 patients with mean age of 63.1 years were included in our study. We found age ≥50 years, male sex, presence of diabetes and hypertension as statistically significant predictors of abnormal coronary angiography. Obstructive CAD (≥50% stenosis) was found in 34.4% patients. Prevalence of single vessel disease, double vessel disease and triple vessel disease was 15.3%, 10.2% and 8.9% respectively. Severe coronary obstruction (≥90% obstruction) was found in 16.25% patients. Revascularization was advised in three fourth of cases of obstructive CAD. Approximately two third of patients didn’t have significant obstruction in coronaries supplying the conduction system. Type 4 was the commonest anatomy in obstructive CAD. SA Nodal artery was found more diseased in patients of SSS with p value of 0.01.ConclusionObstructive CAD was found in one third of patients undergoing PPI. Age ≥50 years, male sex, diabetes and hypertension were found significantly correlated with presence of CAD and may act as important markers for the judgment of further coronary evaluation.     

老年患者植入永久起搏器术后早发型囊袋感染的处理

起搏器囊袋感染是永久起搏器植入术后较为常见的并发症之一,若不及早发现和处理,将导致囊袋破溃,迁延不愈,严重者可出现感染全身播散,甚至合并感染性心内膜炎。1 对象与方法 1．1对象 选取2000年3月至2011年3月在解放军总医院第一附属医院干部病房一科住院患者322例,男186例,女136例,年龄60488（73．5±9．1）岁。心律失常类型包括病态窦房结综合征129例,房颤伴长R—R间歇98例,Ⅱ度Ⅱ型和Ⅲ度房室传导阻滞69例,双结病变26例。共植入永久起搏器322台,其中单心房起搏器18台,单心室起搏器128台,双腔起搏器176台。     

The bioprosthesis type and size influence the postoperative incidence of permanent pacemaker implantation in patients undergoing aortic valve surgery

Background. Long-standing aortic stenosis (AS) causes significant progressive left ventricular dysfunction and may result in subendocardial ischaemia and conduction disorders. Though stentless bioprosthesis show better haemodynamic profiles compared with stented, yet debate exists about the differential effects of valve substitutes on the incidence of permanent pacemaker (PPM) implantation following aortic valve replacement (AVR). Methods. 510 consecutive patients aged 65–77 years with predominant AS accepted for isolated non-emergent AVR (360 received stented and 150 stentless) were studied over three years period. A stepwise logistic regression analysis was used and statistical significance was accepted at P < 0.05. Results. Mean age ± standard deviation for the stented group was 70.43 ± 7.2 and the stentless was 61.7 ± 12.3. Perioperative (30-day) mortality was 1% (5 of the 510 patients). Smaller aortic prosthesis size was identified as a significant predictors of hospital mortality [univariate and multivariate analysis (P < 0.05)]. Risk factors identified for PPM by univariate analysis were: preoperative: age, left atrial enlargement (LAE), MI, left bundle branch block (LBBB), poor ejection fraction < 35% (P < 0.05), postoperative; bypass time > 100 min with x-clamp time > 70 min, concomitant aortic surgery and prosthetic valve size ≤ 21 mm (P < 0.05). Multivariate analysis identified the preoperative MI (P = 0.003), poor ejection fraction < 35% (P = 0.007), LAE, (P = 0.001) and LBBB (P = 0.002), the perioperative variables; bypass time > 100 min with x-clamp time > 70 min (P < 0.001) and prosthetic valve size ≤ 21 mm (P = 0.003). Test of interaction analysis identified valve type as an important predictor of PPM (P = 0.01) Conclusions. The results demonstrated that where stentless valves required longer bypass and cross clamp times, more stented valves were small (< 21 mm, P < 0.05). In précis, this suggests that prevalence of PPM seems to be dependent on the size and type of bioprosthesis used in patients undergoing isolated AVR and this incidence of PPM is twice in stentless group (18% vs. 9.1%, P = 0.01).     

永久性心脏起搏器植人术后感染患者的临床资料分析

目的回顾性分析永久性心脏起搏器植入术后感染患者的临床特点,并对不同治疗方法进行评价。方法纳入2005年8月~2013年3月植入心脏起搏器[包括双腔及三腔起博器（CRT）]后发生感染的患者12例,分析感染者的临床特点,同时比较不同抗感染治疗（包括抗生素＋局部换药;抗生素＋原囊袋清创消毒＋起搏器原侧换位植入;起搏器及导线拔除＋抗生素＋起搏器对侧植入）方案的疗效差异。结果12例患者中植入双腔起搏器11例（91.6%）,CRT 1例（8.3%）,感染出现的中位时间为4.5个月,平均随访（33.0±19.0）个月。12例患者中有10例（83.3%）患者合并1种或以上其他疾病（包括糖尿病、心功能不全、慢性阻塞性肺病、结缔组织病等）,4例（33.3%）患者体内有2根以上的电极导线。10例首选保守治疗（应用抗生素＋局部换药,或抗生素＋原囊袋清创消毒＋起搏器原侧换位置入）中有8例感染复发,其中6例通过去除整个起搏系统治愈,1例起搏器消毒后重新置入治愈,1例形成窦道持续换药;2例首选去除起搏系统的患者均痊愈。结论起搏器感染多发生在合并危险因素的患者,一旦感染累及起搏系统,去除整个起搏系统是合理的。     

房室结消融联合起搏治疗老年永久性房颤患者的初步探讨

目的观察房室结消融联合起搏治疗与正规药物治疗对老年房颤患者心功能及生存质量的影响。方法选择2003年7月至2006年7月在两家3级甲等医院心内科住院且未正规口服抗心律失常药物治疗的老年永久性房颤患者52例。将患者分成两组,其中10例接受房室结射频消融联合起搏手术治疗(手术组),42例接受正规药物治疗(药物组)。采用心脏超声测量心功能,在常规二维超声切面上测量心输出量(CO)、心脏指数(CI)、每搏输出量(SV)、心搏出量指数(SVI)、左室射血分数(LVEF)。以中文版简明健康调查问卷SF-36,评估患者生存质量。首次问卷调查及心功能检查在入院后进行,随访调查在正规药物治疗6个月及起搏手术治疗后6个月进行。采用配对t检验、两个独立样本的秩和检验进行统计学分析。结果老年永久性房颤患者房室结消融联合起搏治疗与常规药物治疗后比较,患者心功能及生存质量各项指标均得到改善(P<0.01);两组组间比较分析,差异均无统计学意义(P>0.05)。结论房室结消融联合起搏治疗与药物治疗均能改善老年房颤患者的心功能及生存质量。     

双腔起搏33例随访报告

目的 观察双腔起搏疗效及并发症。方法 对33例植入双腔起搏器患者按常规时间和程序进行随访观察。结果 经4个月－10年平均5.5年随访发现：85％患者心功能改善，其中改善1级22例，2级6例，并发房颤2例占6％，死于难治性心衰1例，心房电极脱位1例，外伤致心房电极断裂1例，败血症后继发囊袋感染1例，脑梗塞1例，介入性心动过速2例，交叉感染2例，肌电感知致心室停搏2例，感知不良1例。结论 双腔起搏可明显改善心功能，但必须加强随访，捕捉并及时处理起搏器并发症。