老年人永久起搏器置入术并发症的发生原因及处理策略

目的探讨老年人永久起搏器置入术并发症的发生原因及处理策略。方法393例老年患者，男251例，女142例，年龄60～94（77．5±5．3）岁。病态窦房结综合征237例，高度房室传导阻滞144例，双束支阻滞12例。置入单腔起搏器255例；双腔起搏器135例；三腔起搏器1例；置入性心脏除颤器2例。结果各种并发症共29例，发生率7．4％。导线电极移位14例（3．56％），囊袋血肿6例（1．53％）、囊袋感染3例（0．76％），废弃电极脱入右室、起搏器综合征各2例（0．51％），电极导线不全断裂、心肌穿孔各1例（0．25％）。结论做好充分的术前准备工作．术中熟练的无菌操作技术以及术后的密切观察和随访，可减少老年人永久起博器置入术并发症的发生；及时有效地处理并发症．可避免严重后果。     

电极导管消融术治疗室上性心动过速的长期疗效观察

总结应用电极导管消融术治疗３７例室上性心动过速患者随访约０．９２～８．１６年的结果。本组射频电能消融术总有效率为９５．２％，其中射频消融房室旁道的有效率为９３．３％，较直流电者（６２．５％）为高，复发率为６．６％，较直流电者（３３．３％）为低。射频电能房室结改良术治疗房室结折返性心动过速的有效率为１００％，说明射频电能应用于室上性心动过速消融术较直流电具有成功率高、并发症少、长期疗效好、复发率低等特点。在应用射频电能消融慢径治疗房室结折返性心动过速时，应作最早逆行心房活动标测，以策安全。如能完全消除慢径传导则可明显降低复发率。     

射频消融电极导管协助下经静脉拔除心内膜电极导线一例

患者男,75岁。因"起搏器囊袋感染"行起搏系统移除术及囊袋清创术。采用直接拔除法拔除电极,心室电极顺利拔除;心房电极与心肌组织粘连明显,难以拔除。穿刺右股静脉,经静脉鞘置入射频消融电极导管,钩挂心房电极,协助拔除心房电极成功。术后1周在对侧重新植入起搏器。患者恢复良好,无并发症。     

房室结折返性心动过速射频消融术后复发机制探讨

目的: 探讨房室结折返性心动过速射频消融术后复发原因。方法: 对356 例房室结折返性心动过速患者射频消融术后进行随访,回顾性分析其电生理资料。结果: 356例中10例复发,复发率2.8%,320例患者射频术后无心房回波,无跳跃现象,一直未复发;术后有心房回波无跳跃现象未诱发出室上速17例,其中3例复发;术后有跳跃及心房回波未诱发出室上速11例,其中5例复发;术后有跳跃无心房回波未诱发出室上速8例,2例复发。10例复发患者,第2次射频消融术后房室结不应期均较第1次术后延长,且与术前快径不应期差值明显减小,第2次射频消融术后随访至今（>9个月）,无1例复发。结论: 慢径残存是房室结折返性心动过速射频消融术后复发的主要原因。     

心房起搏法在房室结射频消融术中的应用

目的探讨对房室结折返性心动过速,射频消融术中应用心房起搏的效果。方法6l例房室结折返性心动过速被随机分为心房起搏组(n=30)、常规组(n=31)进行射频消融术,比较两组消融放电次数、时间、能量及并发症、复发率等。结果与常规组比较,心房起搏组缩短总放电时间(132.6±48.2svs178.4±58.4sP<0.05),增加单次持续放电的成功率(93.3%vs6.5%,P<0.001),同时可减少术中并发症和降低术后复发率,常规组有3例术中出现一过性房室阻滞,1例永久性房室阻滞,3例术后1年内复发,而起搏组无一例出现上述现象。结论房室结射频消融术中采用心房起搏法进行放电比常规法更为安全有效。     

射频导管消融改良房室结术中发生一过性完全性房室传导阻滞的预后意义

目的：探讨射频导管消融改良房室结术中发生一过性完全性房室传导阻滞（ＴＣＡＶＢ）的预后意义。方法：对５６例房室结折返性心动过速病人行射频导管消融治疗。在射频导管消融术中发生ＴＣＡＶＢ者为Ｉ组（ｎ＝６），无ＴＣＡＶＢ者为Ｉ组（ｎ＝５０）。用ｔ检验和χ２检验对所有指标进行统计学分析。结果：两组的平均放电次数、释放能量、放电时间及Ａ／Ｖ比值均无显著差异（Ｐ＞０．０５），但消融电极位置偏高者Ｉ组占６６．７％，Ｉ组占１２．０％（Ｐ＜０．００１）。在随访期间，Ｉ组２例（３３．３％）发生迟发性房室传导阻滞，Ｉ组则无迟发性房室传导阻滞发生（Ｐ＜０．００１）。结论：射频导管消融术中出现的ＴＣＡＶＢ与术后发生的迟发性房室传导阻滞密切相关。     

射频消融时对埋藏起搏器的处理(附2例报告)

临床资料例1 女,73岁.因“高血压伴晕厥发作”入院.ECG为房颤(室率150次/分)及窦性心动过缓(35次/分).诊为慢—快综合征.于1990年4月安置东德产VVI起搏器,出院后无晕厥,但仍有心悸发作.Holter检查有阵发房颤,室率222次/分.药物治疗效果不满意.1990年12月做射频房室结高位消融术,因起搏器不能程控,考虑到射频对起搏器有影响,术时先取出起搏器并脱离电极,从右股静脉插入6F电极到右心室做临时起搏,消融术后再埋入起搏器,迄今患者自身心律为QRS不宽的Ⅲ°AVB(胸壁刺激试验),起搏功能良好.     

预激综合征合并完全性房室阻滞的诊断及治疗

目的 报道5例预激综合征合并完全性房室阻滞患者的诊断和治疗。方法 进行心内电生理检查和射频消融旁路。结果 电生理检查未诱发房室折返性心动过速，心房刺激时体表心电图的预激程度无变化。消融阻断旁路前传后，均示完全性房室阻滞。4例患者在消融术后植入永久性起搏器．随访中无心房颤动发作。1例患者放弃对旁路的消融治疗。结论 预激综合征合并完全性房室阻滞是射频消融的适应证。消融前对房室传导功能的评定十分重要。成功消融旁路后应植入永久性起搏器。     

心房感知不良导致心室安全起搏1例

患者男性 ,６２岁 ,因病态窦房结综合征置入Ｂｉｏｔｒｏｎｉｋ公司产ＡｃｔｒｏｓＤＤＤＤ型起搏器 ,起搏参数为 :ＤＤＤ模式 ,基础频率６０次／ｍｉｎ ,滞后频率ＯＦＦ ,睡眠频率５５次／ｍｉｎ,上限频率１３０次／ｍｉｎ ,动态房室间期１８０／１００ｍｓ,安全房室间期 (ＳＡＶＤ)１００ｍｓ,心房、心室不应期为４２５／３００ｍｓ,心房、心室起搏电压均为３．６Ｖ ,起搏脉宽均为０．４ｍｓ,感知灵敏度为１．５／２．５ｍＶ ,心室空白期为２４ｍｓ。术后心电图示起搏器心房电极感知不良 ,心室频繁安全起搏。心电图 (图１)Ａ、Ｂ行心房感…     

心房起搏的远期随访

目的了解心房起搏的远期效果及并发症。方法对６６例心房起搏患者进行了临床、心电图、起搏参数的定期随访，随访时间为３８±２０４个月。结果所有患者术后生活质量明显改善，无１例心衰及死亡。术中、术后心电参数符合起搏要求。１６例术前阵发性心房颤动者，术后发作频率及时间明显减少（Ｐ＜００１、００５）。１５例（２２７％）发生过感知，电极移位４例（６１％），房室传导阻滞２例（３０％）。结论心房起搏是一种安全的起搏方式，可保持正常的房室收缩顺序功能及血流动力学效果，而明显优于心室起搏     

Cardiac pacing. Percutaneous extraction of infected pacing catheter

Infection of a cardiac pacemaker is a rare but serious complication. Percutaneous ablation of the pacemaker and pacing catheter is the only effective treatment. Techniques of extraction of pacing systems have been evaluated but the long term results require analysis. Eighteen patients with infection of cardiac pacemakers underwent extraction of one or more pacing catheters (14 atrial and 20 ventricular) in one same centre. The indication was infection of the pacemaker unit (12 cases) or septicaemia (6 cases) The causal organism was a staphylococcus (aureus: 7 cases, epidermidis: 10 cases, capitis: 1 case). Three techniques were used: 1) direct external manual traction, 2) internal traction with several devices, 3) endovascular counter-traction (Byrd-Cook system). The time from primary implantation of the pacing catheter to its extraction was 42 months and from last pacemaker manipulation to infection, 23 months. The average duration of the extraction procedure was 120 +/- 45 minutes; that of fluoroscopy was 10 +/- 6 minutes. The first technique was used 12 times, the second 8 times and the third 14 times, with complete extraction of the catheter in 88.2% of cases. The metallic tip of the distal electrode embolised in 2 cases and remained stuck in the right ventricle in 1 case. Only one pacing catheter was abandoned. After an average follow-up of 45 months, none of the patients had recurrent infection or any other complication. The authors conclude that extraction of infected pacing catheters is safe and effective. It is the treatment of choice of this complication.     

射频消融房室交界区和植入起搏器治疗心房颤动

目的 对9例阵发性心房颤动(房颤)和8例慢性房颤患者行房室交界区消融和植入起搏器(Abl+Pm)治疗,探讨这一方法的临床治疗效果。方法 经右股静脉植入4极电极导管于右心室心尖部和4极大头消融导管至房室交界区,于记录到希氏束电位处放电消融,直至出现三度房室阻滞,然后植入VVI或DDD起搏器。结果 所有患者均成功阻断房室交界区并植入起搏器。8例慢性房颤患者植入VVI起搏器,术后血流动力学稳定、临床症状改善,3个月后心胸比例由原来的0.62±0.04缩小为0.57±0.05,差异有显著性(P<0.05),心功能(NYHA分级)均提高Ⅰ级以上;9例阵发性房颤患者中,8例植入VVI起搏器,1例植入DDD起搏器,房颤发作时,8例无临床症状,1例仅有轻微心悸。随访1～47个月,无1例出现起搏器综合征、栓塞和心功能恶化。结论 房颤患者的Abl+Pm治疗可有效控制临床症状、改善心功能和提高生活质量。     

永久起搏器常见并发症的临床分析

目的　探讨永久起搏器术后常见并发症发生原因、处理方法及预防措施。方法　回顾沈阳军区总医院 1988- 0 9～ 2 0 0 3- 0 7安装起搏器者 5 16例临床资料分析其并发症。结果　术后常见并发症共 6 9例次 ,其中感染 5例 (7 2 % )、血肿 10例 (14 5 % )、囊袋破溃 7例 (10 1% )、血气胸 10例 (14 5 % )、起搏器综合征 10例 (14 5 % )、感知障碍 7例 (10 1% ) ,起搏器介入性心动过速 2例 (2 9% )、电池提前耗竭 3例 (4 4 % )、术后心律失常 3例(4 4 % )、电极脱位 10例 (14 5 % )、电极断裂 2例 (2 9% )。结论　加深对起搏器常见并发症的了解、提高鉴别能力、重视术前预防、术中规范操作、加强术后随访及起搏器知识教育 ,早期发现积极处理各种并发症 ,可将并发症减少到最低限。     

The ilio-femoral approach: an alternative for implanting permanent cardiac pacemakers. Three case reports

Permanent endocavitary cardiac pacing is a widely used therapeutic method. The implantation of pacing catheters is usually performed by the supracardiac veins, the epicardial approach being the classical alternative. The ilio-femoral approach is a third possibility. The authors report three cases in which this approach was used. The implantations were performed under general anaesthesia with an abdominal pacemaker. In two cases, atrial and ventricular catheters were implanted. After an average of 19 months' follow-up, no short or long-term complications were observed: displacement or fracture of the pacing catheter, infection, venous thrombosis, threshold elevation. These results show that this is a safe and feasible alternative to implantation by the traditional or epicardial techniques when these approaches cannot be used.     

永久性心脏起搏器植人术后感染患者的临床资料分析

目的回顾性分析永久性心脏起搏器植入术后感染患者的临床特点,并对不同治疗方法进行评价。方法纳入2005年8月~2013年3月植入心脏起搏器[包括双腔及三腔起博器（CRT）]后发生感染的患者12例,分析感染者的临床特点,同时比较不同抗感染治疗（包括抗生素＋局部换药;抗生素＋原囊袋清创消毒＋起搏器原侧换位植入;起搏器及导线拔除＋抗生素＋起搏器对侧植入）方案的疗效差异。结果12例患者中植入双腔起搏器11例（91.6%）,CRT 1例（8.3%）,感染出现的中位时间为4.5个月,平均随访（33.0±19.0）个月。12例患者中有10例（83.3%）患者合并1种或以上其他疾病（包括糖尿病、心功能不全、慢性阻塞性肺病、结缔组织病等）,4例（33.3%）患者体内有2根以上的电极导线。10例首选保守治疗（应用抗生素＋局部换药,或抗生素＋原囊袋清创消毒＋起搏器原侧换位置入）中有8例感染复发,其中6例通过去除整个起搏系统治愈,1例起搏器消毒后重新置入治愈,1例形成窦道持续换药;2例首选去除起搏系统的患者均痊愈。结论起搏器感染多发生在合并危险因素的患者,一旦感染累及起搏系统,去除整个起搏系统是合理的。     

Radiofrequency catheter ablation of accessory pathways in infants.

OBJECTIVE: To evaluate the indications, results and complications of radiofrequency catheter ablation in small infants with supraventricular tachycardia due to an accessory atrioventricular pathway. METHODS: Five infants less than 9 months old underwent radiofrequency catheter ablation of accessory pathways. Ablation was done for medically refractory tachyarrhythmia associated with aborted sudden death in two patients, left ventricular dysfunction in one, failure of antiarrhythmic drugs in one, and planned cardiac surgery in one. All five patients underwent a single successful procedure. Three left free wall pathways were ablated by transseptal approach, a right posteroseptal pathway was ablated from the inferior vena cava, and a left posteroseptal pathway was approached from the inferior vena cava into the coronary sinus. A deflectable 5F bipolar electrode catheter with a 3 mm tip was used. RESULTS: A sudden increment in impedance indicative of coagulum formation was observed in two procedures. One patient developed a transient ischaemic complication after ablation of a left lateral accessory pathway by transseptal approach. This patient had mild pericardial effusion after the procedure. Moderate pericardial effusion was also noted in another patient. After a mean follow up of 18.4 months all patients are symptom free without treatment. CONCLUSIONS: Radiofrequency catheter ablation can be performed successfully in infants. Temperature monitoring in 5F ablation catheters would be desirable to prevent the development of coagulum. Echocardiography must be performed after the ablation procedure to investigate pericardial effusion.     

射频消融治疗频发单源性室性期前收缩（附三例报告）

采用起搏标测法对３例有明显症状的频发单源性室性期前收缩（下称室早）患者进行射频导管消融（ＲＦＣＡ）治疗。经标测２例定位于右室流出道、１例定位于左室间隔。以３０～４０Ｗ的功率消融，持续时间３０～６０ｓ，获得成功。术后５～７ｄ复查动态心电图未发现室早。随访１～１１个月，２例未复发，１例出现偶发室早。认为对有明显临床症状且药物难以奏效或不能耐受其副作用的单源性室早患者，可考虑ＲＦＣＡ治疗。该疗法有可能成为根治室早的有效方法     

Effects of Radiofrequency Catheter Ablation on Patients with Permanent Pacemakers

The objective of this study was to assess the effects ofradiofrequency energy application on implanted pacemaker functions.Radiofrequency (RF) catheter ablation may cause pacemaker dysfunction dueto electromagnetic interferences. The effects of RF on pacemaker behaviorwere studied in a series of 38 pacemakers, implanted 18 ± 26 monthsprior to a RF procedure using either a right ventricular approach (AV nodeablation, n = 35) or a left ventricular approach (left concealedaccessory pathway ablation, n = 1; VT ablation, n = 2). The38 patients (mean age 65 ± 9 years) included 20 men and 18 women.Before energy applications, the 23 different pacemaker models wereprogrammed to the VVI mode at the lowest available rate. The continuoussurface ECG was recorded throughout the procedure. Thorough testing of thedevices was performed before and after each RF delivery. Unusual pacemakerresponses occurred in 20 of the 38 cases studied (53%). The impactof RF delivery was unpredictable, and variable dysfunctions were observedat different times for a given patient or could vary for a given model.Unusual pacemaker responses included pacemaker inhibition (n = 8), untoggled backup mode (n = 3), electromagnetic interference noisemode (n = 3), temporary RF-induced pacemaker tachycardia (n =2), erratic behavior (n = 1), oversensing of RF onset and offset (n= 8), and transient loss of ventricular capture, (n = 1).Postablation, most devices automatically toggled back to fullfunctionality. The three devices in the untoggled backup mode had to bereprogrammed to obtain normal operations. At the end of the procedure,pacing thresholds remained unchanged in all but one patient, in whom theincrease in ventricular threshold was due to a nicked lead. In conclusion,implanted pacemakers frequently exhibit transient, unpredictable responsesto RF energy application. Although all pacemaker functions were restored postablation, some devices had to be reset manually. The anomalies observedduring the RF application argue for the simultaneous use of an externalpacemaker in pacing-dependent patients.     

Pacemaker infections--treatment with total or partial pacemaker system removal

During the years 1977 to 1983, 1,458 pacemakers were implanted or reimplanted in our clinic. Seventy-nine patients were treated during the same period for pacemaker system infections. The time interval between the preceding surgical maneuver and the manifest infection was 11.9 +/- 10.2 months in the catheter fistulas and 12.2 +/- 11.5 months in the pacemaker pocket infections. Forty-one of 79 infections (52%) occurred following the first generator implantation. In 33/43 (76.7%) patients with partial pacemaker system removal, recurrent infection occurred 19.6 +/- 17.2 months later. The infection was treated with similar surgical maneuvers resulting in subsequent infections in 9 patients after 9.8 +/- 7.2 months. In the patients with total pacemaker system removal infection developed in 2/25 (8%). The infection resulted in septicemia in 9 patients. Major surgical intervention was necessary for removal of the infected endocardial electrode in 7 patients. According to our experience there are no grounds for partial removal of the pacemaker system if infection occurs. The primary results may be satisfactory but re-infection will appear in the majority of the patients after a period of several months.     

Management of infected transvenous permanent pacemakers]

Between November, 1980, and January 1991, a total of 115 transvenous pacemakers were implanted in 102 patients at our hospital. Infection at the site of implantation developed in three cases or 2.6%. The median time of the onset of infection postoperatively was eleven and a half months, the range being two and a half to twenty-four months. Coagulase positive Staphylococcus aureus was cultured from the infected site of one patient and coagulase negative Staphylococcus epidermidis and saprophyticus in two patients. Staphylococcus aureus septicemia developed in one patient. Conservative medical treatment consisting of the application of two or more antibiotics was unsuccessful in all three cases. In two patients, removal of the infected pacemaker generator and implantation of a completely new pacemaker system at a new, clean site were conducted. In one of these two patients, the septic pacemaker electrode was withdrawn 3 months after removal of the infected pacemaker generator. In the other patient, limited thoracotomy with incision of the left brachiocephalic vein was performed for removal of the electrode three weeks after removal of the infected pacemaker generator.