对安置起搏器病人在不同心脏起搏模式下生活质量的评价

[目的]探讨不同心脏起搏模式下病人生活质量状况。[方法]选取均能进行日常活动且植入全自动双腔起搏（DDD）型或全自动双腔起搏频率适应（DDDR）型起搏器的Ⅲ度房室传导阻滞且窦房结功能正常（32例）和病窦综合征（心房、心室感知均≤10％）（51例）病人83例，进行前瞻性、随机、交叉、双盲对照研究，对起搏器随机程控为不同模式各1个月，在每种模式末，所有病人均填写Hacetepe生活质量问卷和Karolinska生活质量问卷中心血管症状学问题问卷。[结果]Ⅲ度房室传导阻滞且窦房结功能正常的病人，与心室起搏感知频率适应（VVIR）模式相比，DDD起搏模式下，心血管症状和生活质量显著改善；病窦综合征病人，与DDD模式相比，DDDR、VVIR起搏模式时，心血管症状和生活质量显著改善；与VVIR模式相比，DDDR起搏模式时，心血管症状和生活质量总分显著改善，但心血管症状和生活质量各维度的改善均无统计学意义。[结论]Ⅲ度房室传导阻滞且窦房结功能正常的病人，DDD模式是较佳的起搏模式；病窦综合征（心房、心室感知均≤10％）病人，DDDR模式是最佳的起搏模式。     

安装起搏器患者不同起搏模式下生活质量评价

采用Karolinska生活质量问卷评估法观察安装永久起搏器后患者在心室按需起搏器(VVI)、频率应答型心室按需型起搏器(VVIR)、全自动型起搏器(DDD)、频率适应型双腔起搏器(DDDR)不同模式下生活质量差异及患者对起搏模式的满意率。结果显示DDDR为最优起搏模式，房室顺序性起搏DDD模式优于单腔心室起搏VVI模式，具有频率应答功能的起搏器由于生理性增加心率，可以改善生活质量。提示接受生理性起搏器植入的患者术后生活质量高于非生理性起搏患者。     

安装起搏器患者不同起搏模式下生活质量评价

采用Karolinska生活质量问卷评估法观察安装永久起搏器后患者在心室按需起搏器(VVI)、频率应答型心室按需型起搏器(VVIR)、全自动型起搏器(DDD)、频率适应型双腔起搏器(DDDR)不同模式下生活质量差异及患者对起搏模式的满意率。结果显示DDDR为最优起搏模式,房室顺序性起搏DDD模式优于单腔心室起搏VVI模式,具有频率应答功能的起搏器由于生理性增加心率,可以改善生活质量。提示接受生理性起搏器植入的患者术后生活质量高于非生理性起搏患者。     

病态窦房结综合征伴房室传导延迟AAI与DDD起搏模式右心功能的超声评价

目的探讨AAI与DDD起搏模式下病态窦房结综合征伴房室传导阻滞患者的右心功能。方法 35例病态窦房结综合征伴Ⅰ度房室传导阻滞植入DDD双腔起搏器患者,先用程控仪将起搏器程控为DDD模式,最后程控为AAI模式。超声心动图检测患者2种起搏模式下的各参数变化情况。结果 DDD起搏模式下的RVPEP、RVPEP/RVET、Sm、Tei指数明显高于AAI起搏模式（P〈0.05）,E/Em低于AAI起搏模式（P〈0.05）。结论 AAI起搏模式右心的收缩和舒张功能均优于AV间期优化的DDD起搏模式。     

双腔起搏器治疗严重缓慢性心律失常

目的 :评价双腔起搏器治疗严重缓慢性心律失常的临床疗效及价值。方法 :5 2例双腔起搏器 ,其中 41例DDD起搏器 ,11例DDDR起搏器。病态窦房结综合征 (sicksinussyndrome,SSS) 39例 ,房室传导障碍 13例 ,其中包括Ⅲ度房室传导阻滞 (thirddegreeAVblock ,Ⅲ°AVB) 3例 ,高度房室传导阻滞 (highdegreeAVblock ,HDAVB) ,Ⅱ度Ⅱ型房室传导阻滞 (typeⅡseconddegreeAVblock ,Ⅱ°Ⅱ型AVB) ,三分支传导阻滞 (threefascicularblock ,TFB)病人 ,以上病人均伴有昏厥、黑朦或严重头晕。电极植入途径为锁骨下静脉或头静脉。结果 :5 2例术后随访 1 78个月 ,临床疗效显著 ,不仅防止心博骤停发生 ,脑缺血症状消失 ,而且生活质量明显提高。 3例SSS者阵发房颤 (atrialfibrillation ,Af)术后消失 ,10例SSS者结合药物治疗Af发作次数减少。 1例扩张性心肌病死于左心衰竭。并发症 :心房感知过度 2例 ,心房感知不足 1例 ,心室电极阈值升高 1例 ,囊袋感染 1例 ,血肿 1例。结论 :双腔起搏器为较理想的生理性起搏 ,本研究证实能有效地治疗严重SSS和房室传导障碍的病人     

AAI与DDD起搏模式治疗病窦综合征的系统评价

目的 系统评价AAIR 和DDDR 两种生理性起搏模式比较治疗病窦综合征的有效性及安全性。 方法 采用Cochrane 系统评价方法,计算机检索Cochrane 图书馆临床对照试验数据库（2009 年第2 期）、MEDLINE（1980 ～ 2009.6）、EMbase（1980 ～ 2009.6）、CBM（1990 ～ 2009.6）,同时手工检索相关期刊,纳入AAIR 对比DDDR 起搏治疗病窦综合征的随机对照试验、半随机对照试验及随机交叉试验,评价所有纳入研究的方法学质量,并提取有效数据采用RevMan 5.0 软件进行Meta 分析。 结果 共纳入AAIR 对比DDDR 起搏治疗病窦综合征的随机对照试验6 个和随机交叉试验2 个,合计509 例患者,但研究质量均不高。Meta 分析结果显示：AAIR 起搏模式较之DDDR 起搏模式治疗不伴房室传导阻滞的病窦综合征可能更能缩小左房直径［MD=2.09,95%CI （0.22,3.97）］、左室舒张末内径［MD=3.00,95%CI（– 1.58,7.58）］和减低房颤的发生（P=0.026）,改善患者生活质量（P〈0.05）,但在治疗中由于患者发生房室传导阻滞需要重调或更换起搏器事件较多;对于患者的全因病死率（P=0.51）、心血管原因病死率（P=0.43）、心衰（P=0.17）、中风（P=0.32）、左室收缩末内径［MD=1.21,95%CI（– 0.85,3.28）］及左室射血分数［MD= – 2.91,95%CI（– 6.53,0.70）］的改善二者相似;未见明显副作用。 结论 AAIR 起搏模式较之DDDR起搏模式治疗病窦综合征可能更能缩小患者左房直径及左室舒张末径,减低房颤的发生,改善生活质量,但同时也存在较多的重调或更换起搏器事件。由于纳入研究质量普遍偏低,样本量普遍偏少,尚不能确定其疗效及安全性,今后尚需开展大样本、高质量的随机对照试验以证实。     

植入永久型人工心脏起搏器手术前后的护理体会

人工心脏起搏是应用人工心脏起搏器,通过置于心房及心室的导管起搏电极,向心肌发放脉冲电流刺激心肌,使心肌兴奋并将兴奋传导到心脏的其它部位,导致整个心室兴奋收缩,使心脏按脉冲电流的频率有效的搏动。常用于心脏起搏传导功能发生暂时性或永久性障碍而不能正常搏动的病人。我科自1989年12月至1992年1月,共行人工心脏起搏器植入术45例,其中首次植入29例,占64％,更换植入16例,占36％。植入指征:病窦综合征(sss)22例。占49,<,Ⅲ°房室传导阻滞23例,占51％。起搏类型:心室起搏心室感知抑制型(vvI)39例,双腔程控多功能起搏器(DDD)3例,心房起搏心房感知抑制型(AAI)1例。术后评价:成功43例,成功率96％。另外2例,其中1例因上腔静脉畸形,电极导管不易插入右心室,而迫使手术终止,转外院行心外膜电极起搏器植入术。另1例因术中电极导管插入不畅病人出现休克而终止手术。     

房室全能型起搏器临床应用体会

<正> 房室全能型起搏器(DDD)是近年来人工心脏起搏的一项极为重要的进展,由于其起搏方式能维持正常的房室收缩顺序,可以明显改善血流动力学状况,国外临床已广泛应用,国内开展此项工作尚不多,我们从1991年1月相继为4例患者安置了DDD型起搏器,现结合临床应用体会讨论如下: 资料与方法一、一般资料4例患者,男3例,女1例,年龄43～61岁,4例均为病态窦房结综合征,其中2例为快慢综合征,心电图表现有:严重窦缓、窦停、     

心室起搏管理对病态窦房结综合征患者生活质量的影响

目的探讨心室起搏管理（MVP）对病态窦房结综合征（SSS）患者生活质量的影响。方法在15例植入具有MVP功能的双腔起搏器SSS患者中,先以传统频率应答双腔起搏（DDDR）模式工作1个月,再程控为MVP模式工作1个月,分析不同起搏模式下患者累计心室起搏百分比（CumVP％）、4种起搏和感知状态时间百分比的变化,采用明尼苏达心力衰竭生活质量评分表（LiHFe）评估患者在两种不同起搏模式下生活质量的变化。结果随访期间,患者CumVP％由DDDR模式下的91．3％下降至MVP模式下的1．6％（U=130．5,P〈0．01）;4种起搏和感知状态时间百分比比较差异均有统计学意义（P〈0．01）;患者LiHFe总分在DDDR模式下（34．0±3．4）分,MVP模式下（10．4±4．2）分,差异有统计学意义（t=49．4,P〈0．01）,其他各项评分比较差异均有统计学意义（P〈0．01）。结论对植入心脏起搏器的SSS患者,MVP不仅是一种安全、有效和可靠的起搏模式,还可以提高患者的生活质量。     

不同类型心动过缓起搏器植入前后血压变化的比较

起搏器植入已经成为治疗严重的心动过缓的标准方法[1]。符合起搏器植入指征的心动过缓中,绝大多数为病态窦房结综合征（SSS）及Ⅲ°房室传导阻滞（Ⅲ°AVB）。由于这二者病变的部位分别在心脏传导系统的窦房结和房室结,就导致了其对血流动力学产生了不同的影响。本研究通过总结SSS和AVB的临床、血压、心脏结构等方面的资料,探讨不同类型心动过缓在起搏器植入前后血压的变化特点及原因。     

Complications of Permanent Transvenous Cardiac Pacing: A 14-Year Review of all Transvenous Pacemakers Inserted at One Community Hospital

Five hundred and eighty-nine consecutive transvenous pacemakers implanted between January 1, 1971 and January 1, 1985 were reviewed. A complication incidence of 17% early in the study period (1971–1977) was caused by electrode displacement and perforation. As of 1975, smaller-sized electrodes with endocardial fixation were used and were associated with a significant decrease in this complication incidence to 2% by 1985. All other complications occurring during the entire study period (1971–1985) occurred at a frequency of 3% (20/589). Infection occurred in 3 of 589 cases; there were no extrusions or erosions. No mortality was attributed to pacemaker insertion. The "twiddler" syndrome seems to be increasing in frequency. Transvenous permanent pacing can be accomplished today with a low complication rate of 5% or less. The majority of these complications are minor and can be corrected easily. Our studies suggest that the reduced complication incidence is mainly related to improved technology.     

Rate-Responsive Pacing by Means of Activity Sensing Versus Single Rate Ventricular Pacing: A Double-Blind Cross-Over Study

The clinical appiicabiJity of rate-responsive pacing (RRP) by means of activity sensing has been tested in 15 patients. The patients (ages 24–85) had sinus node dysfunction (2), atrial fibrillation (7), or sinus rhythm (6) combined with complete atrioventricular block. Exercise capacity was investigated on a bicycle ergometer and on a treadmill in a double-blind cross-over study design following one week each of fixed rate ventricu/ar pacing (70 bpm) and rate-responsive pacing (60/125–150 bpm). The patients answered a questionnaire concerning subjective symptoms. A Holter ECG was recorded during 24 hours of all day activity on rate-responsive pacing. During exercise in the rate-responsive mode, heart rate increased more on the treadmill than on the bicycle. A majority of the patients (13 of 15) preferred rate-responsive pacing mainly due to less dyspnea and tiredness. Exercise capacity improved significantly both on bicycle (+7%; p < 0.01) and on treadmill (+19%; p < 0.01) during rate-responsive pacing. There were no complications during the follow-up period. In conclusion, the activitysensing pacemaker is a valuable supplement to existing types o/ pacemakers. It should be used in patients in whom an atrial electrogram cannot be used for rate triggering.     

Choice of the Optimum Pulse Duration for Precordial Cardiac Pacing: A Theoretical Study

In precordial pacing with skin-surface electrodes, the goal is to excite the ventricles with minimal stimulation of overlying tissues. A theoretical analysis is presented to identify the relevant factors; the two most important are electrode location and pulse duration. Using the basic law of stimulation, we developed a model which indicates that the optimum pulse duration for the closed-chest pacing pulse is one that is long with respect to the membrane time constant of cardiac muscle. Current-versus-duration curves are presented for pacing and pain, based on experimentally obtained data. For pacing with minimum pain, the optimum stimulus duration was found to be about 10 ms.     

Characteristics of Bifocal Pacing:

Bifocal RIGHT ventricular stimulation (BRIGHT) is an ongoing, randomized, single-blind, crossover study of atrial synchronized bi-right ventricular (RV) pacing in patients in New York Heart Association heart failure functional class III, a left ventricular ejection fraction <35%, left bundle branch block and QRS complexes ≥120 ms. This analysis compared the electrical and handling characteristics, and the complications of pacing at the RV apex (Ap) with passive, versus RV outflow tract (OT) with active fixation leads. A mean of 1.6 ± 0.9 and 2.2 ± 2.0 attempts were needed to position the Ap and OT leads, respectively (ns). R-wave amplitudes at Ap versus OT were 23 ± 13 mV versus 14 ± 8 mV (n = 36, P < 0.001). R-wave amplitudes at the Ap remained stable between implant and M7. R-wave amplitudes at the OT could not be measured after implantation. In two patients, atrioventricular block occurred during active fixation at the OT. Conduction recovered spontaneously within 4 months. Ventricular fibrillation was induced in one patient during manipulation of an Ap lead in the RV. Marked differences were found between leads positioned in the OT versus Ap, partly related to the difference in lead design. Mean R-wave amplitude was higher at the Ap that at the OT. Ease and success rate of lead implant was similar in both positions.     

Characteristics of bifocal pacing: right ventricular apex versus outflow tract. An interim analysis

Bifocal RIGHT ventricular stimulation (BRIGHT) is an ongoing, randomized, single-blind, crossover study of atrial synchronized bi-right ventricular (RV) pacing in patients in New York Heart Association heart failure functional class III, a left ventricular ejection fraction <35%, left bundle branch block and QRS complexes >/=120 ms. This analysis compared the electrical and handling characteristics, and the complications of pacing at the RV apex (Ap) with passive, versus RV outflow tract (OT) with active fixation leads. A mean of 1.6 +/- 0.9 and 2.2 +/- 2.0 attempts were needed to position the Ap and OT leads, respectively (ns). R-wave amplitudes at Ap versus OT were 23 +/- 13 mV versus 14 +/- 8 mV (n = 36, P < 0.001). R-wave amplitudes at the Ap remained stable between implant and M7. R-wave amplitudes at the OT could not be measured after implantation. In two patients, atrioventricular block occurred during active fixation at the OT. Conduction recovered spontaneously within 4 months. Ventricular fibrillation was induced in one patient during manipulation of an Ap lead in the RV. Marked differences were found between leads positioned in the OT versus Ap, partly related to the difference in lead design. Mean R-wave amplitude was higher at the Ap that at the OT. Ease and success rate of lead implant was similar in both positions.     

The Subpectoral Pocket: The Preferred Implant Site for Pediatric Pacemakers

Implantation technique for pediatric pacemaking has evolved from predominantly epicardial to predominantly endocardial. One of the potential problems with endocardial pacing in children is their very thin subcutaneous tissue, which can result in an unpleasant cosmetic result. The superficialness of the pacemaker pulse generator also may render it more susceptible to erosion and infection. A series is presented of pediatric patients who underwent implantation of a transvenous bipolar pacing system in the pediatric catheterization laboratory. The pacemaker was implanted under the pectoralis major muscle after a muscle spreading incision was made. The lead was also introduced into the subclavian vein under the pectoralis muscle. No complications resulted, and the cosmetic result was judged to be good to excellent by the parents and physicians. No infections or erosions occurred. The subpectoral pocket is recommended as the preferred site for implantation of transvenous pacemakers in pediatric patients.     

Pathological aspects of transcutaneous cardiac pacing

Although electrical energy has the potential to produce myocardial injury, the risk of tissue damage from transcutaneous cardiac pacing is largely unknown. This study reports the anatomical findings of a canine transcutaneous stimulation study. Ten dogs had 100-mA, 20-msec (pulse duration), transcutaneous impulses delivered across the thorax for 30 minutes at a rate of 80 stimuli per minute. Seventy-two hours later the animals were sacrificed, and the heart, lungs, and tissues of the chest wall were examined for pathological changes. Gross and microscopic lesions consistent with electrically induced myocardial damage were found in all hearts examined. These lesions included myocardial pallor and focal myofibril coagulation necrosis in the right ventricular outflow tract and perivascular microinfarcts in the posterior left ventricular myocardium. These lesions were not extensive; less than 5% of the right ventricular free wall and less than 1% of the left ventricular posterior wall were involved. Lesions of this extent would not be expected to cause clinically detectable changes in cardiovascular status. Short-term use of transcutaneous pacing appears to be safe. Determination of the potential for clinically significant injury with long-term use requires further study.     

Transcutaneous cardiac pacing

Transvenous cardiac pacing is currently the pacing procedure of choice in patients with severe, life-threatening bradyarrhythmias that do not respond to pharmacotherapy. However, pacing catheters can be difficult to insert and frequently fail to capture in severely hypotensive patients. Therefore, there has been a recent resurgence of interest in external pacing methods. Newer transcutaneous cardiac pacing units are easy to apply and especially suited for unconscious patients with severe, life-threatening bradyarrhythmias. There is no operator danger and, if need be, cardiopulmonary resuscitation can continue while the electrodes are in place and the unit is operating. Human and animal studies to date have shown that there are no significant short-term clinical hazards or pathologic abnormalities when using this technique.     

Precordial Pacing Windows

The threshold peak current for cardiac pacing with 10 ms rectangular pulses applied to precordial electrodes was determined in 18 anesthetized dogs (average weight 20.8 kg). The entire left and right precordium was mapped with a 1 cm diameter (cathode) electrode, paired with a 10 cm diameter reference electrode on the opposite chest. It was found that the lowest current required for pacing corresponded to the region of the apex beat on the left chest. At this site the average pacing threshold with the 1 cm electrode was 34.3 mA (peak). No sharply defined low pacing current area was found on the right chest, indicating that the location for the right chest electrode is not critical. The term "pacing window" is introduced to identify the region on the precordium where the pacing threshold is lowest. Studies were also performed to determine the manner in which the pacing current increased as electrode diameter was increased beyond the diameter of the pacing window. It was determined that little is to be gained with a left chest electrode larger than 5 cm in diameter in this animal study.