穿刺胸廓外锁骨下静脉和腋静脉安置永久起搏器电极

目的　评价穿刺胸廓外锁骨下静脉 (ESV)和腋静脉安置永久起搏器电极的方法。 1998年 8月～ 2 0 0 0年 1月 ,共 44例病人 ,男 2 6例 ,女 18例 ,年龄 37～ 82岁 ,病态窦房结综合征 33例 ,Ⅱ°～Ⅲ°房室传导阻滞 11例 ,其中双腔起搏器 2 8例。方法　X线下 ,用 18G针 ,于锁骨下第一肋外 2～ 3cm进针 ,与水平面成 45度 ,针头指向肋锁交界处锁骨下第一肋外缘至内缘间 ;若无回血 ,针头逐步向胸骨侧移动 ,范围 2cm ;针头始终触及第一肋是保证穿刺安全和成功的标志。另采用HP 5 5 0 0型彩色多谱勒血流显像仪 (CDFI)测定 2 5例正常成人ESV和腋静脉内径和解剖位置 ,探查部位在右上胸第一肋和第一肋以下。结果　 44例病人共穿刺 47例次均成功 ,其中ESV 46例次和腋静脉 1例次。每例穿刺次数 1～ 5次 ,平均 3次 ;进针深度 2～ 4cm ,平均 2 5cm。经皮穿刺点距锁骨 3～ 4cm ,针头入锁骨下静脉时距锁骨下 0 5～ 1 5cm。一例穿刺入锁骨下动脉 ,无其他并发症。CDFI测定ESV的走行在肋锁交界处第一肋上方 ,位置固定。结论　本方法安全、成功率高 ,避免了锁骨下和头静脉的缺欠和并发症 ,适于安置各种起搏电极。CDFI可指导穿刺ESV。本法远期效果尚待长期观察。     

Prospective study to develop surface landmarks for blind axillary vein puncture for permanent pacemaker and defibrillator lead implantation and compare it to available contrast venography guided technique

Objective

To develop surface landmarks for blind axillary vein puncture for pacemaker lead implantation.

Methods and results

Patients for routine coronary angiography were counseled for participating in our study. 20 patients who gave consent were taken up for axillary venogram after proper positioning at the time of coronary angiogram. The venograms of these 20 patients, were reviewed and the landmarks were used to develop a blind axillary puncture technique. Success rate of 100% was achieved with surface landmark guided axillary vein puncture. The implantation time while using surface landmark guided axillary puncture was not significantly longer than when venography based approach was used. Another interesting observation made from the study was that increasing BMI had a positive correlation with the time taken for venous access, the fluoroscopic time and the volume of contrast used, all the associations being statistically significant. Thus, the surface landmark guided technique is more safe and expeditious in non obese patients and probably in pediatric patients as well. Moreover, the new surface landmark guided approach is a significant safety step in terms of reducing the unwanted and avoidable radiation exposure to the hands.

Conclusion

The results of this study demonstrate that placement of endocardial permanent pacemaker and ICD leads via the developed surface landmarks is effective and safe and is devoid of the harmful effects of radiation and contrast exposure.     

Occlusion of the proximal subclavian vein complicating pacemaker lead implantation.

A set of images in which a pacemaker lead replacement procedure was complicated by occlusion of the proximal subclavian vein is presented. However, this was not detected on venography performed before the procedure. Physicians should be aware of a more proximal occlusion of the subclavian vein while replacing pacemaker leads, even in cases with seemingly normal venography.     

造影指导下穿刺腋静脉植入起搏器电极导线

目的探讨造影指导下穿刺腋静脉植入起搏器电极导线的方法。方法2009年5月至2010年4月,共145例患者采用造影指导下穿刺腋静脉植入电极导线。经前臂静脉注射造影剂,记录腋静脉影像,以此为指导,行腋静脉穿刺。结果穿刺腋静脉植入起搏器电极导线成功率为91．6％,穿刺成功组与穿刺不成功组平均年龄、性别比例差异无统计学意义,1例（0．7％）患者出现气胸,1例（0．7％）因误穿腋动脉并插入扩张管及外鞘导致皮下广泛出血,无电极导线磨损、断裂。结论造影指导下穿刺腋静脉植入起搏器电极导线安全、有效,是起搏器电极导线植入的重要方法。     

造影指导下穿刺腋静脉植入起搏器电极导线

目的 探讨造影指导下穿刺腋静脉植入起搏器电极导线的方法.方法 2009年5月至2010年4月,共145例患者采用造影指导下穿刺腋静脉植入电极导线.经前臂静脉注射造影剂,记录腋静脉影像,以此为指导,行腋静脉穿刺.结果 穿刺腋静脉植入起搏器电极导线成功率为91.6%,穿刺成功组与穿刺不成功组平均年龄、性别比例差异无统计学意义,1例(0.7%)患者出现气胸,1例(0.7%)因误穿腋动脉并插入扩张管及外鞘导致皮下广泛出血,无电极导线磨损、断裂.结论 造影指导下穿刺腋静脉植入起搏器电极导线安全、有效,是起搏器电极导线植入的重要方法.     

Axillary vein puncture guided by ultrasound vs cephalic vein dissection in pacemaker and defibrillator implant: A multicenter randomized clinical trial

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Permanent pacemaker implantation in the cardiac catheterization laboratory: The subclavian vein approach

During a 36-month period, 171 permanent pacemaker procedures were performed in the cardiac catheterization laboratory by invasive cardiologists. This included 111 initial pacemaker system implants, via the percutaneous subclavian vein approach, 45 pulse generator changes, and 15 miscellaneous procedures. In no case did subclavian vein puncture result in pneumothorax, hemothorax, or brachial plexus injury. In patients undergoing initial lead placement, the dislodgment rate was 0.8% over a 16-month follow-up period. The reoperation rate for causes other than premature battery depletion was 5.4% during the first 12 months. The implantation of permanent pacemakers can be safely and effectively accomplished by experienced invasive cardiologists in the cardiac catheterization laboratory. In our series not only was continuity of patient care improved, but also medical costs were reduced.     

经腋静脉和锁骨下静脉途径植入或拔除心内膜电极的对比研究

目的 探讨经皮腋静脉穿刺植入与拔除心内膜电极导线的可行性与安全性.方法 538例具有起搏器或植入式心律转复除颤器（implantable cardioverter defibrillator,ICD）植入指征的患者分为实验组与对照组,分别经腋静脉途径和经锁骨下静脉途径植入心内膜电极导线.对比分析两种途径植入心内膜电极导线的穿刺成功率和并发症.对同期入院因起搏器囊袋感染拔除心内膜电极导线的47例患者和81例起搏器升级患者的手术情况进行回顾分析,对比不同植入途径心内膜电极导线拔除成功率和增加心内膜电极导线的成功率.结果 实验组与对照组穿刺成功率及并发症发生率比较,差异无统计学意义[98.5％（268/272） vs.98.9％（263/266）,P＞0.05; 13.2％（36/272） vs.13.9％ （37/266）,P＞0.05].其中,对照组发生锁骨下静脉挤压综合征1例,气胸5例,实验组无一例发生气胸和锁骨下静脉挤压综合征.经腋静脉途径植入心内膜电极导线的拔除成功率及新增电极导线的植入成功率均高于经锁骨下静脉途径,差异有统计学意义[94.4％（17/18）vs.86.2％（25/29）,P＜0.05;97.2％（35/36）vs.88.9％（40/45）,P＜0.05].结论 经腋静脉途径植入心内膜电极导线安全可行,并为可能的电极导线拔除和起搏器升级增加心内膜电极导线预留更大的解剖空间,值得在临床推广应用.     

Doppler ultrasonography versus venography in the detection of deep vein thrombosis in patients with pulmonary embolism

In patients with acute pulmonary embolism (PE) the frequency of deep vein thrombosis (DVT) varies between 13–93%. The aim of this study was to compare Doppler ultrasonography (DUSG) and venography in the detection of DVT in patients with PE. Fifty-one patients who were clinically diagnosed as having PE from January 1st 2001 to January 31st 2005 were entered into the study and comorbid conditions and risk factors were noted. The diagnosis of PE was confirmed by ventilation-perfusion (V/Q) scintigraphy, spiral tomography and angiotomography while the diagnosis of DVT was made by DUSG and venography. DVT was confirmed by both DUSG and venography in 19 (37,3%) patients. In the remaining 32 patients DUSG was negative. Venography confirmed DVT in 6 of these patients while in 26 no DVT was found. The sensitivity and specifity of DUSG in the diagnosis of DVT were 76% and 100% respectively and the negative and positive predictive values were 81% and 100% respectively. The mean d-dimer concentration was 1187 in patients with DVT and 641 in patients without DVT (p > 0.05). Aquired risk factors were found in 4 of 6 patients with DVT, CRP was elevated in 5 (83%) and ALT-AST were elevated in 2 (33%). Although DUSG alone is considered sufficient for the diagnosis of DVT, venography still remains the gold standard in the diagnosis of DVT. Especially in patients with PE, where the diagnosis of DVT may increase the success of treatment, venography or other diagnostic tools may be used instead of a second DUSG if the first DUSG is negative.     

锁骨下静脉途径心脏起搏器置入术中撕剥式电极导线导引器的应用

目的探讨撕剥式电极导线导引器在经锁骨下静脉途径行永久性心脏起搏器置入术中的应用价值。方法103例经锁骨下静脉途径行永久性心脏起搏器置入术患者根据电极导线置入时是否保留撕剥式电极导线导引器分为非保留组(n=50),保留组(n=53),每组又根据置入起搏器类型分为单腔起搏器组和双腔起搏器组两个亚组。比较两组手术时间、X线曝光时间、电极导线放置失败率、手术并发症并随访切口及囊袋情况、起搏器工作状态等。结果保留组手术时间、X线曝光时间及电极导线放置失败率明显少于非保留组(68.8±18.3minvs77.5±18.9min;4.36±1.34minvs5.57±1.62min;0%vs7.9%,P均<0.05~0.01),亚组分析显示不论单腔、双腔起搏器置入,保留组手术时间、X线曝光时间均明显短于非保留组(P均<0.01)。保留组与非保留组各有1例术后出现需处理的囊袋血肿,2组术后随访5个月~4.3年,未见其他并发症,起搏器工作状态良好。结论经锁骨下静脉穿刺途径置入永久性心脏起搏器时,保留撕剥式电极导线导引器能缩短手术时间、X线曝光时间,减少电极导线置放失败率,值得在临床进一步推广应用。     

置入双腔起搏心脏复律除颤器及经腋静脉送入心内电极的初步临床体会

目的初步评价新型双脏起搏心脏复律除颤器抗室性心动过速／心室颤动（室速／室颤）及心动过缓起搏的临床效果,了解经腋静脉送人心房及心室电极的安全性及有效性。方法７例室速及（或）室颤同时伴有心动过缓患者接受了双腔起搏心脏复律除颤器治疗,其中冠心病５例、扩张性心肌病２例。心房及心室电极均在Ｘ线透视、静脉注人造影剂指导下,直接穿刺腋静脉,从该静脉送人。结果脉冲发生器埋在左上胸皮下５例,埋在胸大肌与胸小肌之间２例。仪器对所有室速／室颤均能及时识别并成功治疗,同时提供有效的房室顺序起搏功能。所有心内电极均成功地经腋静脉送人,无并发症。结论双腔起搏心脏复律除颤器不但能有效地治疗严重室性心律失常,而且提供可靠的房室顺序性起搏功能。经腋静脉送入电极安全、可靠。     

经头静脉植入双腔起搏器的可行性和安全性

目的:探讨经头静脉切开途径同时置入2根电极行双腔起搏的可行性和安全性。方法:对92例有脑缺血症状的病窦综合征、Ⅱ度Ⅱ型或Ⅲ型房室传导阻滞患者,常规经右头静脉切开途径行双腔起搏治疗,了解其成功率,并随访1-36个月,观察其术后并发症情况。结果:71例(77.2％)患者直接成功植入双腔起搏器,12例(13％)患者经超滑导丝引导置入静脉鞘管后成功引入,故共83例(90.2％)患者经头静脉切开成功植入,较直接植入成功率显著增高(P<0.01);9例患者(9.8％)改经右锁骨下静脉穿刺途径植入。随访期间经头静脉途径植入起搏器的83例(100％)患者术后局部切口愈合良好,均未见电极移位或断裂,且脑缺血症状均消失。结论:经头静脉切开途径行双腔起搏治疗成功率较高,简便、安全,可推广应用。     

Electrical isolation of pulmonary veins in patients with atrial fibrillation: reduction of fluoroscopy exposure and procedure duration by the use of a non-fluoroscopic navigation system (NavX).

AIMS: The aim of the study was to investigate the feasibility of performing segmental pulmonary vein (PV) isolation guided by the NavX (Endocardial Solutions, St Jude Medical, Inc., St Paul, MN, USA) system without the three-dimensional (3D) geometric reconstruction option and whether the use of NavX system will reduce the radiation exposure and procedure duration. METHODS AND RESULTS: The study included 64 patients with symptomatic paroxysmal or permanent atrial fibrillation, in whom PV isolation was performed using fluoroscopic guidance (n=32) or the NavX system (n=32). Pulmonary vein mapping with a circular mapping catheter allowed the identification and localization of myocardial connections between the PV and the left atrium. PV isolation was performed by radiofrequency ablation of these connections at the atrial aspect of the PV ostium. Primary success rate for isolated PVs did not differ significantly in patients ablated under fluoroscopic guidance vs. those ablated under guidance of NavX system [100/107 PVs (93.5%) vs. 120/124 PV (96.8%; P=n.s.)]. Compared with fluoroscopy guided procedures, NavX-guided procedures showed a significant reduction in the fluoroscopy time (75.8+/-24.5 vs. 38.9+/-19.3 min, P<0.05), total X-ray exposure (93.2+/-51.6 vs. 56.6+/-37.9 Gy cm(2), P=0.03), and total procedural time (237.7+/-65.4 vs. 188.6+/-62.7 min, P=0.01). The mean follow-up was 9.5+/-3.0 months. One patient in each group was lost to follow-up. Seven-day Holter monitoring showed that 23 of 31 patients (74.2%) in the NavX-guided group and 21 of 31 patients (67.7%) in the fluoroscopy-guided group were in sinus rhythm (P=0.57). CONCLUSION: The 3D visualization of the catheters by NavX system allows a rapid and precise visualization of the mapping and ablation catheters at the PV ostia and markedly reduces fluoroscopy time, total X-ray exposure, and procedural duration during PV isolation compared with ablation performed under fluoroscopy guidance.     

Over the wire lead extraction and focused force venoplasty to regain venous access in a totally occluded subclavian vein

Introduction  Venoplasty allows the addition or replacement of leads despite subtotal or total subclavian occlusion. Methods  The threshold of the LV pacing lead implanted for biventricular pacing over a period of 18 months increased to greater than 5 V. A pre implant venogram revealed total subclavian occlusion. Venous access was maintained by extraction of the 4 F LV lead over a wire. Subsequently the sheath would not advance despite 6mm balloon inflation to 30 atm with no residual waist. A wire was placed beside the balloon and the balloon was reinflated. Results  The subclavian obstruction was eliminated without damage to the existing leads. Conclusion  The obstruction formed by the fibrous track around an extracted lead may persist despite what appears to be successful balloon dilation. Inflation with a wire beside the balloon increases the effect eliminating the resistant obstruction without damaging the leads. Acknowledgements of Sources of Financial Support:Dr. Worley receives compensation in various forms from Medtronic, Pressure Products, Guidant, and St Jude Medical. Dr. Gohn receives compensation in various forms from Medtronic. No financial support was provided for the creation of this case report     

Catheter ablation of an epicardial accessory pathway via the middle cardiac vein guided by monophasic action potential recordings.

This report describes a case of permanent junctional reciprocating tachycardia (PJRT) that was ablated via the middle cardiac vein, guided by monophasic action potential recording. The patient was a 63-year-old woman who had been suffering from palpitation for 10 years. ECG during palpitation showed a narrow QRS tachycardia with a long RP interval. Electrophysiological study revealed that this tachycardia was an orthodromic reciprocating tachycardia, via an accessory pathway with a decremental property and a long ventriculoatrial interval (130 ms): PJRT. The earliest atrial activation during tachycardia was detected at the junction of the middle cardiac vein with the coronary sinus. Monophasic action potentials were recorded to confirm that the ablation catheter was in contact with the epicardium.     

联合应用磁共振扫描与三维电解剖标测系统图像融合技术及Lasso导管标测技术指导环肺静脉隔离治疗心房颤动

目的报道联合应用三维电解剖标测系统图像融合技术(Carto-Merge)及Lasso导管标测技术指导环肺静脉电隔离术治疗心房颤动(房颤)的结果。方法共入选56例症状明显、药物治疗无效的阵发性房颤患者,男性41例,女性15例,平均年龄58·5±12·7岁。应用Carto-Merge技术定位肺静脉口,之后环双侧肺静脉前庭线形消融左心房,终点为Lasso导管所标测的同侧肺静脉电位消失或肺静脉电位与心房电活动的分离。结果全组患者的电解剖标测点与影像图像(MRI)的空间差距均值1·79±0·33mm。首次手术的肺静脉隔离率为92·9%(52/56)。经随访18·3±5·7个月,有73·2%的患者(41/56)仍维持窦性心律。10例患者接受再次消融;经再次随访8·2±6·9个月,8位患者仍维持窦性心律。无一例患者出现肺静脉狭窄。结论联合应用Carto-Merge及Lasso导管标测技术,可有效地确保肺静脉的隔离,降低肺静脉狭窄等并发症的发生率。     

电解剖系统引导下环肺静脉线性消融隔离肺静脉治疗心房颤动

目的采用双Lasso导管标测技术行环肺静脉及其周围组织隔离预防心房颤动复发。方法13例心房颤动(房颤)患者,男性8例,女性5例,平均年龄为(56±8)岁,行电生理检查和射频导管消融。其中,8例为频发的阵发性房颤(1~20年),5例为持续性房颤(1~4年)。窦性心律下起搏远端冠状静脉窦或房颤发生时,利用电解剖系统进行左心房重建。然后,将两根Lasso多极导管同时置于右(左)上、下肺静脉之内。在距肺静脉口1cm左右处行环肺静脉及其周围组织电隔离。消融终点为左心房-肺静脉/周围组织完全性阻滞,表现为放电时肺静脉电位消失。结果7例阵发性房颤患者在窦性心律下电隔离成功,5例持续性房颤和1例阵发性房颤患者在窦性心律和房颤发生时电隔离成功。3例患者放电时房颤终止:左肺静脉隔离时房颤终止1例,右肺静脉隔离时房颤终止1例,左肺静脉隔离完成后54s自行终止1例。其余3例需体外电转复。消融术时间为(256±56)min,X线曝光时间为(39±11)min。无并发症发生。在术后平均随访(104±50)d,只有1例患者在第71d时出现不典型心房扑动,自行终止。其余12例患者均无房性快速性心律失常复发。结论有明确心电学隔离指标的环肺静脉及其周围组织电隔离是一种安全有效的方法。肺静脉既可为房颤的诱发机制,亦有可能参与房颤的维持机制。     

双Lasso导管和三维标测指导下环肺静脉线性隔离术治疗心房颤动

目的在双Lasso导管和三维标测指导下环肺静脉线性消融并彻底隔离肺静脉以治疗心房颤动(简称房颤)。方法28例房颤患者接受射频消融治疗,其中阵发性房颤12例,持续性房颤16例。所有患者首先利用三维电解剖标测系统(CARTO)进行左房重建,然后将两根Lasso导管同时置入右(左)上下肺静脉内,在肺静脉口外0.5~1cm左右行环肺静脉线性消融,消融终点为左房-肺静脉完全性传导阻滞。结果28例均电隔离成功,肺静脉完成隔离后,共86.6%(97/112)的肺静脉内可见缓慢自律性电活动。手术时间205±67min,X线透视时间27±16min,无并发症发生。术后随访8.5±3.7个月,23例无房颤复发,总成功率82.1%。结论双Lasso导管和三维标测指导下有明确电学隔离指标的环肺静脉线性消融术治疗房颤安全而有效。