心房起搏预防和治疗心房颤动

近年研究提示心房起搏可以达到预防和治疗心房颤动 (简称房颤 )的目的。本文就房颤发生的病理生理学机制 ,生理性起搏、双房起搏及右房多部位起搏、抗心律失常起搏等在房颤预防和治疗方面的进展予以综述。     

特殊起搏程序预防阵发性心房颤动的临床应用

心房颤动(房颤)是临床上最常见的持续性心律失常，发生率随年龄的增长而增高，是老年人缺血性脑卒中的主要原因之一，严重影响患者的生活质量。对阵发性房颤进行早期干预，防止过早地进展为慢性房颤成为临床治疗的主要目标之一。电生理机制的研究表明，房性早搏(房早)等触发因素在房颤的发生中起着重要的作用。Vitatron公司根据常见     

特殊心房起搏程序预防和治疗心房颤动研究进展

心房颤动是临床上最常见的心律失常之一,严重影响了患者的生活质量,增加病死率。根据心房颤动发生的电生理机制,许多起搏器公司设计了可以减少或预防心房颤动发生的起搏程序。现就这些特殊程序的具体工作原理做一综述。     

阵发性心房颤动的起搏预防与治疗

心房颤动是临床十分常见的心律失常。其发生随着年龄逐渐增加,60岁以下的房颤发生率低于1%,而70岁以上的老年人心房颤动的发生率高达10%以上。心房颤动的危害极大已是众所周知,主要包括:(1)使血栓栓塞事件增加4~10倍;(2)可诱发或加重充血性心力衰竭,房颤减少心排出量10%~45%;(3)使窦房结和房室结功能急剧下降;(4)使患者的生活质量下降或恶化,诱发心衰时甚至成为功能性残疾人;(5)房颤可使死亡率增加达2倍。这些都说明心房颤动并非是一种良性心律失常,必须给予有效的预防和治疗。1房颤起搏治疗和预防的机制房颤发生的主要因素包括触发因素和基…     

心房起搏治疗心房颤动

近年来起搏器新功能如自动频率夺获心房起搏方式 ,频率平稳功能 ,频率适应性功能的出现 ,以及双心房同步或心房多部位起搏技术的临床应用 ,明显提高了心房起搏的抗心律失常作用 ,使心房起搏已成为治疗心房颤动 (房颤 )的重要、有效的方法。　　一、治疗和预防心房颤动的心房起搏方式　　按照心房起搏部位 ,治疗和预防房颤的心房起搏可分为两种 1单部位心房起搏 [1] :单部位心房起搏的位置可在右心耳、高位右房、右侧房间隔、界嵴、冠状静脉窦开口附近等部位。右心耳是目前最常采用的部位 ,仅需被动固定方式的心房导线电极则可。而高位右房或…     

起搏器特殊起搏程序在心房颤动管理中的应用价值

目的 探讨起搏器心房颤动(简称房颤)管理程序在房颤管理中的作用.方法 入选因缓慢性心律失常合并阵发性房颤或心房扑动植入永久性双腔起搏器的患者,随机分为双腔起搏模式(DDDR)组、预防/抗心动过速起搏(DDDRP)组、管理心室起搏(MVP)组和兼有DDDRP和MVP组程序的DDDRP+MVP组.DDDRP、MVP和DDD...     

采用特殊起搏程序治疗病窦综合征伴阵发性心房颤动的近期疗效

目的评价具有预防心房颤动(AF)功能的特殊起搏程序治疗病窦综合征(SSS)伴阵发性AF(PAF)的近期疗效。方法34例置入DDDR起搏器(Vitatron900E和9000型)SSS伴PAF患者分3阶段治疗。第1阶段(4周):监测记录房性快速性心律失常;第2阶段(4周):根据第1阶段获悉AF触发因素启动相关具有预防AF功能的特殊起搏程序。第3阶段(4周):特殊起搏程序启动同时给予抗AF药物治疗。观察比较各阶段AF情况。结果34例手术全部成功,4例未记录到PAF的发生,余30例均发生PAF,其中突然发作8例,房性早搏触发AF20例,运动后心率突然减慢而触发AF2例。特殊程序抗AF治疗14例显著有效,11例有效,5例无效,无恶化发生;第2阶段与第1阶段比较,每天AF发作次数、发作总时间及单次最长发作时间明显减少(P<0.01),第3阶段与第2阶段比较,AF发作总时间及单次最长发作时间明显减少(P<0.01),但每天发作次数无明显变化(P>0.05)。结论VitatronSelection900E和9000起搏器具有较准确的监测PAF功能,心房超速起搏及特殊起搏方式对PAF发生具有一定疗效和耐受性,伴PAF的SSS患者可采用预防AF起搏程序功能起搏同时配合抗AF药物的综合性治疗。     

特殊心房起搏算式对病态窦房结综合征伴阵发性心房颤动的预防价值

目的 评价特殊心房起搏算式对病态窦房结综合征伴阵发性心房颤动的预防作用.方法 21 例确诊患者植入Vitatron 起搏器,观察比较术后起搏监测、起搏治疗I 及起搏治疗II 等3 阶段心房颤动有症状事件数、事件总数、事件总持续时间和心房颤动负荷4 项指标的变化.结果 根据起搏监测阶段记录到的心房颤动触发因素,分别启用房性期前收缩抑制功能、房性期前收缩后反应功能、运动后心率控制功能和起搏调节功能.4 项指标在与起搏监测阶段比较,21 例起搏治疗I 阶段差异均无统计学意义(均P ＞0.05),起搏治疗II阶段差异均有统计学意义(均P<0.05);16 例由房性期前收缩、房性心动过速和运动后心率突然减慢触发者起搏治疗I 阶段差异均无统计学意义(均P ＞0.05);起搏治疗II 阶段差异均有统计学意义(均P<0.05);5 例由其他因素触发者起搏治疗I、II 阶段差异均无统计学意义(均P ＞0.05 ).所有患者无血栓栓塞及死亡事件发生.结论 特殊心房起搏程算式可以减少病态窦房结综合征患者阵发性心房颤动发生,降低心房颤动负荷,改善症状,尤其是对由房性期前收缩、房性心动过速和运动后心率突然减慢触发者.     

房间隔起搏对病窦综合征并阵发性心房颤动的影响

目的探讨房间隔起搏(ASP)对病窦综合征(SSS)合并阵发性心房颤动(PAF)的影响。方法 12例SSS合并PAF行DDD(房间隔部)起搏,术前查常规心电图、24h动态心电图(DCG)及超声心动图,测量最长P波时限(Pmax)、最短P波时限(Pmin),计算P波离散度(Pd),观察PAF发作例数、发作次数及持续时间,测量左房直径等,术后1周内、3个月及1年时复查心电图、DCG及超声心动图,并统计起搏心搏比例。结果与起搏前窦性心律心电图比较,ASP后1年内Pmax和Pd均较术前明显缩短(P均0.05)。ASP1周内,PAF发作例数、发作次数及持续时间明显减少(P均0.05);但随着时间延长,PAF发作例数、发作次数及持续时间有增多趋势;术后发现再发心房颤动者均有基础病,且已转变为持续心房颤动者心房直径明显大于非持续心房颤动及窦性心律者,但与起搏心搏比例无关;术后左房直径有缩小趋势。结论 ASP能明显缩短Pmax及Pd,可以预防和治疗PAF,降低PAF的发生率,但有基础心脏病、心房直径增大者远期疗效不佳。     

Right atrial overdrive pacing for prevention of symptomatic refractory atrial fibrillation.

AIMS: Our aim was to investigate whether right atrial overdrive pacing is effective for the prevention of atrial fibrillation (AF) in patients without bradyarrhythmias. METHODS AND RESULTS: Patients with symptomatic paroxysmal or persistent AF refractory to at least two Class I or III antiarrhythmic drugs and without bradyarrhythmias were included. Successful therapy was defined as the combination of (a) a reduction of AF burden with or without AAD use >75%, (b) total AF burden < or =5% per year, and (c) less than one electrical cardioversion per year. Lower rate was set at 70 b.p.m. Additional AF prevention and termination features were used in case of no success.After a median follow-up of 18 (10-55) months, therapy was effective in 19 of the 36 included patients (53%). In 74% of the successfully treated patients, additional antiarrhythmic drugs were used. In successfully treated patients, the AF burden was reduced from 15% (5-100%) to 0% (0-4%). Multivariate analysis showed that the concomitant use of a Class I or III antiarrhythmic drug, a lower AF burden before implantation and the use of an angiotensin converting enzyme inhibitor were predictors of successful therapy. CONCLUSION: Right atrial overdrive pacing in combination with antiarrhythmic drugs seems an attractive treatment option in drug refractory symptomatic AF patients.     

No evidence of automatic atrial overdrive pacing efficacy on reduction of paroxysmal atrial fibrillation.

AIMS: Paroxysmal atrial fibrillation (PAF) is frequently encountered in pacemaker patients, most commonly in sick sinus syndrome. The combination of site-specific pacing in conjunction with an overdrive algorithm combined with antiarrhythmic drugs on the incidence of PAF in patients with a conventional indication for pacing is unknown. METHODS AND RESULTS: Patients with pacemaker indication and PAF received a DDDR-pacemaker, which included an automatic atrial overdrive (AO) algorithm. The atrial lead was implanted in either the right atrial appendage (RAA) (n = 83) or the right low-atrial septum (LAS) (n = 94). The algorithm was switched on or off in a 3 month, single blind crossover design and antiarrhythmic drugs were kept stable. A control group of 96 patients (LAS, n = 14; RAA, n = 84) without PAF served as controls to assess any proarrhythmic effect of overdrive pacing. Atrial fibrillation (AF) burden defined as cumulative time in mode switch was not reduced during automatic AO from either the RAA or from the LAS. The reduction was not effective both for AF of short (<24 h) and long (> or =24 h) duration. There was no atrial proarrhythmia induced by the overdrive algorithm in the control group. CONCLUSIONS: We could not demonstrate a reduction of AF burden defined as cumulative time in AF by the AO algorithm, in patients who are paced for standard indications and PAF, neither from the RAA nor from the LAS.     

不同部位起搏对阵发性心房颤动患者心房激动时间的影响

目的　比较右心耳 (RAA)、冠状窦远端 (DCS)、右心房双部位 (右心耳加冠状窦口 ,DSA)和双房 (右心耳加冠状窦远端 ,Bi A)起搏对阵发性心房颤动 (PAf)患者心房激动时间的影响。方法 2 2例接受心脏电生理评价试验的PAf患者在窦性心律下行心房不同部位起搏 ,同步记录 12导心电图 ,测量最大 P波时限。结果　与窦性 P波时限相比 ,RAA起搏明显延长 P波时限 (P<0 .0 1) ,DCS、DSA及 Bi A起搏则明显缩短 P波时限 (P<0 .0 1,P<0 .0 1,P<0 .0 1)。结论　 DCS、DSA及 Bi A起搏明显缩短心房激动时间 ,减少心房电活动的离散度 ,有利于 PAf的防治。     

抗房颤起搏器对缓慢心率患者合并阵发性房颤的预防作用

目的评价抗房颤起搏器对缓慢心率患者阵发性房颤(PAF)的预防效果。方法14例心动过缓并PAF患者,12例置入Vitatron900E型起搏器,2例置入St.JudeMedicalIntegrityTMAFXDR5346型起搏器,对患者进行一年随访,记录术后第1月(预防房颤程序未启动)、术后第2月、术后第6月、术后第12月房颤(AF)事件。结果患者术后2个月较术后1个月,术后6个月、12个月较术后第2个月有症状PAF数(9.21±5.47和16.18±9.82;4.31±3.22,3.89±2.87和9.21±5.47),PAF总数(24.31±27.24和46.23±31.52;9.34±8.37,9.16±8.25和24.31±27.24),AF总持续时间[(2.63±1.21)d和(3.18±1.58)d;(1.16±0.86)d,(1.02±0.82)d和(2.63±1.21)d],AF负荷[(8.77±4.57)%和(12.62±5.68)%;(3.86±2.52)%,(3.42±1.79)%和(8.77±4.57)%]均降低(P<0.05)。结论抗房颤起搏器能减低心率缓慢患者阵发性房颤的发生,降低房颤负荷,具有明显的短期及中期疗效。     

Paroxysmal atrial fibrillation prevention by pacing in patients with pacemaker indication.

AIMS: The prevent-atrial fibrillation (AF) registry analyses the clinical relevance and usefulness of the four preventive pacing algorithms, available in a family of cardiac stimulators, to prevent atrial fibrillation. METHODS AND RESULTS: This study is a prospective, non-randomized, multicentre registry. Patients are eligible for the registry if they have sick sinus syndrome (SSS) with or without pre-existing atrial fibrillation. The preventive pacing algorithms were programmed for each patient on an individual basis using the diagnostic features of the devices. In the period from April 2000 to April 2001 a total of 68 patients (33 male, 35 female) has been included in the registry in 14 hospitals in Spain. Mean age was 72+/-12 years and the pacemaker indication was SSS in 15 patients (22%) and SSS with paroxysmal AF in 53 patients (78%). The median AF burden for the total group (n=32) was significantly reduced from 3.9 to 1.3% (67%, P=0.034, Wilcoxon signed rank test). The decrease in AF burden was accompanied by a non-significant decrease in the median number of episodes per day from 1.47 to 0.64 (a decrease of 56%). The average atrial pacing % was increased from 72 to 78%. CONCLUSIONS: The prevent-AF registry demonstrated the usefulness of four preventive pacing algorithms in daily clinical practice. During the registry a significant reduction in AF burden and all other endpoints was observed. Dedicated diagnostics were key to adapting the optimal pacing therapy during follow-up.     

心房颤动起搏治疗的临床试验与研究现状

本文综述了起搏治疗和预防心房颤动(简称房颤)的主要临床试验和研究进展,包括生理性起搏、双房起搏、右心房多部位起搏、心房特殊位点起搏、起搏预防程序、心腔内电复律等。     

长期心房与心室起搏对心房颤动发生率的影响

目的 为比较长期心房与心室起博心房颤动(Af)发生率的影响.方法 选择国内较大的三家医院1992年至1994年期间内安装人工心脏起搏器的病人,随访观察心房起搏(安装了AAI、AAIR、DDD及DDDR起博器)和心室起搏(植入了VVI或VVIR起搏器)Af的发生情况.结果 发现心室搏Af发生有逐年增加的趋势,Af4年发生率为33%,5年为41%,6年为52%.单纯心房起搏或房室顺序起搏Af发生率3%,而单纯心室起搏的病人中约40%出现Af,明显高于心房起搏组,P<0.01.结论 研究证明心房起搏可以减少Af的发生,为起搏方式的选择提供了一个客观根据,提示在临床实践中应该尽量选择AAI和DDD等生理性起搏方式.     

Impact of anti-tachycardia pacing on atrial fibrillation burden when added on top of preventive pacing algorithms: results of the prevention or termination (POT) trial.

AIMS: The efficacy of preventive pacing algorithms (PPA) and anti-tachycardia pacing (ATP) in reducing atrial fibrillation (AF) burden remains controversial. The aim of this study was to assess whether ATP on top of PPA decreases AF burden. METHODS AND RESULTS: A series of 199 consecutive patients, with conventional indications for pacing, and documented AF, received a DDDR (rate adaptive dual chamber pacemaker) pacemaker with ATP capabilities (AT 500 Medtronic). After 3 months of conventional DDDR pacing at 70 b.p.m., AF burden was analysed. If patients had >30 min/week of AF, they were randomized to PPA or to PPA+ATP for 3 months (period 1). They were then crossed to the alternative therapy (period 2) and followed three additional months with a 1-month wash out period in-between. A group of 85 patients were randomized. Mean age 68 +/- 8 years, 61% men. Both groups showed a significant decrease in AF burden at the end of period 1 (64 and 81%, respectively). CONCLUSIONS: Atrial pacing with PPA decreases AF burden in patients with pacing indication. We did not observe a further decrease in AF burden or in the number of episodes when adding ATP on top of PPA.     

硫氮(卓)酮治疗阵发性心房颤动的长期临床观察

目的 :探讨硫氮酮对阵发性心房颤动 (房颤 )的治疗效果。方法 :选择 6 2例阵发性房颤患者 ,随机分为硫氮酮组 (31例 )和对照组 (31例 ) ,随访 3年 ,观察房颤年发作次数、持续时间和转变为持续性房颤的情况。结果 :①硫氮酮明显减少房颤年发作次数、持续时间 (P <0 .0 1) ,但用药后 1～ 2年间差异无显著性意义(P >0 .0 5 ) ;②对照组房颤年发作次数、持续时间逐年增加 ,年与年之间差异有非常显著性意义 (P <0 .0 1) ;③随访期间 ,对照组有 6例而硫氮酮组无一例转变为持续性房颤 ,两组间差异有显著性意义 (P <0 .0 5 )。结论 :硫氮酮可明显减少阵发性房颤发作次数和持续时间 ,在阻止其转变为持续性房颤也有一定的作用 ,推测与硫氮酮阻止房颤电重构的发生有关