程序胸壁刺激试验对DDD起搏器各功能间期的检测

１０例ＤＤＤ起搏器置入者，其中８例Ｃ．Ｐ．ＩＤｅｌｔａ９３７型，２例ＢｉｏｔｒｏｎｉｋＧｅｍｎｏｓ型，置入时间平均为１７．９±９．９个月，均在寿命期内且运转正常。使用程序胸壁刺激试验对起搏器各功能间期进行了检测。采用程序单刺激（ＲＳ２）法，测得心房不应期平均为２４３±１４．９ｍｓ，与出厂额定值２４５±１０ｍｓ相比，差异无显著性（Ｐ＞０．０５）。使用连续递增（Ｓ１Ｓ１）法刺激，测定ＤＤＤ起搏器跟踪快速心房频率的反应，在上限频率（ＵＲＬ）范围内，均按１：１触发心室起搏。刺激频率超过ＵＲＬ后，则以文氏型传导方式或以２：１传导阻滞方式触发心室起搏，从而可免于发生快速心室起搏反应。检查发现，在一定频率范围内，行胸壁连续快速刺激，可以使体内ＤＤＤ起搏器的房、室起搏均受到抑制。此外源性刺激频率范围形成ＤＤＤ起搏器的全抑制区（ＣＩＡ），经测定Ｄｅｌｔａ９３７和Ｇｅｍｎｏｓ型的ＣＩＡ分别为９０～１２６３±３１７次／分和９０～５１０±１４次／分。继续增加刺激频率超过ＣＩＡ，ＤＤＤ起搏器则自动转换为ＤＯＯ方式，以下限频率起搏。说明ＤＤＤ起搏器对外电干扰有自动保护能力，但在ＣＩＡ频率范围内的外电干扰仍可使起搏器抑制而具一定危险性。     

室性心律失常患者的心率变异性分析

为研究自主神经系统活动在室性心律失常发生中的作用，分析３５例正常人（对照组）、３４例无器质性心脏病室性心律失常者（无心脏病组）及３５例器质性心脏病室性心律失常者（心脏病组）的心率变异性。结果显示（１）与对照组比较，无心脏病组ＳＤＮＮ、ＰＮＮ５０、ＲＭＳＳＤ、ＨＲＶＴＩ显著降低（Ｐ〈０．０５～０．０１），ＳＤＡＮＮ、ＳＤＮＮＩｎｄｅｘ无显著差异（Ｐ〉０．０５）；而心脏病组各项指标均非常显著降低（Ｐ〈     

植入VVI型起搏器伴心律失常62例分析

植入ＶＶＩ型起搏器伴心律失常６２例分析段宝祥，耿其吉，戴国强，戴苏泉，查铭凡，黄进（南京市第一医院心内科南京２１０００６）我院于１９７９～１９９２年对２１４例植入ＶＶＩ型起搏器患者进行随访，随访时间１～１２年。在随访中发现起搏器功能正常者伴有心律失常...     

埋藏式起搏器治疗老年缓慢型心律失常52例远期随访

我们对５２例安置埋藏式心脏起搏器的老年缓慢型心律失常患者进行了远期随访观察，现报告如下。１临床资料１．１一般资料本组男３４例，女１８例；安置起搏器时的年龄为５８～７７岁。基础疾病为冠心病、高血压病、心肌炎及心肌病。心律失常为病窦综合征（ＳＳＳ）、Ⅱ～...     

病态窦房结综合征生理性起搏治疗

对１１例ＳＳＳ患者安置了生理性起搏器，其中７例应用彩色三维超声心动图比较了心房按需型起搏（ＡＡＩ）、房室顺序起搏（ＤＶＩ）与单心室按需起搏（ＶＶＩ）三种不同起搏方式的血液动力学改变。结果显示ＡＡＩ、ＤＶＩ起搏较ＶＶＩ起搏每搏量明显增加分别达３７％、２０％（Ｐ＜０．０１）。通过程控调测、胸壁抑制试验、ＤＣＧ等定期随访患者心律失常及房室传导阻滞变化情况，在平均２０多个月的随访中尚未发现新的快速房性心律失常和传导阻滞，原有的房性心律失常也得到较好控制。认为ＳＳＳ患者的生理性起搏与ＶｖＩ起搏比较可产生较好的血液动力学效果，新的快速性房性心律失常及房室传导阻滞的发生率较低，因此对有适应症的ＳＳＳ患者应尽量选用。     

动态心电图在评估起搏器间歇性感知功能异常的作用

目的探讨动态心电图检测对起搏器间歇性感知功能异常的诊断价值。方法采用美国GESEERMC型三导及十二导联动态心电图仪，对48例（64例次）安装起搏器的患者进行随访，分析起搏、感知功能异常及与起搏器相关的心律失常。结果共检测出起搏器间歇性感知功能异常22例（39例次），检出率为45．83％。有7例（11例次）合并两项感知功能异常，所有感知功能异常除2例经常规心电图检出外，其余20例在动态心电图中被发现。检出与起搏器相关心律失常14例。经临床处理后，大部分起搏器的感知功能异常消失。结论起搏器的感知功能异常多为间歇性，而动态心电图对其检出率高，是起搏器随访不可缺少的手段。     

动态心电图在起搏器随访中对心律失常的分析

目的 观察动态心电图(DCG)对起搏器随访时的心律失常分析.方法 采用美国博利屋8000Ⅱ型3导联及美林公司12导联DCG,对128例人工心脏起搏器者行24h检测、分析.结果 检出起搏源性心律失常16例,自身传导系统引起的心律失常44例,电池耗竭引起的心律失常12例.结论 DCG对植入起搏器者的心律失常检出率较高,是起搏器随访的重要检查方法.     

病窦综合征的动态心电图评估及预后

９５例病窦综合征（ＳＳＳ）病人依据动态心电图（ＤＣＧ）表现，分为Ⅰ型：严重而持续的窦性心动过缓（窦缓）；Ⅱ型：窦缓伴窦性停搏或窦房阻滞；Ⅲ型：慢快综合征；Ⅳ型：双结病变。其中双结病变型晕厥或黑朦发生率（７０．６％）明显高于其他各型。临床表现晕厥或黑朦者ＤＣＧ平均间歇时间为４．９±０．７秒，显著长于无症状者（２．６±０．１ｓ），Ｐ＜０．００１。９５例中２２例行电生理检查。将Ⅱ型和Ⅳ型中有电生理检查结果的１５例依据窦性暂停或窦房阻滞时间分为间歇时间≥３ｓ组和间歇时间＜３ｓ组，发现平均ＳＮＲＴ前者（３１５７±３６８ｍｓ）显著长于后者（１９５２±２１８ｍｓ），Ｐ＜０．０５。ＤＣＧ间歇时间与ＳＮＲＴ间存在明显的正相关（ｒ＝０．６，Ｐ＜０．０５）。对未用起搏治疗的５６例进行了平均为期９年半的长期随访，结果显示该组病例有相当长的自然病史，随访期间无死于本综合征者。结论：ＤＣＧ作为无创伤性检测方法，在对ＳＳＳ的评估中具有不可替代的作用。起搏治疗虽可显著改善ＳＳＳ病人生活质量，但对远期预后影响不大。     

心房超常传导与房性心律失常相关性探讨

目的：探讨心房超常传导（ＳＮＣ）与房性心律失常发生之间的关系。方法：按常规行心内电生理检查，观察有无ＳＮＣ发生及心房超常传导带与传导时间最大减少值。结果：有自发或诱发房性心律失常者（Ⅰ、Ⅱ组），ＳＮＣ检出率较无自发或无诱发房性心律失常者（Ⅲ组）明显增加（Ｐ＜０．０５）；３６例有ＳＮＣ者中２０例（５５．５６％）有自发或诱发的房性心律失常，而３９例无ＳＮＣ者中仅８例（２０．５１％）有自发或诱发的房性心律失常，两者比较相差非常显著（Ｐ＜０．００５）。结论：ＳＮＣ与房性心律失常的发生密切相关。     

中老年起博器植入患者的动态心电图分析

目的探讨动态心电图（DCG）监测对起搏器起搏及感知功能异常的诊断价值。方法采用美国惠普43400B型DCG分析系统,对95例年龄在50岁以上植入起搏器的患者进行随访,分析起搏、感知功能及与起搏器相关的心律失常并与常规心电图对照。结果共检出起搏器功能障碍23例,其中间歇性起搏功能障碍2例（占2%）,间歇性感知功能障碍21例（占22%）。检出与起搏器相关的心律失常17例（18%）。而常规心电图仅发现感知功能障碍2例。两种检查方式在检测间歇性感知功能障碍及与起搏器相关的心律失常方面存在显著性差异（P<0.01）。检出起搏功能异常的差异性未达到显著水平。DCG对3种类型（AAI、VVI、DDD）之间感知功能异常检出率无显著性差异。根据DCG结果,进行临床相应处理后,起搏器的起搏及部分感知功能障碍消失,相关心律失常引起的临床症状逐渐消失。结论起搏器的起搏、感知功能障碍及与起搏器相关的心律失常多为间歇性发生,DCG对其检出率较高,并可系统了解起博器工作状态及各种心律失常,是对起博器随访的重要手段之一。     

Benefits of dual chamber pacing in sick sinus syndrome

The effects of DDD (fully automatic) and VVI (ventricular demand) pacing modes on exercise tolerance, symptom diary cards, and Holter monitoring were investigated in a randomised double blind crossover study of 16 patients who had had DDD pacemakers implanted because of frequent syncope. Eight patients presented with sick sinus syndrome and, with one exception, retrograde atrioventricular conduction and eight age and sex matched patients presented with 2:1 or complete atrioventricular block. Maximal symptom limited exercise in those with atrioventricular block was significantly higher after one month of DDD pacing than after VVI pacing. In those with sick sinus syndrome, however, maximal effort tolerance was not significantly different for the two pacing modes. In all but one patient with sick sinus syndrome sinus rhythm developed during exercise in VVI pacing. For both VVI and DDD modes maximal atrial rates were significantly lower in those with sick sinus syndrome. Palpitation and general wellbeing were significantly improved during DDD pacing in the eight patients with sick sinus syndrome. Shortness of breath was improved by DDD pacing in the eight patients with atrioventricular block but not in those with sick sinus syndrome. Holter monitoring showed that sick sinus syndrome patients remained in paced rhythm, either DDD or VVI, for most of the 24 hour period. DDD pacing was better than VVI pacing in sick sinus syndrome with retrograde atrioventricular conduction. Despite their ability to show sinus rhythm and inhibit their pacemakers on exercise patients with sick sinus syndrome are just as likely to have symptomatic benefit from DDD pacing as patients with atrioventricular block.     

Benefits of dual chamber pacing in sick sinus syndrome.

The effects of DDD (fully automatic) and VVI (ventricular demand) pacing modes on exercise tolerance, symptom diary cards, and Holter monitoring were investigated in a randomised double blind crossover study of 16 patients who had had DDD pacemakers implanted because of frequent syncope. Eight patients presented with sick sinus syndrome and, with one exception, retrograde atrioventricular conduction and eight age and sex matched patients presented with 2:1 or complete atrioventricular block. Maximal symptom limited exercise in those with atrioventricular block was significantly higher after one month of DDD pacing than after VVI pacing. In those with sick sinus syndrome, however, maximal effort tolerance was not significantly different for the two pacing modes. In all but one patient with sick sinus syndrome sinus rhythm developed during exercise in VVI pacing. For both VVI and DDD modes maximal atrial rates were significantly lower in those with sick sinus syndrome. Palpitation and general wellbeing were significantly improved during DDD pacing in the eight patients with sick sinus syndrome. Shortness of breath was improved by DDD pacing in the eight patients with atrioventricular block but not in those with sick sinus syndrome. Holter monitoring showed that sick sinus syndrome patients remained in paced rhythm, either DDD or VVI, for most of the 24 hour period. DDD pacing was better than VVI pacing in sick sinus syndrome with retrograde atrioventricular conduction. Despite their ability to show sinus rhythm and inhibit their pacemakers on exercise patients with sick sinus syndrome are just as likely to have symptomatic benefit from DDD pacing as patients with atrioventricular block.     

Pulmonary vein isolation for atrial fibrillation in patients with symptomatic sinus bradycardia or pauses

Introduction: Sick sinus syndrome is commonly associated with tachyarrhythmias and bradyarrhythmias that often are symptomatic. The aim of this study was to assess the effect of pulmonary vein isolation in patients with sick sinus syndrome and atrial fibrillation (AF).
Methods and Results: Three hundred fourteen consecutive patients who underwent pulmonary vein isolation between December 2000 and January 2002 were included in the study. Thirty-one patients had sick sinus syndrome, which was defined as a preprocedural history of symptomatic sinus bradycardia or pauses. Endpoints included AF recurrence, change in the frequency of sinus pauses, and symptoms of presyncope or syncope, as well as mean heart rate and percentage of atrial pacing in patients with pacemakers implanted prior to the pulmonary vein isolation. Patients had AF for an average of 6 ± 3 years. Patients were 58 ±8 years old and had ejection fractions of 55 ± 4%. Sixty-one percent had implanted pacemakers. AF recurred within 6 months in 4 patients. Two had a successful second pulmonary vein isolation procedure. There were no recurrences of presyncopal events (P < 0.05) or documented sinus pauses (P < 0.05) after successful pulmonary vein isolation in the patients without permanent pacemakers. Patients with pacemakers had a 13-fold reduction in the percentage of atrial pacing (P < 0.05). Both groups showed a significant increase in average heart rates at 6-month follow-up.
Conclusion: Cure of AF by pulmonary vein isolation helped resolve the clinical manifestations of sick sinus syndrome, suggesting that the occurrence of AF and/or the associated treatment could be partially responsible for sick sinus syndrome. (J Cardiovasc Electrophysiol, Vol. 15, pp. 784-789, July 2004)     

全军心律失常介入治疗资料总汇

目的汇总分析全军心律失常介入治疗资料,了解此领域工作的现状与不足。方法由全军心血管内科专业委员会组织对2005年1月1日至2006年12月31日期间全军医疗单位心律失常介入治疗资料进行注册登记和统计分析。结果①此次注册共收到全军40家医院共9 934例注册资料。开展射频消融(RFCA)工作的医院共33家,注册病例数6 242例,其中开展三维标测技术治疗快速心律失常的医院有9家,病例数达180例;开展心脏器械置入治疗工作的医院共39家,病例数3 656例。②6 242例RFCA注册资料总成功率97.45%,复发率2.12%,并发症发生率0.54%。各类心律失常中,房室折返性心动过速(AVRT)最多,房室结折返性心动过速(AVNRT)次之,AVRT和AVNRT成功率始终保持在较高的水平,而心房颤动(AF)的复发率最高。34例并发症中血管并发症和完全性房室传导阻滞占绝大部分。③多家单位开展了新型三维标测系统治疗复杂快速性心律失常。180例注册病例中,AF最多、共110例(61.11%),成功率99.09%,复发率24.55%;非特发性室性心动过速(non-IVT)次之、共26例(14.44%),成功率88.46%,复发率8.33%;其余类型心律失常完成例数较少。④3 656例心脏器械置入病例总成功率99.92%(3 653/3 656),并发症发生率1.94%(71/3 653)。在各种器械置入适应证中,病窦综合征占最大比例,其次为房室传导阻滞。双腔起搏比例远超过心室单腔起搏。三腔双心室起搏器及埋藏式心脏转复除颤器的临床应用尚较少。结论全军心律失常介入治疗发展迅速。     

Pacing interventions for falls and syncope in the elderly

There is a high prevalence of cardiovascular disorders among elderly patients with recurrent falls or syncope, and cardiovascular causes are implicated in a significant proportion of three cases. Common cardiovascular causes of falls and syncope include carotid sinus syndrome, vasovagal episodes, sick sinus syndrome, and atrioventricular block. A comprehensive history and physical examination supplemented by electrocardiographic monitoring, carotid sinus massage, and tilt-table testing in appropriately selected patients form the basis of the diagnostic evaluation to exclude a significant cardiovascular disorder. Patients with documented symptomatic bradycardia often benefit from pacemaker implantation, as evidenced by a reduction in recurrent events and improved quality of life. Although dual-chamber pacemakers, particularly those with rate responsiveness, provide more physiologic pacing than single-chamber ventricular devices, the superiority of dual-chamber pacemakers in reducing major clinical events has not been demonstrated. The efficacy of an aggressive evaluation and patient-management strategy that includes pacemaker implantation for elderly patients with recurrent falls has been validated only by one prospective clinical trial; however, available data are compelling. For a variety of cardiovascular conditions, permanent pacemaker implantation has a demonstrated efficacy to prevent symptoms that arise from transient hypotension and decreased cerebral perfusion. The implication of these data is that many falls may be preventable through permanent pacemaker implantation in appropriately selected patients.     

心律失常的起搏治疗

为探讨永久性人工心脏起搏器及埋藏式心内自动除颤器(ICD)纠治重症缓慢性及快速性心律失常的临床疗效、心律失常类型与起搏模式的关系,对我院植入永久性人工心脏起搏器及ICD的102例患者进行回顾性分析.结果53例病态窦房结综合征患者植入DDD或VVI,48例房室传导阻滞植入DDD、VDDR或VVI,1例室性心动过速、心室颤动、反复心脏停搏患者植入ICD后临床症状均明显改善或消失.提示植入合适的永久性人工心脏起搏器及ICD,对重症缓慢性心律失常及致死性快速性心律失常能起到良好治疗作用.     

病态窦房结综合征患者非典型性胸痛的临床意义

目的探讨病态窦房结综合征患者非典型性胸痛的病因及临床意义。方法 对34例临床诊断为病态窦房结综合征且需安装心脏永久起搏器、同时伴有非典型性胸痛的患者,在行心脏永久起搏器植入术的同时或术前和术后行冠状动脉造影术,分析冠状动脉病变及左心室功能,其中21例在冠状动脉造影时行乙酰胆碱试验。结果31例患者冠状动脉均正常或狭窄程度<50％,3例患者冠状动脉狡窄程度>75％,但在心动过缓患者可见冠状动脉血流速度明显缓慢。部分患者左心室明显扩大、左心室射血分数足室壁运动降低,9例乙酰胆碱试验阳性。无严重冠状动脉病变者多在起搏器植入术后或合并钙拮抗剂治疗后胸痛消失。结论 病态窦房结综合征患者的非典型性胸痛多数不具有严重冠状动脉病变基础,可能与心动过缓所导致的冠状动脉血流缓慢或冠状动脉痉挛有关,在安装起搏器和服用钙拮抗剂后胸痛多缓解。     

Improvement of symptoms in patients with sick sinus syndrome by spontaneous development of stable atrial fibrillation.

Fifty-six patients with symptomatic chronic sinus bradycardia because of sick sinus syndrome (SSS) were followed for periods from one month to 11 years (average 3-2 years). Eleven developed stable atrial fibrillation persisting for 8 to 61 months; 52 had permanent demand pacemakers implanted before atrial fibrillation commenced. In the 11 patients with atrial fibrillation, 10 had adequate ventricular rate, 8 with rates greater than 100 beats/min requiring digoxin for rate control. The 8 patients with atrial fibrillation with pacemakers remained asymptomatic for 13 to 18 months without requiring reimplantation; battery failure occurred in 2 whose rapid ventricular rates were controlled by digoxin. In the other 6 patients with pacemakers who developed atrial fibrillation, adequate ventricular rates persisted resulting in overdrive suppression. No patient had systemic embolisation. The previous duration of symptomatic sinus bradycardia was longer in patients developing atrial fibrillation (average 5-5 years) compared (P less than 0-01) with patients without atrial fibrillation (1-9 years). Further, premature atrial contractions occurred in all 11 patients before atrial fibrillation in contrast to only 21 of the 45 patients without atrial fibrillation. It is concluded that occurrence of atrial fibrillation in SSS with symptomatic sinus bradycardia provides a natural cure of symptoms caused by bradycardia. These data indicate that permanent ventricular pacing may not be necessary if persistent atrial fibrillation develops in SSS.     

Realisierbarkeit und Sicherheit einer alleinigen AAI(R)-Schrittmacherbehandlung beim isolierten symptomatischen Sinusknotensyndrom

Recent investigations prove that AAI(R) pacing is the "ideal" stimulation mode in isolated sick sinus syndrome. Nevertheless, in Germany this bradycardia is treated by AAI(R) pacemakers in less than 4% of cases compared to 25% in other countries. In our institution treatment of patients with isolated sick sinus syndrome is uniform and corresponds to the actual guidelines since the early 1990s; therefore the aim of our study was to analyze feasibility and safety of AAI(R) pacing in a retrospective study.Between 1998 and 2000, 52 of 165 patients (31.5%) with isolated sick sinus syndrome were treated by an AAI(R) pacemaker. The median follow-up duration was 51.5 months (minimal: 36 months). 6 patients died, in all cases unrelated to the stimulation mode. Three patients required reoperations, however, in only one case due to second degree AV block with the need for upgrading to DDD stimulation. Thus, the yearly incidence of this specific complication in the AAI(R) cohort is 0.64%.In conclusion, permanent atrial stimulation in isolated sick sinus syndrome is feasible in a quarter of all cases. It is safe if performed corresponding to actual guidelines. Additionally, single lead AAI(R) pacing is a cost-effective therapy and the only stimulation mode which, today, reliably prevents unnecessary right ventricular stimulation. If, on the other hand, algorithms providing automatic mode switching from AAI to DDD and vice versa are implemented reliably into all dual chamber pacemakers, single chamber atrial pacing will no longer be a subject for discussion.     

Pacemaker syndrome and retrograde ventriculoatrial conduction

19 cases of pacemaker syndrome were observed in 121 patients implanted with VVI pacemakers. The main manifestations of pacemaker syndrome were dizziness, lightheadedness, fatigue, hypotension and congestive cardiac failure after permanent ventricular pacing. The incidence of pacemaker syndrome was 20% in patients with sick sinus syndrome and 13.2% with A-V block. Pacemaker ECG showed retrograde ventriculoatrial conduction in 25 of 121 cases. Among these patients, 14 (56%) had pacemaker syndrome, while only 5 of 96 cases without ventriculoatrial conduction had this syndrome, so the incidence of the two groups were quite different, P less than 0.0001. The frequency of ventriculoatrial conduction in patients with sick sinus syndrome was higher than in patients with A-V block (16/45 vs 9/76, P less than 0.05). The electrophysiologic study were performed in 17 cases before PM implantation. 3 cases had 170-190 ms ventriculoatrial 1:1 conduction. Retrograde ventriculoatrial conduction in pacemaker ECG were present during ventricular pacing in all of them.