68例儿童植入心脏起搏器临床分析

A clinical analysis of cardiac pacemaker implantation in 68 children

摘要:

目的：探讨植入心脏起搏器儿童的临床特点。方法：回顾性分析重庆医科大学附属儿童医院2011年9月至2017年10月植入心脏起搏器病例的临床资料，年龄2 h至18岁11个月，平均（66.96±58.14）个月，包括病因、临床表现、辅助检查、起搏方式、植入后心脏大小、心功能改变等情况。结果：共收集68例患儿，初期植入临时起搏器61例，永久起搏器7例。临时起搏器组中心外膜起搏25例，均为先天性心脏病（心脏外科手术术中植入），心内膜起搏36例，包括暴发性心肌炎25例，先天性心脏病术后Ⅲ度房室传导阻滞（Ⅲ degree atrio ventricular block，Ⅲ°AVB）5例，心律失常3例（导管消融术后Ⅲ°AVB、房性心动过速、室性心动过速各1例），心肌病3例（伴Ⅲ°AVB、室上性心动过速）；临时起搏器植入同时给予药物综合治疗，46例患儿4周内恢复窦性心律，其中心外膜起搏20例（20/25，80%），心内膜起搏26例，包括暴发性心肌炎20例（20/25，80%），先天性心脏病术后2例（2/5，40%），心律失常3例（3/3，100%），心肌病1例（1/3，33.3%），8例最终植入永久起搏器，6例死亡，1例放弃治疗；初期7例植入永久起搏器的患儿病因包括QT间期延长综合征、先天性病态窦房结综合征各1例，暴发性心肌炎1例（外院已植入临时起搏器），Ⅲ°AVB伴阿－斯综合征（病因不明）4例；临时起搏过程中3例发生电极移位，永久起搏器植入术后1例出现皮肤囊袋感染。临时起搏组植入前、后左室收缩期末内径（left ventricular end-systolic diameter，LVDs）、左室舒张期末内径（left ventricular end-diastolic diameter，LVDd）及永久起搏组植入前、后LVDs比较有统计学差异（P<0.05）。结论：临时心脏起搏可以保证重要脏器血供，为药物治疗起效赢得时间，保证心功能恢复；在临时起搏器植入4周内仍未恢复窦性心律者则需植入心脏永久起搏器。

Abstract:

Objective：To investigate the clinical characteristics of children with cardiac pacemaker implantation. Methods：The clini－cal data of patients with a mean age of （66.96±58.14） months（range，2 hours to 227 months），who underwent cardiac pacemaker implantation in our hospital from September 2011 to October 2017，were retrospective analyzed，including etiology，clinical manifesta－tions，auxiliary examination，pacing methods，cardiac size after implantation，and changes in cardiac function. Results：A total of 68 children were collected，including 61 with temporary pacemaker implantation and 7 with permanent pacemaker implantation in early stage. In the temporary pacemaker group，25 children were treated with epicardial pacemaker implantation during cardiac surgery for congenital heart disease，and 36 children were treated with endocardial pacemaker implantation，including 25 cases of fulminant my－ocarditis，5 cases of Ⅲ-degree atrioventricular block after surgery for congenital heart disease，3 cases of arrhythmia（1 of Ⅲ-degree atrioventricular block after catheter ablation，1 of atrial tachycardia，and 1 of ventricular tachycardia），3 cases of cardiomyopathy with Ⅲ-degree atrioventricular block and supraventricular tachycardia. All the 61 children were given drug therapy simultaneously with temporary pacemaker implantation，46 of whom recovered sinus rhythm within 4 weeks，including 20（20/25，80%） treated with epicardial pacing and 26 treated with endocardial pacing[20（20/25，80%） of fulminant myocarditis，2（2/5，40%） of congenital heart disease，3（3/3，100%） of arrhythmia，and 1（1/3，33.3%） of cardiomyopathy]. Eight children were eventually implanted with permanent pacemaker，six died，and 1 abandoned treatment. The etiologies of 7 children with permanent pacemaker implan－tation in early stage included QT prolongation syndrome in 1 case，congenital sick sinus syndrome in 1 case，fulminant my－ocarditis in 1 case（temporary pacemaker implanted in the other hospital），and Ⅲ-degree atrioventricular block with attack of Adams-Strokes syndrome（unknown etiology） in 4 cases. There were 3 children with electrode displacement during temporary pacing，and 1 with skin pouch infection after permanent pacemaker im－plantation. The temporary pacemaker group showed a significant change in left ventricular end-systolic diameter and left ventricular end-diastolic diameter after implantation，and the permanent pacemaker group showed a significant change in left ventricular end-di－astolic diameter after implantation（P<0.05）. Conclusion：Temporary cardiac pacing can ensure the blood supply of important organs，gain time for drug treatment，and ensure the recovery of cardiac function. Permanent cardiac pacemaker should be implanted if sinus rhythm is not restored within 4 weeks after temporary pacemaker implantation.