植入埋藏式自动复律除颤器四例随访分析

４例患者因恶性室性心律失常伴心源性晕厥于１９９１年４～１２月安置埋藏式自动心脏复律除颤器（ＡＩＣＤ）。术后随访３０～３９（３４．５±４．１）个月。共发作室性心动过速（ＶＴ）１２７次，ＡＩＣＤ放电１４８次。除例１在１次发作ＶＴ时５次放电不能转复外，其余每例每次发作ＶＴ时，ＡＩＣＤ均能有效地识别并终止。其中例１ＶＴ发作４次共放电１６次。例１、例２分别于术后１２个月及９ｄ开始服用抗心律失常药物治疗后未见ＶＴ发生。例３ＶＴ发作与心功能有关，使用相应药物后ＶＴ不再发生。例４ＶＴ发作频繁与精神因素有关。结果提示：①ＡＩＣＤ能迅速有效地终止ＶＴ；②ＡＩＣＤ可能存在误放电；③植入ＡＩＣＤ的病人要配合药物治疗；④植入ＡＩＣＤ的病人进行精神治疗亦不可忽视。     

植入起搏器患者强烈心理应激诱发多形性室性心动过速(附二例报告)

报道冠心病、Ⅲ度房室阻滞安置ＶＶＩ起搏器的２例患者因强烈心理应激诱发多形性室性心动过速（简称室速）。其特点为临床症状凶险，表现为反复发作性晕厥、抽搐，心电图示多形性室速，ＱＴ间期正常。其中１例为顽固性多形性室速，联律间期极短，一般抗心律失常药物无效。提示行为心理治疗应作为综合治疗此类心律失常的必要措施之一。     

埋藏式心脏起搏后晕厥的原因分析

对我院 1989年 7月～ 1999年 12月埋置心脏起搏器的10 2例患者进行临床随访。置入起搏器后晕厥 9例 (男 5例、女 4例 ) ,年龄 34～ 79岁。其中病窦综合征 6例、Ⅲ度房室阻滞 3例 ;置入起搏器类型 :非生理性起搏 (ＶＶＩ) 3例 ,生理性起搏ＡＡＩ、ＤＤＤ各 3例。晕厥发生时间 :术后 1个月以内 1例、3～ 6个月 4例、2～ 9年 4例 ;晕厥原因 :起搏系统故障者 2例 ,均对起搏器依赖 ,表现为术前症状的再现。 1例为脉冲发生器线路故障 ,1例为电极尾端与起搏器输出端连接松脱 ;致命性室性心律失常 2例 ,均有心脏扩大 ,实为原有心脏病加剧 ,或有电解…     

心动过速终止后短暂心室复极异常和严重室性心律失常

目的 观察长时间心动过速终止后对心室复极和恶性室性心律失常发生的影响.方法 3例长时间心动过速(9 d～6个月)患者,两例为长时间发作室性心动过速(室速),其中1例为无休止性左心室特发性室速并诱发心动过速性心肌病;另1例为主动脉瓣换瓣术后5年发生束支折返性室速;第3例为持续性心房扑动伴心功能不良并因三度房室阻滞于10年前植入单腔起搏器.结果 3例患者在心动过速时并无晕厥和恶性室性心律失常发生,而在心动过速间隙或射频导管消融终止后均出现qr间期延长和恶性心律失常,其中1例持续心房扑动合并心力衰竭的患者最后死于多脏器功能衰竭;另两例室速射频导管消融治疗后1周QT间期逐渐恢复正常,分别随访20和39个月无室速和晕厥发作.结论 长时间心动过速后可导致短时间心室复极异常及恶性室性心律失常,应加强防范,防止发生心脏性猝死.     

143例Sigma系列起搏器临床分析

目的 通过143例Sigma系列起搏器的临床分析，了解起搏器术后随访的重要性以及起搏器诊断功能对临床的帮助，以便及时发现并处理与起搏器有关的问题。方法 回顾性分析了143例Sigma系列起搏器患者的临床情况，了解其基础病因、心律失常类型、植入起搏器类型以及并发症。结果 143例患者中更换37例；首次植入起搏器的106例患者中，病态窦房结综合征54例、房室阻滞26例、病态窦房结综合征合并房室阻滞l例、心房颤动合并RR长间歇24例、长QT综合征伴尖端扭转性室性心动过速、窦性心动过缓l例。DDD起搏方式占35．7％。术后有2例患者发生心室导线移位，均发生在住院期间。44例新植入DDD起搏器的患者进行了术后定期随访及程控，植入3个月后与植入时比较，心房、心室电压阈值均很低，无统计学差异。14例植入DDD起搏器的病态窦房结综合征患者中有7例发生模式转换，743 d中模式转换次数为14 416次，平均每天19．4次。结论 ①合理应用现代起搏器的自动化功能和诊断功能，有助于临床医生了解病人的心律、心率情况以及起搏器的工作情况，及早发现有关并发症。②术前根据患者的心律失常情况、心脏病变情况选择合适的起搏器及导线系统，并且在术后定期随访、定期程控非常重要。     

植入型心电监测仪在不明原因晕厥中的临床应用：单中心前瞻性研究

目的探讨植入型心电监测仪(ICM)在不明原因晕厥中的诊断价值。方法前瞻性观察性研究2017年7月至2021年10月在中国医学科学院阜外医院心律失常中心诊断为不明原因晕厥, 并植入ICM的患者45例, 其中男29例, 女16例。中位年龄52.6岁, 年龄范围11～87岁。所有患者每3个月随访1次, 随访内容包括是否再次发生晕厥及晕厥前兆事件、ICM程控读取随访期间记录到的事件。若患者出现晕厥, 则及早行ICM程控。结果随访(15.0±12.3)个月, 15例(15/45, 33.3%)患者再发晕厥或晕厥前兆, 其中9例为心动过缓导致的(窦性停搏7例, 高度房室传导阻滞2例), 2例为室性心动过速(室速), 1例为心房颤动(房颤), 另有3例意识丧失发作时ICM未记录到心律失常事件, 后经脑电图证实为癫痫。在心源性晕厥患者中, 9例植入永久起搏器, 2例选择药物治疗, 有1例室速患者发生心脏性猝死。结论 ICM可有效提高不明原因晕厥患者的诊断效率。     

埋藏式心脏复律除颤器在治疗恶性室性心律失常中 …

评价埋藏式心脏复律除颤器（ＩＣＤ）在恶性室性心律失常治疗中所起的作用,４例因反复发作室性心动过速／心室颤动（ＶＴ／ＶＦ）住院患者,采用ＩＣＤ和药物治疗,并随访２１～３６个月。结果：４例患者均有室性心律失常再发,复发率１００％,在复发心律失常时全部经ＩＣＤ复窦性心律,有效率１００％。对４例ＩＣＤ患者随访发现,共有３４次持续性ＶＴ／ＶＦ发作,相对集中在８个不同时间段,而每个时段都与患者全身状态改变有关     

经静脉植入心律转复除颤器的临床应用

植入型心律转复除颤器（ｉｍｐｌａｎｔａｂｌｅ　ｃａｒｄｉｏｖｅｒｔｅｒ　ｄｅｆｉｒｉｌｌａ－ｔｏｒ，ＩＣＤ）的应用大大降低了由室性心动过速（室速）、心室颤动（室颤）引起的心脏性淬死的发生率。成为治疗室性快速心律失常最有效的方法。 资料和方法５例均为男性，年龄３９－７４岁。基础心脏病为冠心病３例（其中１例为前壁心肌梗死）、心肌病１例和扩张性心肌病１例。心肌梗死患者住院期间３次发生室颤，经电除颤转为窦性心律。其余４例均有院外晕厥发作。扩张性心肌病患者同时伴有左束支阻滞及一度房室阻滞。抗心律失常药物疗…     

变异型心绞痛诱发严重心律失常

６例变异型心绞痛（ＶＡ）患者于胸痛发作时经１２导联和（或）２４ｈ动态心电图记录到心律失常。其中心绞痛发作时伴发室性早搏二联律３例、短阵室性心动过速１例、Ⅲ度房室阻滞（ＡＶＢ）２例。１例Ⅲ度ＡＶＢ者伴有发作性晕厥。冠状动脉造影提示与缺血有关的冠状动脉狭窄３例;余３例冠脉造影结果大致正常,但麦角新碱激发试验均为阳性。２例行药物治疗,３例接受经皮冠状动脉腔内成形术治疗,１例Ⅲ度ＡＶＢ伴晕厥者置入永久性人工心脏起搏器。结果表明冠状动脉痉挛在ＶＡ患者致命性心律失常的发生中具有重要作用。     

磁铁频率起搏终止起搏器埋藏后室上性心动过速一例

磁铁频率起搏终止起搏器埋藏后室上性心动过速一例王世襄（南通医学院第二附属医院江苏２２６００１）患者男性，６３岁，因慢－快综合征伴晕厥于１９９３年７月埋藏ＳｕｐｒｉｍａＩＩＩ型ＶＶＩ心脏起搏器。术后仍有心动过速发作。但未再晕厥。同年１０月４日因右侧偏瘫...     

Long-term results of pacemaker therapy in hypersensitive carotid sinus syndrome

131 patients received permanent pacemakers to treat their hypersensitive carotis sinus syndrome (HCSS). Prior to implantation, HCSS was diagnosed whenever spontaneous episodes of faintness or dizziness (n = 25) or syncope (n = 106) coincided with an abnormal response to carotis sinus massage (asystole greater than 3 s). 123 patients were followed for 48 +/- 27 months after implantation to assess the value of pacemaker therapy. 77% of all patients were free of initial symptoms. 90% of patients with syncope prior to pacemaker therapy were free of recurrence. Therefore, permanent pacing appears to be the treatment of choice for these patients. Since carotis sinus massage produced high-degree AV-block in at least 33% of patients, ventricular (rather than exclusive atrial) pacing seems to be mandatory. However, syncope did recur in 10% despite normal pacemaker function. The etiology of these recurrences remained unclear in almost all patients. As opposed to patients with syncope, cardiac pacing prevented symptoms in only 26% of patients with faintness or dizziness without full syncope. In these patients primary and sole pacemaker therapy does not appear to be appropriate.     

The value of intracardiac electrophysiologic techniques in recurrent syncope of "unknown cause"

We prospectively evaluated and followed-up 45 patients with syncope in whom conventional cardiovascular and neurological investigations did not reveal the cause. All patients underwent electrophysiologic studies to assess the function of the sinus node and the integrity of atrioventricular conduction. These included the ajmaline test and the inducibility of supraventricular or ventricular tachycardia. Seven patients (15.5%) had evidence of sinus node dysfunction, 8 patients (17.7%) had evidence of infra-His atrioventricular block after ajmaline administration and 5 patients (11.1%) had inducible ventricular tachycardia. The remaining 25 patients (55.5%) had non-diagnostic studies. All patients with sinus node dysfunction and inducible infra-His atrioventricular block were asymptomatic during a mean follow-up period of 14.3 +/- 9.5 months after implantation of a permanent pacemaker. Patients with inducible ventricular tachycardia (except 1 with poor left ventricular function who died) were likewise asymptomatic while receiving laboratory guided anti-arrhythmic drug therapy. Twenty-five patients with non-diagnostic studies who were treated empirically are alive but the symptoms persist in 14 (56%). Provocative electrophysiological studies are of diagnostic and therapeutic utility in a significant number of patients with recurrent syncope of "unknown cause".     

A randomized, double-blind, placebo-controlled study of permanent cardiac pacing for the treatment of recurrent tilt-induced vasovagal syncope. The vasovagal syncope and pacing trial (SYNPACE).

AIMS: Recently, some studies revealed the efficacy of pacemaker implantation in decreasing recurrences in patients with vasovagal syncope. As these studies were not blinded or placebo-controlled, the benefits observed might have been due to a bias in the assessment of outcomes or to a placebo effect of the pacemaker. We performed a randomized, double-blind, placebo-controlled study in order to ascertain if pacing therapy reduces the risk of syncope relapse. METHODS AND RESULTS: Twenty-nine patients (53 +/- 16 years; 19 women) with severe recurrent tilt-induced vasovagal syncope (median 12 syncopes in the lifetime) and 1 syncopal relapse after head-up tilt testing underwent implantation of a pacemaker, and were randomized to pacemaker ON or to pacemaker OFF. During a median of 715 days of follow-up, 8 (50%) patients randomized to pacemaker ON had recurrence of syncope compared to 5 (38%) of patients randomized to pacemaker OFF (p = n.s.); the median time to first syncope was longer in the pacemaker ON than in pacemaker OFF group, although not significantly so (97 [38-144] vs 20 [4-302] days; p = 0.38). There was also no significant difference in the subgroups of patients who had had a mixed response and in those who had had an asystolic response during head-up tilt testing. CONCLUSION: Our data were unable to show a superiority of active pacing versus inactive pacing in preventing syncopal recurrence in patients with severe recurrent tilt-induced vasovagal syncope.     

Disopyramide for transient high-degree atrioventricular block in a young patient with a history of syncope

Although high-degree atrioventricular (AV) block in patients with a history of syncope usually requires pacemaker implantation, therapeutic strategies should also be considered. A 35-year-old man presented with complaints of palpitations, nausea and dysgeusia. Since aged 30, the patient had experienced three episodes of syncope. Holter monitoring showed transient high-degree AV block (up to 5:4 block) associated with nausea, eructation and dysgeusia irrelevant to posture as well as ventricular ectopic beats with palpitation. A head-up tilt test revealed neurally mediated vasodepression but electrophysiological study showed no abnormalities. These results indicated that his transient high-degree AV block was functional, and syncope would have been because of neurally mediated vasodepression, not bradycardia. After administration of disopyramide at 300mg daily, the symptoms subsided and ventricular ectopic beats and AV block disappeared. He has been well for 20 months.     

Late complete atriovenous block after percutaneous closure of a perimembranous ventricular septal defect.

Percutaneous closure of a perimembranous ventricular septal defect (VSD) is an alternative to surgical closure. Complications include arrhythmias and in particular early postoperative complete atrioventricular (AV) block. We report the cases of two patients, aged 2.5 and 4 years, treated with an eccentric VSD occluder device whom developed complete AV block 4 and 12 months after the procedure. The first patient experienced syncope, while the second one was completely asymptomatic. Both subjects underwent endocardial ventricular pacemaker implantation.     

The vasovagal Syncope and pacing (Synpace) trial: rationale and study design.

BACKGROUND: Though vasovagal syncope probably does not directly cause death, it is often associated with severe trauma and, when recurrent, significantly impairs the patient's quality of life. While drug therapy for vasovagal syncope is still controversial, recently two randomized studies revealed the efficacy of dual-chamber pacemaker implantation in decreasing recurrences in very symptomatic patients. However, since both studies were not placebo-controlled, the benefits observed might have been due to the placebo effect of the pacemaker. AIM OF THE STUDY: The aim of the vasovagal Syncope and pacing (Synpace) trial, a multicentre, prospective, randomized, double-blind, placebo-controlled trial, is to ascertain whether, in patients suffering from recurrent vasovagal syncope, the implantation of a dual-chamber pacemaker with rate drop response algorithm programmed to ON, will reduce syncope relapses compared with the implantation of a pacemaker programmed to OFF. Moreover, in order to evaluate the role of the haemodynamic response during tilt-induced syncope in identifying those patients who will benefit most from pacemaker implantation, enrolled patients will be divided into two groups on the basis of their haemodynamic behaviour during tilt-induced syncope: group 1, asystolic response (development of asystole >3 s), and group 2, mixed response (development of bradycardia <60 bpm, without asystole >3 s). The head-up tilt testing protocol will consist of 20 min at 60 degrees without drug potentiation, followed by 15 min at the same inclination after 400 microg of sublingual nitroglycerin. Results from the two groups will be analysed both separately and globally. The primary clinical endpoint of the study will be syncope. INCLUSION AND EXCLUSION CRITERIA: To be enrolled, patients will have to meet the following criteria: at least six syncopal episodes in the patient's lifetime; positive head-up tilt testing with asystolic or mixed response; at least one syncope recurrence following a positive head-up tilt test. The following constitute exclusion criteria: non-vasovagal syncope; other indications for pacing. SAMPLE SIZE: We hypothesize a risk of syncope recurrence of 70% after one year, and we estimate that--owing to the placebo effect alone--pacemaker will produce a 20% decrease in risk, which corresponds to a 50% risk of recurrence after one year, in those patients randomized to 'pacemaker OFF'. We calculate conservatively a risk decrease of 60% in patients with 'pacemaker ON'. This implies a 10% incidence of syncope recurrence after one year, vs 50% in patients with 'pacemaker OFF'. Fifty patients will need to be enrolled in the study: 25 patients for each group.     

Complete heart block. Studies of atrial and ventricular pacemaker site and function.

Atrial and ventricular pacemaker function was studied in 20 patients with idiopathic chronic complete heart block using the rate response to an intravenous bolus dose of isoprenaline (5 mug/70 kg bodyweight). Pacemaker responses were compared with those of 16 normal control subjects. None of the patients was having syncopal attacks at the time of admission and they were therefore selected in that none required immediate pacing. Ten of the patients had His bundle electrograms; all were shown to have a pre-His type of atrioventricular block. Two major groups emerge from the responses to isoprenaline. (a) High risk group: 11 of the 14 patients with reduced ventricular pacemaker responses had frequent syncopal attacks; 8 of the patients with Adams-Stokes syncope had a bundle-branch block pattern, while 3 had a narrow QRS. These patients require pacing. (b) Low risk group: a low risk asymptomatic group (5 patients) was identified with atrial and ventricular responses to isoprenaline within normal range. One of these patients had a bundle-branch block pattern, while 4 had a narrow QRS. These patients might be managed without pacing. The atrial response to isoprenaline was reduced in 12 of the 20 cases, 10 of whom also had reduced ventricular responses. All 9 patients with bundle-branch block had reduced ventricular responses, while 7 had reduced atrial responses. This evidence indicates that cardiac conducting tissue pathophysiology is widespread in complete heart bolck. The present work suggests that consideration of the ventricular pacemaker function is important in assessing liability to syncope in complete heart block. While patients with Adams-Stokes attacks require pacing it is suggested that all asymptomatic patients with complete heart block and those with minor symptoms are assessed using studies of both ventricular pacemaker function and site. A low risk group not requiring a pacemaker may emerge after sufficient follow-up assessment.     

阵发性高度及完全房室传导阻滞的临床及电生理特点

目的 探讨阵发性高度及阵发性完全房室传导阻滞的临床特点及心脏电生理特点,明确传导阻滞位置,指导起搏器植入治疗.方法 34例因阵发性高度及阵发性完全房室传导阻滞住院行起搏器植入患者,根据心脏电生理检查结果 ,将其分为房室结阻滞组(16例)和希蒲传导系统阻滞组(18例),比较两组的临床特点和电生理特点.结果 两组患者体表心...     

Complete heart block. Studies of atrial and ventricular pacemaker site and function.

Atrial and ventricular pacemaker function was studied in 20 patients with idiopathic chronic complete heart block using the rate response to an intravenous bolus dose of isoprenaline (5 mug/70 kg bodyweight). Pacemaker responses were compared with those of 16 normal control subjects. None of the patients was having syncopal attacks at the time of admission and they were therefore selected in that none required immediate pacing. Ten of the patients had His bundle electrograms; all were shown to have a pre-His type of atrioventricular block. Two major groups emerge from the responses to isoprenaline. (a) High risk group: 11 of the 14 patients with reduced ventricular pacemaker responses had frequent syncopal attacks; 8 of the patients with Adams-Stokes syncope had a bundle-branch block pattern, while 3 had a narrow QRS. These patients require pacing. (b) Low risk group: a low risk asymptomatic group (5 patients) was identified with atrial and ventricular responses to isoprenaline within normal range. One of these patients had a bundle-branch block pattern, while 4 had a narrow QRS. These patients might be managed without pacing. The atrial response to isoprenaline was reduced in 12 of the 20 cases, 10 of whom also had reduced ventricular responses. All 9 patients with bundle-branch block had reduced ventricular responses, while 7 had reduced atrial responses. This evidence indicates that cardiac conducting tissue pathophysiology is widespread in complete heart bolck. The present work suggests that consideration of the ventricular pacemaker function is important in assessing liability to syncope in complete heart block. While patients with Adams-Stokes attacks require pacing it is suggested that all asymptomatic patients with complete heart block and those with minor symptoms are assessed using studies of both ventricular pacemaker function and site. A low risk group not requiring a pacemaker may emerge after sufficient follow-up assessment.     

回顾性调查线粒体疾病患者的心脏病变

目的 分析线粒体疾病心脏受累的表现,提高对该病的认识.方法 回顾北京协和医院20年来诊断的90例线粒体疾病患者临床与病理资料,包括心电图、动态心电图和心脏超声检查.结果 90例线粒体疾病患者中合并心脏病变29例.其中合并心肌病变5例(5.6%),为左心室肥厚2例、心脏扩大伴心力衰竭3例;合并先天性结构性心脏病4例(4.4%),包括三尖瓣或(和)二尖瓣脱垂各1例,房间隔或室间隔缺损各1例;各种不同程度心律失常20例(22.2%),包括安装永久起搏器者4例(3例在安装起搏器后1～3年才诊断为线粒体疾病),多种心律失常包括室性心动过速1例,阵发性房性心动过速1例,无症状的心律失常14例(分别是右束支传导阻滞4例,右束支合并左前分支传导阻滞1例,短PR间期综合征5例,B型预激综合征2例,室内传导阻滞2例).心脏传导阻滞在Kearns-Sayre综合征(9例)中发生率高达66.7%.8例患者检出线粒体基因A3243G突变.结论 线粒体疾病可以心肌病、心力衰竭、恶性心律失常为首发表现,对青壮年心肌病、伴发严重的心脏传导阻滞应尽可能寻找病因包括进行相关基因检查.此外,对所有诊断为线粒体疾病患者需定期进行心电图和超声心动图等检查以便尽早发现异常及早处理以改善预后.