Amplaze Left 1造影导管在心脏再同步化治疗手术中的应用

目的心脏再同步化治疗(CRT)的技术关键是植入左室导线。笔者介绍用Amplaze Left 1造影导管寻找冠状静脉窦的方法。方法选择充血性心力衰竭伴完全性左束支传导阻滞患者18例。应用Amplaze Left1造影导管快速寻找冠状静脉窦后进行逆行冠状静脉窦造影,经冠状静脉窦插入导线至心脏静脉相关分支进行左室起搏,然后植入右房和右室电极导线。结果18例均成功应用Amplaze Left 1造影导管很容易地寻找到冠状静脉窦。结论Amplaze Left 1造影导管用于CRT术中寻找冠状静脉窦简便易行,成功率高。     

初期开展心脏再同步化治疗慢性心力衰竭的效果及技术难点

目的总结分析初期开展心脏再同步化治疗(CRT)慢性心力衰竭(简称心衰)的效果及技术问题。方法对20例植入CRT/CRTD的患者观察术前、术后6个月的心功能指标,描述左室电极的植入过程,随访患者预后。结果术后6个月有关心功能指标均明显改善(P均<0.01),随访32.9±21.9个月,死亡4例,其中1例猝死,3例非心脏原因死亡。左室导线进入冠状窦失败改为右室双位点起搏2例(2/20,10%),左室导线难以固定于靶静脉改为经心中静脉与靶静脉吻合支1例(1/20,5%),冠状静脉阶段性狭窄1例(1/20,5%),术后导线脱位3例(3/20,15%)均成功复位。术前冠状动脉造影/冠状静脉显影9例(9/20,45%),术中测试左室电极刺激膈肌跳动经调整电极位置均可避免。结论 CRT治疗心衰有效;术前冠状动脉/冠状静脉造影对指导和易化左室导线植入有益。右室双位点起搏改善心衰不明显,适当调整电极可避免膈肌刺激。     

117例双心室再同步起搏器植入术并发症分析

目的　双心室同步起搏已经被证明可有效改善充血性心力衰竭患者的心功能。进行双心室再同步治疗 (cardiacresynchronizationtherapy ,CRT)的技术关键是植入左心室导线。植入左心室导线技术难度大 ,操作复杂 ,有一定的并发症发生率 ,本文分析了 117例双心室起搏器植入术并发症。方法　充血性心力衰竭伴心室内阻滞患者 117例 ,其中男性 86例 ,女性 31例 ,平均年龄 (5 3 0 0±8 2 5 )岁。患者在进行逆行冠状静脉窦造影后 ,经冠状静脉窦插入导线至心脏静脉 (主要为心脏后静脉和侧后静脉 )进行左心室起搏。然后植入右心房和右心室电极导线。结果　 117例患者中 111例成功植入双心室起搏系统 ,成功率为 95 %。主要植入术的相关并发症包括 :冠状静脉窦夹层 4例(3 4 % % ) ,膈肌刺激需要重新植入 2例 (1 7% ) ;电极导线脱位 2例 (1 7% ) ,结论　双心室再同步治疗 (cardiacresynchronizationtherapywithbiventricularpacing)起搏器植入术有一定的术中并发症和一定的风险 ,术前应掌握好适应证并作好充分的准备 ,术中必须规范操作 ,严密观察 ,以减少并发症     

应用PTCA导引钢丝指引左心室电极导线的植入

双心室同步起搏已被充分证明可有效地改善充血性心力衰竭伴心室内传导阻滞患者的心功能[1,2 ] 。进行双心室同步起搏的一个技术关键是植入左心室起搏电极导线。目前可行并广泛应用的方法是经冠状静脉窦途径将电极导线插入心脏静脉起搏左心室 ,由于进入冠状静脉窦的心脏静脉较细、弯曲度大以及变异较多 ,直接用目前临床应用的冠状静脉窦电极导线插管难度大 ,X线照射时间长 ,且成功率受到影响。近来 ,一种新设计的带侧孔的 ,可用PTCA导引钢丝指引下插入的冠状静脉窦电极导线开始在临床应用。资料和方法2 2例充血性心力衰竭伴心室内阻滞患者 …     

110例心脏再同步化治疗中左室电极导线植入的临床经验和并发症分析

目的探讨心脏再同步化治疗(CRT)中左室电极的植入方法、特殊病情的个体化处理及并发症的预防。方法对110例心力衰竭患者行CRT。左室电极植入的方法:冠状静脉窦(CS)插管、CS及心脏静脉逆行造影(RCV)、选择靶静脉并植入电极。根据RCV静脉解剖特点选择靶静脉及特殊情况个体化处理。观察左室电极植入的成功率、左室电极的型号、置入CS靶静脉的部位、并发症。结果左室电极植入成功率为96.4%(106/110),4例左室电极未成功植入者包括1例植入DDD双腔起搏器、2例植入埋藏式心脏转复除颤器(ICD)及1例行心外膜左室电极植入术。9例特殊情况需个体化处理,其中2例心侧静脉狭窄应用球囊扩张数次,3例应用多根经皮球囊扩张冠状动脉成形术(PTCA)导丝加强支撑下植入左室电极,4例需更换不同型号或厂家的电极(包括3例术中和1例择期更换)。术中发生冠状静脉夹层或心肌穿孔5例(4.7%),仅1例择期CRT成功,另4例发生轻微夹层,少量或未见心包积液,但血流动力学稳定未影响左室电极置入。术中急性左室心力衰竭4例(3.7%),室性心动过速、心室颤动2例(1.9%),均经治疗未影响手术。结论左室电极植入有一定的风险和难度,采取个体化处理策略,可提高左室电极植入的成功率、并使并发症降至最低限度。     

经皮冠状动脉成形术导丝在经冠状窦左室电极安置中的应用

目的研究和总结经皮冠状动脉成形术(PTCA)导丝在心脏再同步化治疗(CRT/CRT-D)患者左室起搏电极导线安置中的应用价值和技巧。方法 32例患者,心功能(NYHA分级)Ⅲ～Ⅳ级。左室射血分数0.31±0.05(0.23～0.35),左室舒张末期内径70±10(60～78)mm。根据冠状静脉窦及心脏静脉造影结果选择左室起搏电极的靶静脉,选用左室后静脉18例,心侧静脉14例。根据心脏静脉走行选择PTCA导丝(BMW导丝19例,ATW导丝8例。采用双导丝技术2例)或直接使用左室起搏电极的配套导丝(3例)将左室起搏电极送至靶静脉。结果左室起搏电极一次植入成功31例,另1例首次植入失败,第2次手术获得成功。左室电极首次植入成功率为97%。左室起搏阈值1.2±0.5V,阻抗947±231Ω,R波振幅10±3mV。结论应用PTCA导丝,并借鉴PTCA的一些操作技巧,可大幅提高经冠状窦左室起搏电极的植入成功率。     

心脏再同步治疗术中一些特殊情况的处理

目的心脏再同步治疗(cardiacresynchronizationtherapy,CRT)已被证实是治疗药物治疗无效的难治性充血性心力衰竭患者的一种有效方法。但是虽然植入技术在不断进展,仍然有许多问题尚未解决。本文介绍本组病例在术中出现的一些特殊情况的相应处理方法。方法从1999年2月至今50余例患者均成功完成CRT植入治疗。在3例患者中留置了经皮腔内冠状动脉成形术(PT-CA)导丝稳定导线。5例患者发生冠状静脉损伤,但仍顺利完成了植入手术。2例早期行CRT治疗的患者在起搏器更换时发现起搏阈值过高。结果留置PTCA导丝的3例患者术中测试起搏阈值满意,未出现任何并发症。5例发生冠状静脉损伤的患者也同样顺利完成冠状静脉导线的植入。2例患者在更换起搏器时成功拔除了2188导线。结论冠状静脉导线的植入是CRT治疗术中的关键步骤,及时发现和处理一些特殊的情况能提高手术的成功率。     

经永存左上腔静脉植入心脏再同步化起搏除颤器二例

两例扩张型心肌病患者均符合心脏再同步化治疗(CRT)Ⅰ类适应证而行CRT起搏除颤器(CRTD)安置术。术中均发现存在永存左上腔静脉,且均与上腔静脉无交通支(头臂静脉缺如)。心脏静脉粗大,冠状静脉分支较少。可供选择的靶静脉均为心中静脉。均自右侧路径植入右房及右室除颤电极导线。例1自冠状静脉口成功送入左室电极导线至靶静脉,例2因心中静脉太靠近冠状静脉口,而粗大的冠状静脉口使鞘管不能很好的支撑,多次尝试未果后选择自左侧永存左上腔静脉内送入左室递送系统并成功将左室电极植入心中静脉,经皮下隧道将左室电极拉至右侧与脉冲发生器相联。     

心脏再同步化治疗留置左室电极导丝致导线断裂后再植入1例

本文介绍1例患者,心脏再同步化治疗(cardiac resynchronization therapy,CRT)以侧静脉为靶血管,但左室电极导线不能送至远端且在近段难以固定,予留置导丝至靶血管远端以固定左室电极导线.术后左室阈值和电极导线阻抗升高,患者对CRT无反应.第2次手术选后静脉的侧支为靶血管,顺利将左室电极导线放置到侧壁区域,患者出现超反应.全面分析冠状静脉整体情况,选择合适路径放置左室电极导线十分重要.     

冠状动脉介入技术在经静脉左室电极植入中的应用价值

目的探讨冠状动脉介入(PCI)技术在心脏再同步化治疗(CRT)左室电极导线植入术中的应用技巧和价值。方法心力衰竭拟行CRT植入患者178例,观察术中经冠状静脉途径植入左室电极导线的成功率、PCI技术应用情况、靶静脉选择及参数测定情况及随访结果。结果①CRT植入成功率97.75%(174/178),4例手术失败;经冠状静脉左室起搏电极导线植入成功率98.28%(171/174),3例行开胸心外膜电极植入。②左室起搏电极植入左室后静脉2例,心侧静脉89例,侧后静脉54例,心中静脉侧分支23例,心大静脉3例。③86例次使用了PCI技术(50.29%),其中10例(5.85%)应用鞘中鞘技术指引导丝到达靶静脉,双导丝技术38例(22.22%),导丝锚定技术15例(8.77%),逆向导丝技术12例(7.02%),球囊导管扩张冠状静脉中段11例(6.43%)。④术中左室起搏阈值(0.96±0.49)V,阻抗(677.06±215.93)Ω,R波振幅(16±3)mV,术后半年内左室电极起搏参数稳定。结论运用PCI技术可协助经冠状窦左室起搏电极的植入,并提高成功率。     

心脏再同步化治疗的总结及分析

目的对心脏再同步化治疗(CRT)围手术期的处理进行探讨。方法对104例符合CRT植入指证的患者行CRT/心脏再同步化除颤器(CRTD)治疗和随访,并对围手术期的注意事项进行总结和分析。结果共成功植入CRT73例,CRTD28例。总手术成功率为97%(101/104),经心内膜成功率为93%(97/104),3例手术失败(2例术中发生急性肺水肿,1例术中发生心室颤动),另外4例因未找到冠状静脉窦开口或心脏静脉成角畸形明显或固定不可靠而分别改为右室双部位和心外膜电极。随访92%(93/101)有效,7例死亡,其中4例死于终末期心力衰竭,2例为心源性猝死,1例死于脑出血。结论 CRT手术安全、疗效可靠,应重视围手术期的管理。     

Coronary venoplasty during the implantation of the cardiac resynchronisation device--a case report

We describe a case of a 76-year-old patient with advanced block in the His-Purkjnie system, who underwent implantation of a cardioverter-defibrillator with cardiac resynchronisation therapy. Complete heart block occurred during the insertion of the coronary sinus cathether. The implantation of the left ventricular (LV) lead was impossible due to difficult anatomy of the coronary venous system. The right ventricular pacing caused the further prolongation of the QRS duration and exacerbation of heart failure symptoms. Thus, the LV lead was successfully implanted during the second procedure after the balloon venoplasty of the lateral cardiac vein. The biventricular pacing was successful during 4 months follow-up.     

Challenges and Solutions for Difficult Implantations of CRT Devices: The Role of New Technology and Techniques

Introduction: Cardiac resynchronization therapy (CRT) can markedly improve heart failure treatment in selected patients, but left ventricular (LV) lead implantation can be difficult or optimal lead position not obtainable.
Methods: This review examines newer techniques and technologies to optimize implant success. Goals of implant include placement of the LV lead in a coronary vein near the midlateral left ventricle with good lead stability, adequate thresholds, and no phrenic nerve stimulation. We will examine methods to access difficult and tortuous veins, test multiple veins for the best pacing site, and avoid complications. Newer technologies that will be discussed include magnetic wire navigation using Stereotaxis™, endoscopic, and CT-guided approaches, and nontraditional methods such as pericardial puncture for epicardial LV lead placement.
Conclusion: The methods discussed here may help to make CRT implant safer, faster, and more successful.     

一种新型Visionwire标测导丝在心脏再同步化治疗中的应用

目的探讨一种新型Visionwire标测导丝在心脏再同步化治疗(CRT)左室电极植入过程中的应用价值。方法 5例因心力衰竭接受CRT的患者,分别采用Visionwire导丝及左室电极到达可植入左室电极的冠状静脉(CS)分支内进行起搏参数测试及电生理标测,比较两种方法的起搏参数测试、电生理标测结果及手术时间。结果在5例患者的16个CS分支中,两种方法所测的起搏参数值无显著性差异,二者的起搏阈值有强相关性(r=0.90,P<0.01),感知亦有相关性(r=0.67,P<0.01),二者最大起搏电压引起膈肌刺激的部位相似。应用Visionwire导丝可以进行局部电位电激动顺序标测。Visionwire导丝对单个CS分支进行起搏参数测定比应用左室电极进行起搏参数测定所需时间明显缩短(12.4±7.5 min vs 18.3±12.2 min,P<0.01)。结论应用Visionwire标测导丝可以预测CS分支的左室电极起搏参数,根据局部电位延迟可准确定位左室电极植入部位。     

普通电极导线行右房左室或双心室起搏的初步临床观察

探讨普通电极导线置入心脏静脉起搏左室的可行性。选择 9例患者为研究对象 ,其中扩张型心肌病 3例、缺血性心脏病 3例、其他 3例 ,均伴不同程度的心力衰竭 ,心功能Ⅱ～Ⅳ级。所有患者都安置DDD起搏器。窦性心律伴房室阻滞 (AVB)或完全性左束支阻滞 (CLBBB)患者 ,行右房左室顺序起搏 ;房颤患者行双心室起搏。左心室起搏是将普通右心室导线 (MedtronicCapSureSP 4 0 2 3)通过冠状窦送入心脏静脉施行的。结果 :7例成功 ,2例失败。导线定位在左室后静脉 1例、后侧静脉 3例、侧静脉 3例。术中测左室起搏阈电压、阻抗和R波振幅分别是 0 .7± 0 .2V、6 2 3± 6 6Ω、10 .1± 6 .0mV。术后 2～ 18个月阈电压、阻抗分别是 0 .5± 0V、5 2 1± 5 1Ω。术后 1～ 2周平均心功能从2 .9级改善到 1.9级 ,平均心胸比值从 0 .6 1缩小到 0 .5 7,平均左室射血分数从 0 .39升至 0 .4 4。随访期未发现左室导线脱位 ,膈肌起搏等并发症。结论 :普通电极导线置入心脏静脉长期起搏左心室是可行的、牢靠的。     

Implantation of cardiac resynchronization therapy systems in the CARE-HF trial: procedural success rate and safety.

AIMS: To assess procedural characteristics and adjudicated procedure-related (300 cm(3); and, influence of the participating study-centres. Implantation was attempted in 404/409 patients assigned to CRT, and in 65/404 patients assigned to medical therapy. Among these 469 patients, 450 (95.9%) received a successfully implanted and activated device. Complications occurred within 24 h in 47 patients (10.0%), mainly lead dislodgments (n = 10, 2.1%) and coronary sinus dissection/perforation (n = 10, 2.1%), and between 24 h and 30 days in 26 patients (5.5%), mainly lead dislodgment (n = 13, 2.8%). Mean LV lead stimulation threshold was significantly higher than at the right atrium or right ventricle, though remained stable, delivering effective, and reliable CRT. Implanting experience was the only predictor of procedural outcome. CONCLUSION: Transvenous CRT system implantation, using a CS lead designed for long-term LV pacing, was safe and reliable. As implanting centres become more experienced, this success rate is expected to increase further.     

Electrical and mechanical cardiac resynchronisation by novel direct his-bundle pacing in a heart failure patient

Efficacy of standard cardiac resynchronisation therapy (CRT) by biventricular pacing via coronary sinus depends on the target site for left ventricular (LV) pacing, which in a not insignificant number of patients is limited by anatomical constraints. Direct His-bundle pacing (DHBP) is considered an alternative method of pacing for patients requiring cardiac stimulation in order to obviate detrimental effects of right ventricular pacing on LV function. However, its role in CRT has not been investigated, with scarce number of cases recently reported. We present a case of a heart failure patient in whom CRT was considered and treated by DHBP. In addition to electrical resynchronisation and optimal clinical response, echocardiography showed successful ventricular mechanical synchrony. To our knowledge, these latter findings are for the first time described in the setting of CRT by DHBP.     

Assessment of regional wall motion using strain Doppler imaging during right ventricular bifocal pacing in a patient with severe congestive heart failure: a case report

A 79-year-old man presented with dilated cardiomyopathy and chronic atrial fibrillation. A DDD pacemaker was implanted due to sick sinus syndrome. His left ventricular ejection fraction was 23%. He was repeatedly admitted with congestive heart failure. Although cardiac resynchronization therapy was attempted, insertion of a pacing lead into the coronary sinus failed. Right ventricular bifocal pacing was done. The QRS width was shortened to 155 msec during bifocal pacing and 157 msec during right ventricular outflow pacing from 221 msec during right ventricular apical pacing. Heart failure was improved from New York Heart Association class III to II. Regional wall motion was assessed by strain of the myocardium. Bifocal pacing increased stroke volume due to improvement of longitudinal dyssynchrony of the septal and lateral walls. Bifocal pacing is effective for patients with severe congestive heart failure in whom biventricular pacing therapy has failed. Strain Doppler imaging is useful for the assessment of regional wall motion during cardiac pacing.