心脏性猝死一级与二级预防植入型心律转复除颤器患者临床特征单中心分析

目的 了解植入型心律转复除颤器(ICD)植入数量与心脏性猝死(SCD)一级与二级预防患者临床资料特征,为ICD患者筛选提供实践依据.方法 连续入选2006年1月至2011年12月于我院行ICD或心脏再同步治疗除颤器(CRT-D)植入术的患者,收集患者术前资料与患者植入ICD类型,分析历年ICD植入数量与一级、二级预防患者资料的特征与差异.结果 入选214例患者,一级预防108例,二级预防106例.ICD植入数量与一级预防患者比例逐年增加.与二级预防患者相比,一级预防患者术前心功能(NYHA分级)更差(P＜0.01),术前左心室射血分数更低[(0.34±0.01)对(0.50±0.16),P＜0.01],QRS时限更长[(135.83±35.08)ms对(111.68±34.15)ms,P＜0.01],log (NT-proBNP)水平更高[(3.32±0.62)pg/ml对(2.83±0.83) pg/ml,P＜0.01],肾小球滤过率更低[(75.15±24.23) ml/min对(90.25±70.30) ml/min,P=0.037];一级预防患者冠状动脉疾病与扩张型心肌病占90％,与二级预防患者疾病组成差异有统计学意义(P＜0.01),两组内冠状动脉疾病比例均较低(13.1％与22.6％);二级预防患者主要植入单腔ICD(84.0％),而一级预防患者植入CRT-D比例最高(74.1％),组间植入ICD类型差异有统计学意义(P＜0.01).结论 ICD植入数量与一级预防患者比例逐年增加,一级预防患者的识别与植入工作有待改进,特别是心肌梗死后左心室功能不良患者与未符合心脏再同步治疗适应证的慢性心功能不良患者的识别.     

功能性排便障碍患者合并焦虑、抑郁和躯体症状的调查

目的了解功能性排便障碍患者合并焦虑、抑郁及躯体症状阳性率及其危险因素分析。 方法选择2020年11月~2021年9月期间就诊于西京消化病院便秘专科门诊的功能性排便障碍患者86例,根据GAD-7、PHQ-9和PHQ-15量表计分,统计患者合并焦虑、抑郁及躯体症状的发生率,并采用Logistics回归分析其危险因素。 结果入组患者86例,男性18例（20.9%）,女性68例（79.1%）,平均年龄（46.7±13.4）岁,中位病程7.5（3~15.3）年。焦虑的发生率80.2%,抑郁的发生率73.2%,躯体症状的发生率94.2%。单因素回归分析可见排便费力（χ²=10.489,P＜0.05）和排便不尽感（χ²=9.389,P＜0.05）与患者合并躯体症状相关。多因素回归分析显示排便不尽感是患者合并焦虑（OR=4.831,95%CI：1.364~17.117,P＜0.05）、抑郁（OR=4.214,95%CI：1.162~15.282,P＜0.05）和躯体症状（OR=7.809,95%CI：1.058~57.617,P＜0.05）的独立危险因素。 结论功能性排便障碍患者极易伴发焦虑、抑郁及躯体症状且患者具有排便不尽症状是合并焦虑、抑郁及躯体症状的独立危险因素。     

植入埋藏式心脏复律除颤器患者的电风暴

埋藏式心脏复律除颤器（ICD）预防心源性猝死,提高患者生存率。电风暴是ICD植入后可能出现的一种严重室性心律失常事件,不仅缩短ICD的寿命,还提示患者预后不良。文章就电风暴的定义、发生率、长期预后、促发因素及治疗进行综述。     

植入型心律转复除颤器电风暴的临床随访和治疗

目的本文观察植入犁心律转复除颤器（ICD）植入后电风暴的发生率、临床特征、临床治疗。方法回顾性分析了51例接受ICD治疗的病人,随访2～85个月,其中9例病人出现ICD电风暴,比较ICD电风暴组和无ICD电风暴组的年龄、病因左心室射血分数（LVEF）、心功能分级、临床特征、临床治疗方案。结果有电风暴的患者与无电风暴患者相比年龄更大,差异有统计学意义[（69±14）岁对（61±8）岁];心功能分级（2．7±0．7对2．1±0．6,P〈0．05）差异有统计学意义;两组LVEF（0．38±n09对0．48±0．04,P〈0．05）差异有统计学意义。在本文中导致ICD电风暴的主要因素是心功能的减退。结论有电风暴的病人比没有电风暴的病人年龄更大,心功能更差,LVEF更低。心力衰竭的加重和焦虑导致的交感神经兴奋是电风暴发生主要的原因。抗心律失常药物胺碘酮和美托洛尔是预防和治疗电风暴的主要手段。射频消融可作药物治疗无效后减少电风暴的主要于段。     

肝硬化门脉高压症患者心脏功能影响因素及其状况评价*

目的 研究肝硬化门脉高压症患者心脏功能状态,探讨其与肝功能的关系,并分析影响左心室舒张功能不全的相关危险因素。方法 我院消化科住院的肝硬化门脉高压症患者126例,其中 Child-Pugh A级76例、B级41例、C级9例,MELD分级≤9分64例和>9分62例。行心电图和超声心动图（包括脉搏波多普勒和组织多普勒成像）检测。采用回归分析影响舒张功能不全的相关因素。结果 在126例患者中,有1例（0.8%）被诊断为左心收缩功能不全,77例（61%）被诊断为左心室舒张功能不全,心电图异常率为65%,其中QTc延长发生率为41%;不同Child-Pugh分级和MELD评分患者左心室舒张功能不全、心电图异常率和QTc延长发生率差异无统计学意义（P>0.05）;Logistic回归分析发现年龄（OR=1.163,95%CI：1.086~1.244）和心率（OR=1.106,95%CI：1.018~1.201）是影响舒张功能不全的相关危险因素。结论 肝硬化门脉高压症患者心功能改变主要以舒张功能减退和电生理异常为主,而与肝病严重程度和大量腹水并无显著相关性。对于年长和心率增快的肝硬化门脉高压症患者,要加强心脏舒张功能的评估,尽早诊断和及时干预可能能改善肝硬化患者的预后。     

伴卒中史患者非体外循环冠状动脉旁路移植术后再发急性脑梗死的影响因素分析

目的探讨伴有卒中史患者非体外循环冠状动脉旁路移植(OPCAB)术后再发急性脑梗死的相关因素。方法回顾性分析首都医科大学附属北京安贞医院2010年1月—2012年9月,468例有卒中史OPCAB手术患者的临床资料。根据术后有无再发急性脑梗死分为再发脑梗死组(A组)41例和无再发脑梗死组(B组)427例。分析与缺血事件发生的相关因素[术后再发脑梗死的时间为完成手术入住重症监护病房(ICU)期间]。结果 468例OPCAB手术患者术后再发急性脑梗死41例,占8.8%。①单因素分析显示,A、B组间术前双侧颈内动脉重度狭窄[(41.5%(17/41),8.9%(38/427)]、术前左心室射血分数≤35%[53.7%(22/41),25.8%(110/427)]、术中En-closeⅡ主动脉近端吻合器的应用[19.5%(8/41),76.3%(326/427)]、术后急性心肌梗死[34.1%(14/41),9.1%(39/427)]、术后心房颤动[48.8%(20/41),10.8%(46/427)]、术后低血压[68.3%(28/41),18.7%(80/427)]、术后机械通气时间>72 h[(75.6%(31/41),15.0%(64/427)]、入住ICU时间>72 h[(82.9%(34/41),25.3%(108/427)]及病死率[(29.3%(12/41),5.4%(23/427)],差异均有统计学意义(均P<0.01)。②多因素Logistic回归分析显示,术前双侧颈内动脉重度狭窄(OR=6.338,95%CI:2.283～21.019)、术前左心室射血分数≤35%(OR=2.737,95%CI:1.267～6.389)、术后急性心肌梗死(OR=3.656,95%CI:1.933～6.894)、术后心房颤动(OR=3.104,95%CI:1.135～8.016)与术后低血压(OR=4.173,95%CI:1.836～9.701)是OPCAB患者术后再发急性脑梗死的独立危险因素。术中应用EncloseⅡ主动脉近端吻合器(OR=0.556,95%CI:0.337～0.925)是OPCAB患者术后再发急性脑梗死的保护因素。结论伴有卒中史患者行OPCAB术后,再发急性脑梗死的发生率及病死率高,术前双侧颈内动脉重度狭窄、术前左心室射血分数≤35%、术后急性心肌梗死、术后心房颤动和术后低血压是伴有卒中史患者OPCAB术后再发急性脑梗死的独立危险因素。而术中应用EncloseⅡ主动脉近端吻合器是伴有卒中史患者OPCAB术后再发急性脑梗死的保护因素。     

儿童经内镜逆行胰胆管造影术61例临床分析

目的 探讨儿童经内镜逆行胰胆管造影术（endoscopic retrograde cholangiopancreatography,ERCP）的主要适应证及主要并发症的危险因素。方法 2010—2017年于北京友谊医院内镜中心行ERCP诊治的年龄≤14岁胆胰疾病患儿61例,共行ERCP操作101例次,回顾分析行ERCP的病因、麻醉方式、操作成功率、并发症发生率等情况,对主要并发症的影响因素先后行单因素分析和多因素Logistic回归分析。结果 101例次操作中成功97例次,成功率为96.0%。慢性胰腺炎（68.3%,69/101）、胰腺分裂（11.9%,12/101）、胆管结石（8.9%,9/101）分别占适应证的前3位。总体并发症发生率为32.7%（33/101）,以高淀粉酶血症（13.9%,14/101）及术后胰腺炎（13.9%,14/101）最常见。多因素Logistic回归分析发现慢性胰腺炎与高淀粉酶血症及术后胰腺炎呈负相关（P＜0.01,OR=0.020,95%CI：0.002～0.160）,而胰腺分裂（P＜0.01,OR=7.4,95%CI：1.4～37.9）、胰管插管（P＜0.01,OR=79.7,95%CI：6.5～972.6）为高淀粉酶血症及术后胰腺炎的独立危险因素。结论 儿童行ERCP以慢性胰腺炎为主要适应证,总体操作成功率较高,但相关并发症发生率不低,尤其在一些特殊患儿（如胰腺分裂）的操作过程中应当引起重视。     

经皮冠状动脉介入治疗中应用替罗非班的疗效及安全性的Meta分析

目的 评价经皮冠脉介入治疗中应用替罗非班的疗效及安全性.方法 检索Cochrane library、PubMed、EMBASE、中国期刊全文数据库、中国生物医学文献数据库、中文科技期刊全文数据库和万方数据库（截至2011年10月）.由2名评价者独立评价纳入研究的质量、提取资料并交叉核对,对同质研究采用RevMan 5.0 软件进行Meta分析.结果 共纳入7项随机对照试验,包括909例患者.Meta分析显示：与安慰剂对照组比较,替罗非班可以降低无再流/慢血流的发生率（OR=0.24,95%CI：0.13～0.45,P＜0.01）,增加左心室射血分数（MD=6.24,95%CI：4.33～8.16,P＜0.01）,降低心力衰竭的发生率（OR=0.23,95%CI：0.10～0.53,P＜0.01）及病死率（OR=0.13,95%CI：0.02～0.75,P=0.02）;但两组TIMI计帧数（MD=-5.63,95%CI：-11.65～0.33）、靶血管重建、再次心肌梗死及出血发生率无统计学差异（P均＞0.05）.结论 替罗非班可对PCI术后冠脉无再流的发生具有较好的预防作用,但由于本文纳入的研究质量较低,样本量较小,有必要进行大样本随机对照临床试验进一步的验证其疗效和安全性.     

超声内镜引导细针穿刺抽吸术在胰腺占位中应用的安全性分析

目的　探讨超声内镜引导细针穿刺抽吸术（endoscopic ultrasound‑guided fine‑needle aspiration,EUS‑FNA）在胰腺占位性病变中应用的安全性及其风险因素。方法　选择2012年1月至2022年12月于复旦大学附属肿瘤医院内镜科行EUS‑FNA的5 160例患者作为回顾性研究对象,计算操作相关并发症的发生率,利用单因素和logistic回归分析并发症发生的独立风险指标。结果　术后胰腺炎发生率为1.38%（68/4 930）,术中出血发生率为0.82%（42/5 143）,术后出血发生率为0.78%（40/5 143）,无直接相关的消化道穿孔和死亡事件发生。年龄>60岁（OR=0.581,95%CI：0.356~0.946,P=0.029）、颈体尾部肿瘤（OR=0.355,95%CI：0.194~0.652,P=0.001）、病灶长径>20~40 mm（OR=0.450,95%CI：0.227~0.893,P=0.023）和病灶长径>40 mm（OR=0.382,95%CI：0.168~0.869,P=0.022）为术后胰腺炎发生的独立保护因素,经十二指肠穿刺（OR=2.435,95%CI：1.319~4.496,P=0.005）是术后胰腺炎独立危险因素。穿刺3~4次（OR=0.439,95%CI：0.235~0.821,P=0.010）、病灶长径>20~40 mm（OR=0.154,95%CI：0.069~0.341,P<0.001）、病灶长径>40 mm（OR=0.326,95%CI：0.143~0.743,P=0.008）是术中出血的独立保护因素。细针穿刺活检（fine‑needle biopsy,FNB）针（OR=2.314,95%CI：1.189~4.502,P=0.014）为术后出血的独立危险因素。结论　EUS‑FNA是一项安全的操作,总体并发症发生率低。术后胰腺炎和术中出血的发生主要与病变临床特征有关,而术后出血与穿刺针类型有关。     

阵发性房颤随访情况和阵发性房颤进展的危险因素

目的 观察阵发性房颤的随访情况和分析阵发性房颤进展的危险因素。方法 对216例阵发性房颤患者进行随访,观察其主要结局（是否发生房颤进展）和临床事件（卒中、心力衰竭、再住院和出血事件）,再按是否房颤进展分为房颤进展组（n=87）和房颤未进展组（n=129）。采用巢式病例对照研究方法,进行单因素分析和多因素分析（采用多因素Logistic回归模型）,分析影响房颤进展的危险因素。结果 216例阵发性房颤患者经过3.45年（中位数）随访发生房颤进展者87例,其发生进展率为40.2%,年进展率为11.7%。房颤进展组脑卒中、心力衰竭、房颤相关的再住院发生率均显著高于房颤未进展组（分别17% vs. 6%,18% vs. 5%,37% vs. 17%, 分别P<0.05,P<0.01和P<0.01）;两组间病死率及出血发生率差异未达到显著水平。多因素分析显示,年龄(OR 1.082,95%CI 1.016-1.392,P<0.05)、左房内径>45 mm(OR 2.339,95%CI 1.445-3.785,P<0.05)、CHADS2评分>3分(OR 1.382,95%CI 1.081-1.987,P<0.05)以及超敏C反应蛋白（hs-CRP）水平(OR 1.124,95%CI 1.005-2.345,P<0.05 )是房颤进展的独立危险因素。结论 阵发性房颤进展的年发生率为11.6%。影响房颤进展的独立危险因素为年龄、左房内径、hs-CRP水平及CHADS2评分。     

Gender difference in arrhythmic occurrences in patients with nonischemic dilated cardiomyopathy and implantable cardioverter-defibrillator

Previous studies indicated that women were less likely to experience ventricular arrhythmia recurrence than men among patients with coronary artery disease and implantable cardioverter defibrillator (ICD). However, it is not clear whether the risk for ventricular tachyarrhythmia is gender-dependent in patients with nonischemic dilated cardiomyopathy. This study included 173 consecutive nonischemic dilated cardiomyopathy patients with a left ventricular ejection fraction of <45% (122 men and 51 women), who received ICD therapy between 1990 and 2008. The average follow-up period was 33 ± 28 months. There was no significant difference in event-free rates of appropriate ICD therapy between genders for all patients (P = 0.15) and by indication of ICD (primary prevention: P = 0.43, secondary prevention: P = 0.24). There was also no significant difference in event-free rates of electrical storm between genders (P = 0.17). In high-risk patients with nonischemic dilated cardiomyopathy who received ICD, there was no gender difference in the incidence of appropriate ICD therapy or electrical storm.     

Electrical storm presages nonsudden death: the antiarrhythmics versus implantable defibrillators (AVID) trial

BACKGROUND: Electrical storm, multiple temporally related episodes of ventricular tachycardia (VT) or ventricular fibrillation (VF), is a frequent problem among recipients of implantable cardioverter defibrillators (ICDs). However, insufficient data exist regarding its prognostic significance. METHODS AND RESULTS: This analysis includes 457 patients who received an ICD in the Antiarrhythmics Versus Implantable Defibrillators (AVID) trial and who were followed for 31 +/- 13 months. Electrical storm was defined as > or = 3 separate episodes of VT/VF within 24 hours. Characteristics and survival of patients surviving electrical storm (n = 90), those with VT/VF unrelated to electrical storm (n = 184), and the remaining patients (n = 183) were compared. The 3 groups differed in terms of ejection fraction, index arrhythmia, revascularization status, and baseline medication use. Survival was evaluated using time-dependent Cox modeling. Electrical storm occurred 9.2 +/- 11.5 months after ICD implantation, and most episodes (86%) were due to VT. Electrical storm was a significant risk factor for subsequent death, independent of ejection fraction and other prognostic variables (relative risk [RR], 2.4; 95% confidence interval [CI], 1.3 to 4.2; P = 0.003), but VT/VF unrelated to electrical storm was not (RR, 1.0; 95% CI, 0.6 to 1.7; P = 0.9). The risk of death was greatest 3 months after electrical storm (RR, 5.4; 95% Cl, 2.4 to 12.3; P = 0.0001) and diminished beyond this time (RR, 1.9; 95% CI, 1.0 to 3.6; P=0.04). CONCLUSIONS: Electrical storm is an important, independent marker for subsequent death among ICD recipients, particularly in the first 3 months after its occurrence. However, the development of VT/VF unrelated to electrical storm does not seem to be associated with an increased risk of subsequent death.     

CHADS2评分及改良CHADS评分对心房颤动消融术后复发的预测价值

目的：探讨心力衰竭高血压、年龄、糖尿病和脑卒中（包括一过性脑缺血）（CHADS2）评分及改良CHADS评分对心房颤动（房颤）射频消融术后复发的预测价值。方法对2010年7月至2012年3月在我院行射频消融术的93例房颤患者追踪随访12个月,术后1,3,6,9,12个月行12导联心电图或长程心电图检查,结合临床症状及心电图检查结果将其分为复发组（n＝40）和未复发组（n＝53）,采用单因素和多因素分析消融术后房颤复发的危险因素。结果93例房颤患者中持续性房颤35例（37.63%）,随访12个月时复发40例（43.01%）。房颤复发组与未复发组在平均年龄（P＜0.01）、年龄＞70岁（P＜0.05）、病史（P＜0.05）、房颤类型（P＜0.01）、左房内径（P＜0.001）、左室射血分数（P＜0.05）、血细胞比容（P＜0.05）、是否伴心力衰竭（P＜0.05）、是否伴高血压（P＜0.01）、是否伴糖尿病（P＜0.05）、是否有一过性脑缺血或脑卒中史（P＜0.05）、术后是否服用血管紧张素转换酶抑制剂和血管紧张素Ⅱ受体拮抗剂（ACEI/ARB,P＜0.01）、术后是否服用Ⅲ类抗心律失常药（P＜0.05）、CHADS2评分≥1（P＜0.001）等方面差异有统计学意义。logistic回归分析发现,病史、房颤类型、左房内径、CHADS2评分≥1为房颤术后复发的独立危险因素（病史长短：OR＝1.16,P＝0.020;左房内径：OR＝1.17,P＝0.025;房颤类型：OR＝3.34,P＝0.050;CHADS2评分≥1：OR＝5.93,P＝0.019）。进一步分析发现,CHADS2评分≥2、改良CHADS评分≥1、改良CHADS评分≥2亦为房颤术后复发的独立危险因素（CHADS2≥2：OR＝5.42,P＝0.028;改良CHADS评分≥1：OR＝6.64,P＝0.015;改良CHADS评分≥2：OR＝7.32,P＝0.002）。截断点分析显示,CHADS2与改良CHADS均≥1时对房颤消融预后的预测价值最高,对CHADS2评分≥1与改良CHADS评分≥1预测房颤消融预后的灵敏度、特异度、曲线下面积进行比较发现,差异均无统计学意义[分别为0.775 vs 0.800、0.358 vs 0.377、0.708（95%CI 0.601～0.806） vs 0.711（95%CI 0.605～0.818）,均P＞0.05]。结论病史长短、左房内径、房颤类型、CHADS2评分≥1、CHADS2评分≥2、改良CHADS评分≥1、改良CHADS评分≥2均为心房颤动消融术后复发的独立危险因素,且改良CHADS评分与CHADS2评分对房颤消融预后具有同等的预测价值。     

Implantable cardioverter defibrillator therapy in patients with cardiac sarcoidosis

ICD Shocks in Cardiac Sarcoidosis . Background: An implantable cardioverter defibrillator (ICD) is indicated for some patients with cardiac sarcoidosis (CS) for prevention of sudden death. However, there are little data regarding the event rates of ICD therapies in these patients. We sought to identify the incidence and characteristics of ICD therapies in this patient population. Methods: We performed a cohort study of patients with ICDs at 3 institutions. Cases were those patients with CS and an ICD implanted for primary or secondary prevention of sudden death. Additionally, we included a comparison with historical controls of ICD therapy rates reported in clinical trials evaluating the ICD for primary and secondary prevention of sudden death. Results: Of the 112 CS subjects identified, 36 (32.1%) received appropriate therapies for ventricular tachyarrhythmias (VT) over a mean follow‐up period of 29.2 months. VT storm (>3 episodes in 24 hours) occurred in 16 (14.2%) CS subjects. Inappropriate therapies occurred in 13 CS subjects (11.6%). Covariates associated with appropriate ICD therapies included left ventricular ejection fraction (LVEF) <55% (OR 6.52 [95% CI 2.43–17.5]), right ventricular dysfunction (OR 6.73 [95% CI 2.69–16.8]), and symptomatic heart failure (OR 4.33 [95% CI 1.86–10.1]). Conclusions: In our cohort of patients with CS and ICDs, almost one‐third receive appropriate therapies. This may be due to a myocardial inflammatory process leading to increased triggered activity and subsequent scarring leading to reentrant tachyarrhythmias. Adjusted predictors of ICD therapies in this population include left or right ventricular dysfunction. (J Cardiovasc Electrophysiol, Vol. 23, pp. 925‐929, September 2012)     

Electrical storm in patients with transvenous implantable cardioverter-defibrillators: Incidence, management and prognostic implications

Objectives. The purpose of this study was to determine the precise incidence, therapeutic options and prognostic implications of electrical storm in patients with transvenous implantable cardioverter-defibrillator (ICD) systems.

Background. Approximately 50% to 70% of patients treated with an ICD receive appropriate device-based therapy within the first 2 years. Most arrhythmic events require only one appropriate ICD firing for termination. However, some patients receive multiple appropriate shocks during a short period of time, a condition referred to as “arrhythmic or electrical storm.”

Methods. This prospectively designed observational study comprised 136 recipients of transvenous ICDs who were followed for 403 ± 242 days. Electrical storm was defined as ventricular tachycardia or fibrillation resulting in device intervention ≥3 times during a single 24-h period.

Results. During follow-up, 57/136 patients (42%) received appropriate ICD therapy. Electrical storm occurred in 14/136 patients (10%) at an average of 133 ± 135 days after ICD implantation. The mean number of arrhythmic episodes constituting electrical storm was 17 ± 17 (range: 3 to 50; median 8) per patient. In 12 patients, electrical storm required hospital admission. The arrhythmia cluster could be terminated by a combined therapy with β-blockers and intravenous amiodarone whereas class I antiarrhythmic drugs were only occasionally successful. The cumulative probability of survival as estimated by the Kaplan-Meier method showed that patients with an episode of electrical storm did not have a worse outcome compared to those without such an event.

Conclusions. Electrical storm represents a frequent event in patients treated with modern ICDs. It occurs most commonly late after ICD implantation and can be managed by combined therapy with β-blockers and amiodarone. Electrical storm does not independently confer increased mortality.     

埋藏式心脏转复除颤器误治疗原因分析

目的分析埋藏式心脏转复除颤器(ICD)误治疗的主要原因并探讨应对策略。方法对30例符合纳入标准的ICD植入病人进行随访分析,其中心脏性猝死一级预防23例,二级预防7例;单腔ICD17台,双腔ICD13台(包括CRT-D4台)。术后3个月进行常规随访,以后每6个月随访1次。随访期间如果病人自觉ICD放电或其它相关症状尽早至医院随访。由2位有经验的电生理专业医生根据ICD治疗事件心内电图对ICD治疗方式进行分类,如果治疗不是针对室性心动过速(VT)或心室颤动(VF)则该治疗定义为误治疗。结果78例次随访中,45次ICD治疗事件包括36次抗心动过速治疗(ATP)和9次放电,其中误治疗33次(73%),包括27次ATP治疗和6次放电。33次误治疗共涉及5例病人(17%),均为单腔ICD。误治疗的原因均为室上性快速性心律失常(SVT-A)。结论误治疗是比较常见的ICD相关事件。植入ICD后应尽早打开SVT-A相关的诊断功能。     

具有埋藏式心脏转复除颤器植入适应证患者的调查与随访

目的调查符合植入埋藏式心脏转复除颤器(ICD)适应证患者的基础病因、临床特征、治疗选择及预后。方法入选本院符合ICD适应证的152例患者,收集其基本资料及相关病史,记录入院期间检查结果及治疗情况,并对死亡率和恶性室性心律失常发生率进行随访。结果符合ICD适应证患者以缺血性心脏病最多;ICD心脏性猝死一级预防适应证患者明显多于二级预防适应证患者(118 vs 34);二级预防适应证患者植入ICD的比例明显多于一级预防适应证患者[44.1%(15/34)vs 9.3%(11/118)];随访结束发现植入ICD/CRT-D患者的全因死亡率要明显低于未植入ICD/CRT-D患者[0%vs 17.5%(20/114)](P<0.05)。结论 ICD/CRT-D能减低ICD适应证患者的全因死亡率,然而临床上ICD作为心脏性猝死预防的实际应用要远远低于其指征范围。     

Elektrischer Sturm bei ICD-Patienten

Medical progress and demographic changes cause a continuous increase in patients with implantable cardioverter-defibrillators (ICD). Up to one third of patients with ICDs for secondary prevention and half of the patients with previous electrical storm (ES) will suffer from (further) ESs. When multiple ICD shocks are reported by patients (ICD storm), appropriate, inappropriate and phantom shocks have to be distinguished. Reported shocks without clinical correlates (phantom) often affect patients suffering from posttraumatic stress syndrome after an ICD storm. Approximately one third of all ICD shocks are inappropriate, most often due to supraventricular tachycardia with fast atrioventricular (AV) nodal conduction or lead failure. Within 10 years after implantation lead failure can be detected in up to 20?% of cases and approximately one third of these failures are only seen after inappropriate ICD shocks. Furthermore, inappropriate shocks are due to oversensing of far field atrial electrograms, T-waves, diaphragmatic potentials and electrical noise. Appropriate ICD shocks can rarely also be stimulated by the proarrhythmogenicity of lead implantation or ICD programming. Modifications of the waiting period to therapy, time to detection, detection window, antitachycardia pacing (ATP) stimulation and supraventricular discrimination algorithms may minimize ICD shocks. Some stimulation algorithms may improve the hemodynamic stability during ES. In addition to ventricular ablation, blockade of the sympathetic autonomic nervous system and antiarrhythmic treatment are the main pillars of ES treatment. The best ES prevention, however, is optimized heart failure treatment, especially when a cardiac resynchronization with defibrillator (CRT-D) system is implanted.     

Predictors of appropriate implantable defibrillator therapies in patients with arrhythmogenic right ventricular dysplasia

BACKGROUND: Arrhythmogenic right ventricular dysplasia (ARVD) is an inherited cardiomyopathy characterized by ventricular arrhythmias and sudden cardiac death. The risk factors for sudden death and indications for implantable cardioverter-defibrillator (ICD) placement in patients with ARVD are not well defined. OBJECTIVES: The purpose of this study was to determine which clinical and electrophysiologic variables best predict appropriate ICD therapies in patients with ARVD. Particular attention focused on whether the ICD was implanted for primary or second prevention. METHODS: We enrolled 67 patients (mean age 36 +/- 14 years) with definite or probable ARVD who had undergone ICD placement. Appropriate ICD therapies were recorded, and Kaplan-Meier analysis was used to compare the event-free survival time between patients based upon the indication for ICD placement (primary vs secondary prevention), results of electrophysiologic testing, and whether the patient had probable or definite ARVD. RESULTS: Over a mean follow-up of 4.4 +/- 2.9 years, 40 (73%) of 55 patients who met task force criteria for ARVD and 4 (33%) of 12 patients with probable ARVD had appropriate ICD therapies for ventricular tachycardia/ventricular fibrillation (VT/VF; P = .027). Mean time to ICD therapy was 1.1 +/- 1.4 years. Eleven of 28 patients who received an ICD for primary prevention (39%) and 33 of 35 patients who received an ICD for secondary prevention (85%) experienced appropriate ICD therapies (P = .001). Electrophysiologic testing did not predict appropriate ICD interventions in patients who received an ICD for primary prevention. Fourteen patients (21%) received ICD therapy for life-threatening (VT/VF >240 bpm) arrhythmias. There was no difference in the incidence of life-threatening arrhythmias in the primary and secondary prevention groups (P = .29). CONCLUSION: Patients who meet task force criteria for ARVD are at high risk for sudden cardiac death and should undergo ICD placement for primary and secondary prevention, regardless of electrophysiologic testing results. Further research is needed to confirm that a low-risk subset of patients who may not require ICD placement can be identified.     

上海市城乡结合部社区卒中再发患者影响因素的研究

目的分析影响上海市城乡结合部社区卒中再发的危险因素。方法2012年1月-2012年12月以上海浦东新区城乡结合部3个社区（周浦、康桥、航头）居民中的卒中患者为调查对象,共纳入符合标准的患者892例。其中480例有卒中再发史（再发组）,412例无再发史（首发组）。采用横断面问卷调查方法,收集患者的一般情况、卒中常见危险因素,血压控制、药物二级预防、康复治疗等资料。结果单因素分析显示,再发组中有高血压、冠心病、心房颤动、糖尿病、高脂血症、体质量指数≥24kg／m^2患者的比率高于首发组,年龄高于首发组,差异均有统计学意义,P〈0．05,或P〈0．01;而收缩压控制≤140mmHg、规范服用活血化瘀类药、进行康复治疗患者的比率低于首发组,差异均有统计学意义,均P〈0．01。多因素Logistic回归分析显示,年龄（OR=1．032,95％CI：1．015～1．050）、高血压（OR=2．782,95％C1：1．812～4．271）、冠心病（OR=1．654,95％CI：1．138～2．404）、糖尿病（OR=1．803,95％CI：1．200～2．709）、体质量指数≥24kg／m。（OR=1．438,95％CI：1．074～1．926）是影响卒中再发的独立危险因素,而康复治疗为卒中再发的保护因素（OR=0．832,95％CI：0．696～0．996）。均P〈0．05,或P〈0．01。结论社区卒中二级预防应加强对高血压、冠心病、糖尿病、超重或肥胖等因素的治疗与控制,康复治疗可降低卒中再发的风险。