心室起搏心律不适患者的起搏器参数优化

目的通过对起搏器参数的优化,尽可能减少心室起搏,提高患者生活质量。方法 2005年1月~2013年10月在我院病态窦房结综合征(SSS)患者植入双腔起搏器后心室起搏时诉胸闷、心悸不适,82例患者,设置最长的房室间期(AVD),延长心室后心房不应期(PVARP)至450ms,关闭心室自动阈值夺获功能,如仍有不适症状,通过起搏器程控仪较长时间监测或Holter等检查方法查找发生心室起搏的原因,并进行相应的处理。结果 62例病人症状消失,仍有20例有不适症状。导致心室起搏的原因及处理方法如下:(1)2例活动后因起搏器频率适应性功能致心房起搏频率增加后,出现二度I型房室阻滞,关闭频率适应性起搏功能后症状缓解;(2)2例因心房误感知设置较高的感知灵敏度后心室起搏消失;(3)2例提高心房起搏电压,1例重新植入心房电极,解决了心房失夺获从而避免了心室起搏;(4)5例阵发性房速/房扑患者缩短心室后心房空白期,使模式转换能发生,3例心房率较慢的房速患者设置为DDI模式,5例房颤患者降低下限频率,减少了心室起搏。结论心室起搏心律不适患者设置较长的AV间期,设置PVARP 450ms,关闭心室自动阈值夺获功能,如仍有不适症状,通过起搏器程控仪进行较长时间的心电监护或动态心电图检查找出导致心室起搏的原因,并对起搏器相关参数进行设置,能有效减少或消除心室起搏。     

如何分析起搏心电图的房室间期

起搏心电图的起搏的房室间期(PAV)和感知的房室间期(SAV)间期并不是固定不变的,在心房感知功能不良、频率适应性AV延迟、AV滞后、心室安全起搏、非竞争性心房起搏、心室自动测阈值、起搏器特殊的程控模式、心室起搏管理等情况下,实际的PAV和SAV间期可能和程控值不同。随着起搏器现代功能的日益增多,多数情况下PAV和SAV间期和程控值不同并不是起搏器功能障碍,而是起搏器的特殊功能在发挥作用。     

心室起搏后逆向隐匿性传导致心室连续起搏一例

患者女,75岁,5年前因二度Ⅱ型房室传导阻滞植入起搏器,常规随访时心电图显示心室跟踪心房1∶1起搏,伪似三度房室传导阻滞。测试心房心室感知时发现自主心律为二度房室传导阻滞(2∶1下传),PR间期150ms。降低上限跟踪频率后,心室呈文氏型跟踪心房起搏,可见窦性P波下传时PR间期仍为150ms。提示心室起搏后存在室房隐匿性逆传,使房室结重整不应期,故产生连续的心室起搏。     

起搏心电图问答

<正>按起搏心电图回答问题:患者因Ⅲ度房室传导阻滞植入永久起搏器(SJ Medical 5356),起搏器参数:上限跟踪频率110次/分,下限频率60次/分,PAV/SAV 200/175 ms,PVARP(心室后心房不应期)275 ms。请根据心电图分析起搏器的心房、心室电极起搏和     

房室双腔起搏伴一度心房传出阻滞及假性室性融合波

患者男性。68岁。临床诊断：病态窦房结综合征、窦性心动过缓、窦性停搏。双腔起搏器入术后3年。查心电图示：心房起搏心律。起搏间期固定为780ms。起搏频率77次／分。Ⅰ、Ⅱ、Ⅲ、aVL、aVF、V5、V6导联P′波直立．aVR、V1～V3导联P′波倒置。心房起搏电极位于右房上部。P′-R间期0．21s。一度房室传导阻滞。心室起搏脉冲落入QRS波群之中,形成假性室性融合波。标肢体导联R＋S〈0．5mV。     

Ⅲ度房室传导阻滞患者行不同房室间期起搏对血流动力学及功能的影响

目的探讨Ⅲ度房室传导阻滞(AVB)患者不同房室间期(AVD)起搏对血流动力学及功能的影响。方法选择植入双腔起搏器的Ⅲ度AVB患者51例,按不同AVD分为前后4期:A期AVD为心房感知(SAV)90 ms、心室起搏(PAV)120 ms;B期为SAV 120 ms、PAV 150 ms;C期为SAV 150 ms、PAV 180 ms;D期为SAV 180 ms、PAV 210 ms。每期观察2个月,分别比较Ⅲ度AVB患者4期心电图QRS波时限和形态,血清氨基末端脑钠肽前体(NT-proBNP)水平及心脏超声左房内径(LAD)、左室收缩末期内径(LVDs)、左室舒张末期内径(LVDd)、室间隔厚度(IVST)、左室后壁厚度(LVPWT)、左室射血分数(LVEF)及二、三尖瓣返流等参数。结果Ⅲ度AVB患者行不同AVD起搏时LAD、LVDd、LVDs、IVST、LVPWT及LVEF无变化;而二尖瓣及三尖瓣返流随AVD的延长而依次减少;起搏QRS波时限A期较D期长(149.21±8.10 ms vs 145.27±6.94 ms,P<0.05);NT-proBNP随AVD的延长而减少(中位值分别为365.51,327.54,279.13和270.10 pg/ml)。结论Ⅲ度AVD患者不同AVD起搏对心脏血流动力学会产生影响,短期内对心脏的结构及功能影响不明显,选择起搏间期为SAV180 ms、PAV 210 ms时患者的获益最大。     

心房感知起搏器的临床应用探讨

目的：探讨心房感知起搏器(AAI)的临床应用状况和对病态窦房结综合征(SSS)患者预后的影响。方法：回顾性调查1998-2002年在长征医院进行起搏治疗的175例SSS患者的病例资料。将其中132例患者分成AAI、双腔感知起搏器(DDD)、心室感知起搏器(VVI)三组，定期门诊随访，观察房颤、中风、心力衰竭、起搏器综合征、手术并发症、起搏电极脱位、生活质量改善以及Ⅱ度以上房室传导阻滞(AVB)发生率等临床情况。结果：175例SSS患者中共有AAI适应证42％(73例)，但仅有13％(22例)置入AAI起搏器。AAI组的房颤、中风、心力衰竭发生率显著低于VVI组。AAI组中未发现新发生的AVB。结论：AAI起搏较其他起搏方式更有利于SSS的预后。应该注意纠正临床上AAI起搏器应用率偏低的不合理情况。     

起搏器房室导线反接致心电图异常一例

患者女性，53岁。起搏器更换术后第5天动态心电图发现心房脉冲起搏心室产生QRS波，心室起搏脉冲起搏心房产生P波，短AV间期心室安全起搏，起搏器介导的心动过速。通过起搏器程控证实房室导线反接，手术调整导线连接，使起搏器恢复正常工作。     

不同房室间期对右室起搏比例影响的研究

目的：研究不同AV间期对右室起搏比例的影响,并探讨如何进一步进行AV间期的优化。方法：2012年9月至2015年12月,入选在我院接受圣犹达双腔起搏器植入患者,根据病因,分为“病窦综合征（SSS）”及“房室传导阻滞(AVB)”组。所有患者为DDD起搏模式,植入时默认AV间期PV/AV：150/170ms（5286型）及150/200ms（5816、5826型）;植入两个月后,AV间期设为PV/AV：325/350ms;植入4个月后,打开自动自主传导搜索功能（5286型）及VIPTM功能（5816、5826型）,PV/AV按照5286型起搏器固定参数设置,即每间隔5分钟搜索3个心动周期,并设置搜索时间120ms。每次随访时记录心室起搏比例,以秩和检验比较不同设置对起搏比例的影响。结果： SSS组入选38例,AVB组入选41例。SSS组一例患者因持续性心房颤动终止研究。两组患者中,默认设置、最长AV间期设置及自主传导搜索设置时起搏比例中位数分别为：37% 、3%、5%（SSS组）,83%、50%、54%（AVB组）三种设置间差异存在显著性（P<0.05）,从数值上看,SSS组差异更显著。结论：可以通过延长AV间期减少右室起搏,但对起搏器治疗患者,首先推荐个体化设置。     

非竞争性心房起搏

非竞争性心房起搏(NCAP)是美敦力公司的起搏器在双腔起搏模式下的一种常见功能,NCAP间期一般程控为300ms(有200,250,300,350,400ms可程控)(部分为300ms,不可程控)。NCAP功能打开后,落于心室后心房不应期之中的房性早搏被感知,启动NCAP间期,心房起搏脉冲在NCAP间期之外发放,可避免心房起搏所诱发的快速性房性心律失常的发生。不同起搏模式下NCAP的运作各有特点、从而对心房、心室时间间期和其他功能产生影响。     

Optimal Atrioventricular Delay in CRT Patients Can Be Approximated Using Surface Electrocardiography and Device Electrograms

Electrocardiographic AV Delay Adjustment . Background: Optimization of the atrioventricular (AV) delay (AVD) may result in an improvement in cardiac resynchronization therapy (CRT) outcome. Previous studies have shown positive correlation between interatrial conduction time measured invasively during the implant procedure and optimal AVD determined postimplant using Doppler echocardiography. We hypothesized that the optimal AVD can be predicted noninvasively from surface electrocardiogram (ECG). Methods: The optimal sensed (SAV) and paced (PAV) AVDs were determined for CRT patients (n = 63) by programming different AVDs (in 20 ms steps, in random sequence) and evaluating Doppler images of the mitral flow (iterative method). The time intervals between atrial sensing (As) and pacing (Ap) to the end of the P‐wave (Pend) and to the right ventricular sensing (RVs) were measured from 5 ECG leads (limb, V1, and V3) and device telemetry during sinus rhythm and atrial pacing. Results: Optimal SAV was 120 ± 30 ms and correlated with As‐Pend (R = 0.69, P < 0.0001) and As‐RVs (R = 0.45, P = 0.0003). Optimal PAV was 172 ± 38 ms and correlated with Ap‐Pend (R = 0.65, P < 0.0001) and Ap‐RVs (R = 0.60, P < 0.0001). Regression analysis suggested a simple method of AVD adjustment by pacing the ventricles 40 ms after the end of the sensed P‐wave or 30 ms after the end of the paced P‐wave but not at the expense of biventricular capture. Such a method would have resulted in significantly lower deviation from echo‐optimal AVDs compared with programming fixed values. Conclusion: A simple method of providing 30–40 ms separation between the end of the P‐wave and ventricular pacing pulse can be used to approximate echocardiographically optimal AV delays. (J Cardiovasc Electrophysiol, Vol. 21, pp. 1226‐1232, November 2010)     

M-mode echocardiograms for determination of optimal left atrial timing in patients with dual chamber pacemakers

To determine if the A wave of the mitral valve echocardiogram can be used as a marker for left atrial (LA) activity and assist in the programming of dual chamber pacemakers, 156 echocardiograms with the mitral A wave present were obtained from 23 patients with dual chamber pacemakers, all of whom had bipolar esophageal recordings of LA depolarization. Twelve of these patients also underwent hemodynamic study with cardiac function determined at 5 different pacemaker settings: ventricular demand pacing and dual chamber sequential pacing at 0 or 25, 150, 200 and 250 ms programming atrioventricular (AV) delay. The time delay from right atrial pacing artifact to onset and peak of mitral A wave was linearly related to the time from atrial pacing artifact to LA depolarization on the esophageal lead (p less than 0.001). As pacing mode changed from dual chamber sequential pacing (DVI) mode to atrial synchronous-ventricular pacing (VDD), the A wave came earlier relative to the ventricular pacing spike, linearly related to the LA to ventricular extension with mode change determined with the esophageal lead (r = 0.94, p less than 0.001). The time from atrial pacing to peak of A wave was shorter in patients whose optimal programmed AV delay was 150 ms compared with those whose optimal AV delay was 200 or 250 ms (p less than 0.02). At the optimal programmed delay for cardiac output, the peak of the A wave was an average of 13 +/- 36 ms after the ventricular pacing spike.(ABSTRACT TRUNCATED AT 250 WORDS)     

Preimplantation echo Doppler evaluation of VVI versus DDD pacing

This study was carried out to select before permanent pacemaker implantation patients with complete atrioventricular block (CHB) who would benefit best from DDD pacing, and to determine the optimal atrioventricular delay (AVD) for each of those patients. This was achieved with the aid of Doppler echocardiography. The effect of different AVDs on both the systolic and diastolic function of the normal and failing heart was also delineated in this study. METHODS: Thirty patients with CHB and normal sinoatrial function were selected, with no age or sex predilection. These patients were categorized into three equal groups: groups A, B, and C with normal left ventricular (LV) systolic and diastolic function, LV diastolic dysfunction, and LV systolic dysfunction, respectively. For each patient, systolic and diastolic function was calculated utilizing echo Doppler during CHB, temporary VDD pacing with different AVDs, and temporary VVI pacing with a rate matching that during VDD mode. Temporary VDD mode of pacing was performed utilizing a temporary bipolar ventricular lead for ventricular pacing and an esophageal lead for atrial sensing to trigger ventricular pacing. RESULTS: Qualitatively the most obvious change in the pattern of LV filling as AVD is increased in the three groups, is the earlier occurrence of active atrial filling A wave due to progressive approximation of the ECG P wave toward the previous QRS. As the AV interval is increased, the following changes occur: (a) A wave occurs progressively earlier with superimposition onto the early filling E wave resulting in a progressive increase in its velocity (VA), its FVI, and its percent atrial contribution (%AC); (b) the three times diastolic filling time (DFT), mitral valve opening to Q wave (MVO-Q), and closure (Q-MVC) progressively shorten; (c) since DFT decreases, less passive filling occurs early during diastole, thus E.FVI decrease with longer AV intervals; (d) the ratios VE/VA and FVI E/A decrease subsequently to the previous described changes. Compared to CHB, percent ejection fraction (% EF) was not significantly changed during VVI pacing. Percent EF increased significantly during VDD in comparison to VVI pacing modes. Percent EF was highest at optimal AVD and decreased as this AVD increased or decreased. The cardiac output (CO) increment during VDD in comparison to VVI pacing modes differed much among the three groups. In group A, a 10.29% increase in CO was seen when comparing VDD pacing (with optimal AVD) with that of VII one; in group B, this increment was much greater and reached 29.48%; in group C it reached 23.68%.(ABSTRACT TRUNCATED AT 400 WORDS)     

双腔起搏器不同房室延迟对左心房功能的影响

目的：探讨双腔起搏器不同房室延迟（AVD）起搏时对左心房功能的影响。方法：选择植入双腔起搏器的40例患者,分为舒张功能正常组（20例）和舒张功能不全组（20例）。应用实时三平面应变率成像分别测算两组患者在不同AVD时左心房心肌在收缩期、舒张早期和舒张晚期平均峰值应变率（SRs、SRe和SRa）。结果：在舒张功能正常组,不同AVD起搏对左心房功能的影响不显著（P〉0．05）。在舒张功能不全组：①AVD自80ms开始增至250ms时,SRa随AVD的延长相应增大,在AVD为200ms时达到最大,达峰值后又逐渐下降,AVD为150ms、200ms时SRa和LAEF较AVD为80ms、100ms、250ms时明显升高[SRa：（-2．87±0．50）S-1、（-3．14±0．44）S-1,比（-2．35±0．53）S-1、（-2．55±0．52）S、（-2．55±0．49）S-1,LAEF：（46．00±3．67）％、（51．22±3．33）％比（37．99±3．56）％、（39．64±3．08）％、（43．78±3．83）％,P〈0．05];②当AVD为80ms、250ms时,SRs增大,SRe减小;AVD为200ms时SRs明显低于AVD为80ms时[（3．02±0．56）S。比（3．27±0．62）S-1,P〈0．05]。结论：不同房室延迟对舒张功能正常患者左心房功能的影响不明显,但对于单纯舒张功能不全的患者,适当延长房室延迟更有利于左心房的功能,改善血流动力学。     

Suppression of atrial fibrillation by atrial pacing.

BACKGROUND: Atrial fibrillation (AF) is a common arrhythmia in patients with an implanted pacemaker, but the role of atrial pacing in preventing AF is still unclear. METHODS AND RESULTS: Sixty-six patients (67.8+/-12.1 years) were enrolled: 54 with sick sinus syndrome (SSS), 11 with atrioventricular blocks (AVB), and 1 with SSS and AVB. The prevalence of AF was investigated. In 22 patients with AF, the AF burden was estimated under "back-up pacing" (40-50 beats/min), then under "atrial pacing" (60-85 beats/min). The prevalence of AF in the SSS group tended to be higher than that in the AVB group (48.1% vs 18.2%, p=0.06). The AF burden in patients with a percentage of atrial pacing (% atrial pacing) <50% was significantly greater than that in patients with % atrial pacing >or=50% (12.5+/-21.1% vs 4.2+/-10.3%, p<0.05). AF disappeared immediately after "atrial pacing" in 4 patients (18.2%). In 9 patients (40.9%), the AF burden decreased gradually, and AF disappeared in 6 patients (27.3%) after 207.9+/-130.2 days. CONCLUSION: The prevalence of AF may be higher in patients with SSS than in those with AVB. Atrial pacing has a preventive effect on AF, and the effect of atrial pacing is not always immediate but is progressive in some patients.     

The effect of different atrioventricular delays on left atrium and left atrial appendage function in patients with DDD pacemaker

Background: Although it has been known that optimization of atrioventricular delay (AVD) has favorable effect on the left ventricular functions in patients with DDD pacemaker, the effect of different AVDs on left atrium (LA) and left atrial appendage (LAA) functions has not been exactly evaluated. The aim of the present study was to assess the effect of different AVDs on LA and LAA functions in DDD pacemaker implanted patients with atrioventricular block. Methods: Forty‐eight patients with DDD pacemaker were enrolled into the study. Patients were divided into two groups according to the echocardiographic diastolic function: Group I (normal diastolic function) and Group II (diastolic dysfunction). LAA emptying velocity on pulsed wave Doppler and LAA late systolic wave velocity by using tissue Doppler were recorded. Patients were paced for five successive continuous pacing periods of 10 minutes duration using five selective AVDs (80–250 ms). Results: Significant effect on LA and LAA functions has not been observed by the setting of AVD in Group I. However, when the AVD was gradually shortened form 150 ms to 80 ms, LA and LAA functions gradually decreased in Group II patients. When AVD increased to 200 ms, LA and LAA functions were improved. Further increase in AVD resulted in decreased LA and LAA functions. Conclusion: Setting of AVD has not significant effect on the LA and LAA functions in patients with normal diastolic function, but moderate prolongation of AVD in physiological limits improved LA and LAA functions in DDD pacemaker implanted patients with diastolic dysfunction. (Echocardiography 2011;28:626‐632)     

Doppler echocardiography of the effect of atrioventricular delay on transmitral flow in dual chamber pacing. Role of associated cardiopathy]

Doppler echocardiography was used to analyse transmitral blood flow in 23 patients undergoing DDD pacing under basal conditions at a pacing rate of 70/min. Changes in the atrioventricular delay led to changes in Doppler parameters corresponding to the different phases of ventricular filing. When the atrioventricular interval was increased, the maximum velocity, the velocity time integral and the duration of the E wave decreased and the maximum velocity, the velocity time integral and duration of the A wave increased. The atrial contribution to left ventricular filing increased by 15 to 46% (p less than 0.001). The changes of the Doppler parameters with respect to the duration of the atrioventricular interval varied according to the patient group studied. Patients without ventricular dilatation with or without hypertrophy had greater maximum velocities and velocity time integrals of the A wave than patients with left ventricular dilatation. However, for the same changes in atrioventricular delay, the A wave and atrial contribution to left ventricular filing were more variable in patients without left ventricular dilatation than those with left ventricular dilatation confirming the greater sensitivity of patients without left ventricular dilatation to the setting of the atrioventricular interval. These results confirm the great variability of transmitral flow with changes in atrioventricular delay. They illustrate the need for appropriate programming of the atrioventricular delay especially in patients in whom the mitral flow is most sensitive to this adjustment.     

Importance of left atrial timing in the programming of dual-chamber pacemakers

To determine the hemodynamic effect of different programmed atrioventricular (AV) delays and the importance of the actual timing of left atrial (LA) depolarization, 16 patients with dual-chamber pacemakers were studied and all were found to have an optimal programmed AV delay for cardiac function. However, randomly chosen AV delays of 150, 200 or 250 ms actually provided worse stroke volume than VVI pacing in 7 patients. The optimal programmed AV delay was variable between patients and was related to the interatrial conduction delay, measured as the time from right atrial pacing artifact to LA depolarization (mean 144 +/- 82 ms, range 70 to 380.) Patients with short interatrial delays (less than or equal to 90 ms) were served better by shorter programmed AV delays (150 ms), and patients with longer interatrial delays (greater than or equal to 120 ms) were served better by longer programmed AV delays (greater than or equal to 200 ms) (p less than 0.05). Furthermore, as pacing mode changed from dual-chamber sequential pacing (DVI) to atrial synchronous ventricular pacing (VDD), the LA to ventricular sequence increased from 6 +/- 81 ms to 137 +/- 50 ms (p less than 0.001). This change in the LA to ventricular sequence with mode change produced a significant decrease in stroke volume (p less than 0.05). Thus, the optimal programmed AV delay in patients with dual-chamber pacemakers is predicted by the relation of LA and ventricular activation. Because interatrial conduction delays vary widely, optimal programming requires knowledge of the LA to ventricular sequence.(ABSTRACT TRUNCATED AT 250 WORDS)     

体表心电图在双腔起搏器房室传导间期最佳化中的价值

目的:探讨置入了双腔起搏器的患者,在随访时,根据体表心电图P波宽度调节房室传导间期(AV间期)对血流动力学的影响。方法:因高度或Ⅲ度房室传导阻滞而安装美墩力SD303双腔起搏器的患者31例。测量患者体表心电图自身P波宽度,和(或)心房起搏脉冲至起搏的P波末端的宽度,在此测量值上加100ms,分别设定双腔起搏器的感知AV间期和起搏AV间期。使用多普勒超声仪,分别在出厂常规设置的AV间期和根据体表心电图优化的AV间期设定值,进行超声检查。结果:经体表心电图调整AV间期后的左室每搏量、左室舒张末期容量和左室射血分数、左室充盈时间、二尖瓣血流速度时间积分,均高于常规出厂设置的AV间期,前三者差异显著(P<0.05)。结论:根据体表心电图中P波宽度的变化来调节AV间期,不但能获得良好的血流动力学效果,且由于其简单易行,而具有广泛的临床实用价值。