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.     

117例双心室再同步起搏器植入术并发症分析

目的　双心室同步起搏已经被证明可有效改善充血性心力衰竭患者的心功能。进行双心室再同步治疗 (cardiacresynchronizationtherapy ,CRT)的技术关键是植入左心室导线。植入左心室导线技术难度大 ,操作复杂 ,有一定的并发症发生率 ,本文分析了 117例双心室起搏器植入术并发症。方法　充血性心力衰竭伴心室内阻滞患者 117例 ,其中男性 86例 ,女性 31例 ,平均年龄 (5 3 0 0±8 2 5 )岁。患者在进行逆行冠状静脉窦造影后 ,经冠状静脉窦插入导线至心脏静脉 (主要为心脏后静脉和侧后静脉 )进行左心室起搏。然后植入右心房和右心室电极导线。结果　 117例患者中 111例成功植入双心室起搏系统 ,成功率为 95 %。主要植入术的相关并发症包括 :冠状静脉窦夹层 4例(3 4 % % ) ,膈肌刺激需要重新植入 2例 (1 7% ) ;电极导线脱位 2例 (1 7% ) ,结论　双心室再同步治疗 (cardiacresynchronizationtherapywithbiventricularpacing)起搏器植入术有一定的术中并发症和一定的风险 ,术前应掌握好适应证并作好充分的准备 ,术中必须规范操作 ,严密观察 ,以减少并发症     

左心室和双心室起搏对心力衰竭患者运动能力影响的荟萃分析

目的比较左心室起搏（LVP）和双心室起搏（BVP）对心力衰竭患者运动能力的影响。方法在MEDLINE、Cochrane临床试验中心登记库、EMBASE和中国期刊网中检索以心力衰竭为研究对象,评价了6min步行距离（6MWD）和／或峰值耗氧量（PVO2）的LVP与BVP对比的研究。结果共检索到87篇文献,其中3项研究符合人选标准,共纳入73例患者。交叉起搏4～8周后,BVP组比LVP组的PVO2明显增加[加权均数差（WMD）=-0．35ml·kg·min^-1,95％可信区间（CI-0．66,-0．05）,P=0．02];6MWD在BVP组有增加的趋势,但差异无统计学意义（WMD=-1．2m,95％CI（-7．98,5．57）,P=0．73]。结论BVP对心力衰竭患者运动能力的改善可能优于LVP。     

左心室双部位双心室同步起搏两例

常规的心脏再同步治疗（cardiac resynchronization,CRT）是通过将右心房、右心室和左心室导线分别放置在右心耳、右心室心尖部（或问隔部）及心脏后或侧后静脉内来实现的。新近左心室双部位起搏（dualsite left ventficular pacing）逐渐引起人们的关注并开始应用于临床,国内尚罕见报道。现报道本中心植入的2例。     

心脏静脉球囊扩张及双心室同步起搏

临床资料.患者男性，54岁，因反复发作胸闷气短4年加重1个月入院，既往高血压病史30余年，未行系统降压治疗。入院后查心电图QRS波130ms，超声心动图示左心室舒张末期内径(LVEDD)75mm，左心室射血分数(LVEF)0．35。诊断为高血压性心脏病，心功能Ⅲ级(NYHA分级)。入院后给予药物治疗心力衰竭，在病情相对稳定的情况下，接受三腔双心室起搏治疗。     

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 …     

双心室起搏在严重心力衰竭病人中的应用

目的：探讨双心室心脏起搏在技术上的可行性及其在严重心力衰竭中的应用价值。方法：４例原发性扩张型心肌病,心功能Ⅲ或Ⅳ级,合并左束支传导阻滞,ＱＲＳ时间≥２０ｍｓ。经锁骨下静脉将左心室外膜起搏电极置于心脏后侧支静脉,按常规方法安置右心房和右心室电极。起搏器程控为ＤＤＤ工作方式,ＡＶ间期设置为１００ｍｓ。在１２个月随访中,观察临床、心电图、运动试验（６ｍｉｎ步行距离）和超声心动图指标的变化以评价疗效。结果：（１）４例均成功安置双心室心脏起搏器,术后心力衰竭症状明显缓解,并于手术后９～２０ｄ出院。出院前停用所有静脉用药,包括利尿剂、强心剂和扩血管药;（２）随访：４例心功能均改善一级,６ｍｉｎ步行距离增加７６～２８４ｍ。超声心动图显示：左心室和左心房前后径分别减小３～７ｍｍ和２～７ｍｍ,左心室射血分数增加４％～７％。结论     

双心室起搏治疗充血性心力衰竭的进展

充血性心力衰竭 (CHF)是常见而又难治的心脏疾病 ,其患病率和死亡率一直高居不下 ,在全球范围内 ,估计有 2 2 50万心衰患者并且以每年 2 0 0万速度递增 ,而且即使在最好的医疗条件下 ,慢性 CHF5年的死亡率仍高达 50 %。近 2 0年来对那些药物难治的患者提出多种非药物治疗的措施 ,其中心脏移植无疑是治疗晚期 CHF的金标准 ,但是 ,供体的缺乏和排斥反应限制了它的应用 ;永久性埋植人工心脏仍处于临床试验阶段 ;心肌成形术的长期效果也有争论。近几年来国内外的一些医师开始进行双心室起搏治疗 CHF的临床研究和应用 ,初步结果证实心脏再同…     

左心室电极导线放置的研究进展

心脏再同步治疗心力衰竭的效果已经得到大规模临床验证。而心脏再同步治疗的关键是左心室电极导线的放置，只有当左心室电极导线放置到理想的左心室部位，心力衰竭的治疗效果才能是显著的。目前有3种途径放置左心室电极导线：经心脏静脉途径、外科手术开胸途径、穿刺房间隔途径。最常用的方法是经心脏静脉途径。     

双心室起搏治疗顽固性心力衰竭一例

近几年 ,国外双心室起搏治疗充血性心力衰竭已取得初步疗效 ,国内也开始用于临床。最近 ,我们应用双心室、右房起搏治疗顽固性心力衰竭 (简称心衰 ) 1例获成功 ,报道如下。患者男性 ,6 2岁 ,因反复发作心慌、气促、胸闷、呼吸困难、全身浮肿 10年 ,再发加重 10天于 2 0 0 0年 11月 12日第13次入院。前 12次均因心衰入院 ,最严重时 1年住院 4次。超声心动图检查全心扩大、二尖瓣中度返流、心电图示窦性心律、完全性左束支阻滞、ＱＲＳ波宽度 0 .16ｍｓ。入院诊断扩张性心肌病。经药物治疗控制心衰后 ,于 2 0 0 0年 12月 2 1日行双心室、右心…     

Robotically assisted left ventricular epicardial lead implantation for biventricular pacing

OBJECTIVES: Ventricular resynchronization might be achieved in a minimally invasive fashion using a robotically assisted, direct left ventricular (LV) epicardial approach. BACKGROUND: Approximately 10% of patients undergoing biventricular pacemaker insertion have a failure of coronary sinus (CS) cannulation. Rescue therapy for these patients currently is limited to standard open surgical techniques. METHODS: Ten patients with congestive heart failure (New York Heart Association class 3.4 +/- 0.5) and a widened QRS complex (184 +/- 31 ms) underwent robotic LV lead placement after failed CS cannulation. Mean patient age was 71 +/- 12 years, LV ejection fraction (EF) was 12 +/- 6%, and LV end-diastolic diameter was 7.1 +/- 1.3 cm. Three patients had previous cardiac surgery, and five patients had a prior device implanted. RESULTS: Nineteen epicardial leads were successfully placed on the posterobasal surface of the LV. Intraoperative lead threshold was 1.0 +/- 0.5 V at 0.5 ms, R-wave was 18.6 +/- 8.6 mV, and impedance was 1,143 +/- 261 ohms at 0.5 V. Complications included an intraoperative LV injury and a postoperative pneumonia. Improvements in exercise tolerance (8 of 10 patients), EF (19 +/- 13%, p = 0.04), and QRS duration (152 +/- 21 ms, p = 0.006) have been noted at three to six months follow-up. Lead thresholds have remained unchanged (2.1 +/- 1.4 V at 0.5 ms, p = NS), and a significant drop in impedance (310 +/- 59 ohms, p < 0.001) has been measured. CONCLUSIONS: Robotic LV lead placement is an effective and novel technique which can be used for ventricular resynchronization therapy in patients with no other minimally invasive options for biventricular pacing.     

Monitoring biventricular pacing parameters depending on the left ventricle lead configuration

OBJECTIVES:

To evaluate whether pacing or sensing configuration has an effect on pacing parameters or their time progression. Three left ventricular (LV) pacing parameters were monitored – the LV pacing threshold, pacing impedance and intrinsic R-wave amplitude.

METHODS:

Data were collected at three intervals: during implantation; between the second and fifth month after implantation (first follow-up); and between the eighth and 15th month after implantation (second follow-up). Repeated-measures ANOVA was used for the statistical analysis.

RESULTS:

The impedance, but not its time progression, was significantly higher for the LV tip to LV ring configuration than for other configurations. R-wave amplitude and impedance increased significantly (without dependance on configurations) between implantation and first follow-up, as expected. The time progression of any parameter was not dependent on configuration of the LV lead.

CONCLUSIONS:

LV tip to LV ring is the best configuration for maintaining a high impedance level. It is better to maintain an individual approach for pacing threshold and R-wave amplitude, and their settings.     

Coronary sinus spasm during left ventricular lead implantation for biventricular pacing.

The authors present a case of coronary sinus spasm during left ventricular lead implantation for biventricular pacing relieved by direct infusion of nitroglycerin.     

The interaction of interventricular pacing intervals and left ventricular lead position during temporary biventricular pacing evaluated by tissue Doppler imaging

Objective

To determine the effects of interventricular pacing interval and left ventricular (LV) pacing site on ventricular dyssynchrony and function at baseline and during biventricular pacing, using tissue Doppler imaging.

Methods

Using an angioplasty wire to pace the left ventricle, 20 patients with heart failure and left bundle branch block underwent temporary biventricular pacing from lateral (n = 20) and inferior (n = 10) LV sites at five interventricular pacing intervals: +80, +40, synchronous, −40, and −80 ms.

Results

LV ejection fraction (EF) increased (mean (SD) from 18 (8)% to 26 (10)% (p = 0.016) and global mechanical dyssynchrony decreased from 187 (91) ms to 97 (63) ms (p = 0.0004) with synchronous biventricular pacing compared to unpaced baseline. Sequential pacing with LV preactivation produced incremental improvements in EF and global mechanical dyssynchrony (p<0.0001 and p = 0.0026, respectively), primarily as a result of reductions in inter‐LV–RV dyssynchrony (p = 0.0001) rather than intra‐LV dyssynchrony (NS). Results of biventricular pacing from an inferior or lateral LV site were comparable (for example, synchronous biventricular pacing, global mechanical dyssynchrony: lateral LV site, 97 (63) ms; inferior LV site, 104 (41) ms (NS); EF: lateral LV site, 26 (10)%; inferior LV site, 27 (10)% (NS)). ECG morphology was identical during biventricular pacing through an angioplasty wire and a permanent lead.

Conclusions

Sequential biventricular pacing with LV preactivation most often optimises LV synchrony and EF. An inferior LV site offers a good alternative to a lateral site. Pacing through an angioplasty wire may be useful in assessing the acute effects of pacing.     

Rescue left bundle branch area pacing in coronary venous lead failure or nonresponse to biventricular pacing: Results from International LBBAP Collaborative Study Group

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Long-term left ventricular pacing: assessment and comparison with biventricular pacing in patients with severe congestive heart failure

OBJECTIVE

The purpose of this study is to report prospectively the results of six-month follow-up of permanent left ventricular (LV) based pacing in patients with severe congestive heart failure (CHF) and left bundle branch block (LBBB).

BACKGROUND

Left ventricular pacing alone has been demonstrated to result in identical improvement compared to biventricular pacing (BiV) during acute hemodynamic evaluation in patients with advanced CHF and LBBB. However, to our knowledge, the clinical outcome during permanent LV pacing alone versus BiV pacing mode has not been evaluated.

METHODS

Pacing configuration (LV or BiV) was selected according to the physician’s preference. Patient evaluation was performed at baseline and at six months.

RESULTS

Thirty-three patients with advanced CHF and LBBB were included. Baseline characteristics of LV (18 patients) and BiV (15 patients) pacing groups were similar. During the six-month follow-up period, seven patients died three BiV and four LV). In the surviving patients at 6 months, 8 of 14 patients in the LV group and 9 of 12 in the BiV group were in New York Heart Association class I or II (p = 0.39). No significant difference was observed between the two groups in terms of objective parameters except for LV end-diastolic diameter decrease (−4.4 mm in BiV group vs. −0.7 mm in LV group; P = 0.04).

CONCLUSION

At six-month follow-up, a trend toward improvement was observed in objective parameters in patients with severe CHF and LBBB following LV-based pacing. The two pacing modes (LV and BiV) were associated with almost equivalent improvement of subjective and objective parameters.     

单纯左室起搏与双心室起搏治疗慢性心力衰竭的疗效比较

目的比较单纯左室起搏与双心室起搏治疗慢性心力衰竭(CHF)的可行性及临床效果。方法选择窦性心律、NYHA心功能分级Ⅲ~Ⅳ级、左室射血分数(LVEF)≤0.35、QRS波时限≥120 ms的CHF患者36例,成功植入心脏再同步化(CRT)起搏器后,随机分为两组,第一组先以右房左室起搏模式治疗(LV起搏模式)7天,然后以右房双室起搏模式治疗(Biv起搏模式)7天;第二组先以Biv治疗7天,然后以LV治疗7天。收集术前、术后第7天、第14天的临床资料,所有数据应用交叉设计资料方差分析及单变量一般线性模型分析。结果 6 min步行距离、明尼苏达生活质量评分、体表心电图QRS波时限、左室舒张末期内径、左室射血分数、左室间隔部与侧壁基底段收缩期达峰时间差值等6种评价指标的结果相似:评价指标测量值在处理效应即LV、Biv两种起搏模式上、在顺序效应即两种起搏模式顺序上的差异均无统计学意义(P均>0.05);但在阶段效应即术后第7天、第14天两阶段上的差异有统计学意义(P<0.05)。结论单纯左室起搏与双心室起搏治疗CHF的疗效相仿;对窦性心律、完全性左束支传导阻滞的CHF患者,单纯左室起搏可作为CRT的一种选择。