第7页／低位房间隔起搏对病窦综合征伴发作性房颤患者的临床应用（摘要）

目的：探索低位房问隔起搏导线定位方法，评价房间隔起搏对病窦综合征患者房颤的预防作用。方法：病窦综合征患者48例，以X线及心电图特征定位，主动固定心房电极于低位房间隔，观察起搏后P波时限的变化及房颤的发作频率。     

低位房间隔起搏的初步临床应用

目的探索主动固定电极导线在低位右心房间隔部起搏的可行性、安全性；比较低位房间隔起搏与高位右心房游离壁起搏对，心房激动时间和起搏参数的影响。方法共入选了50例，患者平均年龄（64．8±11．2）岁，随机分配到低位房间隔起搏组（n=25）和高位右心房游离壁起搏组（n=25），通过比较植入术时间、X线曝光时间、导线固定成功率、起搏参数、植入术并发症等评价低位右心房间隔起搏的可行性；测定不同部位起搏时P波宽度，以评价起搏部位对心房激动时间的影响。结果与高位右心房游离壁起搏组结果比较，低位房间隔起搏组的植入时间、X线曝光时间略有延长；低位房间隔起搏组的导线固定成功率低于右心房游离壁起搏组（84％ VS 100％），两组间的起搏参数、植入术并发症相比差异无统计学意义。低位房间隔起搏时心房激动时问明显短于高位右心房游离壁起搏[（140．5±23．0）ms VS（89．0±14．0）ms]，差异具有统计学意义。结论采用主动固定电极导线在低位房间隔起搏是安全、可行的，它明显缩短左、有心房激动时间，使心房的除极趋于同步化。但低位房间隔起搏的主动固定电极导线植入技术具有一定的难度，需要熟练掌握主动固定导线植入技术的人员方可实施。     

房间隔起搏临床应用的体会

目的　探讨有适应症的阵发性房颤患者行永久房间隔起搏的可行性及有效性。方法　先行心内电生理标测 ,寻找使双心房同步激动的房间隔最佳起搏点 ,采用主动固定起搏导线固定于该部位。结果　 4例患者窦性心律时房间传导为 10 6 0± 4 3ms ,标测后房间隔起搏房间传导时间为 11 0± 1 1ms,(P <0 0 0 1)。达到了双心房同步起搏。 3例患者成功地植入房间隔主动固定导线 ,一例患者失败。结论　永久房间隔起搏方法在伴有房间传导阻滞的阵发性房颤患者中的应用是安全可行的。     

低位房间隔起搏的临床应用

目的行低位房间隔(LAS,Koch三角处)起搏并与右心耳(RAA)起搏进行比较和评价。方法60例需置入DDD起搏器的患者,随机分为RAA起搏组和LAS起搏组各30例,其中LAS组先将主动螺旋固定电极导线放置在RAA测量起搏参数后再将其植入LAS,而RAA组则用被动翼状电极导线直接固定在RAA。分别测量不同部位的起搏参数,比较手术成功率、X线曝光时间、术中及术后脱位率。结果两个部位的起搏电压阈值、阻抗无明显差别,但腔内P波振幅LAS明显高于RAA(3.8±0.7 mV vs 2.2±0.8 mV),LAS起搏的P波宽度明显短于RAA起搏的P波宽度(88±18 ms vs 154±37 ms)。与RAA组相比,LAS组的手术成功率偏低(90%vs 100%),手术曝光时间亦明显延长(128±45 s vs 12±4 s),术中脱位率在低位房间隔明显高于右心耳(33.3%vs 0%)。结论LAS起搏是可行的,能较RAA起搏明显缩短心房激动时间,但植入手术较传统RAA起搏复杂。     

心房起搏脉冲传导延迟一例

患者女性 ,40岁 ,因病窦综合征置入起搏器 ,配用IS 1BI双极心房 /心室电极 ,心房电极于右心耳起搏时参数较好 ,但电极难以固定 ,无SP间期 (起搏脉冲至P波的时限 )延长 ;于是行右房上部起搏 ,发生起搏脉冲传导延迟 (SP间期 14 0ms)。术后起搏器工作正常 ,SP间期为 10 0ms。产生其SP延迟的原因不太明确。     

双房同步起搏临床应用中的若干重要问题探讨

双房同步起搏治疗病窦综合征伴房间传导阻滞导致的阵发性心房颤动 (简称房颤 )已应用于临床。通过对 6例安置双房同步起搏器病人术前及术后 1～ 2年的随访来探讨实际应用中若干需要重视的问题。结果 :①术前P波时限和离散度分别在 110～ 15 0ms和 10～ 5 0ms之间 ,双房同步起搏后则分别为 80～ 12 0ms和 10～ 30ms。② 1例房颤发作消失、3例控制、2例无效。③冠状窦电极脱位 3例。结论 :①严格掌握双房同步起搏的指征是确保疗效的关键 ,P波时限和离散度同时延长且延长越多 ,越适于双房同步起搏。②程控为双极AAT模式才能真正实现双房同步 ,合并房室阻滞的病人应选用具有DDTA功能的起搏器。③双房同步起搏体表心电图表现为P波时限短、负向或正负双向 ,PR间期相应缩短。④Medtronic 5 86 6 38M型适配器串联连接双房电极 ,心房电极总阻抗是右房和冠状窦电极阻抗之和 ,不应误认为电极脱位 ,需相应提高起搏电压以维持有效起搏。⑤冠状窦专用电极头端两个弯度必须均进入窦内 ,以深处为佳 ,导管缝扎固定须谨慎。     

双腔频率应答起搏对病窦综合征合并的阵发性心房颤动的干预

探讨双腔频率应答起搏对病窦综合征(SSS)合并的阵发性心房颤动(简称房颤)的窦性心律维持及电生理干预。48例SSS并阵发性房颤患者安装了双腔频率应答起搏器,通过起搏器正确的心房感知监测房颤的发作情况,在窦性心律时测量P波时限和P波离散度,心脏B超测量左房内径、左室射血分数。比较术后1,12个月以及房颤控制组与复发组上述指标的差异。结果:置入起搏器术后1年,房颤控制和房颤负荷减少37例,占77%。术后1个月与1年左房内径,P波时限,房颤平均每天发作时间、发作次数均有显著性差异(3.6±0.6cmvs3.2±0.5cm,129.2±11.0msvs111.2±9.3ms,93.6±10.4min/dvs42.8±9.6min/d,8.1±3.2次/天vs5.3±1.4次/天,P<0.001)。与术后房颤复发组比较,房颤控制组术前左房内径较小,P波时限较短、离散度小(P<0.001)。结论:双腔频率应答起搏对SSS合并的阵发性房颤有预防和治疗作用。     

永久性心脏起搏器植入术中发生心房纤颤时心房电极导线定位经验

目的:研究永久性心脏起搏器植入术中心房纤颤(房颤)发作时以右心房波振幅最大处为右心房电极导线固定位置的可行性。方法:22例房颤发作时植入右心房电极导线的患者术中,测试右心房波振幅,术后随访恢复窦性心律(窦律)时测试右心房波振幅、起搏阈值,2者进行对比分析。结果:房颤心律时,所测得的右心房振幅与转为窦律后所测得的右心房波振幅有较好相关性,2者差异无统计学意义[(2.4±1.0)mv比(2.7±1.2)mv,P>0.05]。房颤时术中右心房波振幅平均(2.4±1.0)mv(1.6～3.7mv)者,在房颤转为窦律后所测定的心房感知和起搏功能良好。结论:在房颤发作时,右心房波振幅作为永久心脏起搏器合适的感知及起搏参数,有一定的临床实用价值。     

主动固定电极导线行心脏特殊部位起搏的临床应用

目的探索主动固定电极导线行心脏特殊部位起搏临床应用的可行性和安全性。方法需要安置心脏起搏器患者88例,其中男54例、女34例,年龄67.6±24.3(28～91)岁。患者为缓慢性心律失常或者严重心力衰竭,放置主动固定电极导线,测定有关参数并随访观察。结果手术顺利完成,未出现严重并发症。共使用主动电极导线151根,其中心室电极导线88根(右室流出道间隔部80根,右室流入道间隔部5根,右室中间隔3根);心房电极63根(右心耳37根,低位房间隔10根,高位房间隔10根,心房侧壁6根)。起搏参数在电极导线置入15min后可达到理想值。术后7天及出院后1,3,6个月随访无电极导线脱位,起搏参数与置入时比较没有差异。结论使用主动固定电极进行心脏特殊部位起搏是可行和安全的。     

双房单室三腔起搏器治疗病窦综合征并快速房性心律失常

观察双心房、单心室三腔起搏器治疗病窦综合征合并阵发性房性快速心律失常患者的疗效。三根电极导线分别置入冠状静脉窦内、右心耳和右室心尖部行三腔起搏。冠状窦电极导线与右心房电极导线通过一个Y型转接器构成心房部分。结果 :10例患者 ,9例经左锁骨下静脉径路置入导线 ,1例因存在残存左上腔静脉 ,从右锁骨下静脉置入。 10例中 9例冠状窦电极导线置于冠状静脉窦中部、1例置于冠状静脉窦远端。冠状窦起搏阈值为 1.0 6±0 .2 0V、起搏阻抗 6 11± 115 .8Ω、P波振幅为 4.0 7± 0 .88mV ;右室电极起搏阈值为 0 .5 3± 0 .12V、起搏阻抗 6 70 .3±191.7Ω、R波振幅为 9.6 6± 1.87mV。随访 5～ 2 4个月有 9例起搏器呈DDD工作方式 ,1例呈AAT工作方式。起搏和感知功能良好。 10例中 8例快速性房性心律失常完全控制 ,2例发作次数减少 ,持续时间明显缩短。无一例出现并发症。结论 :三腔起搏器技术安全、可靠。适合于缓慢型心律失常合并阵发性房性快速性心律失常     

房间隔起搏的初步临床应用经验

目的 探讨有适应证的阵发性心房颤动(房颤)患者永久性房间隔起搏的可行性和安全性。方法 先行心内电生理标测，寻找使双心房同步激动的房间隔最佳起搏点，采用主动固定方法将导线固定于该部位。结果 18例伴有房间传导阻滞的阵发性房颤患者，14例患者完成房间隔标测和永久性起搏导线植入手术，4例未能成功植入房间隔起搏导线。结论 在伴有房间传导阻滞的阵发性房颤患者中永久性房间隔起搏是安全可行的。     

Atrial septal pacing in the prevention of paroxysmal atrial fibrillation refractory to antiarrhythmic drugs

BACKGROUND: Early reports have shown that pacing the atria at a site or sites other than the right atrial appendage may prevent atrial fibrillation. Our centre has shown that pacing the atrial septum reduces the duration of atrial activation which is an important determinant of predisposition to paroxysmal atrial fibrillation. Ablation of the atrioventricular (AV) node together with implantation of a pacemaker can control symptoms due to paroxysmal atrial fibrillation in patients in whom antiarrhythmic drugs have failed. The aim of this study was to investigate the effect of atrial septal pacing on patients who were candidates for AV node ablation. METHODS: Atrial septal pacemakers were implanted in 28 patients with symptomatic, paroxysmal atrial fibrillation that had been unresponsive to two or more antiarrhythmic drugs. Pacing was not indicated for any reason other than the anticipated need to proceed to AV node ablation. Change in symptoms was assessed by quality of life questionnaires and recurrence of atrial fibrillation was measured objectively by pacemaker interrogation and ambulatory electrocardiographic monitoring. RESULTS: Atrial septal pacing in combination with an antiarrhythmic agent resulted in a substantial subjective improvement in 19 patients (68%). Objective data confirmed similar findings; atrial fibrillation was completely or markedly reduced in 17 patients (60%). Six patients experienced a modest improvement in symptoms; in only four patients was it necessary to proceed to AV node ablation. CONCLUSIONS: Atrial septal pacing together with continuance of previously ineffective antiarrhythmic therapy may prevent or markedly reduce the frequency of paroxysmal atrial fibrillation and obviate the need to ablate the AV node.     

房间隔起搏对阵发性心房颤动患者最大P波时限和P波离散度的影响

观察房间隔起搏对阵发性心房颤动 (AF)患者最大P波时限 (Pmax)及P波离散度 (Pd)的影响 ,探悉房间隔起搏防治AF发作的电生理机制。对 2 1例阵发性AF患者和 2 6例室上性心动过速行射频消融术无阵发性AF患者 ,分别进行右心耳和房间隔起搏 ,比较不同部位起搏对阵发性AF和无阵发性AF患者的Pmax和Pd影响。结果 :阵发性AF患者较无阵发性AF患者Pmax和Pd值明显大 (分别为 1 35± 1 5vs 1 1 9± 1 4ms ,P <0 .0 5 ;36 .5± 9.2vs 1 9.7± 7.1ms ,P <0 .0 1 ) ;房间隔起搏使阵发性AF患者Pd、Pmax显著下降 (分别为 2 3 .4± 8vs 36 .5± 9.2ms ,1 2 0± 1 1vs1 35± 1 5ms,P均 <0 .0 5) ;右心耳起搏使无阵发性AF患者Pmax和Pd明显增加 (分别为 1 32± 1 2vs 1 1 9± 1 4ms,2 5 .5± 8.5vs 1 9.7± 7.1ms ,P均 <0 .0 5)。结论 :右心耳起搏能够使无阵发性AF患者Pmax和Pd值增加。房间隔起搏能够明显降低阵发性AF患者Pmax、Pd ,纠正房内或房间传导延缓 ,改善心房内电活动的各向异性 ,防治AF发作     

A simple method for Bachmann's bundle pacing with indigenous modification of J-stylet

BackgroundPacing in the Bachmann's bundle (BB) area (upper atrial septum) appears superior to right atrial appendage or free wall stimulation for the prevention of paroxysmal atrial fibrillation in patients with atrial conduction delay. However, insertion of active fixation lead in the upper atrial septal position is difficult and time consuming with conventional stylet, inhibiting application of this pacing method in routine practice.MethodsThe technique of positioning the atrial lead in BB with hand-made stylet is presented with emphasis on electrocardiographic P-wave pattern and fluoroscopic landmarks.ResultsThe results demonstrate an acute implantation and short-term success of BB pacing of 14 patients out of 15 patients without major complications. Pacing parameters at implantation and 3 months postprocedure were noted which were within normal limits.ConclusionThese favorable initial results indicate that the positioning of active fixation atrial lead in BB with fluoroscopic landmarks is feasible and reproducible with a simple technique.     

Effect of Atrial Tachyarrhythmia Duration on Percentage of Time with Atrial Pacing in Pacemaker Patients with Paroxysmal Atrial Fibrillation

Atrial pacing can prevent the recurrence of paroxysmal atrial tachyarrhythmia (AT) in pacemaker patients. The aim of the study was to determine in pacemaker patients the effect of AT duration on the percentage of time with atrial pacing by programming the same setting twice. METHODS: In 14 pacemaker patients with paroxysmal AT the dual-chamber pacemaker was programmed to identical parameters for two consecutive follow-up periods. The pacemakers were interrogated after three months to determine the percentage of time with atrial pacing relative to the total time of follow-up periods and the AT duration (atrial rates >150 bpm). The two three-month follow-up periods were compared to each other. The differences between the two follow-up periods were determined for the percentage of time with atrial pacing as well as for the AT duration. To assess the relationship between atrial pacing and AT duration, the differences between the two follow-up periods for atrial pacing and AT duration were correlated to each other. In addition, the percentage of atrial pacing was corrected for AT duration. RESULTS: Median percentage of atrial pacing relative to the complete follow-up period was 73% after the first and 76% after the second period and median AT duration 21% and 18%, respectively (not significantly different). The differences between the first and second study period were 1% for atrial pacing and -2% for AT duration. The percentage of atrial pacing and AT duration were inversely related together with a significant correlation coefficient of r = 0.95 ( p = 0.0001). After atrial pacing was corrected for AT duration, the percentage of atrial pacing relative to the time in sinus rhythm was significantly higher with a median of 93% for the first and second period ( p = 0.005). The correlation coefficient between the percentage of atrial pacing relative to the time in sinus rhythm and AT duration was r = 0.08 (not significant). CONCLUSIONS: The percentage of time with atrial pacing can be underestimated in patients with paroxysmal atrial fibrillation and should be carefully interpreted in relation to AT duration.     

Impact of Consistent Atrial Pacing Algorithm on Premature Atrial Complexe Number and Paroxysmal Atrial Fibrillation Recurrences in Brady-Tachy Syndrome: A Randomized Prospective Cross Over Study

Aim of the study: The Consistent Atrial Pacing (CAP) algorithm has been designed to achieve a high percentage of atrial pacing to suppress paroxysmal atrial fibrillation. The aim of our study was to compare the impact of DDDR+CAP versus DDDR pacing on paroxysmal atrial fibrillation recurrences and triggers in patients with Brady-Tachy Syndrome. Methods: 61 patients, 23 M and 38 F, mean age 75±9 y, affected by Brady-Tachy Syndrome, implanted with a DDDR pacemaker, were randomized to DDDR or DDDR+CAP pacing with cross over of pacing modality after 1 month. Results: 78 % of patients in DDDR pacing and 73 % in DDDR+CAP pacing (p=n.s.) were free from symptomatic paroxysmal atrial fibrillation recurrences. During DDDR+CAP pacing, the atrial pacing percentage increased from 77±29 % to 96±7 % (p<0.0001). Automatic mode switch episodes/day were 0.73±1.09 in DDDR and 0.79±1.14 (p=n.s.) in DDDR+CAP. In patients with less than 50 % of atrial pacing during DDDR, automaticmode switch episodes/day decreased during DDDR+CAP from 1.13±1.59 to 0.23±0.32 (p<0.05) and in patients with less than 90 % from 1.23±1.27 to 0.75±1.10 (p<0.001). The number of premature atrial complexes per day decreased during DDDR+CAP from 2665±4468 to 556±704 (p<0.02). Conclusion: CAP algorithm allowed continuous overdrive atrial pacing without major side effects. Triggers of paroxysmal atrial fibrillation induction, such as premature atrial complexes, were critically decreased. Paroxysmal atrial fibrillation episodes were reduced in patients with atrial pacing percentage lower than 90 % during DDDR pacing.     

A Prospective Randomized Study to Assess the Efficacy of Rate and Site of Atrial Pacing on Long-Term Development of Atrial Fibrillation

The Septal Pacing for Atrial Fibrillation Suppression Evaluation (SAFE) study is a single-blinded, parallel randomized designed multicenter study in pacemaker indicated patients with paroxysmal atrial fibrillation (AF). The objective is to evaluate whether the site of atrial pacing–-conventional right atrial appendage versus low atrial septal—with or without atrial overdrive pacing will influence the development of persistent AF. The study will provide a definitive answer to whether a different atrial pacing site or the use of AF suppression pacing or both can give incremental antiarrhythmic benefit when one is implanting a device for a patient with a history of paroxysmal AF.     

食管心房调搏诱发阵发性房颤的心房电生理特性

为了探讨食管心房调搏对阵发性房颤检查的临床价值。回顾食管心房调搏诱发２５例阵发性房颤的心房电生理特性。其结果；程序刺激，分级起搏诱发１１例房颤，均有明确的房颤 史，猝发电脉冲诱发的１４例中１０例有明确的房颤史。房颤组２５例与正常对照组２５例相比心房有效不应期缩短，相对不应期区域扩大，最大房间传导时间延长，房间传导延缓更显著，这些可能是食管心房调搏诱发房颤的重要电生理基础。认为食管心房调搏对确定临床