ICD植入术后颈内、锁骨下、腋静脉血栓形成并治疗成功1例

ICD植入术后,起搏电极植入血管发生深静脉血栓(deep venous thrombosis,DVT)的报道罕见.本文报道1例穿刺血管血栓形成并经抗凝治疗成功患者. 1 病例报道 患者男性,19岁,因原发性室颤在我院行单腔ICD植入术,ICD电极通过穿刺左侧腋静脉植入右室心尖部,手术后一周拆线并顺利出院.但出院20天后患者逐渐出现左上肢酸涨、沉重感,伴左侧头部胀痛而重新入住我科.     

Brugada综合征一例

患者男,27岁。反复胸闷,心慌8年,不明原因夜间晕厥1次,无明显器质性心脏病。口服普罗帕酮诱发心室颤动,心电图表现:V1、V2是完全性右束支传导阻滞,ST呈穹隆形和鞍形抬高,T波倒置。经静脉滴注异丙肾上腺素后心电图恢复正常。上级医院证实为Brugagda综合征,置入埋藏式心脏转复除颤器。     

Current state of knowledge and experts’ perspective on the subcutaneous implantable cardioverter-defibrillator

ICD implantation is today a well-recognized therapy to prevent sudden cardiac death. The available implantable devices at present need the use of permanent endocavitary leads which may cause, in some instances, serious troubles to the patients (lead dislodgement, ventricular perforation, lead infections, etc.). A new implantable defibrillator provided by only a subcutaneous lead is at present under evaluation. Its potential indications, usefulness benefits, and problems represent an interesting field of investigation and discussion. This paper describes the conclusions recently reached by a panel of experts, with regard to the potential role of an implantable subcutaneous defibrillator in the prevention of sudden cardiac death.     

Prevalence and Predictors of Cable Extrusion and Loss of Electrical Integrity with the Riata Defibrillator Lead

Prevalence and Predictors of Riata Cable Extrusion. Introduction: Recently, a medical advisory was issued regarding the Riata and Riata ST silicone endocardial defibrillator leads (St. Jude Medical, Sylmar, CA, USA) addressing the issue of conductor cables extruding in an “inside‐out” fashion from the main body of the lead. However, little data exist to guide our management of patients with these leads. Methods and Results: A retrospective analysis was performed of 84 patients with a Riata lead who underwent cine‐fluoroscopy and electrical evaluation as part of a screening program to assess for cable extrusion. All leads screened were dual‐coil except for one single‐coil lead. Of 84 patients, 23 patients (27.4%) had fluoroscopic evidence of cable extrusion. Multivariate analysis showed that the duration of time since lead implant and the presence of multiple right ventricular leads were significantly associated with cable extrusion. All 23 patients had normal electrical parameters on routine device interrogation. Fifteen of these 23 patients (65%) with extruded cables had high‐voltage shocks within 12 months of lead screening; only one patient demonstrated postshock electrical abnormalities. Conclusions: The prevalence of cable extrusion in dual‐coil Riata leads is significantly higher at 27.4% than previously reported. The duration of time since implantation and the presence of multiple right ventricular leads are associated with cable extrusion. High‐energy shocks did not reveal electrical abnormalities in most patients with cable extrusion. (J Cardiovasc Electrophysiol, Vol. 23, pp. 1207–1212, November 2012)     

Subcutaneous implantable cardioverter-defibrillator electrode fracture: Follow-up,troubleshooting, and evaluation

The subcutaneous-implantable cardioverter-defibrillator (S-ICD) and its electrode were developed to avoid long-term complications of transvenous leads in the vasculature. We report a case of unexpected, inappropriate S-ICD shocks due to oversensing of high-amplitude, nonphysiologic, electrical noise artifacts that were not preceded by high-impedance alerts or sensing electrogram noise detections. Following explant, high-magnification X-ray imaging of the S-ICD electrode demonstrated partial fracture of the distal sensing conductor located near a short radius bend in the electrode at the electrode-header interface. Clinicians should be aware of a potential for fatigue failure fracture of the S-ICD electrode. Recommendations for systematic S-ICD follow-up and troubleshooting are discussed.     

第四代埋藏式自动复律除颤器的临床应用

2例冠心病,陈旧心肌梗塞并持续室性心动过速的病人,服用2～3种抗心律失常药无效而考虑埋藏式自动复律除颤器(ICD)治疗.术前电生理检查均诱发了持续室速,并了解了诱发和终止条件.经锁骨下静脉穿刺安装了第四代ICD.术后随访7～12个月中,2例均有室速发作而正确放电,但1例有窦性心动过速被误感知现象,经程序调整而消失.本文强调了适应症选择,术前电生理检查和术后随访的重要性.     

Can we implant cardioverter defibrillator under minimal sedation?

Aim In a prospective study, we tested the feasibility of implantable cardioverter-defibrillator (ICD) implantation under local anaesthesia (LA) with minimal sedation (MS) vs. short general anaesthesia (SGA) for defibrillation test (DT). METHODS AND RESULTS: We implanted ICDs in 118 patients between October 2002 and November 2003. Surgery was performed under LA with MS. Depending on the day of admission, patients had DT without SGA with a shock delivered when patient is unconscious (MS group, n = 73) or with short general anaesthesia (SGA group, n = 45). The patients were asked to rate the intensity of pain on a 10-point visual analogue scale (VAS) at the end of the implantation procedure and for the patient of MS group just after DT (VAS-DT). Visual analogue scale was not influenced by the type of anaesthesia (MS vs. SGA). Univariate analysis showed that NYHA >III, 3 leads implanted and an incomplete understanding of the explanation on the procedure were risk factors of VAS >4. Only understanding of the explanation on the procedure has an influence on pain in multivariate analysis. CONCLUSION: ICD implantation under MS even for DT is feasible and acceptable for the patient.     

Symptomatic heart failure is the most important clinical correlate of impaired quality of life, anxiety, and depression in implantable cardioverter-defibrillator patients: a single-centre, cross-sectional study in 610 patients

Aims: To identify correlates of impaired quality of life (QOL), anxiety,and depression in patients with an implantable cardioverter-defibrillator(ICD). Methods and results: Surviving patients (n = 610) who received an ICD in our institutionsince 1989 completed the Short Form Health Survey (SF-36) andthe Hospital Anxiety and Depression Scale. Mean age was 62.4years with 18% females. In a multivariate logistic regressionanalysis, symptomatic heart failure was the most important correlateof impaired QOL (SF-36) across all eight subscales [odds ratios(ORs) ranging from 5.21 to 22.53)], whereas psychotropic medication,age, comorbidity, amiodarone, and ICD shocks all correlatedto a lesser extent. Symptomatic heart failure was also the mostdominant correlate of anxiety [OR 5.15 (3.08–8.63), P< 0.001] and depression [OR 6.82 (3.77–12.39), P <0.001]. Implantable cardioverter-defibrillator shocks correlatedless yet significantly with anxiety [OR 2.21 (1.32–3.72)P < 0.01] and depression [OR 2.00 (1.06–3.80), P <0.05]. Conclusion: Symptomatic heart failure was the single most important clinicalcorrelate of impaired QOL, anxiety, and depression, with ICDshocks playing only a secondary role. This suggests that comorbidityrather than ICD therapy per se influences patients' device acceptance,supporting the increasing use of prophylactic ICD implantation.     

Utility of cardiovascular implantable electronic device–derived patient activity to predict clinical outcomes

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Remote detection of incessant slow VT with an ICD capable of home monitoring.

In this case report, we present a 57-year-old patient who suffered from incessant slow ventricular tachycardia because of a change in therapy 2 weeks after the implantation of an implantable cardioverter defibrillator (ICD) with Home Monitoring (HM). HM is a fully automatic and wireless system capable of transmitting device data including episode counters. The patient had mild symptoms with only short episodes of dizziness and would not have contacted the primary care centre. Due to HM, the arrhythmia was detected before the next routine follow-up, and the patient was seen the next day. HM made it possible to adjust the dosage of the newly established beta-blocker treatment in an outpatient setting and avoid hospitalization. HM yields the potential for remote detection of arrhythmias in ICD recipients, allowing alterations in device programming or medication.     

Can Implantable Defibrillators Reduce Non-arrhythmic Mortality?

Several authors have made the intriguing observation that Implantable Cardioverter Defibrillators (ICD) appear not only to reduce sudden deaths, but also mortality due to non-arrhythmic causes. Studies have shown that this observation can not be attributed to patient selection bias. In trying to explain this apparent anomaly, it should be noted that two treatment strategies are being compared.Thus, it might be that, under certain circumstances, antiarrhythmic drugs contributeto non-arrhythmic deaths, not that ICDs reduce them. There appear to be some plausible explanations for this phenomenon, e.g., the long-term effect on cardiac function of episodes of ventricular tachycardia lasting for several hours for patients treated solely by antiarrhythmic drugs, compared to their quick termination by an ICD. However, further research into this curious mode of deathissue is needed, and may provide further insights into patient populations deriving greatest benefit from one therapy or the other.     

Fatal inappropriate ICD shock

Introduction: Inappropriate implantable cardioverter defibrillator (ICD) therapy carries a low but relevant risk of ventricular proarrhythmia. In the present case, the extremely rare event of a fatal arrhythmia caused by inappropriate therapy is reported. Dislodgement of the ventricular lead to the level of the tricuspid annulus led to additional sensing of the atrial signal during sinus tachycardia. Spuriously, ventricular fibrillation was sensed and induced inappropriate ICD shocks. The fourth inappropriate shock caused ventricular fibrillation, which was subsequently undersensed by the dislodged lead due to low ventricular amplitudes. The ICD started antibradycardic pacing during ventricular fibrillation. After initial successful resuscitation, the patient died 1 week later due to severe hypoxic brain damage. Although not preventable in the present case, it underlines the necessity of immediate interrogation of the ICD after ICD therapy and deactivation of the ICD in the setting of a dislodged endocardial lead and intensive care monitoring of the patient until revision.