心脏起搏与心包填塞

经静脉植入心脏起搏器是一普通且安全的手术,其并发症发生率很低。常见的并发症包括感染、血气胸、导线断裂、移位、三尖瓣损伤、静脉血栓形成、心包炎、心脏穿孔等[1]。起搏导线所致心脏穿孔是较为罕见的并发症,即使出现心脏穿孔,其主要表现仅是起搏障碍而不是心包填塞。心包填塞是更为罕见却威胁生命的并发症,早期识别与积极处理能够减少致命并发症的发生。1 心脏起搏所致心包填塞的发生率 心包填塞一般由起搏导线所致的心脏穿孔引起。可发生在起搏导线植入术中、术后以及废用导     

长期右心室流出道间隔部起搏安全性及有效性的临床研究

目的评价长期右心室流出道间隔部起搏的安全性及有效性。方法回顾性分析480例右心室流出道间隔部起搏患者资料,术中采用单导丝双弯塑形技术,主动固定起搏电极导线,观察起搏导线置入成功率,随访置入术中及术后参数、心功能、导线脱位率、心脏穿孔等指标。结果右心室流出道间隔部起搏成功475例,占98.96%。平均随访(28.4±11.5)个月,随访过程中,起搏阈值、感知及阻抗参数与术中的参数比较,差异无统计学意义(P>0.05),仅1例患者发生导线脱位,并再次置入成功。无心脏穿孔及心包填塞病例,且心功能指标均未见明显变化。结论右心室流出道间隔部起搏成功率高,长期安全有效,值得临床推广应用。     

主动固定式电极导线导致心脏穿孔三例

因生理性起搏的需要以及可以根据具体情况选择理想起搏部位等优点,主动固定式电极导线在临床应用越来越广泛,但是许多临床工作者对于主动固定式电极导线可能带来的并发症特别是心脏穿孔认识不足.     

主动固定电极导线行心脏特殊部位起搏的临床应用

目的探索主动固定电极导线行心脏特殊部位起搏临床应用的可行性和安全性。方法需要安置心脏起搏器患者88例,其中男54例、女34例,年龄67.6±24.3(28～91)岁。患者为缓慢性心律失常或者严重心力衰竭,放置主动固定电极导线,测定有关参数并随访观察。结果手术顺利完成,未出现严重并发症。共使用主动电极导线151根,其中心室电极导线88根(右室流出道间隔部80根,右室流入道间隔部5根,右室中间隔3根);心房电极63根(右心耳37根,低位房间隔10根,高位房间隔10根,心房侧壁6根)。起搏参数在电极导线置入15min后可达到理想值。术后7天及出院后1,3,6个月随访无电极导线脱位,起搏参数与置入时比较没有差异。结论使用主动固定电极进行心脏特殊部位起搏是可行和安全的。     

起搏电极导线引起早期心脏穿孔临床特点及处理

目的:探讨起搏电极导线引起心脏穿孔后的临床表现、影像学特点,以及处理方法。方法:连续观察应用心室起搏电极导线引起早期心脏穿孔后的临床及影像学特点,所有患者均常规采用在外科保护及超声检测下直接牵引拔除进行处理。结果:8例患者发生早期心脏穿孔,确诊时间为2~8(5.4±2.1)d,手术处理时间为4~13(7.4±3.5)d。所有患者均出现起搏或感知功能异常,其中5例出现心前区疼痛,4例出现隔肌或胸部肌肉刺激症状,2例经超声心动图检查有少量心包积液,所有患者均成功经直接牵拉拔除电极导线,未发现心包积液增加及心脏压塞表现。结论:心室电极导线导致心脏穿孔后,有其特征,在外科保护及超声检测下经静脉直接拔除电极导线通常是安全可行的。     

固定螺旋主动固定导线植入早期及后期参数变化与安全性评价

目的 评价固定螺旋主动固定导线（Fineline Ⅱ EZ,美国波科公司）植入术中及术后3个月参数变化情况,评价其安全性.方法 2012年1月至2013年9月在青岛大学附属医院156例缓慢性心律失常患者行单腔或双腔起搏治疗,心室起搏导线均选用固定螺旋主动固定导线,经左或右侧锁骨下静脉置于右心室流出道间隔部,分别于导线旋入心肌即刻、旋入后5 min、术后即刻、术后3个月测试起搏参数：起搏阈值、导线阻抗和R波幅度,并观察术后有无导线脱位、导线穿孔、与经静脉有关的血栓形成及囊袋感染等严重并发症发生.结果 导线旋入即刻起搏阈值较高,5 min后明显下降[（0.76±0.22）V对（0.39±0.13）V,P＜0.001];术后即刻阈值较旋入5 min后进一步下降[（0.35±0.10）V对（0.39±0.13）V,P＜0.001].R波幅度在导线旋入后5 min测试较术后即刻降低[（12.70±4.94）mV对（8.94±4.07） mV,P＜0.001].术后仅1例患者出现导线脱位,无导线穿孔、囊袋感染等并发症发生.结论 固定螺旋主动固定导线旋入心肌5 min后起搏阈值明显降低,故可常规于旋入5min后进行测试,确定是否需要调整导线位置.固定螺旋主动固定导线在应用过程中是安全有效的.     

起搏电极导线引起心脏穿孔的处理策略研究

目的探讨起搏电极导线引起心脏穿孔的处理策略。方法研究入选2007年1月至2017年12月就诊于北京大学人民医院并明确诊断心脏穿孔的患者46例。回顾性分析患者的基本情况、穿孔电极类型、临床表现、胸片、超声心动图、CT、程控参数以及处理方法等。总结心脏穿孔的最佳处理策略。结果46例患者发生了心脏穿孔,急性心脏穿孔者23例(50.0%),发生于术后1~29(14±8)d,慢性心脏穿孔者23例(50.0%),发生于术后35~2555(1147±812)d。临床表现中以胸痛、肌肉跳动最常见,分别为18例(39.1%)、8例(17.4%)。程控参数中以起搏阈值升高为主,为42例(91.3%)。29例(63.0%)患者的胸片提示电极顶端紧贴或穿出心脏影外缘,20例(43.5%)患者的超声心动图提示心脏穿孔。6例接受胸部CT检查的患者均发现了心脏穿孔。本研究中由内科经静脉拔除电极导线者34例,成功拔除者32例(94.1%),2例患者因考虑术后心脏压塞风险较大,故保留原电极导线;外科参与电极导线拔除者12例,且全部(100%)成功拔除穿孔电极导线,44例心脏穿孔患者拔除穿孔电极导线后均未出现心包积液以及心脏压塞。结论心脏穿孔常以胸痛、膈肌刺激为主要临床表现,可通过程控、影像学检查明确诊断。在血流动力学稳定且无周围器官损伤的情况下,采用经静脉拔除穿孔电极的手术方式是安全可靠的。     

CT诊断右心房起搏器导线电极脱位合并右心房穿孔一例

<正>起搏器导线移位、穿孔是较少见的起搏器置入术后并发症,一旦发生可造成严重后果,应尽早诊断。心电图和胸部X线等常用方法有一定局限性,敏感性较低,CT可作为一种补充方法,弥补其不足,防止导线移位、穿孔的漏诊和误诊。1临床资料患者男性,76岁,2007年3月因病态窦房结综合征、阵发性心房颤动而置入心脏起搏器,模式为频率适应性双腔起搏。术后不适症状缓解,定期规律程控。近期多次出现心前     

主动固定电极导线的应用研究

目的探索主动固定电极导线行心脏起搏临床应用的可行性与安全性。方法将需要安置永久性心脏起搏器的60例病人,随机分为两组,30例用主动固定电极行右心房、右心室间隔部起搏(主动电极组),30例用被动固定电极行右房心耳部、右室心尖部起搏(被动电极组),记录两组在术中、术后的各项参数并进行比较。结果两组均顺利完成手术,未出现严重并发症。两组曝光时间无明显差异。主动电极置入后5min后可达到理想阈值。两组起搏阈值、R波波幅置入时比较无明显差异。主动电极组置入时起搏阻抗、P波波幅较被动电极组低,但7d后,两组无明显差异。所有病人均在术后7d和出院后1个月、3个月进行随访。术后7d、1个月时两组起搏阈值均升高,相反,阻抗降低。3个月时均恢复至置入时水平,两组比较无明显差异。起搏心电图比较,主动电极组的QRS、P波宽度均较被动电极组窄,差异有统计学意义(P<0.05)。被动电极组有1例发生电极脱位,主动电极组均未发生电极脱位。结论使用主动固定电极行心脏起搏是可行的、安全的。     

主动固定型心脏起搏电极导线的临床应用

随着人口的老龄化和心脏起搏适应证的拓宽，心脏起搏器的植入数量逐年增加。起搏导线的植入在起搏系统植入中占有举足轻重的地位，而主动固定螺旋起搏导线的临床应用除有减少导线脱位、植入较快，容易拔除等优点外，同时还可以选择部位起搏，是心脏起搏学领域今后应用的方向。现将山西省心血管疾病医院今年开展的6例主动固定起搏电极导线植入报道如下。     

双心腔主动电极起搏与心房被动心室主动电极起搏的对比研究

目的:观察心房心室双螺旋主动电极在双腔心脏起搏器植入术中的有效性和安全性。方法:回顾性将90例符合双腔起搏器植入指征的患者分为心房心室双螺旋主动电极组(双螺旋电极组42例)与心房被动电极、心室螺旋主动电极组(单螺旋电极组48例)。观察2组术中及术后随访情况。结果:2组均成功植入起搏器及起搏电极。双螺旋电极组中1例孕妇零射线下完成双螺旋电极及起搏器植入;4例永存左上腔静脉患者在左侧锁骨下完成双螺旋电极及起搏器植入。双螺旋电极组和单螺旋电极组的手术时间及射线时间无显著差别,双螺旋电极组术后卧床时间显著缩短[(4.2±1.5)h vs(56.3±22.5)h,P0.05]。单螺旋电极组术中出现心房电极导线脱位3例,双螺旋电极组未见导线移位、心肌穿孔及心包填塞等情况。术后随访,2组均无电极脱落和起搏阈值升高。结论:心房心室双螺旋主动电极在双腔心脏起搏器植入术中安全可行,并不增加手术时间和射线时间,特别是应用于心腔结构异常和特殊患者,显著增加手术成功率。     

Tricuspid valve malfunction and ventricular pacemaker lead: case report and review of the literature

Pacemaker implantation can be associated with several complications, including myocardial perforation with or without pericardial effusion, venous thrombosis, vegetations of the tricuspid valve (TV) or pacing lead, and tricuspid regurgitation (TR). The TR is thought to be derived from deformity or perforation of the TV by the pacing lead or secondary to atrioventricular discordance with asynchronous ventricular pacing. Severe TR can be deleterious to the patient because it raises the central venous pressure by increasing the right sided preload. Chronically, the increase in right sided blood volume can result in an increase in the right atrial pressure leading to a decrease in venous return and low cardiac output. Severe TR from leaflet adhesion to the pacemaker lead has not been reported before. With the aging of the population and the expanding use of pacemakers and implantable cardioverter defibrillators (ICD) in clinical practice, this complication may be seen more frequently. We present a patient diagnosed with severe TR, years after his pacemaker implantation. His TR was thought to be caused by adhesion of the tricuspid valve to his pacemaker lead.     

心电图判断起搏器主动固定电极的可靠性

目的探讨永久性起搏器植入术中,体表12导联心电图判断主动固定电极固定的可靠性的意义。方法选择2011年1月至2012年8月我院心内科住院的56例患者,男37例,女19例,年龄55．73岁,平均65±9岁,符合永久性起搏器植入适应证。右室电极采用流出道间隔部主动固定电极,12导联心电图,连接好肢体导联,而V,导联连接起搏电极远端,记录心内膜损伤电流,同时与美敦力公司2290型起搏器分析仪直接测量的损伤电流进行对比。结果V,导联测定的损伤电流sT段弓背上抬振幅至少≥5mV1且高于R波振幅,持续至少5rain时,与美敦力公司2290型起搏器分析仪直接测量的损伤电流的可靠指标相一致。螺旋电极旋出15min后,最后测定起搏参数,均符合起搏阈值≤1．0V、阻抗300～1000Ω、R波振幅≥5．OmV156例患者中,除3例右室流出道植入失败,被迫改为心尖部起搏外,另53例临床3个月随访发现,无一例电极脱位。结论12导联心电图机V1导联测定的损伤电流,可以作为起搏器主动固定电极植入可靠性的一项指标。     

永久起搏器主动固定电极导线的长期随访观察

目的观察主动固定电极导线的长期参数变化,并探讨其应用的稳定性。方法2006年1月至2007年8月在沈阳军区总医院植入永久起搏器并置放主动固定电极导线的患者124例（共心房电极1根,心室电极124根）,其中男67例,平均年龄为（69±9）岁。植入部位：右心耳1例,室间隔93例,心尖部31例。测试手术后即刻及术后1、3、6、12个月的参数变化。结果参数变化：起搏阈值：手术即刻增高,术后1个月下降,两者有显著的统计学差异,术后3、6、12个月起搏阈值与术后1个月比较无明显改变。感知：手术即刻与术后多次随访均无明显变化。阻抗：手术即刻增高,术后随访各个月的阻抗均较手术即刻的阻抗低,与术中比较有显著统计学差异。2例患者在术后6个月时阈值升高。结论主动固定电极导线固定较牢固,脱位率低于被动固定电极导线,术后阈值升高发生率较低（1.6%）,长期观察参数均较稳定。     

Current of injury predicts adequate active lead fixation in permanent pacemaker/defibrillation leads

OBJECTIVES: The aim of this study was to determine whether current of injury can guide adequate placement of active-fixation pacing leads. BACKGROUND: Active-fixation leads cause injury to the myocardium at the time of fixation, manifested as a current of injury (COI) that may result in acute elevation of pacing thresholds. The relationship of COI to subsequent improvement in pacing thresholds is not clear. METHODS: Sixty-five patients undergoing active-fixation lead implantation were enrolled. Current of injury was characterized as the duration of the intracardiac electrogram (EGM) and the magnitude of ST-segment elevation. Pacing parameters were measured up to 10 min after fixation. RESULTS: A total of 96 active-fixation leads were studied, and 76 leads had a current of injury. From baseline to the time of fixation, the duration of the intracardiac EGM in ventricular leads increased from 150 +/- 31 ms to 200 +/- 25 ms (p < 0.001), and the ST-segment increased from 1.5 +/- 0.2 mV to 10.0 +/- 2.0 mV (p < 0.001), with subsequent improvement in pacing thresholds from 1.5 +/- 0.4 V to 0.8 +/- 0.3 V (p < 0.001) at 10 min. Atrial leads with a current of injury had similar findings. Of the 20 leads without a COI, 5 dislodged acutely and 15 had high pacing thresholds at 10 min, requiring repositioning. CONCLUSIONS: The development of a COI indicates that within 10 min of fixation, pacing threshold will return to an acceptable range even if the initial measurement is high. Conversely, without a COI, lead fixation is not adequate and the lead should be repositioned.     

经皮冠状动脉介入治疗并发心包积液及心脏压塞的临床分析

目的 了解经皮冠状动脉介入治疗(PCI)中心包积液／心脏压塞发生率、发生的相关因素、处理以及预后，为PCI的正确操作及合理选用器械提供参考。方法 分析了1246例PCI资料，包括住院病历、PCI操作记录、护理记录和影像学资料，判定心包积液／心脏压塞发生原因、时间、临床表现、处理方式和结果。结果 共8例心包积液(0．64％)、3例心脏压塞(0．24％)，其中10例(91％)在导管室确诊，1例(9％)延期发现。冠状动脉造影直接发现导引钢丝和／或球囊致冠状动脉穿孔9例(81．8％)，其中球囊通过冠状动脉破口未扩张2例，球囊通过冠状动脉破口并扩张1例，冠状动脉穿孔多发生在慢性完全闭塞性病变(CTO)；通过临床表现、超声心动图证实起搏电极导线致右心室穿孔2例(18．2％)，均出现在心肌梗死后患者。球囊通过冠状动脉破口并扩张1例，发生迟发性心脏压塞，6h后急诊外科干预引流后治愈；右心室临时起搏电极导管穿破右心室2例，1例行心包穿刺术，另1例心包穿刺后留置猪尾导管引流2d成功治愈。结论 冠状动脉及右心室穿孔是PCI并发心包积液／心脏压塞的主要原因，前者多发生在CTO患者，后者易出现于心肌梗死后患者。正确的操作方法及合理的器械选择可能减少此并发症的发生。冠状动脉穿孔较心室穿孔易于诊断，心包积液／心脏压塞多数能在导管室早期发现，并能得以合理的处理。     

Use of an Active-Fixation Coronary Sinus Lead to Implant a Biventricular Pacemaker via the Femoral Vein

Cardiac resynchronization therapy, which involves the placement of a pacing lead in the right atrium and in each ventricle, is effective in treating heart failure that is caused by left bundle branch block and cardiomyopathy. The left ventricular lead is usually placed into a lateral branch of the coronary sinus via the subclavian route. When the subclavian route is unavailable, insertion of a standard, passive-fixation coronary sinus lead via the femoral approach is feasible; however, the likelihood of subsequent dislodgment is high. Herein, we describe the placement of a novel, self-retaining, active-fixation coronary sinus lead—the Attain StarFix® Model 4195 OTW Lead—in an elderly heart-failure patient, via the femoral approach. We believe that this is the 1st report of this procedure.Key words: Aged, 80 and over; cardiac pacing, artificial/methods; cardiomyopathy; catheterization, central venous/contraindications; electrodes, implanted; femoral vein; heart failure/complications/therapy; quality of life; treatment outcomeIn cardiac resynchronization therapy, coronary sinus (CS) lead placement is required for the implantation of an endocardial biventricular pacemaker. The insertion of passive-fixation CS leads via the femoral vein¹ is typically avoided because of the high likelihood of lead dislodgment, although this route remains useful when subclavian venous access is unattainable. Here, we describe our use of the femoral approach in combination with an active-fixation CS lead to place a biventricular lead system and pacemaker in an elderly patient.     

Surgical treatment of ventricular and pericardial perforation by a permanent pacing lead: a case report

An 83-year-old woman was transferred to our hospital because of pacing failure and suspected ventricular perforation by a permanent pacing lead. She had undergone permanent pacemaker implantation 5 months previously. Chest radiography showed the pacing lead running out of the cardiac shadow. Computed tomography and echocardiography confirmed the diagnosis of ventricular perforation by the pacing lead. No evidence of cardiac tamponade was found. The lead was surgically removed through a median sternotomy. Intraoperatively, the lead was found perforating the ventricle and the pericardium, and reaching into the left pleural cavity but not injuring the left lung. A pacing lead may potentially injure the heart or the lung. Regular check-up of lead position and pacing status is recommended.