中文摘要

目的

心血管疾病的发生发展有性别差异，国外有研究证实植入起搏器的女性患者病态窦房结综合征的比例高于男性。但是国内尚无资料分析植入起搏器患者缓慢性心律失常类型的性别差异。本研究通过单中心大样本分析临床植入起搏器治疗患者在缓慢性心律失常类型、起搏器植入年龄、起搏参数及围术期并发症等方面是否存在性别差异。

方法

研究对象为自2015-01至2017-12在阜外医院心律一病区连续收治的因缓慢性心律失常植入起搏器治疗的患者。回顾性收集年龄、性别等人口学资料和缓慢性心律失常的病因诊断、植入起搏器的类型、起搏器测试参数和住院期间围术期并发症等资料。缓慢性心律失常的病因类型分为病态窦房结综合征、二度二型以上房室传导阻滞、持续性心房颤动（房颤）伴长间歇、窦房结和房室结双结病变。起搏器参数包括心房心室导线手术时测量的感知、起搏阈值、导线阻抗。起搏器类型有双腔起搏器和单腔起搏器。围手术期并发症定义为起搏器术后发生的电极脱位、电极穿孔、气胸、起搏器感染。整体人群按照年龄是否小于60岁分为青中年患者(<60岁)和老年患者（≥60岁）人群，分析植入起搏器治疗的缓慢性心律失常类型、起搏参数及围术期并发症等方面是否存在性别差异。

结果

本研究入选1431例成年缓慢性心律失常患者，平均年龄（68.1±13.1）岁，男性占47.5%（680例），51.1%诊断为病态窦房结综合征，19.5%诊断为三度房室传导阻滞，11.9%诊断为持续房颤伴长间歇，8.2%诊断为二度房室传导阻滞，9.3%为双结病变。按性别分析缓慢性心律失常的类型，发现植入起搏器的女性患者缓慢心律失常不同病因所占的比例与男性对比存在显著差异（P<0.001）。女性植入起搏器患者中病态窦房结综合征所占比例明显高于男性（60.1% vs 41.2%, P＜0.001），二度二型以上房室传导阻滞所占的比例显著低于男性（23.3% vs 32.5%, P＜0.001），持续性房颤伴长间歇所占比例显著低于男性（9.6% vs 14.6%, P=0.004）。按年龄区分为青中年和老年人群后，发现男性与女性植入起搏器患者缓慢心律失常类型构成比例均存在和整体人群类似的性别差异（P<0.001）。青中年人群中，男性患者因病态窦房结综合征植入起搏器的平均年龄显著低于女性平均植入年龄（49.7±10.3 vs 53.0±7.1, P=0.037）；老年人群中，男性患者因二度房室传导阻滞植入起搏器的平均年龄（75.5±7.7 vs 72.8±6.2, P=0.012）和因持续性房颤伴长间歇植入起搏器的平均年龄（74.5±8.4 vs 70.8±6.9, P=0.007）均显著高于女性患者的平均植入年龄。植入起搏器的类型方面，在青中年人群中，不同类型起搏器的比例无显著性别差异；在老年人群中，女性患者植入DDD起搏器的比例显著高于男性（89.5% vs 79.5%, P<0.001）。起搏器的相关参数方面，青中年人群中，男性患者起搏器心室感知显著高于女性（11.1±5.2mv vs 10.0±4.6mv, P=0.04）。老年人群中，男性患者的起搏器心房感知（3.7±5.1mv vs 2.9±1.5mv, P=0.001），心室感知（11.3±5.0mv vs 10.7±4.7mv, P=0.02）显著高于女性。心房心室导线的起搏阈值和起搏阻抗在青中年和老年人群中均未发现性别差异。起搏器术后0.3%发生气胸、1.1%发生电极脱位、0.2%发生电极穿孔、0.4%发生感染。但是无论整体人群还是青中年和老年人群中的并发症均未在男性和女性之间发现差异。

结论

成年人植入起搏器患者男性和女性缓慢性心律失常类型的构成比存在差异，女性患者中病态窦房结综合征所占的比例高于男性，而房室传导阻滞、房颤伴长间歇所占比例低于男性。这种性别差异在青中年人群和老年人群中均存在。青中年人群中，女性病态窦房结综合征患者植入起搏器的平均年龄较大，老年人群中，男性因二度房室传导阻滞、持续房颤伴长间歇植入起搏器的平均年龄较大。男性和女性的起搏器的心室感知参数有差异。老年女性患者植入双腔起搏器的比例更高。围术期并发症的发生率在男女性别间无差异。

[Abstract]

Objective

The aim of this study was to analyze whether there are gender differences in bradyarrhythmia, age of implantation, pacing parameters, and perioperative complications in patients with pacemaker implantation.

Methods

A series of consecutive patients who had been implanted pacemaker due to bradycardia from January 2015 to December 2017 at Fuwai Hospital arrhythmic department Ward 1 were retrospectively enrolled. We collected the demography data including age and sex, the type of bradycardia, the type of pacemaker, pacing parameters, perioperative complications and other clinical data. The types of bradyarrhythmia were defined as sick sinus syndrome, two degree and complete atrioventricular block, persistent atrial fibrillation with long interval, binodal (sinoatrial node and atrioventricular node) disease. Pacemaker parameters included the atrial and ventricular sensing, pacing thresholds, and lead impedances measured during implantation procedure. There were dual-chamber and single-chamber pacemakers. Perioperative complications were defined as electrode dislocation, electrode perforation, pneumothorax, and pacemaker infection. According to whether patients are less than 60 years old, all patients were divided into young and middle-aged patients (<60 years old) and elderly patients (≥60 years old). We then analyzed whether there are gender differences in the type of bradycardia, pacing parameters, perioperative complications and so on in pacemaker implantation.

Results

A total of 1431 adult patients who were dignosed bradyarrhythmia were finally enrolled. The average age of general patients is 68.1±13.1 and the proportion of male is 47.5% (680 cases). Among all patients, 51.1% of patients were diagnosed with sick sinus syndrome, 19.5% with third-degree atrioventricular block, 11.9% with persistent atrial fibrillation with long interval, 8.2% with second-degree atrioventricular block, and 9.3% with binodal disease. Sex-specific analysis found that the type of bradyarrhythmia were significantly different between male and female patients（P＜0.001）. In female patients, the prevalence of sick sinus syndrome were significantly higher than that in male patients（60.1% vs 41.2%, P＜0.001）, while the prevalence of atrioventricular block（23.3% vs 32.5%, P＜0.001） and persistent atrial fibrillation with long interval（9.6% vs 14.6%, P＜0.01）were significantly lower than that in male patients. This gender differences were also found in the young and middle-aged patients as well as in the elderly patients.  In the young and middle-aged patients, the age of implantation of male patients with sick sinus syndrome was significantly younger than that of female patients（49.7±10.3 vs 53.0±7.1, P＜0.05）.In the elderly patients, the age of implantation of male patients was older than that of female patients with II° degree atrioventricular block（75.5±7.7 vs 72.8±6.2, P＜0.05） as well as female patients with atrial fibrillation with long interval（74.5±8.4 vs 70.8±6.9, P＜0.01）. The type of pacemaker was not different between male and female in young and middle aged group. In elderly population, female patients were more common to receive DDD pacemaker (89.5% vs 79.5%, P<0.001). Most pacing parameters did not differ between male and female patients except for the higher R wave of ventricular lead sensing （11.1±5.2mv vs 10.0±4.6mv, P=0.04）in male in the young and middle-aged patients, as well as the higher P wave of atrial lead sensing（3.7±5.1mv vs 2.9±1.5mv, P=0.001） and the higher R wave of ventricular lead sensing（11.3±5.0mv vs 10.7±4.7mv, P=0.02） in male  in the elderly population. The incidence of pneumothorax is 0.3%. The incidence of electrode dislocation is 1.1%. The incidence of electrode perforation is 0.2%. The incidence of pacemaker infection is 0.4%. Gender differences were not found in the perioperative complications in all patients.

Conclusions

The types of bradyarrhythmia were different between female and male patients with pacemakers. The prevalence of sick sinus syndrome was higher in female than that in male, while the prevalence of atrioventricular block and persistent atrial fibrillation with long interval were higher in men than that in women. The gender difference in bradyarrhythmia existed in both middle-aged and elderly population. In the middle-aged population, the age of implantation of female patients with sinus node syndrome was older, while in the elderly population, the age of implantation of male patients with second-degree AV block or persistent atrial fibrillation with long interval was older. Pacing parameters were different in lead sensing between male and female patients. Elderly female patients were more common to receive dual-chamber pacemaker than male. Gender difference was not found in perioperative complications.