Hakan AKBAYRAK, Adil POLAT, Hasan ERDOĞAN, Kaan KIRALİ, Hasan ARDAL, Esat AKINCI, Cevat YAKUT, Yücel ÖZEN, Suat Nail ÖMEROĞLU

Açık kalp cerrahisi sonrası kalıcı pacemaker implantasyonu

Amaç: Açık kalp cerrahisi sonrası kalıcı pacemaker takılması nadiren gerekmektedir. Kalıcı pacemaker takılma sıklığı ve etkileyen faktörleri belirlemek amacıyla son on yıl içerisinde ameliyat edilen olgular retrospektif olarak incelendi. Çalışma planı: Kliniğimizde son on yıl içinde ameliyat edilen hastaların, 43’üne kalıcı pacemaker yerleştirildi. Çalışmaya alınan hastaların 13’ü (%30) koroner arter hastalığı (10 erkek, 3 kadın; ort. yaş 66.8±8.1; dağılım 43-77), 24’ü (%55) edinsel kapak hastalığı (10 erkek, 14 kadın; ort. yaş 52.5±15.6; dağılım 16-73) ve altısı (%13) doğuştan kalp hastalığı (5 erkek, 1 kadın; ort. yaş 11.1±10.8; dağılım 3-32) tanısıyla ameliyat edilmişlerdi. Koroner arter hastalığı hastalarının sekizinde başvuru sırasında atriyoventriküler tam blok vardı. On dokuz hastaya aort kapak replasmanı, iki hastaya redo mitral kapak replasmanı, iki hastaya aort kapak replasmanı+mitral kapak replasmanı ve bir hastaya mitral kapak replasmanı+koroner bypass uygulandı. Pacemaker endikasyonları ameliyat sonrası 10 gün devam eden A-V tam blok, hemodinamik probleme yolaçan yavaş ventrikül cevaplı atriyal fibrilasyon/flatter, >3 saniye sinoatriyal arreste neden olan paroksismal atriyal fibrilasyondu.Bulgular: Sekiz hastaya ameliyat öncesinde bulunan A-V tam bloğun devam etmesi, 35 hastaya ise ameliyat sonrası gelişen A-V blok nedeniyle kalıcı pacemaker takıldı. Ameliyatla kalıcı pacemaker implantasyonuna kadar geçen süre ortalama 10.8±4.3 gün, yoğun bakımda kalış süresi ortalama 42.6±14.6 saat, hastanede kalış süresi ise 16.8±4.7 gündü. Hastalar ortalama 23.1±18.3 ay takip edildi. Geç dönemde bir hastada pace batarya protrüzyonu gelişti, bir hastada pulmoner arterde tromboemboli gözlendi. Takip süresince 43 hastanın 36’sı NYHA (New York Heart Association) sınıf I, beşi sınıf II fonksiyonel kapasitedeydi.Sonuç: İleti defektlerinin, ameliyat öncesi dönemde öngörülmesi ameliyat planını doğrudan etkileyebilir. Ayrıntılı risk skorlama sistemleri ameliyat ekibini yönlendirmeye yardımcı olur. Uzun dönem takiplerde, kalıcı pacemaker takılmış olması fonksiyonel kapasiteyi olumsuz yönde etkilememektedir.

Permanent pacemaker implantation after open heart surgery

Background: Permanent pacemaker (PP) implantation is rarely required after open heart surgery. A retrospective analysis of patients operated within last 10 years was performed to determine the frequency and risk factors. Methods: Forty-three of patients, who were operated within the last 10 years in our clinic, required PP implantation. Thirteen (30%), (10 males, 3 females; mean age 66.8±8.1; range 43 to 77 years) of these were operated for coronary artery disease (CAD), 24 (55%), (10 males, 14 females; mean age 52.5±5.6; range 16 to 73 years) for acquired valvular heart disease (AVD) and 6 (13%), (5 males, 1 female; mean age 11.1±10.8; range 3 to 32 years) for congenital heart disease. Eight of the CAD patients had AV block preoperatively. Nineteen of these patients had aortic valve replacement (AVR), 2 had reoperation for mitral valve replacement (MVR), 2 had AVR + MVR and 1 had MVR and CABG. Indications for PP implantation were; persistent complete AV block lasting for 10 days postoperatively, atrial fibrillation/ flutter with slow ventricular response leading to hemodynamic compromise and paroxysmal atrial fibrillation leading to sinusoidal arrest >3 seconds.Results: PP implantation was required for persistence of preoperatively existing complete A-V block in 8 patients and for the new onset A-V block in 35 patients. Mean interval from operation to implantation was 10.8±4.3 days. Mean times of intensive care unit stay and hospital stay were 42.6±14.6 hours and 16.8±4.7 days respectively. Mean follow- up time was 23.1±18.3 months. In long term, one patient had pace-maker battery protrusion, one had pulmonary arterial thromboembolism. During follow-up, 36 patients were in NYHA (New York Heart Association) Class I, 5 were Class II.Conclusion: Preoperative estimation of conduction defects may effect the surgical plan directly. Detailed risk scoring systems are essential to guide the surgical team. In long term follow-up, permanent pacemaker implantation does not affect the functional capacity adversely.

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