目的：本研究总结回顾了单中心先天性心脏病（先心病）外科围手术期心外膜永久性起搏器植入经验和远期随访结果。 方法：回顾性分析2002年-2014年间我院33例8岁以下先心病患儿外科围术期植入心外膜永久性起搏器的临床资料。先天性高度房室传导阻滞6例，医源性高度房室传导阻滞27例。患儿平均年龄（23.2±26.9）个月，平均体重（9.7±5.6） kg。除6例术中即植入起搏器外，其余均于术后（26.0±13.1） d植入起搏器。起搏导线植入于右心室膈面，起搏器均放置于腹直肌后的囊袋。术中收集起搏器植入时间、类型、植入后即刻心室夺获阈值，电极电阻等电生理学信息。随访期间，收集心脏超声心动图、心电图、起搏器电程控信息和恶性心血管事件的发生。术后随访（46.8±33.9）个月。 结果：除2例因先天性传导阻滞植入双腔起搏器外，其余均植入单腔起搏器。起搏器植入后即刻心室夺获阈值（1.34±0.72）V，而末次随访时未见心室夺获阈值明显增加[（1.37±0.81）V，P=0.93]。与植入起搏器即刻比，末次随访时的心室电极电阻[（366.7±88）Ω vs (331.9±95.9)Ω，P=0.32]和R波振幅[（12.3±3.5） mV vs（11.4±4.9） mV，P=0.635]均无明显升高。随访期间4例患儿术后因电池耗竭行起搏器置换术；21.2%（7/33）患儿出现心力衰竭或猝死的恶性心血管事件，发生恶性心血管事件的患儿的年龄和体重与预后良好的患儿相比差异无统计学意义（P>0.05）。随访期间所有患儿均未发生囊袋感染及起搏器电极折断的情况。 结论：医源性高度房室传导阻滞是目前先心病外科围术期植入永久性起搏器的首位原因。心外膜永久性起搏器植入有较好的远期随访效果，但是起搏器类型的选择仍需进一步优化。%Objective: To analyze the 10-year experience for placement of permanent epicardial-pacemaker (PM) during peri-operative period in a single center of patients with congenital heart diseases (CHD). Methods: A total of 33 CHD patients who received the placement of epicardial-PM during peri-operative period in our hospital from 2002 to 2013 were retrospectively analyzed. There were 6 patients with congenital atrio-ventricular block (AVB) 27 with iatrogenic AVB. All patients were younger than 8 years and the mean age was (23.2 ± 26.9) months, with the body weight at (9.7 ± 5.6) Kg. 6 patients with congenital AVB received surgical PM placement combined with CHD repair, and the other 27 patients received PM placement at (26 ± 13.1) days after the surgery. Steroid-eluting bipolar epicardial pacing leads were inserted through median sternotomy and connected to various pulse generators within the subrectus pocket. The time, type, acute ventricular stimulation sensing, impedance and electrophysiological information of PM were collected during the operation. The patients were followed-up for (46.8 ± 33.9) months for echocardiography, ECG, programming information of PM, and the major adverse cardiac events (MACE) were recorded. Results: There were 2 congenital AVB patients received dual chamber PM and the rest patients received single chamber PM. Acute ventricular stimulation sensing was (1.34 ± 0.72) V, no signiifcant increase was identiifed in the last follow-up examination as (1.37 ± 0.81) V,P=0.93. Compared with immediate PM implantation, no signiifcant increases were observed for impedance and R wave in the last follow-up examination as (366.7 ± 88) Ω vs (331.9 ± 95.9) Ω,P=0.32 and (12.3 ± 3.5) mV vs (11.4 ± 4.9) mV,P=0.635 respectively. There were 4 patients received PM replacement because of generator dysfunction, 7/33 (21.2%) of patients had MACE as heart failure or sudden death. The age and body weight in MACE patients were similar with the patients with good prognosis,P>0.05. No pocket infection or lead fracture occurred. Conclusion: Iatrogenic high level of AVB has been the primary reason for surgical placement of epicardial PM in CHD patients during peri-operative period. It has better long term outcome, while the type of PM should be optimized.
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