老年肺癌术后心律失常多因素分析

心律失常是肺癌术后常见的并发症，老年病人心肺功能降低，代偿能力差，术前多并存高血压或糖尿病等动脉硬化性疾病，肺切除术后常有并发心脑并发症的风险，而心律失常又是术后早期的表现。本文旨在探讨肺癌肺切除术后心律失常的危险因素及处理方法。     

795例肺癌术后发生心律失常的多因素分析

目的探讨肺癌术后发生心律失常的危险因素及其防治。方法回顾分析2002年1月～2004年1月我院肺癌手术795例，其中全肺切除术176例，肺叶切除术509例，楔型切除术110例。术后发生心律失常273例，应用Logistic回归对影响术后发生心律失常可能的危险因素进行分析。结果本组病例心律失常总发生率为34.3％（273／795），多因素Logistic逐步回归分析显示高龄、吸烟史、心律失常史、全肺切除、术中心包损伤、术后肺不张是术后心律失常的主要危险因素（P〈0.05），术后镇痛是保护因素（P=0.017）。结论心脏的储备功能降低、对手术损伤及缺氧的耐受力降低是导致术后心律失常的原因，采取一些预防措施可以减少其发生率。     

老年患者全肺切除术后心律失常的护理

心律失常是开胸术后的常见并发症之一。全肺切除术由于创伤大、肺功能丧失多、血流动力学改变明显、术后两侧胸腔压力不均衡而容易产生纵隔移位等原因,较肺叶切除术后并发心律失常更为常见,严重者可致死亡。过去认为,老年肺癌患者由于心肺代偿功能欠佳,不适宜行全肺切除术,但随着现代医学技术的快速发展,各种监护和治疗手段的完善,越来越多的学者认为单纯年龄不属于手术禁忌证,而且人们对自身生活质量的要求也愈来愈高,许多高龄肺癌患者愿意选择外科治疗。我们回顾了近7年来因肺癌行全肺切除术的老年患者89例,术后发生心律失常49例,通过对原因的分析,探讨相应的护理策略。     

全肺切除术后并发心律失常的护理体会

心律失常是一侧全肺切除术后的常见严重并发症之一,2008年11月-2009年2月,我科收治1例行肺癌一侧全肺切除术后发生心律失常的患者。现将体会报告如下：病历摘要 患者,男性,59岁,因“咳嗽、咳痰、右肩部疼痛2月余”于2009年2月4日入院,完善术前准备,于2009年2月22日在全麻下行右肺全切除术,术后转入我科,     

外科术后房性心动过速

房性心动过速是心脏外科手术后常见的一种心律失常,可致血流动力学障碍,甚至更严重的并发症,增加了外科术后的死亡率和致残率。外科术后房性心动过速以心房内折返性心动过速最为常见,比较少见的是外科手术相关的局灶性房性心动过速。     

阵发性室上性心动过速病人行射频消融术86例体会

阵发性室上性心动过速是一种常见的心律失常，具有无诱因反复发作、药物不能根治等特点。射频消融术是借助于X线通过导管利用射频能量，作用于心脏内引起快速心律失常的特殊部位或构成心动过速折返通路的关键组成部分，使该处心肌组织凝固性坏死而丧失传导功能，达到根治心动过速的目的，是目前治疗阵发性室性心动过速最有效的方法。针对病人在术前、术中、术后的不同问题实施有效的护理，是使病人得到有效治疗的重要措施。     

余肺切除术后心律失常原因分析

目的分析余肺切除术后心律失常的原因及对策。方法对36例余肺切除患者临床资料进行回顾性分析。结果 36例患者中术后并发心律失常28例,占77.78%,均经治疗后纠正,无1例死于心律失常。结论余肺切除术后心律失常可以纠正而且不增加死亡率。     

先天性心脏病复合畸形并心律失常的射频消融治疗1例

<正>小儿心律失常是临床常见疾病,长期反复的心动过速发作可导致心动过速心肌病[1],射频消融是根治快速心律失常的有效方法[2]。先天性心脏病(先心病)复合畸形合并外科矫形术后的快速心律失常病情往往较复杂,是先心病术后死亡的常见原因之一[3],而射频消融手术治疗这种心律失常也有一定难度。本文报道先心病复合畸形并多种心律失常的射频消融治疗1例。1病例资料患者,男,12岁,因反复心悸伴出汗7年入院。     

高龄肺癌患者全肺切除术后心律失常的因素分析及临床护理

目的 探讨高龄肺癌患者全肺切除术后并发心律失常的原因并总结临床护理措施.方法 收集近年来于我院普通外科行全肺切除的71例肺癌患者的临床资料,对高危因素进行分析,同时总结相关护理措施.结果 术后1～3 d心律失常发生率为52.1％（37/71）.多因素分析表明,术前合并心血管基础病、心电图异常、重度肺功能障碍、术中出血量多（≥500 ml）、术后血清钾低（≤4.0 mmol/L）均属于高龄肺癌患者全肺切除术后并发心律失常的高危因素（P＜0.05）.手术时长及性别与术后发生心律失常的发生无显著相关性（P＞0.05）.强化术前健康教育、严格手术适应证、充分供氧、预防并改善缺氧、纠正电解质紊乱、有效止痛及持续心电监护等均是有效的护理措施.结论 高龄肺癌患者全肺切除术后心律失常发生与术前心血管基础病、心电图异常、重度肺功能障碍等有关,在因素分析基础上开展有效的临床护理对预防此类心肺并发症的发生有重要意义.     

心房颤动射频导管消融术后左房房性心动过速的发生与处理

心房颤动射频导管消融术后左房来源的房性心动过速是常见的术后并发症。由于这些心律失常更常表现为持续性发作,心室率更快,造成患者显著的症状,甚至影响心功能,具有重要的临床意义。现就心房颤动射频导管消融术后左房房性心动过速的发生情况、机制、预防和处理做一综述。     

Optimal programming of ICDs for prevention of appropriate and inappropriate shocks

Expansion of indications for implantable cardioverter-defibrillators (ICDs) has led to a significant increase in the number of patients receiving ICDs and the number of lives saved because of ICD therapy. However, appropriate or inappropriate shocks are frequent and may result in a significant decrease in quality of life in patients with ICDs. Atrial fibrillation with rapid ventricular response, sinus tachycardia, atrial tachycardia or atrial flutter with rapid conduction, and other supraventricular tachycardias are the most common arrhythmias causing inappropriate therapy. Other causes include oversensing of diaphragmatic potentials or myopotentials, T-wave oversensing, double or triple counting of intracardiac signals, lead fractures or header connection problems, lead chatter or noise, and electromagnetic interference. Strategies to reduce inappropriate therapy using device programming rely on the ability to distinguish supraventricular and atrial arrhythmias from ventricular tachycardia. Avoiding therapy for nonsustained ventricular arrhythmias and increasing the role of antitachycardia pacing to terminate ventricular tachycardia are key approaches to reducing shocks for ventricular arrhythmias. Optimal programming holds great promise for decreasing the overall incidence of shock therapy and increasing ICD acceptance.     

Mechanisms underlying the development of atrial arrhythmias in heart failure

There is an important association between heart failure and the development of atrial arrhythmias. Although most often associated with atrial fibrillation, there is some evidence to suggest an association between heart failure and other atrial arrhythmias and, in particular, atrial flutter and atrial tachycardia. The mechanisms by which these common atrial arrhythmias may arise in patients with heart failure are discussed.     

Value of echocardiography in the diagnosis of arrhythmias

Identification of auricular activity is important for the diagnosis of arrhythmias. P waves however are often difficult to recognize. Using M-mode and 2-D echocardiographic techniques, it is often possible to recognize atrial contraction at the level of the atrial septum or of the free wall of the right atrium. Diagnosis can be made in cases of sinus tachycardia, supra ventricular tachycardia with and without aberrancy and ventricular tachycardia with dissociation. Ventricular tachycardia with one to one retrograde conduction or with atrial fibrillation cannot be recognized by this method.     

Dual chamber arrhythmia detection in the implantable cardioverter defibrillator

INTRODUCTION: Dual chamber implantable cardioverter defibrillator (ICD) technology extended ICD therapy to more than termination of hemodynamically unstable ventricular tachyarrhythmias. It created the basis for dual chamber arrhythmia management in which dependable detection is important for treatment and prevention of both ventricular and atrial arrhythmias. METHODS AND RESULTS: Dual chamber detection algorithms were investigated in two Medtronic dual chamber ICDs: the 7250 Jewel AF (33 patients) and the 7271 Gem DR (31 patients). Both ICDs use the same PR Logic algorithm to interpret tachycardia as ventricular tachycardia (VT), supraventricular tachycardia (SVT), or dual (VT+ SVT). The accuracy of dual chamber detection was studied in 310 of 1,367 spontaneously occurring tachycardias in which rate criterion only was not sufficient for arrhythmia diagnosis. In 78 episodes there was a double tachycardia, in 223 episodes SVT was detected in the VT or ventricular fibrillation zone, and in 9 episodes arrhythmia was detected outside the boundaries of the PR Logic functioning. In 100% of double tachycardias the VT was correctly diagnosed and received priority treatment. SVT was seen in 59 (19%) episodes diagnosed as VT. The causes of inappropriate detection were (1) algorithm failure (inability to fulfill the PR相似文献   

Catheter Ablation of Atrial Arrhythmias in Patients Post-Fontan

Atrial arrhythmias are highly prevalent in the aging Fontan population and contribute importantly to morbidity and mortality. Although the most common arrhythmia is scar-based intra-atrial re-entrant tachycardia, various other arrhythmias may occur, including focal atrial tachycardia, atrioventricular node-dependent tachycardias, and atrial fibrillation. The type and prevalence of atrial arrhythmia is determined, in part, by the underlying congenital defect and variant of Fontan surgery. Although the cumulative incidence of atrial tachyarrhythmias has decreased substantially from the atriopulmonary anastomosis to the more recent total cavopulmonary-connection Fontan, the burden of atrial arrhythmias remains substantial. Management is often multifaceted and can include anticoagulation, anti-arrhythmic drug therapy, pacing, and cardioversion. Catheter ablation plays a key role in control of arrhythmia. Risks and benefits must be carefully weighed. Among the important considerations are the clinical burden of arrhythmia, ventricular function, hemodynamic stability in tachycardia, suspected arrhythmia mechanisms, risks associated with anaesthesia, venous access, approaches to reaching the pulmonary venous atrium, and accompanying comorbidities. Careful review of surgical notes, electrocardiographic tracings, and advanced imaging is paramount, with particular attention to anatomic abnormalities such as venous obstructions and displaced conduction systems. Despite numerous challenges, ablation of atrial arrhythmias is effective in improving clinical status. Nevertheless, onset of new arrhythmias is common during long-term follow-up. Advanced technologies, such as high-density mapping catheters and remote magnetic guided ablation, carry the potential to further improve outcomes. Fontan patients with atrial arrhythmias should be referred to centres with dedicated expertise in congenital heart disease including catheter ablation, anaesthesia support, and advanced imaging.     

Phasic coronary arterial flow velocity during arrhythmias in man

The influence of cardiac arrhythmias on coronary arterial flow velocity studied by means of a Doppler catheter flowmeter system is described in 47 patients. The arrhythmias examined included atrial and ventricular extrasystoles, atrial fibrillation, pacemaker-induced atrial tachycardia, paroxysmal atrial tachycardia, ventricular tachycardia, Wenckebach second degree atrioventricular block and complete heart block.     

Cardiac arrhythmias and conduction disturbances in autoimmune rheumatic diseases

Rhythm and conduction disturbances and sudden cardiac death (SCD) are important manifestations of cardiac involvement in autoimmune rheumatic diseases (ARDs). In patients with rheumatoid arthritis (RA), a major cause of SCD is atherosclerotic coronary artery disease, leading to acute coronary syndrome and ventricular arrhythmias. In systemic lupus erythematosus (SLE), sinus tachycardia, atrial fibrillation and atrial ectopic beats are the major cardiac arrhythmias. In some cases, sinus tachycardia may be the only manifestation of cardiac involvement. The most frequent cardiac rhythm disturbances in systemic sclerosis (SSc) are premature ventricular contractions (PVCs), often appearing as monomorphic, single PVCs, or rarely as bigeminy, trigeminy or pairs. Transient atrial fibrillation, flutter or paroxysmal supraventricular tachycardia are also described in 20-30% of SSc patients. Non-sustained ventricular tachycardia was described in 7-13%, while SCD is reported in 5-21% of unselected patients with SSc. The conduction disorders are more frequent in ARD than the cardiac arrhythmias. In RA, infiltration of the atrioventricular (AV) node can cause right bundle branch block in 35% of patients. AV block is rare in RA, and is usually complete. In SLE small vessel vasculitis, the infiltration of the sinus or AV nodes, or active myocarditis can lead to first-degree AV block in 34-70% of patients. In contrast to RA, conduction abnormalities may regress when the underlying disease is controlled. In neonatal lupus, 3% of infants whose mothers are antibody positive develop complete heart block. Conduction disturbances in SSc are due to fibrosis of sinoatrial node, presenting as abnormal ECG, bundle and fascicular blocks and occur in 25-75% of patients.     

Utility of the filtered bipolar esophageal lead in the diagnosis of arrhythmias

Electrophysiologic study was performed in 25 patients with tachycardia or bradycardia attacks. The coronary sinus (CS) and filtered bipolar esophageal electrograms were recorded simultaneously to compare the phase of atrial activations. During sinus rhythm and high right atrial pacing, the esophageal and proximal CS atrial activations were nearly simultaneous but earlier by 26 +/- 5 msec on the average than the distal CS atrial activations. During reciprocating tachycardia due to reentry using a left-side accessory atrioventricular pathway for retrograde conduction the esophageal and CS atrial activations occurred earlier than the low septal right atrial activation, so the esophageal lead can be used as a substitute for the CS lead to clarify the eccentric retrograde atrial activation sequence. By using the filtered bipolar esophageal lead, the interval from Q wave on the surface electrocardiogram to the first rapid deflection in the esophageal atrial activation (Q-AESO interval) was measured in 15 patients with supra-ventricular tachycardia. All patients with reciprocating tachycardia due to reentry using a left side accessory atrioventricular pathway had Q-AESO intervals between 100 to 130 msec and four of five patients with a right side accessory atrioventricular pathway for retrograde conduction had Q-AESO intervals between 130 to 150 msec. In contrast, all patients with reentry in the atrioventricular node had Q-AESO intervals between 30 to 60 msec. The esophageal lead is also of value in the prompt diagnosis of atrial flutter and ventricular tachycardia, since the esophageal electrograms readily reveal the relationship between atrial and ventricular activations. In conclusion, the filtered bipolar esophageal lead provides a non-invasive method for the quick diagnosis of various arrhythmias.     

Early and late arrhythmias after the Fontan operation: predisposing factors and clinical consequences.

OBJECTIVE--To study the incidence, predisposing factors, and clinical significance of arrhythmias early and late after the Fontan operation for congenital heart disease. PATIENTS AND METHODS--All 104 consecutive patients undergoing Fontan repair from 1975 to 1988 were studied retrospectively. Hospital records were reviewed for perioperative arrhythmia. Clinical information and annual electrocardiograms were available for all 78 hospital survivors during a follow up of up to 13 years (mean 3.7 years). Ambulatory electrocardiographic monitoring was performed in 67 patients (81%). RESULTS--Eleven patients (10.6%) developed a perioperative tachycardia (eight, atrial flutter; three, His bundle tachycardia). Multivariate analysis showed that raised preoperative mean pulmonary artery pressure and low aortic saturation were significant risk factors for the development of atrial flutter (r2 = 0.32, p = 0.0001) but not for His bundle tachycardia. Despite intensive medical treatment 10 of these 11 patients died. At the last visit 72 (92%) of the 78 patients were in sinus rhythm on their standard 12 lead electrocardiogram. Junctional rhythm was present in three patients, two patients had atrial flutter, and one had a paced rhythm. Ambulatory monitoring did not show important bradycardia or ventricular arrhythmias. Actuarial survival free of supraventricular arrhythmia was 82% at eight years after operation. Multivariate analysis identified older age, increased right atrial size, and raised mean preoperative pulmonary artery pressure as risk factors for arrhythmia during intermediate follow-up (r2 = 0.46, p less than 0.001). Late tachycardias, in contrast to those occurring in the perioperative period, were not associated with an increased mortality. CONCLUSIONS--Except for his bundle tachycardia in the perioperative period, early and late arrhythmias after a Fontan operation seem to be a consequence of adverse preoperative and postoperative haemodynamic function. The perioperative outcome is therefore poor even when the patient can be restored to sinus rhythm. Medical and surgical modifications to improve the haemodynamic disturbances associated with arrhythmias are therefore indicated.