应用PTCA导引钢丝指引左心室电极导线的植入

双心室同步起搏已被充分证明可有效地改善充血性心力衰竭伴心室内传导阻滞患者的心功能[1,2 ] 。进行双心室同步起搏的一个技术关键是植入左心室起搏电极导线。目前可行并广泛应用的方法是经冠状静脉窦途径将电极导线插入心脏静脉起搏左心室 ,由于进入冠状静脉窦的心脏静脉较细、弯曲度大以及变异较多 ,直接用目前临床应用的冠状静脉窦电极导线插管难度大 ,X线照射时间长 ,且成功率受到影响。近来 ,一种新设计的带侧孔的 ,可用PTCA导引钢丝指引下插入的冠状静脉窦电极导线开始在临床应用。资料和方法2 2例充血性心力衰竭伴心室内阻滞患者 …     

房室结消融加上双心室起搏治疗心力衰竭伴心房颤动患者

目的 观察了8例充血性心力衰竭伴心房颤动(房颤)患者进行房室结消融后,植入双心室起搏器的治疗效果。方法 8例充血性心力衰竭伴持续性房颤患者,男性5例,女性3例,平均年龄58.4岁,平均左心室内径(68.5±6.3)mm,左心室射血分数(LVEF)0.30±0.03,所有患者均伴有室内阻滞,平均QRS宽度(157.1±22.3)ms。患者先进行射频导管消融阻断房室结(希氏束),然后进行双心室起搏器植入术。在冠状静脉窦造影术后,经冠状静脉窦植入左心室起搏电极导线至一根心脏静脉,通常是心脏后侧静脉或心脏后静脉内。右心室起搏导线置于右心室心尖部,然后与双心室起搏器连接。结果 8例患者均成功地消融房室结,植入双心室起搏器术后超声心动图显示,LVEF从术前的0.30提高至0.38(P<0.05),二尖瓣返流较术前明显减少,患者临床上心慌、气短症状明显改善,心功能(NYHA分级)平均改善Ⅰ级。结论 初步临床观察提示,对于充血性心力衰竭伴有房颤患者,双心室同步起搏同样可改善患者心功能。     

双心室同步起搏治疗充血性心力衰竭的临床应用

目的　观察三腔双心室起搏治疗充血性心力衰竭效果。方法　患者男性 2例 ,女性 1例 ,平均年龄 5 7岁 ,为充血性心功能衰竭伴左束支阻滞 ,植入三 (四 )腔双心室起搏器。左心室起搏通过冠状静脉窦植入 2 187或 2 188电极导线 ,置于心后静脉起搏左心室 ,左右心室电极导线通过 Y形转接器与双腔起搏器连接。结果　双心室起搏并辅以合适的 AV延迟后 ,患者心力衰竭症状明显改善 ,N YHA分级从 ～ 级改善至 级 ,二尖瓣返流明显减少。结论　初步临床应用提示 ,双心室同步起搏治疗充血性心力衰竭是可行而有效的     

双心室起搏的临床疗效观察

目的　探讨缺血性或扩张型心肌病合并充血性心力衰竭行永久性双心室起搏治疗的临床效果。方法　对 1 0例缺血性或扩张型心肌病合并难治性心力衰竭和左束支阻滞患者 ,常规植入右心室起搏导线的同时植入冠状静脉窦电极导线于左室侧静脉、心大或心中静脉 ,行双心室同步起搏 (其中 2例为四腔起搏 )。通过临床观察、超声心动图测定及 6分钟平地行走评定对心功能的影响。结果　在充血性心力衰竭合并左束支阻滞患者植入冠状静脉窦电极导线行双心室起搏 ,产生较窄 QRS波 ,临床心功能从 ～ 级提高至 ～ 级 ( NYHA) ,同时使二尖瓣返流减少 ,射血分数提高 ,左室舒张末期内径缩小 ,6分钟平地行走距离比术前明显提高。结论　双心室起搏对难治性心力衰竭可能有辅助治疗作用。     

普通心室电极在双室右房三心腔起搏治疗充血性心力衰竭中的初步应用

目的 观察普通心室电极起搏治疗扩张性心肌病（DCM）伴充血性心力衰竭（CHF）的疗效。方法患者,男,2例,女2例,平均年龄62.6岁±7.7岁（52岁～70岁）,均为扩张性心肌病伴充血性心衰,且有完全性左束支传导阻滞或左前分支传导阻滞,行双室右房三心腔起搏治疗。左心室起搏通过冠状静脉窦植入剪去一部分尖端羽翼的普通心室电极,置于冠状静脉窦的分支静脉起搏左心室,左右心室电极导线通过Y形转换器与双腔起搏器心室孔相连接。结果 以普通心室电极起搏并辅以合适的房室间期（AVP）,患者心力衰竭的症状明显改善,NY-HA心功能分级从Ⅲ～Ⅳ级提高到Ⅰ～Ⅱ级,超声心动图示心功能指标改善,起搏后心电图QRS时限缩短,其中一例患者已基本上停止服药数月。结论 初步临床应用表明,普通心室电极实行双心室同步起搏治疗心力衰竭既行之有效,又价廉物美。     

三腔双心室起搏治疗20例充血性心力衰竭患者的近期临床效果

目的 观察三腔双心室同步起搏治疗充血性心力衰竭的临床效果。方法 充血性心力衰竭伴心室内阻滞患者20例,男性16例,女性4例,平均年龄54.7岁。心功能均在Ⅲ-Ⅳ（NYHA分级）,体表心电图平均QRS时限为142.6ms。患者均进行了三腔双心室同步起搏,起搏电极导线分别置于右心房、右心室以及经由冠状静脉窦置于一支心脏静脉起搏左心室。观察双心室起搏前后左心室射血分数变化以及体表心电图QRS波变化。结果 双心室同步起搏后,患者心功能得到明显改善,左心室射血分数（left ventricular ejection fraction,LVETF)从24.4%提高至32.1%,左心室充盈时间延长,二尖瓣返流量减少,心功能从Ⅲ-Ⅳ级改善至Ⅱ-Ⅲ级,QRS时限由术前的142.6ms缩短至124.8ms。结论 初步临床观察提示,三腔双心室同步起搏可有效改善充血性心力衰竭伴心室内阻滞患者的心功能。     

双室右房三心腔起搏在充血性心力衰竭治疗中的初步应用

目的　观察InSync80 4 0起搏器治疗扩张型心肌病 (DCM )伴充血性心力衰竭 (CHF)的疗效。方法　患者 ,男 7例 ,女 1例 ,年龄 4 8～ 75 (5 8 7± 10 2 )岁 ,均为扩张性心肌病伴充血性心衰 ,且有完全性左束支传导阻滞或左前分支传导阻滞 ,植入InSync80 4 0起搏器。左心室起搏通过冠状静脉窦植入Medtronic公司生产的 2 187电极 ,置于冠状静脉窦的分支静脉起搏左心室 ,左右心室电极和右房电极导线与InSync 80 4 0起搏器相连接。 结果　以InSync80 4 0起搏器起搏并辅以合适的房室间期 (AVD) ,患者心力衰竭的症状明显改善 ,NYHA心功能分级从Ⅲ -Ⅳ级提高到Ⅰ -Ⅱ级 ,超声心动图示心功能指标改善 ,核素检查示心室收缩较术前协调 ,起搏后心电图QRS时限缩短。结论　初步临床应用表明 ,以InSync80起搏器实行双心室同步起搏治疗充血性心力衰竭行之有效     

双心室起搏的初步临床经验

目的 探讨缺血性或扩张型心肌病合并充血性心力衰竭行永久性双心室起搏治疗的临床效果。方法 对５例缺血性或扩张型心肌病合并难治性心力衰竭和左束支阻滞患者常规植入右心室起搏导线的同时植入冠状静脉窦导线于心大静脉或心中静脉，分别行右心室心尖部起搏及双心室起搏，应用Ｓｗａｎ－Ｇａｎｚ导管或超声心动图测定不同起搏地心功能的影响。结果 在充血性心力衰竭合并左束支阻滞患者植入冠状静脉窦导经至心大静脉或心中静脉行以     

Amplaze Left 1造影导管在心脏再同步化治疗手术中的应用

目的心脏再同步化治疗(CRT)的技术关键是植入左室导线。笔者介绍用Amplaze Left 1造影导管寻找冠状静脉窦的方法。方法选择充血性心力衰竭伴完全性左束支传导阻滞患者18例。应用Amplaze Left1造影导管快速寻找冠状静脉窦后进行逆行冠状静脉窦造影,经冠状静脉窦插入导线至心脏静脉相关分支进行左室起搏,然后植入右房和右室电极导线。结果18例均成功应用Amplaze Left 1造影导管很容易地寻找到冠状静脉窦。结论Amplaze Left 1造影导管用于CRT术中寻找冠状静脉窦简便易行,成功率高。     

双心室起搏治疗心力衰竭的初步经验

目的 介绍双心室起搏治疗心力衰竭衰竭的初步经验。方法 ６例充血性心力衰竭患者,男性４例,女性２例,平均年龄５８岁;心功能ＮＹＨＡ分级：Ⅲ～Ⅳ级：均伴有心室内阻滞。患者均植入了三腔双心室起搏器,左心室导线通过冠状静脉窦插入心脏静脉侧分支或侧后分支。结果 所有患者植入起搏器后临床症状改善,超声心动图检查显示左心室收缩功能和同步性改善,舒张期充盈改善,二尖瓣返流减少,此外,双心定起搏后,所有病例ＱＲＳ时     

双心室起搏治疗充血性心力衰竭

探讨双心室起搏技术治疗慢性充血性心力衰竭的临床疗效。 11例充血性心力衰竭患者 ,男 9例、女 2例 ,年龄 5 4± 7岁。心功能 (NYHA)Ⅲ～Ⅳ级 ,均伴有心室内传导阻滞。全部患者置入三腔双心室起搏器 ,左心室电极置于冠状静脉侧支及后侧分支内。结果 :手术全部成功。所有患者于置入后症状改善 ,体表心电图QRS时限由 15 9.8± 4 .4 2ms缩至 130 .5± 3.6 9ms ,P <0 .0 1。随访 6～ 18个月 ,超声心动图显示左室射血分数由 0 .2 5± 0 .0 5增至 0 .38± 0 .0 5 ,P <0 .0 1、舒张期充盈改善、二尖瓣返流减少。结论 :双心室起搏可以改善药物控制困难的伴室内传导阻滞的心衰患者的临床症状 ,改善心功能 ,提高生活质量。     

Cardiac resynchronization pacing therapy

Approximately one third of patients with congestive heart failure and systolic dysfunction have an intraventricular conduction delay that is manifested as a QRS duration >120 ms. An intraventricular conduction delay adversely affects ventricular performance by causing dyssynchrony in ventricular activation. When ventricular dyssynchrony is present, simultaneous left and right ventricular pacing or cardiac resynchronization therapy can improve ventricular synchrony. This can lead to an improvement in hemodynamics, ventricular remodeling, mitral regurgitation, exercise capacity and quality of life. Candidates for cardiac resynchronization therapy include patients with advanced congestive heart failure that is refractory to medical therapy, a QRS duration >130 ms, left ventricular ejection fraction <0.35 and sinus rhythm. Because patients who are candidates for biventricular pacing are at high risk of sudden death, they should be considered for implantation of a biventricular pacing device that also provides defibrillation therapy. This paper reviews biventricular pacing for congestive heart failure, including results of acute hemodynamic studies and randomized clinical trials, patient and device selection, and procedural issues.     

Ventricular dyssynchrony in dilated cardiomyopathy: the role of biventricular pacing in the treatment of congestive heart failure

Despite advances in pharmacologic therapy, the prognosis of patients with advanced congestive heart failure (CHF) remains poor. Many of these patients have cardiac conduction abnormalities, such as left bundle-branch block or interventricular conduction delays, that can lead to ventricular dyssynchrony (abnormal ventricular activation that results in decreased ventricular filling and abnormal ventricular wall motion). Biventricular pacing is an alternative, nonpharmacologic therapy under active investigation for the treatment of CHF. Resynchronization devices with transvenous leads in the right atrium, right ventricle, and left ventricle (via the coronary sinus) have been implanted in patients to provide atrial triggered biventricular pacing. The use of such devices has been associated with improvement in ejection fraction, dP/dt, stroke work, and functional class. The proposed mechanisms involved in improving ventricular function with biventricular pacing include improved septal contribution to ventricular ejection, increased diastolic filling times, and reduced mitral regurgitation. This article reviews the pathophysiology of ventricular dyssynchrony and examine insights from clinical trials that are evaluating cardiac resynchronization therapy for CHF.     

双心室起搏对慢性心力衰竭患者心肺功能和生活质量的影响

目的观察双心室起搏对慢性心力衰竭患者心肺功能和生活质量的影响.方法慢性心力衰竭伴室内传导阻滞患者9例,比较双心室起搏前后患者超声心动图、心肺功能以及生活质量的变化.结果双心室同步起搏后,患者左心室射血分数(%)由术前21.6±6.7增加到27.3±5.2(术后3个月,P<0.05)、29.5±5.4(术后6个月,P<0.05),6分钟步行距离(m),由术前320±97增加到384±103(术后3个月,P<0.01)、413±110(术后6个月,P<0.01),峰值氧耗量、摄氧效率斜率及每分通气量/每分二氧化碳产生量斜率较术前均有显著增加.生活质量评分分别改善30%(术后3个月,P<0.01)、28%(术后6个月,P<0.01).结论双心室起搏能有效改善慢性心衰患者心肺功能,增加运动能量,提高生活质量.     

双心室起搏对慢性心力衰竭患者心肺功能和生活质量的影响

目的:观察双心室起搏对慢性心力衰竭患者心肺功能和生活质量的影响。方法:慢性心力衰竭伴室内传导阻滞患者9例,植入三腔双心室起搏器,比较双心室起搏前、后患者超声心动图检查、心肺功能和生活质量的变化。结果:双心室同步起搏后.患者左室射血分数(%)由术前(21.6±6.7)%增加到(27.3±5.2)%(术后3月,P< 0.05)。(29.5±5.4)%(术后6月,P<0.05);6 min步行距离,由术前(320±97)m增加到(384±103)m(术后3月.P<0.01).(413±110)m(术后6月.P<0.01);峰值氧耗量、氧通气当量(VE/VO2)、二氧化碳通气当量(VE/VCO2)较术前均有显著增加(P<0.05～<0.01);生活质量评分分别改善30%(术后3月,P<0.01),28% (术后6月,P<0.01)。结论:双心室起搏能有效改善慢性心衰患者心肺功能,增加运动贮量,提高生活质量。     

Cardiac resynchronisation therapy

Left ventricular dysfunction is often associated with myocardial conduction slowing which is usually seen clinically as left bundle branch block on the surface ECG. Left bundle branch block causes asynchronous contraction of the left ventricle with the ventricular septum contracting early and the lateral left ventricular wall contracting late. This leads to a reduction in cardiac output and myocardial contraction efficiency and systolic mitral regurgitation worsens. Patients with this combination of findings may benefit from the implantation of a pacing system that aims to normalise conduction and "resynchronise" the ventricles. This mode of cardiac stimulation is referred to as "biventricular" pacing and relies on the implantation of an additional pacing lead on the epicardial surface of the left ventricle. This is achieved by selectively cannulating the coronary sinus and passing a pacing lead via a posterolateral coronary sinus tributary to an appropriate location. This lead, as well as the two conventional right atrial and right ventricular leads, is then attached to a specialised pacemaker. The procedure may be challenging and usually takes 1-2h depending on the operator's experience. The QRS complex shortens as the lateral wall of the left ventricle becomes "pre-excited" and contracts in concert with the ventricular septum. Improved haemodynamics result immediately and favourable reverse left ventricular remodelling occurs over subsequent weeks. Recently, these physiologic advantages have been translated into real clinical gains for patients with biventricular pacemakers where improvements in exercise tolerance and quality of life and reduced hospitalisations for recurrent heart failure have been conclusively demonstrated.     

心脏再同步治疗60例并发症分析

目的分析心脏再同步治疗(CRT)术中、术后并发症发生规律及防范对策。方法1999年7月至2006年1月,60例慢性心力衰竭患者[男性39例,女性21例,平均年龄(59.8±9.1)岁]接受CRT或CRT-D植入手术,其中52例双心室起搏。在最短1个月、最长66个月、平均22个月的随访期内追踪患者临床表现、死因以及各种并发症发生情况,同时给予相应的治疗干预。结果随访期内17例死亡(28.3%)的原因分别为心脏性猝死7例(11.7%,含1例手术失败)、心力衰竭恶化8例(13.3%,含1例手术失败)、中风1例(1.7%)、车祸1例(1.7%)。31例次并发症(51.7%)中7例左心室导线植入失败(11.7%)、2例冠状静脉窦夹层或穿孔(3.3%)、4例膈肌刺激(6.7%)、1例心律失常风暴(1.7%)、5例术中急性左心衰竭(8.3%)、4例导线脱位(6.7%)、3例阈值升高(5%)、3例交叉感知(5%)、2例囊袋积血(3.3%)。改行右心室流出道+右心室尖双部位起搏的6例患者,QRS波变窄程度和心力衰竭改善程度均不如双心室起搏显著,且3例死于心力衰竭恶化。5例CRT-D患者无心脏性猝死。结论严格把握适应证、提高左心室导线植入成功率、优化起搏系统的硬件和软件等,可确保患者在获益于CRT治疗的同时最大限度降低并发症风险。     

Cardiac stimulation and heart insufficiency

Dilated cardiomyopathies are frequently associated with atrioventricular and intra ventricular conduction disorders. Such conduction disorders modify the cardiac activation sequence and impair left ventricular systolic and diastolic function. The aim of pacing in dilated cardiomyopathy is to restore a cardiac activation sequence as normal as possible. Conventional dual-chamber pacing was first proposed to treat drug-refractory heart failure but was soon replaced by multisite biventricular pacing. The aim of biventricular pacing is to correct intraventricular asynchrony by pacing the two ventricles simultaneously. Acute studies have shown that biventricular pacing could improve hemodynamic parameters in patients with dilated cardiomyopathy and severe intraventricular conduction disorders. More recently, chronic studies demonstrated a significant improvement in exercise tolerance and quality of life with biventricular pacing in patients with drug-refractory heart failure and with intraventricular conduction disorders. To safely pace the left ventricle specific materials and tools had to be developed. With those developments, biventricular pacing is now a feasible and safe technique. Regarding the results of several clinical studies, biventricular pacing could now be proposed to treat patients with drug-refractory heart failure in the setting of chronic left ventricular systolic dysfunction and with major intraventricular conduction disorders.