心脏器械植入后心律失常的药物治疗选择

植入式心脏器械是现代心脏疾病治疗的一大进展,近几十年来在心血管领域得到广泛应用,尤其在心律失常、心力衰竭（简称心衰）等的治疗中占据日趋重要的地位。目前主要的植入式心脏器械有心脏起搏器（主要治疗缓慢性心律失常）、埋藏式心脏转复除颤器（ICD,主要治疗恶性室性心律失常）、心脏再同步化治疗（包括CRT及CRT—D）。此外,左室辅助装置已成为严重心衰患者心脏移植前的一种有效治疗方法,目前主要应用于外科领域。但是,心脏器械植入并不意味着就不再需要抗心律失常药物,相反,选择恰当的抗心律失常药物对优化器械治疗,延长患者寿命,改善生活质量具有重要意义。     

心血管植入型电子器械治疗的性别差异

心血管植入型电子器械（CIED）包括心脏起搏器、植入型心律转复除颤器（ICD）、心脏再同步化治疗（CRT）等。主要崩于心动过缓、心动过速和心力衰竭的诊断、治疗和监测。大量临床试验证实了上述治疗的有效性,目前心脏起搏器已成为缓慢型心律失常的唯一有效治疗手段。而ICD治疗也成为心脏性猝死（SCD）一级预防和二级预防的最有效方法,CRT更是失同步心力衰竭的重要治疗方法,不但可以缓解心力衰竭症状,提高生活质量、运动耐量及左心室功能,而且可以改善心力衰竭患者的预后,降低死亡率。     

具有心力衰竭预警功能的CRT-D临床应用一例

慢性心力衰竭的主要死亡原因是进行性心力衰竭和心脏性猝死。临床研究证实，心脏再同步治疗（CRT）可以改善心力衰竭患者的心功能，并可降低进行性心力衰竭导致的死亡。心脏性猝死最有效的预防方法是植入植入型心律转复除颤器（ICD）。因此，同时具有心脏再同步功能和除颤功能的三腔ICD（CRT—D）已开始在临床应用。     

植入型心律转复除颤器对慢性心力衰竭心脏性猝死的一级预防

目的评价植入型心律转复除颤器（ICD）在慢性心力衰竭患者心脏性猝死一级预防中的治疗作用。方法对2005年1月至2008年12月符合ICD一级预防标准并植入ICD的患者进行随访。ICD的诊断设置室性心动过速（VT）、心室颤动（VF）两个工作区,治疗设置抗-tk,动过速起搏（ATP）、低能量同步转复（CV）和高能量除颤（DF）。术后患者常规给予抗心律失常药物。每3～6个月随访1次,利用程控仪获取ICD储存资料,了解患者心律失常发作情况以及ICD的诊断和治疗是否准确,及时调整相关参数并处理ICD故障。结果共随访了22例患者,平均随访（12．8±8．6）个月。共有10例患者记录到ICD治疗事件。10例患者ICD记录到持续性VT事件,其中由ATP终止6例,CV终止4例。4例患者有VF事件,均1次DF成功。2例ICD将快速心室率心房颤动（AF）识别为VF并进行放电治疗并转复房颤。结论ICD在慢性心力衰竭患者心脏性猝死一级预防中的治疗效果是肯定的,ICD联合抗心律失常药物能有效治疗恶性室性心律失常,预防心脏性猝死。     

有或无室性心律失常的心力衰竭患者进行再同步和自动除颤双重治疗均可获益

目的：评价在有或无室性心律失常的心力衰竭患者中同时运用心脏再同步装置（CRT）与埋植式心脏复律除颤器（ICD）的有效性。背景：试验证实CRT与ICD均能降低严重心力衰竭患者的死亡率，那么结合2种功能于一身的装置（CRT—ICD）更具吸引力。方法：总共对连续的191个严重心力衰竭并左室射血分数（LVEF）〈35％，QRS间期〉120ms的患者进行了CRT—ICD治疗。其中，71位患者有室性心律失常病史（二级预防）；     

已植入心律转复除颤器的心力衰竭患者再行心脏再同步治疗一例

现报道已植入心律转复除颤器（ICD）后再行心脏再同步治疗（CRT）一例。临床资料 患者男性，62岁，因反复气促10余年，加重10d入院。3年前曾冠状动脉造影阴性。1年前因心力衰竭在外院拟做CRT手术，术前因发现心房颤动（房颤）、短阵室性心动过速（室速）而改为植入ICD（Medtronic GEM Ⅲ VR7231）。有糖尿病史3年，无高血压病史。     

右束支阻滞患者心脏再同步治疗疗效分析

目的 回顾分析阜外心血管病医院心律失常中心合并右束支阻滞(RBBB)的心力衰竭患者心脏再同步治疗(CRT)疗效.方法 本中心自2008年1月至2010年12月植入CRT-P/D的合并RBBB的心力衰竭患者,接受常规每3～6个月门诊随访,随访内容包括心功能(NYHA分级)、6 min步行距离、Minnesota生活质量评分、超声心动图及程控等指标.结果 共7例合并RBBB心力衰竭患者植入CRT-P/D,其中男6例,女1例,年龄19 ～74(57±19)岁.随访0.3～43.0(17.6±16.7)个月.随访期间发生心力衰竭住院事件7次,3例患者因心力衰竭加重死亡.6例患者为CRT无反应者,1例为CRT反应者.结论 合并RBBB的心力衰竭患者CRT无明显获益.     

CRT-D在慢性心力衰竭患者的临床应用

目的 心脏再同步治疗（CRT）可以显著改善慢性心力衰竭（CHF）患者心功能,而植入型心律转复除颤器（ICD）可以有效预防心脏性猝死.具有CRT和ICD功能的CRT-D已开始应用于临床.本文初步总结CRT-D的临床应用.方法 4例药物治疗无效的CHF患者,合并左束支阻滞、左心室舒张末内径增大,而且既往有室性心动过速病史.其中扩张性心肌病3例,缺血性心肌病1例.接受组织多普勒检查证实存在心脏运动不同步后,接受了CRT-D治疗.结果 4例患者均成功植入CRT-D.左心室起搏导线植入到心脏后静脉3例,心脏侧后静脉1例.术中测试除颤能量≤20 J,无并发症发生.术后1周左心室射血分数从0.34增加至0.42。结论 CRT-D植入技术难度大,风险高,但其安全性肯定.鉴于其显著疗效,建议同时满足CRT和ICD适应证的患者应该接受CRT-D治疗.     

植入型心脏再同步治疗除颤器治疗扩张性心肌病并恶性心律失常一例

慢性心力衰竭的主要死亡原因为进行性的心功能恶化和心脏性猝死。临床研究已证实心脏再同步治疗（CRT）可改善心功能，并可降低病死率。植入型心律转复除颤器（ICD）能够显著降低心脏性猝死发生率，目前已经成为治疗恶性室性心律失常最有效的治疗方法之一。     

植入型心律转复除颤器对心脏性猝死一级预防临床研究

目的 分析植入型心律转复除颤器(ICD)及心脏再同步治疗除颤器(CRT-D)一级预防患者的室性心律失常发生情况.方法 统计分析2007年1月至2012年6月在浙江医院因一级预防而植入ICD或CRT-D的所有患者.结果 140例患者中,植入ICD的患者51例,CRT-D患者89例,平均随访(26.8±12.6)个月.结果显示在ICD一级预防中启动ICD正确治疗的室性心律失常发生率为19.3％,误治疗率为12.9％,其中误治疗中85.3％发生在单腔ICD一级预防中.ICD一级预防中主要死亡原因为心力衰竭(52.2％),非心脏原因死亡(39.1％).ICD正确治疗组与未治疗组相比,宽QRS时限、低左心室射血分数(LVEF)及高B型脑钠肽(NT-proBNP)容易导致室性心律失常发生.结论 在ICD或CRT-D一级预防患者中,宽QRS时限、低LVEF及高NT-proBNP容易导致室性心律失常发生;ICD误治疗主要发生在单腔ICD患者.     

Moderate exercise training improves functional capacity, quality of life, and endothelium-dependent vasodilation in chronic heart failure patients with implantable cardioverter defibrillators and cardiac resynchronization therapy.

BACKGROUND: The objective of this study was to determine the effects of a moderate exercise training program on functional capacity, quality of life, and hospital readmission rate in chronic heart failure patients with implantable cardioverter defibrillators and cardiac resynchronization therapy. METHODS AND RESULTS: We studied 52 men (mean age 55+/-10 years, ejection fraction 31+/-7%) in chronic heart failure II (n=29) and III (n=23) NYHA functional class with ischemic cardiomyopathy who received implantable cardioverter defibrillators with or without cardiac resynchronization therapy. Patients were randomized into two groups. Group T (n=30 patients, 15 implantable cardioverter defibrillator, 15 implantable cardioverter defibrillator+cardiac resynchronization therapy) underwent a supervised exercise training program at 60% of peak VO2 three times a week for 8 weeks. Group C (n=22 patients, 12 implantable cardioverter defibrillator, 10 implantable cardioverter defibrillator+cardiac resynchronization therapy) avoided physical training. At 8 weeks, only trained patients had improvements in peak VO2 (P<0.01 versus C), endothelium-dependent dilatation of the brachial artery (P<0.001 versus C) and quality of life (P<0.001 versus C). Among trained patients, those with cardiac resynchronization therapy had greater improvements in peak VO2 and quality of life. During the follow-up (24+/-6 months), eight controls had sustained ventricular tachycardia requiring hospital readmission, while no trained patients had adverse events (log rank 8.56; P<0.001). The improvement in peak VO2 was correlated with the improvement in endothelium-dependent dilatation (r=0.65). CONCLUSION: Moderate exercise training is safe and has beneficial effects after implantable cardioverter defibrillator implantation, especially when cardiac resynchronization therapy is present. These effects are associated with improvement in quality of life and outcome.     

Update of implantable cardioverter/defibrillator and cardiac resynchronization therapy in heart failure

PURPOSE OF REVIEW: Heart failure prevalence is reaching epidemic proportion in the United States and is associated with significant morbidity and mortality. A large proportion of the mortality is the result of sudden cardiac death (SCD). Clinical trials have demonstrated the superiority of the implantable cardioverter/defibrillator (ICD) compared with antiarrhythmic drugs for secondary prevention of sudden cardiac death. RECENT FINDINGS: Recently, several clinical trials in primary prevention of sudden cardiac death in both ischemic and nonischemic heart failure have been completed. The 2002 guidelines for implantable cardioverter/defibrillator implantation were recently released as well. Adjunct therapy consisting of antiarrhythmic drugs or radiofrequency ablation is necessary in the subset of patients with implantable cardioverter/defibrillator that have frequent or intractable ventricular arrhythmias. An emerging new therapy in the heart failure population is cardiac resynchronization therapy, which coordinates right and left ventricular pacing in a subset of patients with interventricular conduction delay. SUMMARY: Several randomized clinical trials have demonstrated improvements in heart failure-related symptoms, exercise tolerance, and reversal of ventricular remodeling. Meta-analysis of these trials has also demonstrated mortality benefit. Patient selection, left ventricular pacing site, and optimal device programming are issues that need further investigation. Recent trials have also studied the compatibility between cardiac resynchronization therapy and implantable cardioverter/defibrillator as a single device. Finally, the DAVID trial has raised concerns of conventional right ventricular pacing and the risk of heart failure in a subset of patients.     

Implantable device therapy

Sudden cardiac death (SCD) accounts for two-thirds of fatal events related to heart disease. Coronary heart disease and non-ischemic cardiomyopathy are the most common causes of SCD. Data from major randomized trials have consistently shown that therapy with an implantable cardioverter defibrillator (ICD) results in a significant and meaningful effect on survival through a reduction in the risk of SCD in these population. These data have resulted in a marked increase in the application of implantable device therapy in the past 2 decades from secondary prevention with an implantable cardioverter/defibrillator (ICD) in survivors of a cardiac arrest to primary prevention of SCD in asymptomatic patients with ischemic and non-ischemic left ventricular dysfunction, and prevention of symptomatic heart failure progression and death with cardiac resynchronization therapy (CRT), and devices that combine CRT and ICD therapies (CRT-D). However, there are still areas of uncertainty regarding device therapy that include inconsistent benefit in risk-subgroups of patients with low ejection fraction; increased risk of heart failure after life-prolonging ICD therapy, and a considerable rate of device malfunction despite increasing sophistication. In the present review we focus on current data regarding the clinical indications as well as the safety and efficacy of implantable device therapy, including ICD, CRT, and CRT-D.     

Electrical storm of monomorphic ventricular tachycardia after a cardiac-resynchronization-therapy-defibrillator upgrade.

In patients with significant left ventricular dysfunction and congestive heart failure despite optimal medical therapy, implantation of cardiac resynchronization therapy-defibrillation (CRT-D) devices has been shown to improve symptoms and mortality. In this report, we describe a case of a patient with ischaemic cardiomyopathy who developed incessant ventricular tachycardia (VT) after undergoing an upgrade from an implantable cardioverter defibrillator to a CRT-D device. The patient required multiple anti-arrhythmic agents, removal of the coronary sinus lead, and radiofrequency ablation to control VT. Thus, in rare patients, the CRT devices may potentially cause 'proarrhythmia' with serious consequences.     

Performance of the Seattle Heart Failure Model in implantable defibrillator patients treated with cardiac resynchronization therapy

The Seattle Heart Failure Model (SHFM) is a validated multivariate risk prediction model for mortality in patients with heart failure, using widely available clinical variables. The aim of this study was to assess the performance of the SHFM when applied to patients with heart failure who received cardiac resynchronization therapy devices with defibrillation. A total of 413 patients were identified from 2 prospective implantable cardioverter-defibrillator registries who received cardiac resynchronization therapy devices with defibrillation for the primary prevention of sudden death. Baseline laboratory and clinical data were entered in the SHFM to calculate predicted survival. The end point was all-cause mortality. During a median follow-up period of 2.8 years, 78 patients died and 9 underwent heart transplantation. Observed versus predicted 5-year mortality rates were 11.6% versus 11.4%, 21.5% versus 22.1%, and 41.4% versus 46.1% by ascending tertile of Seattle Heart Failure Score, respectively. No systematic or substantial errors of risk estimation were observed. Discrimination was excellent; the C-statistic ranged from 0.78 at 1-year follow-up to 0.70 at 5-year follow-up, and the Hosmer-Lemeshow chi-square statistic was 0.87 (p = 0.65). In conclusion, in patients with heart failure who received cardiac resynchronization therapy devices with defibrillation, the SHFM offers adequate discrimination of risk for all-cause mortality and estimation of mortality risk without substantial or systematic errors.     

Future prospects for implantable devices for atrial defibrillation

The success of the implantable cardioverter defibrillator (ICD) led to the concept of a device that would terminate atrial fibrillation (AF) using an implantable device. Implantable devices for AF are undergoing rapid evolution. Currently used devices combine pacing and cardioversion therapies to prevent and to treat AE Recent studies have shown that these devices are safe and can decrease the incidence of AF and improve quality of life significantly. Implantable devices for atrial defibrillation are likely to have an increasing role in the near future, particularly when they are used in combination with ICD and cardiac resynchronization therapy in which AF is both common and its termination is clinically beneficial.     

起搏治疗慢性充血性心力衰竭的进展

心脏起搏治疗慢性充血性心力衰竭是非药理学治疗的新方法。已经证实双心室同步起搏可以改善慢性充血性心力衰竭患者的血流动力学、心功能状态和生活质量 ,心脏同步起搏联合心脏内复律除颤器治疗减少了病死率和再住院率 ,相关临床试验仍在进行中。     

Biventricular pacing and defibrillator use in chronic heart failure

Since the 1970s when the implantable cardioverter defibrillator (ICD) was developed, multiple clinical trials have documented survival benefits in certain high-risk subsets of heart failure patients. Over the past decade, cardiac resynchronization therapy (CRT) emerged as an important therapy in carefully selected patients with ongoing symptoms despite optimized pharmacological therapy. ICDs should be considered first-line therapy for survivors of life-threatening ventricular arrhythmic events. Subsets of patients with both ischemic and nonischemic dilated cardiomyopathy appear to have a survival benefit from primary ICD therapy. CRT has resulted in substantial symptomatic improvement and survival benefits in a subgroup of chronic heart failure patients. CRT should be considered in heart failure patients undergoing ICD implantation who have evidence of ventricular dyssynchrony.     

Sex-based differences in cardiac resynchronization therapy and implantable cardioverter defibrillator therapies: effectiveness and use

With the rapid advancements in heart failure device therapy, many physicians now use these devices in everyday clinical practice. However, questions remain regarding the clinical benefit of these therapies in different patient subgroups. Since the majority of patients enrolled in device trials are white men, extrapolating the data to specific patient subpopulations becomes important. Specifically, the question of clinical outcomes in women with implantable device therapy for prevention of sudden cardiac death and management of heart failure is an important clinical issue. In this article, we review the data on survival and clinical outcomes with heart failure device therapy (implantable cardioverter defibrillators [ICDs] and cardiac resynchronization therapy [CRT]) and analyze the results from clinical trials for any differences in outcomes based on gender. Even though women are a significantly under-represented population with regard to clinical investigation and utilization of heart failure devices, they still derive the same morbidity and mortality benefits compared to men. Specifically, ICD devices confer the same rates of sudden cardiac death prevention, and CRT devices improve CHF morbidity and mortality at rates comparable to those found in men. These results support equal use of ICDs and CRT in men and women.