Outcome of tricuspid valve surgery in the presence of permanent pacemaker
Outcome of tricuspid valve surgery in the presence of permanent pacemaker
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DOI：
10.1016/j.jtcvs.2017.11.093
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发表时间：
2018-04-01
影响因子：
6
通讯作者：
Dearani, Joseph A.
中科院分区：
文献类型：
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作者：
Saran, Nishant;Said, Sameh M.;Dearani, Joseph A.
目的：考虑到现有文献的缺乏，我们试图评估三尖瓣反流的机制和永久性起搏器存在下三尖瓣手术的结果。方法：我们回顾性分析了1993年1月至2013年12月期间在永久性起搏器存在下接受三尖瓣手术的622例成年患者的记录。排除假三尖瓣或三尖瓣心内膜炎患者及合并心脏移植患者（n = 23）。将患者分为两组：起搏器相关三尖瓣反流（n = 349, 58%）和起搏器诱发三尖瓣反流（n = 249, 42%）。1例患者未分类，因为不知道是否永久性使用起搏器。结果：平均年龄69.5±12.0岁；女性312例（52%）。在起搏器相关的三尖瓣反流中，最常见的原因是功能性的（n = 304, 87%）。导致起搏器诱导的三尖瓣反流最常见的机制是小叶活动受限（n = 101, 41%），其次是粘附在导联上的小叶（n = 93, 37%）、小叶穿孔（n = 30, 12%）、小叶瘢痕（n = 19, 8%）和索索夹闭（n = 18, 7%）。最常见的小叶是间隔小叶（n = 182, 73%）。起搏器相关三尖瓣返流组三尖瓣修复率（n = 215, 62%）较高。在多变量分析中，起搏器诱发的三尖瓣反流对提高生存率具有保护作用（风险比[HR]， 0.79； 95%可信区间[CI]， 0.68-0.98）。其他死亡的独立危险因素包括三尖瓣置换术（HR, 1.50; 95% CI, 1.20-1.87）、非选择性手术（HR, 1.66; 95% CI, 1.33-2.08）、糖尿病（HR, 1.37; 95% CI, 1.09-1.73）、严重的三尖瓣反流（HR, 1.42; 95% CI, 1.04-1.95）以及合并主动脉瓣手术的年龄较大（HR, 1.44; 95% CI, 1.15-1.79）。结论：起搏器诱导的三尖瓣反流有多种机制。与起搏器相关的三尖瓣反流相比，起搏器诱导的三尖瓣反流预后更好，生存率更高。
Objectives: Given the paucity of available literature, we sought to evaluate the mechanisms of tricuspid regurgitation and the outcomes of tricuspid valve surgery in the presence of permanent pacemakers.Methods: We retrospectively reviewed the records of 622 adult patients who underwent tricuspid valve surgery in the presence of permanent pacemakers between January 1993 and December 2013. Those with prosthetic tricuspid valve or tricuspid valve endocarditis and those undergoing concomitant heart transplant were excluded (n = 23). Patients were divided into 2 etiologic groups: pacemaker-associated tricuspid regurgitation (n = 349, 58%) and pacemaker-induced tricuspid regurgitation (n = 249, 42%). One patient was not categorized, because permanent pacemaker involvement was unknown.Results: Mean age was 69.5 +/- 12.0 years; 312 patients (52%) were female. In pacemaker-associated tricuspid regurgitation, the most common cause was functional (n = 304, 87%). The most common mechanism leading to pacemaker-induced tricuspid regurgitation was restricted leaflet mobility (n = 101, 41%), followed by adherent leaflet to the leads (n = 93, 37%), leaflet perforation (n = 30, 12%), scarring of leaflets (n = 19, 8%), and chordal entrapment (n = 18, 7%). The most common leaflet involved was septal leaflet (n = 182, 73%). Tricuspid valve repair (n = 215, 62%) was higher in the pacemaker-associated tricuspid regurgitation group. In multivariable analysis, pacemaker-induced tricuspid regurgitation was found to be protective with improved survival (hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.68-0.98). Other independent risk factors of mortality included tricuspid valve replacement (HR, 1.50; 95% CI, 1.20-1.87), nonelective surgery (HR, 1.66; 95% CI, 1.33-2.08), diabetes (HR, 1.37; 95% CI, 1.09-1.73), severe tricuspid regurgitation (HR, 1.42; 95% CI, 1.04-1.95), and older age when there was a concomitant aortic valve surgery (HR, 1.44; 95% CI, 1.15-1.79).Conclusions: Several mechanisms lead to pacemaker-induced tricuspid regurgitation. Pacemaker-induced tricuspid regurgitation when compared with pacemaker-associated tricuspid regurgitation carries a better prognosis with improved survival.