Long-term mortality and pacing outcomes of patients with permanent pacemaker implantation after cardiac surgery

Background: Approximately 20,000 permanent pacemakers (PPMs) are implanted annually for bradycardia or atrioventricular (AV) block after cardiac surgery. Little is known about the long‐term pacing and mortality outcomes and the temporal trends of these patients. Methods: We examined 6,268 consecutive patients who underwent cardiac surgery at the Minneapolis Veterans Administration Medical Center between 1987 and 2010. Patients who had a PPM within 30 days of cardiac surgery were identified. Pacemaker interrogation records were retrospectively reviewed and mortality was ascertained. Results: Overall, 141 (2.2%) patients underwent PPM implantation for high‐degree AV block (55%) and bradycardia (45%), 9 ± 6 days after surgery. Age, diuretic use, cardiopulmonary bypass time (CPBT), and valve surgery were independent predictors of PPM requirement. After 5.6 ± 4.2 years of follow‐up, 40% of the patients were PPM dependent. Longer CPBT (P = 0.03), PR interval >200 ms (P = 0.03), and QRS interval > 120 ms (P = 0.04) on baseline electrocardiogram predicted PPM dependency . In univariable analysis, PPM patients had a higher long‐term mortality than those without PPM (45% vs 36%; P = 0.02). However, after adjusting for age, sex, type of surgery, and CPBT, PPM requirement was not associated with long‐term mortality (hazard ratio 1.3; 95% confidence interval 0.9–1.9; P = 0.17). Compared to before, incidence of PPM implantation increased after the year 2000 (1.9% vs 2.6%; P = 0.04). Conclusion: The majority of patients who require PPM after cardiac surgery are not PPM dependent in the long term. Requiring a PPM after surgery is not associated with long‐term mortality after adjustment for patient‐related risk factors and cardiac surgical procedure. (PACE 2011; 34:331–338)     

Predictors and clinical impact of atrial fibrillation after pacemaker implantation in elderly patients treated with dual chamber versus ventricular pacing

The Pacemaker Selection in the Elderly (PASE) trial was a prospective, multicenter, single blind, randomized comparison of single chamber, rate adaptive, ventricular pacing (VVIR) with dual chamber, rate adaptive pacing (DDDR) in 407 patients aged > or =65 years(mean 76 +/- 7 years, 60% male)with standard bradycardia indications for dual chamber pacemaker implantation. The incidence, predictors, and clinical consequences of atrial fibrillation (AF) developing after pacemaker implantation in the PASE trial were studied prospectively. During a median follow-up of 18 months, AF developed in 73 (18%) patients. Kaplan-Meier estimated cumulative incidences of AF in patients with sinus node dysfunction (n=176) at 18 months were 28% in the VVIR and 16% in the DDDR groups (P=0.08). After adjustment for other clinical variables using a Cox multivariate regression model, randomization to VVIR compared with DDDR pacing mode among patients with sinus node dysfunction was independently associated with a 2.6-fold increased relative risk (RR) of developing AF after pacemaker implantation (P=0.01). Other independent clinical risk factors for development of postimplant AF included a preimplant history of hypertension (P=0.02) or supraventricular tachyarrhythmias(P<0.04). Patients who developed AF had similar health related quality of life scores and cardiovascular functional status after 18 months of pacing as patients who remained free of AF. The RR of death, stroke, or heart failure hospitalization was not increased in patients who developed AF. Thus, in the elderly patients with sinus node dysfunction requiring permanent pacing, DDDR pacing mode protected against the development of AF. However, development of AF after pacemaker implantation in this population was not associated with a significant impact on quality-of-life, functional status, or other clinical endpoints during 18 months of follow-up.     

心脏起搏器植入术后早期并发症的护理

笔者分析280例心脏起搏器植入术后早期发生并发症有:伤口出血或囊袋血肿、心律失常、周围组织感染、起搏器综合征、电极脱位、感知障碍,其发生的原因:(1)术前2d未停用抗凝药,术中小血管止血不彻底,损伤胸大肌,病人本身年龄大、消瘦、皮下脂肪薄。(2)起搏器电极的机械刺激、电极移位、起搏器故障及性能不同。(3)病人穿刺部位皮肤消毒不彻底,操作者无菌技术不严,手术时间过长,高龄及瘦弱病人因皮下组织薄起搏器磨损皮肤。(4)房室收缩不同步而引起血液动力学的改变,使心室充盈量减少,心搏量减少。(5)早期导管电极刺激心肌和内膜使组织水肿,右心室过大,电极在心腔内张力过大或突然活动牵拉及体位改变。(6)心腔内R或P波过低,电极故障,电磁干扰。提出术前向病人耐心解释安装心脏起搏器的目的和方法,术中加强无菌技术操作,术后严格实施正确的卧位,严密观察伤口、体温、心率、心律的变化,及时处理,是提高手术成功率的关键。     

A shorter hospital stay after cardiac pacemaker implantation

In an effort to shorten the hospital stay after implantation of a permanent cardiac pacemaker, some physicians have begun performing pacemaker implantation on an ambulatory basis. To assess the potential safety of shortening the duration of hospitalization after pacemaker implantation, we reviewed the complications that occurred in 100 consecutive patients after pacemaker implantation and noted the time after the implantation when the complications occurred. In our study group, all complications that necessitated invasive intervention occurred within 24 hours after the pacemaker implantation. Complications that necessitated noninvasive programming occurred as long as 72 hours after implantation, and all could have been safely corrected at the time of follow-up had the patient been dismissed at the 24-hour period. Although we do not believe that ambulatory pacemaker implantation should be routinely implemented at this time, the practice of dismissing patients at 24 hours after pacemaker implantation and scheduling subsequent outpatient follow-up seems to be safe and effective.     

Progression of coronary arteriosclerosis based on the data from repeat coronary angiography and the clinical course of ischemic heart disease

The clinical and instrumental studies data are compared with the repeated coronarography data in 16 patients with coronary heart disease associated with stable angina pectoris. Repeated coronarography was performed within 4 to 8 years (5.2 years on the average). In 14 out of the 16 patients (87.5%), repeated coronarography revealed the development of coronary atherosclerosis which was accompanied clinically by the patients' status deterioration, the decreased exercise tolerance, the occurrence of new cases of myocardial infarction, appearance of the symptoms of heart insufficiency and heart rhythm disorders.     

New onset of pacemaker dependency after permanent pacemaker implantation

Pacemaker dependency has dangerous consequences under conditions of electromagnetic interference, unrecognized lead dysfunction, and battery depletion, and has been associated with cardiovascular and overall mortality. The aim of this study was to examine the incidence of new onset of pacemaker dependency during long-term follow-up after pacing system implantation. The study included 518 patients (mean age 72.9 +/- 10.4 years) who presented with intrinsic rhythms at the time of implantation. Indications for pacing were sick sinus syndrome (SSS) in 275 (53%) patients, AV block in 209 (40%), and AF with bradycardia in 34 (7%) patients. The mean follow-up was 3.7 +/- 2.7 years (range 1-17). Pacemaker dependency was defined as the absence of an intrinsic rhythm during backup pacing at 30 beats/min for 30 seconds. New onset of pacemaker dependency was observed in 23 (4.4%) of the 518 patients at a mean of 3.1 +/- 2.7 years of follow-up. Pacing indications were SSS in 6 (2.2%) of 275 patients, AV block in 15 (7.2%) of 209, and AF with bradycardia in 2 (5.9%) of 34. Patients with AV block had a significantly higher incidence of pacemaker dependency than patients with SSS (odds ratio 3.51; 95% CI 1.3 to 9.3; P = 0.012). The average annual rate of new pacemaker dependency was 1.6% during an 8-year follow-up. The incidence of new onset of pacemaker dependency varied among pacing indications, and was significantly higher in patients with AV block than patients with SSS.     

老年糖尿病冠心病患者支架植入术后抗血小板治疗的研究

目的 探讨三联抗血小板治疗对预防有出血性卒中病史老年糖尿病冠心病患者金属裸支架(BMS)植入术后支架内血栓形成和再狭窄的有效性及安全性.方法 60例患者行支架植入术后被随机分为治疗组(30例)和对照组(30例).两组均长期服用阿司匹林100 mg/d、氯吡格雷75 mg/d,连用1个月;治疗组加用西洛他唑200 mg/d,连用6个月.6～9个月后进行冠状动脉(冠脉)造影随访.结果 治疗组9个月靶病变重建率明显低于对照组[13.3%比33.3%,P<0.05].随访6个月,治疗组最小管腔直径明显大于对照组,管腔狭窄程度明显小于对照组,再狭窄率和管腔晚期丢失均明显低于对照组(P均<0.05).治疗组患者除心动过速发生率高于对照组(P<0.05)外,其余不良反应发生情况与对照组无明显差异.治疗组随访期间花生四烯酸诱导血小板抑制率明显高于对照组(P均<0.05).结论 对冠脉病变参考血管直径≥3 mm且靶血管病变长度≤20 mm、合并出血性卒中病史的老年糖尿病冠心病患者行BMS植入术后,在阿司匹林、氯吡格雷抗血小板治疗基础上加用6个月西洛他唑,有降低支架内血栓形成的趋势,可增加随访期的冠脉最小管腔直径、减少BMS植入术后再狭窄率和靶病变重建率,且不增加出血并发症.     

冠状动脉支架置入术后患者生活质量及其影响因素的调查

目的 探讨冠心病患者冠脉内植入支架后的生活质量及其影响因素.方法 应用生活质量评定量表（QOLI-74）对植入支架组（n=80）和对照组（n=80）进行评估比较,对可能影响生活质量的因素进行分析.结果 冠脉支架植入患者在躯体功能、心理功能、社会功能方面低于正常人群.单因素分析显示：生活质量总分与面对、E量分、经济状况呈正相关;与屈服、N量分、SAS、精神紧张度呈负相关.冠脉支架植入患者生活质量影响因素依次为焦虑、社会支持、躯体不适感、经济状况、精神紧张度.结论 冠脉支架植入患者生活质量的影响因素是多方面的,其中焦虑、社会支持、躯体不适感、精神紧张度、经济状况是影响生活质量的重要因素.     

Pneumopericardium and pneumothorax after permanent pacemaker implantation

We present a patient with chronic obstructive pulmonary disease who developed discomfort 2 days after dual-chamber pacemaker implantation via the left cephalic vein approach. The pacer was placed with active-fixation leads without obvious complications. A computed tomography (CT) scan taken in the emergency room showed right pneumothorax and associated pneumopericardium without pneumomediastinum. A three-dimensional reconstruction of CT images confirmed the atrial lead protruding into the pleural space. This lead likely ruptured a bulla causing a pneumothorax followed by pneumopericardium through a pleuro-pericardial communication. Chest tube placement relieved both pneumothorax and pneumopericardium without the need for atrial lead extraction.     

Sheathless implantation of permanent coronary sinus-LV pacing leads

BACKGROUND: Implantation of CS-LV pacing leads is usually accomplished through specialized sheaths with additional use of contrast venography and other steps. Direct implantation at a target pacing site could provide a simplified procedure with appropriate leads. METHODS: A progressive CS-LV lead implant protocol was used, with initial attempts made to place the lead directly using only fluoroscopy and lead stylet or wire manipulation. Coronary sinus (CS) sheaths were only used later if direct lead placement failed. RESULTS: There were 105 attempted implants with 96% (101/105) success. Leads were implanted sheathlessly in 69% (70/101) cases. Pacing parameters and final lead position did not differ significantly between implants that did or did not require sheaths for implants. Three peri-procedural complications occurred in implants where sheaths were used. In 33% (33/101) of implants, the leads were placed without the use of sheaths or contrast venography in 20 minutes or less. CONCLUSIONS: Direct placement of the CS-LV pacing lead without sheaths can be accomplished successfully in a majority of implants and in < or =20 minutes in a third, without inferior pacing parameters. This may provide for shorter or less technically difficult or expensive procedures with low risk.     

Two-year results after implantation of a metallic stent EPHESOS in patients with coronary heart disease

AIM: To evaluate two-year results of using a metallic stent EPHESOS in patients with native atherosclerotic lesion of coronary arteries (without prior interventions). MATERIAL AND METHODS: The stent was implanted to 731 patients. 53% had manifestations of unstable angina. 42% of the lesions were complicated. The length of the stenosis was 15.5 +/- 6.8 mm, 44% stenoses were long. RESULTS: The success of stenting was 99.6%. Cases of acute and subacute thrombosis were absent. Non-Q wave myocardial infarction in primary hospitalization developed in 4 patients. For 6 months, cardiovascular complications (death, angina, restenosis, repeated revascularization) occurred in 21%. Angiographic control follow-up of 6 months maximum covered 329 (45%) patients. Hemodynamically significant restenosis was detected in 18% patients. Cardiovascular complications for 24 months occurred in 39%. CONCLUSION: The EPHESOS stent has demonstrated a stable long-term effect on prevention of thrombosis and restenosis in the majority of patients with a relatively high risk of intervention.     

Refractory hypertensive emergency associated with complete heart block resolved after permanent pacemaker implantation: A case report

Severe hypertension sometimes improves with treatment of bradycardia but this phenomenon is under‐reported. Here, an elderly gentleman with complete heart block and a hypertensive emergency was refractory to medical therapies and blood pressure only improved following pacemaker implantation. We discuss the possible mechanisms relating to heart rate and artificial pacing.     

LERANS模式在冠心病支架植入术后患者健康教育中的应用

目的:探讨LERANS模式在冠心病支架植入术后患者健康教育中的应用效果,为患者临床护理提供相关指导。方法:选取2017年10月至2018年10月于阜阳市第二人民医院行冠心病支架植入术的156例患者为研究对象。按照随机单双数法,将所有研究对象分为对照组和研究组,各78例。对照组患者予以常规健康教育模式,研究组患者予以LER A NS模式。对比两组患者教育前后自护能力、自我效能,并分析两组患者生活质量。结果:教育后,两组患者自护能力均明显提高,研究组患者自护能力总评分为(149.82±24.12)分,明显高于对照组[(121.03±21.15)分],差异有统计学意义(P<0.05);教育后,两组患者自我效能均明显提高,研究组患者自我效能评分[(35.84±6.33)分],明显高于对照组[(25.25±5.14)分],差异有统计学意义(P<0.05);研究组患者生活质量总评分[(402.43±98.61)分],明显高于对照组[(328.12±71.57)分],差异有统计学意义(P<0.05)。结论:LER ANS模式在冠心病支架植入术后患者健康教育中的应用效果显著,促进患者自护能力及自我效能提高,从而提高其生活质量,值得大力推广。     

冠心病患者支架植入术后服药依从性现状的调查及分析

目的了解冠心病患者支架植入术后的服药依从性。方法采用MORISKY问卷评价表评价患者支架植入术后的服药依从性,并对相关因素进行分析。结果 108例患者中40例服药依从性差,多元Logistic回归分析显示,服药依从性差与年龄、文化程度、支架植入时间、家庭月收入、医疗报销、药物费用、服药种类相关。结论冠心病支架植入术后患者服药依从性较差,影响因素较多,应加强术后健康教育和出院后随访。     

Five-year mortality and coronary heart disease development after normal coronary angiogram

BACKGROUND:

Previous studies depict low cardiac event and mortality rates in patients with angiographically normal coronary arteries. These studies, however, are limited by small sample sizes, short follow-up intervals, and selection biases. This study was undertaken to determine the natural five-year course of a diverse cohort of subjects with documented normal coronary arteries with respect to coronary heart disease development, revascularization need, and all-cause mortality.

METHODS:

Consecutive adult patients with angiographically normal coronary arteries were followed up for 5 years through medical record review. Patients with any degree of angiographic abnormality, including minimal luminal irregularity or non-critical stenosis, were excluded. Patients were not excluded based on age, co-morbidities (except cardiac transplant and structural heart disease), indication for angiogram, or initial hospitalization status.

RESULTS:

Normal coronary arteries were found in 182 (31.3%) of 582 patients; 129 met all inclusion criteria. The mean age was (49.1±12.5) years; 47 (36.7%) were male and 75 (58.1%) were caucasian. The most common indication for angiography was cumulative risk factors (60.5%). Within 5 years of a normal angiogram, 13 of 129 patients died (10.1%; 95 CI 5.7%-16.9%). Six (40%; 95 CI 19.8% to 64.3%) of 15 patients undergoing repeat angiogram within five years developed new coronary heart disease, with one requiring revascularization. Of traditional risk factors of coronary heart disease, only diabetes was associated with a higher risk of death.

CONCLUSION:

The natural five-year course of a diverse cohort of patients with documented normal coronary arteries suggests that there is significant risk for death and development of coronary heart disease.KEY WORDS: Angiography, Coronary disease, Mortality, Prognosis     

应用组织多普勒显像技术评价冠状动脉支架植入术后左心室舒张功能变化

目的应用超声心动图组织多普勒显像技术(tissue Doppler imaging,TDI)监测冠心病(coronary heart disease,CAD)患者冠状动脉支架植入术前、后左心室舒张功能的变化,探讨冠状动脉支架植入术对左心室舒张功能的影响。方法冠心病患者108例,分别于术前、术后3～7天、术后6～9个月应用TDI测量左心室舒张功能各项指标,二尖瓣环舒张早期速度峰值(Em),二尖瓣环舒张晚期速度峰值(Am),两者比值(Em/Am),并分析其变化。正常对照组80例,应用TDI测量左心室舒张功能各项指标。结果冠心病组术前Em(6.81±1.19)cm/s,Em/Am 0.84±0.35,正常对照组Em(10.72±1.41)cm/s,Em/Am 1.32±0.43(P<0.05)。与冠心病组术前比较,术后3～7天各项指标无明显变化,术后6～9个月Em(9.87±1.33)cm/s,Em/Am 1.19±0.25,较术前改善明显(P<0.05)。结论冠心病患者冠状动脉直架植入术后短期内左心室舒张功能无明显改善,随着术后时间的延长,左心室舒张功能会逐步得到恢复。     

Transvenous implantation of a coronary sinus lead for left ventricular pacing after cutting balloon angioplasty

We describe a patient in whom a localized proximal vein stenosis at the only possible target vein precluded placement of a coronary sinus lead for left ventricular (LV) pacing. After multiple attempts to perform venoplasty with both compliant and noncompliant balloons, a cutting balloon relieved the obstruction, and an LV pacing lead was successfully placed in the midportion of this lateral vein.