双腔起搏器患者术后房室间期的程控管理

目的：探讨最佳房室间期（AVD）的设置和管理方法。方法：选择因高度或完全性房室传导阻滞而安置双腔起搏器的患者,研究组（23例）通过超声心动图指导进行感知房室间期的优化,对照组（21例）则常规设置房室间期。对比起搏器植入后1周和7个月2组患者超声心动图的变化以及心房颤动和心力衰竭的发生率。结果：（1）研究组的AVD为（138.7±8.7）ms,对照组的AVD为（124.8±0.8）ms（P〈0.001）。（2）起搏器植入后1周,2组患者的超声心动图指标无显著差异。（3）随访结束时,研究组与对照组相比,左房内径分别为（36±2.8）mm和（38.7±3.4）mm,P=0.008;左室内径分别为（46.7±4.5）mm和（49.4±5.2）mm,P=0.07,对照组的左心房、左心室较研究组相对增大。E波最大血流速度-时间积分分别为（13.2±0.9）和（9.9±1.7）;A波最大血流速度-时间积分分别为（5.1±0.9）和（4.1±0.9）;左心室射血分数分别为（58.6±2.2）%和（55.3±4.1）%;每搏量分别为（63±5.2）mL和（54.9±6.6）mL,对照组患者的心功能明显降低。结论：最佳房室间期起搏有利于患者的心功能,超声心动图是指导房室间期设置的简便而可靠手段。     

不同的P波幅度选择在PICC导管腔内心电图定位的对比研究

目的探索PICC导管腔内心电图定位时最佳的P波幅度选择方式。方法选取2017年8月-2018年8月收治的795例PICC置管患者,按手指时间将其分成A、B 2组,A组腔内心电图定位时选择将导管尖端位置停留在P波波幅最高水平,B组腔内心电图定位时导管尖端位置停留在P波正向波幅为QRS波幅50%~80%水平,所有患者置管后进行胸片X光检查,以导管尖端在胸T6-T7椎体水平作为导管最佳位置,对比2组患者导管最佳位置的比率。结果 A组导管尖端到达最佳位置的比率为23.59%,B组导管尖端到达最佳位置的比率79.15%,2组比较,有统计学差异(χ^2=245.360,P<0.001)。结论 PICC导管腔内心电图定位时导管尖端位置停留在P波波幅是QRS波幅50%~80%水平时更有利于导管尖端达到最理想的位置,值得在临床上应用。     

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     

双腔起搏器安置术的手术配合

双腔起搏是生理性起搏 ,与右室单腔起搏相比 ,不易引起心功能不全和心房颤动等并发症 ,故既可保证患者的心率 ,又能提高患者的生活质量。我院近几年来为患者安置了双腔起搏器 ,现将手术配合报告如下。1　临床资料1999年 12月～ 2 0 0 2年 9月共为 32例患者安置了双腔起搏器。其中病窦综合征 (SSS) 17例 ,房室传导阻滞 (AVB) 12例 ,束支传导阻滞 (BBB) 4例。 17例SSS及 1例BBB患者安置DDD起搏器 ,其余 14例安置VDD起搏器。2　手术配合2 .1　特殊物品安置DDD起搏器的 18例中 ,15例为Medtronic公司的sigma SD2 0 3型 ,2例为Biotron…     

双腔起搏器植入在缓慢性心律失常并发心力衰竭中的应用价值

目的探讨双腔起搏器植入在缓慢性心律失常并发心力衰竭中的应用价值。方法将2010年7月～2012年11月因缓慢性心律失常并发心力衰竭来我院治疗的69例患者随机分为观察组患者35例(采用双腔起搏器治疗),对照组患者34例(传统药物治疗),比较两组患者的治疗效果。结果两组患者治疗前心功能情况无显著差异;治疗后,观察组心功能总优良率为74.3%,总有效率为62.8%,与对照组比较,有显著差异,P<0.05。结论双腔起搏器植入是治疗缓慢性心律失常并发心力衰竭中的有效治疗方法,值得推广应用。     

食管导联心电图优化左房室间期对双腔起搏器植入的三度房室阻滞患者的影响

目的探讨食管导联心电图优化左房室间期(LAVI)对双腔起搏器植入的三度房室阻滞(Ⅲ°AVB)患者的影响。方法选取开封市中心医院2018年10月至2020年10月收治的100例行双腔起搏器植入治疗的Ⅲ°AVB患者,按入院顺序分为对照组和观察组,各50例,对照组给予经验性程控房室间期,观察组使用食管导联及体表导联心电图优化LAVI,对比心功能、心脏血流动力学、运动耐力。结果观察组术后6个月的左室射血分数(LVEF)(62.44±3.49)%大于对照组(57.68±3.24)%,等容舒张时间(IVRT)(115.23±6.92)ms短于对照组(118.46±7.64)ms,LAVI、脑钠肽前体(Pro-BNP)、左心室舒张末期内径(LVEDD)、二尖瓣口舒张早期血流速度(E)分别为:(30.31±3.56)、(115.63±10.54)pg/mL、(42.13±1.48)mm、(62.08±4.34)cm/s,低于对照组(34.50±3.75)、(169.35±12.67)pg/mL、(44.76±1.56)mm、(73.65±4.68)cm/s;舒张晚期血流速度(A)(73.29±9.37)cm/s高于对照组(67.54±8.65)cm/s,E峰减速时间(DT)(139.05±14.56)ms长于对照组(132.62±12.74)ms(P<0.05),两组的二尖瓣环舒张早期峰值流速(Em)对比差异无统计学意义(P>0.05);6 min步行距离(6MWT)试验(390.46±20.53)m长于对照组(352.95±16.08)m(P<0.05)。结论食管导联心电图优化LAVI可通过改善双腔起搏器植入的Ⅲ°AVB患者的心脏血流动力学,提高心功能及运动耐力,但对于左室早期的舒张功能影响较小。     

床边临时体外心脏双腔起搏器安装术5例报告

目的探讨经左、右锁骨下静脉穿插管，用气囊漂电极导管床边紧急安装临时体外心脏双腔起搏器抢救心动过缓性心律失常。方法分析因不同原因所致严重心动过缓性心律失常并行床边临时体外心脏双腔起搏器安装术进行临时起搏治疗的5例病人的临床资料，按深静脉穿刺置管法行深静脉穿刺，并按漂浮导管置入法推送气囊电极导管，在床边无X线透视条件下，根椐心腔内心电图、室性期前收缩出现或体表起搏心电图判断电极是否进入右心室，行右心心内膜临时起搏。结果成功为4例不同病因所致严重心动过缓性心律。5例病毒性心肌炎导致Ⅲ度房室传导阻滞的病人，1例急性广泛前壁心肌梗塞导致的窦房结功能不全并左束支传导阻滞的病人，1例病态窦房结综合症，及时解除病人循环系统灌注压不足，抢救病人生命，并给予相应的内科药物治疗，均在15天内拆除临时双腔起搏器，病人均无明显不适，先后痊愈出院；亦有1例原因不明心脏骤停病人，因起搏电极到位后无起搏夺获而导致起搏未成功。4例(80％)起搏成功，起搏效果肯定，起搏时间7～15天。1例电极脱位，经重新安置电极后恢复起搏。结论床边临时体外心脏起搏器安装术是创伤小、方便快速、安全有效治疗方法，值得在急救中进一步推广应用。     

双腔起搏器常见并发症的原因分析及护理要点

双腔起搏器是一种能模拟正常心脏传导，符合患者生理需要的新生生理型起搏器。它能够增加患者心输出量，改善患者心衰症状，特别适于Ⅲ°房室传导阻滞（Ⅲ°AVB）、病窦综合征（SSS）及心脏大，心功能不全患者，明显提高了该类患者的生活质量。作为一种治疗手段，它虽然损伤小，操作简单，但仍会出现一些并发症。我院自1999年至2006年安装双腔起搏器200例，现将术后并发症的原因分析及护理要点报告如下。[第一段]     

双腔心脏起搏器置入术围手术期的护理

目的评价双腔心脏起搏器围手术期护理的临床疗效及价值。方法分析36例双腔心脏起搏器置入术患者的临床资料的护理措施。结果36例患者不仅防止了心搏骤停发生,脑缺血症状消失,而且生活质量明显提高。结论双腔心脏起搏器是最常见的生理性起搏器,在围手术期以患者为中心加强护理有着重要意义。     

Relationship between P-wave duration and atrial electromechanical delay assessed by tissue Doppler echocardiography

Background: The aim of the study was to assess the relationship between P‐wave duration on the surface electrocardiogram (ECG) and echocardiographic parameters of atrial electromechanical delay (EMD), as well as contraction synchrony during different atrial pacing modalities. Methods: In 57 patients with sinus node disease and prolonged sinus P‐wave duration treated with multisite atrial pacing (MSAp), the EMD was measured by tissue Doppler in several left and right atrial sites during sinus rhythm, MSAp, and single‐site pacing at right atrial appendage (RAAp), Bachmann's bundle (BBp) region, and coronary sinus (CSp) ostium. Regional atrial synchrony was calculated on the basis of EMD. Results: P‐wave duration was 141 ± 16, 120 ± 17, 138 ± 17, 144 ± 16, and 160 ± 19 ms during sinus rhythm, MSAp, BBp, CSp, and RAAp, respectively (P < 0.001 RAAp and MSAp vs other). P‐wave duration correlated with all atrial EMDs as well as interatrial and intraleft atrial parameters of dyssynchrony. In multivariate analysis, the EMD in lateral left atrial wall was the strongest predictor of P‐wave duration (β 0.41; P < 0.001). The relationship between P‐wave duration and the atrial EMDs was most prominent during RAAp (all left atrial walls r > 0.51; P < 0.01) and BBp (all atrial walls r > 0.42; P < 0.05), while during sinus rhythm and CSp, only weak correlation between echo and ECG was found. Neither of the tissue Doppler parameters correlated with P‐wave duration during MSAp. Interatrial dyssynchrony correlated with P‐wave duration during sinus rhythm and RAAp and intraleft atrial dyssynchrony only during sinus rhythm. Conclusions: P‐wave duration of the surface ECG is highly correlated with the atrial EMD, the relationship is specific for each pacing modality. (PACE 2011; 23–31)     

Optimal atrioventricular delay setting determined by QT sensor of implanted DDDR pacemaker

QT interval (QTI) may change when cardiac function is improved by optimizing the AV delay. QTI is used as the sensor for rate responsive pacemakers. Evoked (e)QTI is measured as the time duration from the ventricular pace-pulse to the T sense point, which is the steepest point of the intracardiac T wave. The relationship between AV delay and eQTI and cardiac function was studied in 13 patients (74.2 +/- 9.3 [SD] years old) with an implanted QT-driven DDDR pacemaker. A special pacemaker software module was downloaded into the pacemaker memory for eQTI data logging. AV delay was set at 100, 120, 150, 180, 210, and 240 ms. Cardiac output (CO) was measured by continuous Doppler echocardiography. eQTI was 343.3 +/- 22.4, 345.1 +/- 22.5, and 343.4 +/- 23.2 ms (P < 0.01, repeated ANOVA) and CO was 4.2 +/- 0.8, 4.6 +/- 0.8, and 4.2 +/- 0.8 L/min (P < 0.0001, repeated ANOVA) when AV delay was set at the AV delay shortened by one step (AV[-]) and prolonged by one step (AV[+]) from the AV delay at which QT interval was maximum (AV[max]) in seven patients, in whom the peak AV delay at which the eQTI was maximal could be identified. eQTI decreased from 341.1 +/- 20.9 to 339.4 +/- 21.1 ms (P < 0.0001) and CO decreased from 4.4 +/- 1.4 to 4.1 +/- 1.3 L/min (P < 0.005) when AV delay was prolonged from AV(max) to AV(+) in all patients. eQTI decreased from 345.1 +/- 22.5 to 343.3 +/- 22.4 ms (P < 0.0005) and CO decreased from 4.6 +/- 0.8 to 4.2 +/- 0.8 L/min (P < 0.05) when AV delay was shortened from AV(max) to AV(-) in seven patients. Thus, CO was maximal when AV delay was set at the AV delay at which eQTI was maximal. In conclusion, the optimal AV delay can be predicted from the eQTI sensed by an implanted pacemaker, and automatic setting of the optimal AV delay can be achieved by the QT sensor of an implanted pacemaker.     

A perspective on atrioventricular delay optimization in patients with a dual chamber pacemaker

Atrioventricular delay (AVD) is critical in patients with DDD pacemakers (PM). Echo/Doppler evaluation of AVD providing the longest left ventricular filling time (FT) or the highest cardiac output (CO) is used for AVD optimization. Recently myocardial performance index (MPI) has been shown to improve by optimizing AVD. The aim was to compare the CO, FT, MPI derived optimal AVD, and to analyze systolic and diastolic performance at every optimal AVD. Twenty-five patients, 16 men 68 +/- 11 years, ejection fraction >or= 50%, with a DDD PM for third-degree AV block, without other major cardiomyopathies, underwent echo/Doppler AVD optimization. CO, FT, and MPI derived optimal AVDs were identified as the AVDs providing the highest CO, the longest FT, and the minimum MPI, respectively. Isovolumic contraction and relaxation time (ICT, IRT), ejection time (ET), ICT/ET, and IRT/ET ratios were also evaluated at every optimal AVD. CO, FT, and MPI derived optimal AVDs were significantly different (148 +/- 36 ms, 116 +/- 34 ms, and 127 +/- 33 ms, respectively). ICT/ET was similar at CO, FT, and MPI derived optimal AVD (0.22 +/- 0.10, 0.23 +/- 0.11, and 0.21 +/- 0.10, respectively). IRT/ET ratio was similar at FT and MPI derived optimal AVDs (0.34 +/- 0.15 and 0.33 +/- 0.15, respectively) and significantly shorter (P < 0.02) than at CO derived optimal AVD (0.40 +/- 0.15). Different methods indicate different optimal AVDs. However analysis of systolic and diastolic performance shows that different AVDs result in similar systolic or diastolic performance. At MPI optimized AVD, a high CO combined with the most advantageous conditions of both isovolumic contraction and relaxation phases is achieved.     

Doppler index and plasma level of atrial natriuretic hormone are improved by optimizing atrioventricular delay in atrioventricular block patients with implanted DDD pacemakers

Doppler index is the sum of isovolumetric contraction time and isovolumetric relaxation time divided by ejection time and has clinical value as an index of combined systolic and diastolic myocardial performance. This crossover study compared the Doppler index and atrial natriuretic hormone (atrial natriuretic peptide) [ANP] between optimal (AV) delay and prolonged AV delay in patients with DDD pacemakers. The study included 14 patients (6 men, 8 women, age 78.4+/-9.3 [SD] years) with AV block with an implanted DDD pacemaker. AV delay was prolonged in a 25-ms, stepwise fashion starting from 125 ms to 250 ms. Pacing rate was set at 70 beats/min. Cardiac output (CO) was assessed by pulsed Doppler echocardiography, and optimal AV delay was defined as the AV delay at which CO was maximum, and an AV delay setting of 250 ms as prolonged AV delay. Plasma level of ANP and Doppler index determined by echocardiography were measured 1 week after programming. AV delay was switched to another AV delay and measurements were repeated after 1 week. Optimal AV delay was 159+/-19 ms. Doppler index was significantly lower at optimal AV delay than at prolonged AV delay (0.68+/-0.26 vs 0.92+/-0.30, P < 0.05). The plasma ANP level was significantly lower at optimal AV delay than at prolonged AV delay (29.0+/-30.7 vs 52.6+/-44.9 pg/mL, P < 0.05). In conclusion, the Doppler index and the plasma ANP level were significantly lower at optimal AV delay than at prolonged AV delay. This study shows the importance of the optimal AV delay setting in patients with an implanted DDD pacemaker, the Doppler index and plasma ANP levels are good indicators for optimizing AV delay.     

Persistent atrial fibrillation is associated with a poor prognosis in patients with atrioventricular block and dual-chamber pacemaker

Background : The prognostic significance of development of persistent atrial fibrillation (AF) in patients with atrioventricular (AV) block and dual chamber (DDD) pacemakers has not been separately investigated. We sought to determine whether persistent AF influences clinical outcome in these patients. Methods: Three hundred‐eight consecutive patients with second‐ or third‐degree AV block and implanted a DDD pacemaker were followed for 36 ± 20 months and retrospectively divided into two groups. Thirty‐four patients who developed persistent AF formed persistent AF group, and 278 patients who remained free of this arrhythmia control group. Clinical and outcome data of the two groups were compared. The primary outcome was cardiovascular death. Results: The primary outcome occurred more often among the patients in the persistent AF group (6.8% per year) than among those in the control group (2.9% per year; P = 0.028). This difference was primarily because of higher rate of heart failure‐related deaths in the persistent AF group (P = 0.009). Secondary outcomes, hospitalization for heart failure and paroxysmal AF episode ≥5 minutes, occurred also more often among the patients in the persistent AF group (P = 0.008 and P < 0.001, respectively), although the risk of nonfatal stroke was similar in both groups (P = 0.628). Conclusion: In patients with second‐ or third‐degree AV block and DDD pacemaker, the development of persistent AF is associated with an increased risk of cardiovascular death and heart failure. (PACE 2012; 35:695–702)     

定量组织速度成像评价不同房室间期对双腔起搏左室收缩功能影响的研究

目的　应用定量组织速度成像 (QTVI)评价不同房室 (AV)间期对DDD双腔起搏患者的左室收缩功能的影响以探求最佳AV间期。方法　 3 0例植入DDD双腔起搏器的患者 ,在DDD起搏方式下将AV间期程控为 10 0ms、13 0ms、15 0ms、170ms、2 0 0ms ,测定后间隔、侧壁、前壁、下壁、前间隔和后壁六个部位二尖瓣环的收缩期平均峰值速度(Vs)及从QTVI曲线上A波结束到S波开始的时间 (TA -S) ,并将Vs与二维法所测的心输出量 (CO )作相关分析。结果　QTVI所测定的二尖瓣环的Vs与CO呈正相关 (r =0 .62 ,P <0 .0 1)。不同的AV间期明显影响Vs的值 ,TA -S则随AV间期的延长而增大。以Vs为标准 ,DDD起搏方式下最佳AV间期为 ( 15 4± 2 4)ms ,相应的TA -S 的平均值为 ( 7.6±2 .3 )s- 2 。结论　DDD双腔起搏时房室 (AV)间期影响左室收缩功能。QTVI可用于选择DDD双腔起搏的最佳AV间期。     

双腔起搏时Tei指数与常用优化房室延迟时间指标的对比研究

目的探讨Tei指数在双腔起搏器置入患者中对房室延迟(AVD)进行优化的价值。方法从首次安装双腔起搏器患者中选择12例,其中9例为病态窦房结综合征,3例为完全性房室传导阻滞。起搏器安装术后(7±3)个月对患者行超声心动图检查。本文以Tei指数优化AVD,与以左心室心输出量(LVCO)及左心室充盈时间(LVFT)常规优化的AVD进行比较,并对不同方法优化下的心功能参数进行比较。结果以LVCO和LVFT优化的AVD差异有统计学意义,AVD分别为(173.07±50.26)ms、(107.69±28.77)ms,P<0.01;Tei指数优化的AVD(157.69±57.17)ms介于以LVCO和LVFT优化的AVD之间;以Tei指数优化AVD时的LVCO与LVCO优化时的LVCO相比差异无统计学意义,LVCO分别为(3.41±0.47)L/min、(3.62±0.57)L/min,P>0.05;Tei指数优化AVD时的LVFT与LVFT优化时的LVFT相比差异亦无统计学意义,LVFT分别为(352.64±66.81)ms、(387.25±58.61)ms,P>0.05。结论Tei指数可以作为AVD优化的指标。