右心室流出道间隔部起搏与心尖部起搏的血流动力学对比研究

目的比较右心室流出道间隔部(RVOTS)与右心室心尖部(RVA)起搏对血流动力学的影响,评价RVOTS起搏的可行性。方法 53例需植入永久起搏器患者,均采用抑制型按需心室起搏模式(VVI),其中RVA起搏28例,RVOTS 25例。随访3～10个月,采用超声心动图检查方法检测血流动力学参数,包括LVEF、左室内径缩短分数(FS)、心输出量(CO)、心脏指数(CI),研究RVOTS与RVA起搏的术前、术后血流动力学差异。结果所有患者心室起搏保证在80%以上,与手术前比较,RVOTS起搏时,LVEF、FS、CO、CI分别下降了3.46%±3.89%、1.20%±2.47%、(0.19±1.32)L/min、(0.09±0.52)L·min~(-1)·m~(-2),差异无统计学意义(均为P>0.5)。与手术前比较,RVA起搏时LVEF、FS、CO、CI分别下降了14.27%±5.83%、8.10%±3.79%、(1.56±1.11)L/min、(1.13±0.52)L·min~(-1)·m~(-2)(均为P<0.01),RVOTS起搏与RVA起搏相比LVEF、Fs、CO、CI明显改善(均为P<0.05),且临床症状明显减轻。结论 RVOTS起搏对血流动力学无明显不良影响。     

采用普通心房电极行右室流出道起搏的初步探讨

目的探讨心房J型电极在右室流出道(RVOT)起搏的临床应用。方法对8例采用普通心房电极行RVOT起搏(其中5例进行了永久性置入)的患者进行了起搏阈值测定及随访。结果心房电极行RVOT起搏,起搏阈值、R波振幅和电极阻抗与心尖部起搏比较无差异(P>0.05);操作简单、起搏成功率高。随访3~6个月无电极脱位,起搏功能良好。结论普通心房J型电极似可以替代螺旋电极行RVOT永久起搏。     

Right ventricular outflow versus apical pacing in pacemaker patients with congestive heart failure and atrial fibrillation

INTRODUCTION: Prior studies suggest that right ventricular apical (RVA) pacing has deleterious effects. Whether the right ventricular outflow tract (RVOT) is a more optimal site for permanent pacing in patients with congestive heart failure (CHF) has not been established. METHODS AND RESULTS: We conducted a randomized, cross-over trial to determine whether quality of life (QOL) is better after 3 months of RVOT than RVA pacing in 103 pacemaker recipients with CHF, left ventricular (LV) systolic dysfunction (LV ejection fraction < or = 40%), and chronic atrial fibrillation (AF). An additional aim was to compare dual-site (RVOT + RVA, 31-ms delay) with single-site RVA and RVOT pacing. QRS duration was shorter during RVOT (167 +/- 45 ms) and dual-site (149 +/- 19 ms) than RVA pacing (180 +/- 58 ms, P < 0.0001). At 6 months, the RVOT group had higher (P = 0.01) role-emotional QOL subscale scores than the RVA group. At 9 months, there were no significant differences in QOL scores between RVOT and RVA groups. Comparing RVOT to RVA pacing within the same patient, mental health subscale scores were better (P = 0.03) during RVOT pacing. After 9 months of follow-up, LVEF was higher (P = 0.04) in those assigned to RVA rather than RVOT pacing between months 6 and 9. After 3 months of dual-site RV pacing, physical functioning was worse (P = 0.04) than during RVA pacing, mental health was worse (P = 0.02) than during RVOT pacing, and New York Heart Association (NYHA) functional class was slightly better (P = 0.03) than during RVOT pacing. There were no other significant differences between RVA, RVOT and dual-site RV pacing in QOL scores, NYHA class, distance walked in 6 minutes, LV ejection fraction, or mitral regurgitation. CONCLUSION: In patients with CHF, LV dysfunction, and chronic AF, RVOT and dual-site RV pacing shorten QRS duration but after 3 months do not consistently improve QOL or other clinical outcomes compared with RVA pacing.     

心内高右房超速起搏转复永久起搏器术中并发的心房扑动

目的 评价心内高右房超速起搏转复永久起搏器术中并发心房扑动的有效性和安全性.方法 回顾性分析我院应用心内高右房超速起搏转复20 例永久起搏器术中并发Ⅰ型心房扑动患者的临床资料.结果 20例中19例转复成功, 总成功率95%.所有患者未出现并发症.结论 心内高右房超速起搏转复永久起搏器术中并发的心房扑动是一种简便、安全和有效的方法.     

电极导线在右室心尖部和右室流出道起搏的随访观察

目的评价螺旋电极导线行右室流出道(RVOT)间隔部起搏的可行性。方法连续入组195例具有植入起搏器适应证患者,术前随机分为螺旋主动固定电极导线的RVOT间隔起搏组(A组)和翼状被动固定电极导线的右室心尖部(RVA)起搏组(B组),两组中每例入选患者均分别行RVA和RVOT两个部位起搏测试,最后固定于相应的位置。比较两组术中手术时间、起搏参数、起搏QRS波宽度、手术成功率及起搏3个月、1年和2年后电极导线参数的变化。结果 A组99例,B组96例。两组起搏后QRS波宽度明显大于起搏前,B组起搏QRS波时限长于A组(176.46±24.54 ms vs 165.45±22.78 ms,P=0.001)。用于固定RVOT间隔部的曝光时间长于RVA。两组术中及术后并发症相似,R波振幅术后2年内及两组间无差别。术中A组起搏阈值高于B组(0.71±0.30 V vs0.56±0.19 V),术后2年内起搏阈值两组内及组间无差异。术后3个月时阻抗下降,A组的阻抗低于B组并持续整个随访期间。术后2年内超声心动图参数组内及组间无差别。结论采用螺旋主动固定电极导线进行RVOT起搏是安全可行的。     

Medium- and long-term survival after pacemaker implant: Improved survival with right ventricular outflow tract pacing

Introduction Long-term prognosis after pacemaker implant depends on numerous variables, particularly structural heart disease. There is evidence that apical stimulation could favor the development of heart failure and, therefore, influence mortality. Other right ventricular pacing sites have been studied, for example the outflow tract, but no reports regarding long-term clinical outcome are available. Objective Compare all-cause mortality between two different sites of stimulation in the right ventricle. Methods We retrospectively analyzed 150 consecutive patients who underwent pacemaker implantation because of complete AV block (spontaneous or after AV node ablation), symptomatic second-degree AV block, and symptomatic atrial fibrillation with slow ventricular response. All patients were implanted at the same institution with the standard technique. Apical stimulation was performed with a passive or active fixation lead and outflow tract pacing with an active fixation lead. Data collection period began in July 1999 and ended on December 2004. All patients included were greater than 70% ventricular paced during pacemaker follow-up. Patients older than 85 years were excluded from the analysis. Age, pacemaker mode, sex, ejection fraction, diabetes, and structural cardiac disease were analyzed. Mean age was 72 ± 7 years (median 74 years, range 27–85 years), 101 (67%) were male, 56 had implanted a VVI PM, and 94 patients a DDD PM. Patients were divided into two groups: outflow tract (55 patients) and apical pacing (95 patients). Mean follow-up was 1,231 ± 642 days (median 1,158 days, range 9 to 2,694 days), which ended on July 2007. Total mortality was examined with the Kaplan–Meier method to construct overall survival curves. Multivariate Cox proportional hazards regression models were performed. Results All patients or relatives were contacted personally or by phone. There were no major statistical differences in patient background between the two groups. During follow-up, 18 patients (32%) died in the outflow tract group and 49 (51%) in the apical group (log-rank p = 0.02). Cox regression multivariate analysis showed that outflow tract pacing and a low left ventricular ejection fraction (<40%) were the only independent variables with significant correlation with survival (p = 0.006 and 0.003, respectively). Conclusions Outflow tract pacing appears to improve medium- and long-term survival. Prospective randomized trials with a greater amount of patients are necessary to confirm the findings of this study.     

Increased base rate of atrial pacing for prevention of atrial fibrillation after implantation of a dual-chamber pacemaker: insights from the Atrial Overdrive Pacing Study.

AIMS: Different pacing sites and various algorithms have been utilized to prevent atrial fibrillation (AF) in pacemaker recipients. However, the optimal pacing rate settings have not yet been established. In this randomized, prospective, multicentre, single-blinded, cross over study, rate-adaptive pacing at a high base rate (BR) in patients, age 60 years or above, or a history of paroxysmal AF, who underwent dual-chamber (DDD) pacemaker implantation for standard pacing indications, was evaluated for prevention of AF. METHODS AND RESULTS: In the study cohort of 145 patients implanted with DDD pacemakers with a programmable rest rate (RR) feature, the BR/RR settings were sequentially but randomly adjusted as follows: 60 bpm/Off for the baseline quarter (initial 3 months) and then to either 'A-B-C' or 'C-B-A' settings (A = 70/65 bpm, B = 70/Off, C = 80/65 bpm) for the subsequent quarters each of 3 months duration. Data on automatic mode switch episodes, device diagnostics, and a questionnaire evaluating pacemaker awareness and palpitations were collected. Ninety-nine patients, mean age 77 +/- 10 years, who completed the study protocol and followed for 12 months did not show significant differences in the number of mode switch episodes between any settings used. The percentage of atrial pacing was lower during baseline pacing compared to settings A, B, and C (P < 0.0001). Setting C produced a higher percentage of atrial pacing than A and B (P < 0.01). Although a higher percentage of atrial pacing correlated with a lower incidence of mode switch episodes, there was no statistically significant difference in the number of mode switch episodes between settings A, B, and C. There were no significant differences in the questionnaire scores relating to pacemaker awareness or palpitation. CONCLUSION: Overdrive single-site pacing in the right atrium achieved by programming analysed settings in the present study did not reduce AF as assessed by mode switch episodes. Additionally, no change in the symptoms of arrhythmia or awareness of pacing was seen.     

右室流出道间隔部和心尖部起搏对心功能和重构的影响

目的比较右室流出道(RVOT)和右室心尖部(RVA)起搏对心脏做功和重构的影响。方法 83例缓慢心律失常的患者,其中男40例,女43例,随机分为RVOT间隔部起搏组(RVOT组,n=42)和RVA部起搏组(RVA组,n=41),观察两组QRS波时限、新出现心房颤动(简称房颤)的情况、心腔内径及左室射血分数(LVEF)的变化。结果随访11.47±1.67个月,两组术后QRS波时限均较术前明显延长(P<0.01),RVA组明显长于RVOT组(P<0.01);两组的左房内径和左室收缩末径均未见明显变化,RVA组1年后左室舒张末径较术前显著增加(53.53±5.72 mm vs 50.03±6.20 mm,P<0.05),两组1年后LVEF均较术前显著降低(RVOT、RVA比较分别为0.57±0.10 vs 0.62±0.11,0.53±0.08 vs 0.63±0.10,P均<0.01);两组新出现房颤例数亦未见差异。结论 RVOT起搏对心室重构的影响要好于RVA起搏。     

食管心房调搏终止室性心动过速的初步探讨

目的：总结15例经食管心房调搏，成功终止室性心动过速的经验与体会。方法：选择15例室性心动过速病人，予以食管心房调搏，先后用分级递增和连续递增两种刺激方式予以刺激，刺激电压为25～30V，对难以终止，静脉注射异搏定，再予以经食管心房调搏。结果：单纯采用分级递增法终止了10例患的室速，2例患需加用连续递增法才能终止，另3例患经上述两种方式均未成功，给予异搏定5mg静脉注射后以分级递增法才终止了室速。结论：经食管心房起搏可以部分地成功终止持续性室性心动过速，减少直流电复律应用的必要性。     

Long-term follow-up of right ventricular outflow tract septal pacing

Objective Right ventricular outflow tract septum has become widely used us an electrode placement site. However, data concerning lead performances and complications for lead repositioning with this technique were scant. The purpose of this study was to observe long- term lead performances and complications of right ventricular outflow tract septal pacing and provide evidences for choosing an optimal electrode implantation site. Methods Thirty-six patients with septal active electrode implantation and 39 with apical passive electrode implantation were enrolled in this study. Pacing threshold, R-wave sensing, lead impedance, pacing QRS width and pacing-related compli- cations for two groups at implantation and follow-up were compared. Results There were higher pacing threshold and shorter pacing QRS width at implantation in the septal group compared with the apical group. There were no differences between the septal and the apical groups in pacing threshold, R-wave sensitivity, lead impedance and pace-related complication during a follow-up. Conclusions Right ventricular outflow tract septum could be used as a first choice for implantation site because it had long-term stable lead performances and no serious complications compared with the traditional apical site.     

2187导线在左心室起搏中的应用价值

目的寻找左心室电极导线的导入途经和技术要点及其在双心室起搏中的临床实用价值.方法 9例病人,男性8例,均为药物治疗无效合并CLBBB的顽固性心力衰竭.CS造影7例采用逆行法,2例采用顺行法显示CS.选择可剥脱CS导引导管和左室电极导线(Medtronic,2187),采用左锁骨下静脉穿刺法,经CS将电极导线置于CS左心室属支,起搏左心室.结果无论是逆行还是顺行冠状动脉造影,均清晰显示CS及其属支静脉.6例病人经导引导管将2187导线成功导入靶静脉,3例病人直接导入2187导线.电极导线尖端1例插进心大静脉远端,2例位于左室侧缘静脉,2例放在左室后静脉, 4例导入左室后侧静脉.导线到位后测量的各起搏参数均符合起搏要求,长期随访未见导线脱位和起搏功能的变化.结论 CS顺行和逆行造影均可清晰显示CS及其属支;直接或经导引导管皆可将2187电极导线导入靶静脉;应用2187型LV电极导线经CS左心室心外膜起搏技术可行、安全可靠,可广泛临床应用.     

主动固定螺旋电极在右室流出道间隔部起搏中的应用体会

目的探索采用主动固定螺旋电极行右室间隔部起搏的临床可行性。方法随机选择54例需要安装双腔起搏器的患者行右室流出道间隔部起搏,将心室起搏螺旋电极先后定位于右室心尖部及右室流出道间隔部并测试起搏参数。结果右室流出道间隔部电极定位成功率为98.15%,该部位起搏参数满足起搏要求,同时起搏的QRS波时限较心尖部变窄(130.45±18.24msvs153.11±20.10ms,P<0.001)。结论采用主动固定螺旋电极行右室流出道间隔部起搏安全性高、可行性好。     

白藜芦醇对快速起搏右心房诱发的持续性心房颤动猪心房结构重构的影响

目的 观察快速起搏猪右心房制备持续性心房颤动（AF）的效果,探讨白藜芦醇（RES）干预对持续性AF猪的心房结构重构的影响.方法 18只小家猪（雌雄不拘）按完全随机设计的分组方法（采用动物编号和随机分组表）分为起搏组（ATP组）、假手术组（Sham组）和RES干预组各6只,采用Seldinger血管穿刺技术送入双极电极至右心房并连接实验用起搏器（AOO）,ATP组和RES干预组的右心房快速起搏（500次/min）2周,制备持续性AF实验模型.3组猪分别于起搏前和起搏2周后进行电生理和经胸壁超声心动图检查,以检测AF的持续时间、左右心房大小及左心房收缩末面积.RES干预组猪于起搏前1周开始服用RES（2.5 mg·kg-1·d-1）.起搏2周后取各组猪的左右心房组织标本,观察心房组织形态学和间质纤维化的改变,用免疫组织化学分析软件计算胶原容积分数（CVF）来反映间质纤维化程度.结果 （1）起搏2周后,ATP组AF的发生率较RES干预组明显升高（100％比66.7％,x2=10,P＜0.01）、持续时间延长[（26.41±9.89）min比（9.56±1.36） min,F=10.7,P=0.01].（2）起搏2周后,ATP组和RES干预组猪的左右心房明显比起搏前增大;但RES干预组的左心房收缩末面积明显低于ATP组[（599.2±8.7） mm2比（744.3±29.9） mm2,F=130.61,P＜0.01].（3）RES干预组左右心房组织CVF明显低于ATP组（56％±6％比73％±7％;59％±6％比75％±7％,均为P＜0.01）.结论 快速起搏猪右心房可成功制备持续性AF模型;RES干预可以明显抑制快速起搏右心房诱发的持续性AF猪的心房结构重构,减少AF的发生.     

最小化心室起搏对阵发性心房颤动的影响

目的观察最小化心室起搏在阵发性心房颤动患者中能否减少心室起搏及房颤发作。方法选择房颤负荷在1%～70%,已植入具有最小化心室起搏功能起搏器的46例患者为研究对象。经过1个月诱导期后,利用EXCEL表格中的随机函数算法随机分为A组(最小化心室起搏功能关闭)和B组(最小化心室起搏功能打开),观察6个月。主要观察指标为心室起搏比率及房颤负荷。结果观察6个月两组之间的房颤负荷,A组为31.9%,B组为7.5%。心室起搏中位数A组显著高于B组,A组为76.0%,B组为2.1%。结论应用最小化心室起搏能显著减少心室起搏比例和房颤发作。     

不同起搏方式对高右室起搏比例患者心功能及心房颤动的影响

目的：探讨不同起搏部位对高右室起搏比例、缓慢性心律失常患者新发心房颤动（AF）及心功能的影响。方法：入选我院心内科2005年1月至2011年1月期间置入 DDD 永久起搏器的缓慢性窦房结功能失调或Ⅱ度以上房室传导阻滞患者,选择其中高右室起搏比例者（右室起搏累积百分比＞50％）共120例,随机分为右室心尖部（RVA）起搏组（n＝47）及右室间隔部（RVS）起搏组（n ＝73）。随访内容包括起搏器置入术前、术后3年 AF 发生情况和超声心动图参数。结果：随访期间 RVA 组新发 AF 患者比例高于 RVS 组（23．40％对16．43％,P ＝0．03）。术后3年,与 RVA 组相比,RVS 组左房内径（LAD）、左室舒张末期内径（LVEDD）明显缩小,左室射血分数（LVEF）则明显升高（P ＜0．05）。结论：对于 DDD 起搏模式下高右室起搏比例患者,与 RVA 起搏相比,RVS 起搏可显著改善患者心功能,减少 AF 的发生。     

Coexistence of 2 types of atrial tachycardias and right ventricular outflow tract tachycardia

Double tachycardia is a relatively uncommon type of tachycardia. In this report, we discuss a 68-year-old woman with history of frequent palpitations. Electrophysiologic study revealed that narrow QRS tachycardias from 2 origins and 1 wide QRS tachycardia were induced and each of the tachycardias was induced by the other. We found that 2 focal atrial tachycardias and 1 ventricular tachycardia originated from right ventricular outflow tract. All of these tachycardias were successfully ablated during one session, and no recurrence appeared during 10 months of follow-up.     

右心室流出道起搏病人炎症介质的改变

目的探讨右心室流出道起搏病人白介素6的改变。方法双腔起搏器安置术后123例．按起搏部位分为右心室心尖部组（n=66）和右心室流出道组（n=57）,比较两组病人血浆白介素6的水平。结果随访时间中位数65d,发现右心室流出道组病人白介素6水平较右心室心尖起搏组低,为（5．0±1．2）ng／L比（5．7±4．8）ng／L。结论右心室流出道起搏病人较右室心尖部起搏病人白介素6释放少。提示抗炎、抗栓治疗可能会优化起搏。     

老年人双腔生理性心脏起搏的临床分析

目的　分析双腔生理性心脏起搏治疗老年人缓慢心律失常 ,改善心功能及生活质量的临床效果。方法　 1 998～ 2 0 0 1年为老年人植入双腔生理性心脏起搏器 39例 ,起搏器 DDD型 2 6例 ,DDDR型 1 3例。术后平均随访 0 .5～ 3年 ,随访内容为起搏阈值等参数 ,左室射血分数(L VEF) ,心功能 (NYHA分级法 )及常见并发症 (如充血性心衰、房颤及栓塞等 )。结果　同期老年人双腔生理性起搏器植入率达 2 7.5%～ 49.5% ,术后 LVEF由 (40 .2± 1 6.8) %增至 (48.1± 1 7.2 ) % (P<0 .0 0 1 ) ,心功能平均提高 (1 .2± 0 .3)级以上 (P<0 .0 5) ,运动耐量增加 ,未见常见并发症发生 ,与同期老年人非生理性心室起搏比较 L VEF提高 1 8.2 % (P<0 .0 1 )。结论　双腔生理性心脏起搏能改善缓慢心律失常老年人心功能 ,提高生活质量。     

Usefulness of rate regulation through continuous ventricular pacing in patients with drug-controlled slower atrial fibrillation and normal or depressed left ventricular systolic function

We studied 33 clinically stable patients with permanent atrial fibrillation (AF), implanted with a ventricular demand rate-responsive (VVIR) pacemaker or an automatic defibrillator, in order to evaluate whether continuous right ventricular apex pacing (VP) conferring rate regulation may be advantageous when compared with slower drug-controlled AF. Devices were chronically programmed at ventricular backup pacing. Patients were divided in two groups according to their normal (n = 17) or depressed (n = 16) left ventricular systolic function (LVSF). Ventricular function was studied by using tissue Doppler and color M-mode and echocardiography, as well as B-type natriuretic peptide (BNP) measurements. Baseline data during AF were compared to corresponding measurements following a 1-month pacing period after the devices were programmed at a base rate of 70 beats/min. In both groups, VP worsened some indexes of left and right ventricular function (P < 0.05) without significantly affecting cardiac output, left ventricular filling pressures and BNP (P = not significant). We conclude that VP should not be considered advantageous compared to slower AF.