未成年患者经心内膜植入永久起搏器的病因分析及随访观察

目的 研究未成年患者经心内膜植入永久起搏器的病因构成及不同起搏部位与模式对心功能的影响.方法 回顾性分析17例经心内膜植入永久起搏器的未成年患者临床资料,并随访患者的术后心电图、心脏正侧位片、心脏彩超及起搏参数等.结果 17例患者的原发病构成:病毒性心肌炎后遗留三度房室阻滞7例,复杂先天性心脏病术后出现的三度房室阻滞6...     

婴儿及儿童房室阻滞的起搏治疗

目的 总结我院34例婴儿及儿童经心内膜方式永久起搏器植入术经验,探讨相关的方法学、参数设置及评价疗效.方法 患儿34例,其中男性22例,女性12例,年龄自5个月至13岁,平均(5.26±3.92)岁,体重5～43(16.66±8.42)kg.其中:先天性心脏病术后三度房室阻滞18例;先天性心脏病术后高二度及三度房室阻滞3例;先天性三度房室阻滞8例;重度肺动脉瓣狭窄伴二度房室阻滞1例;窦性静止1例;心房静止1例;慢-快综合征1例;病毒性心肌炎后三度房室阻滞1例.起搏器植入技术、程控及随访等有一些与成人起搏不同的特殊性.结果 选择插管的静脉途径为,经右头静脉10例,经右锁骨下静脉17例,经右颈内静脉6例(5例为1岁以下),心内膜电极行心外膜起搏1例.脉冲发生器的埋藏部位为,置于右侧胸大肌内16例,置于右胸前皮下18例.起搏方式为,VVIR 16例,VVI18例.起搏频率60～90(68.09±9.85)次/min,起搏阈值0.2-2.2(0.72±0.41)V,感知灵敏度3.6～29.0(8.97±4.87)mV,阻抗394～1000(652.06±140.72)Ω.所有患儿体动阈值均设置于低挡.18例术后首次植入起搏器的患儿,距植入术日13～300(67.17±90.25)d.巳随访1个月至7年.1例术后7个月发生电极导线头端移位至起搏功能丧失.2例随访中发生扩张性心肌病,经改变起搏参数后好转.2例先天性心脏病术后患者起搏器植入后恢复窦性心律.1例起搏器植入术后半年猝死,原因不明.结论 我们的经验表明只要注意与婴儿及儿童有关的一些特点,并在植入、程控及随访中采取一些相应的对策,永久起搏器植入在婴儿及儿童的应用还是安全有效的.     

旋转牵引法拔除两根心室内废弃导线一例

兹报道对 1例心脏起搏患者废用电极导线在直接牵引无效后 ,改用旋转牵引方法 ,成功拔除 2根电极导线。　　临床资料　患者女性 ,5 2岁。因甲状腺功能亢进性心脏病合并三度房室阻滞伴发作性晕厥 ,于 1997年 3月 1日在当地医院植入 VVI起搏器。术后继续按甲状腺功能亢进治疗。 9个月后出现起搏器植入部位胸部肌肉抽动 ,经检查明确为导线断裂 ,在导管室用牵引法未能拔除导线 ,作残端处理后植入新导线。但术后 8个月前胸部起搏器囊袋感染 ,再次入院 ,经动态心电图测定 ,已恢复房室传导功能。遂在导管室切开囊袋 ,取出起搏器 ,并再次用牵引法未…     

开胸放置心外膜电极导线四例随访

报道4例经静脉途径植入电极导线失败的患者进行外科植入心外膜电极,3例心力衰竭病人因心脏冠状静脉解剖结构问题不能经心脏静脉途径植入左室电极,1例先天性心脏病术后完全性房室传导阻滞病人因多次更换起搏器,上腔静脉完全闭塞无法植入右室电极导线。4例均在全麻下成功经开胸手术植入心室心外膜电极导线,术后随访起搏感知参数正常。第1例左室心外膜电极导线于术后3年断裂,第2例术后7个月死亡,改进肋间隙处电极导线固定方法后,第3、4例分别随访29和12个月,均未发生电极断裂的并发症。     

晚期电极心肌穿孔一例

患者女,78岁,因症状性间隙性房室传导阻滞植入人工双腔心脏起搏器,术中、术后一周随访,心房、心室电极导线感知、起搏功能均正常。术后40天随访时发现心室电极起搏阈值升高,经胸片、胸部计算机断层扫描和超声心动图检查,明确心室起搏电极导线导致心肌穿孔。给予留置原起搏器电极,放置新的电极导线的处理,之后患者无不适主诉,随访起搏功能正常,原心室电极导线再无移位。     

小儿植入心外膜永久起搏器术后22例随访分析

目的探讨小儿植入心外膜永久起搏器的治疗效果、并发症及心功能状况。方法对22例儿童植入心外膜永久起搏器。其中男10例,女12例,手术年龄8.5个月(3 d~11岁),体质量6.35(2.7~43.6)kg。因先天性心脏病术后Ⅲ°房室传导阻滞而植入起搏器18例,先天性完全性房室传导阻滞2例,阿斯综合征和病态窦房结综合征各1例。随访3个月~5年3个月,收集患者检查结果及心室夺获阈值、电极阻抗等电生理学信息。结果除1例植入双腔起搏器外,其余均植入单腔起搏器。与心动过缓有关的临床症状消失,患儿发育良好,起搏和感知功能良好。有2例(9.1%)患儿死亡(原因不明),3例(13.6%)出现电池提前耗竭而重新植入起搏器,未出现电极断裂、移位及囊袋感染等并发症。末次复查超声心动图左心室射血分数为66%±6%,有1例(4.8%)患者出现心功能不全,左心室射血分数为51%,没有因心力衰竭入院的患者。将末次复查心室夺获阈值、电极阻抗、灵敏度与植入起搏器即刻进行比较,未发现显著变化。结论心外膜起搏近、中期治疗效果令人满意。本组出现因安装单腔起搏器导致心功能不全的患者,需进一步优化起搏器选择策略。     

先天性心脏病外科围术期心外膜永久性起搏器植入原因及远期效果分析

目的:本研究总结回顾了单中心先天性心脏病(先心病)外科围手术期心外膜永久性起搏器植入经验和远期随访结果。方法:回顾性分析2002年-2014年间我院33例8岁以下先心病患儿外科围术期植入心外膜永久性起搏器的临床资料。先天性高度房室传导阻滞6例,医源性高度房室传导阻滞27例。患儿平均年龄(23.2±26.9)个月,平均体重(9.7±5.6)kg。除6例术中即植入起搏器外,其余均于术后(26.0±13.1)d植入起搏器。起搏导线植入于右心室膈面,起搏器均放置于腹直肌后的囊袋。术中收集起搏器植入时间、类型、植入后即刻心室夺获阈值,电极电阻等电生理学信息。随访期间,收集心脏超声心动图、心电图、起搏器电程控信息和恶性心血管事件的发生。术后随访(46.8±33.9)个月。结果:除2例因先天性传导阻滞植入双腔起搏器外,其余均植入单腔起搏器。起搏器植入后即刻心室夺获阈值(1.34±0.72)V,而末次随访时未见心室夺获阈值明显增加[(1.37±0.81)V,P=0.93]。与植入起搏器即刻比,末次随访时的心室电极电阻[(366.7±88)Ωvs(331.9±95.9)Ω,P=0.32]和R波振幅[(12.3±3.5)m V vs(11.4±4.9)m V,P=0.635]均无明显升高。随访期间4例患儿术后因电池耗竭行起搏器置换术;21.2%(7/33)患儿出现心力衰竭或猝死的恶性心血管事件,发生恶性心血管事件的患儿的年龄和体重与预后良好的患儿相比差异无统计学意义(P0.05)。随访期间所有患儿均未发生囊袋感染及起搏器电极折断的情况。结论:医源性高度房室传导阻滞是目前先心病外科围术期植入永久性起搏器的首位原因。心外膜永久性起搏器植入有较好的远期随访效果,但是起搏器类型的选择仍需进一步优化。     

VVI起搏致类右束支阻滞图形一例

一例 65岁女性 ,因高度房室阻滞而行VVI起搏治疗。术后胸片、超声心动图等检查示起搏电极头端位于右室近心尖部流入道。体表心电图示类右束支阻滞图形。术后检测起搏器感知、起搏功能正常。提示 ,正常右室心尖部或近心尖部起搏 ,可以出现类右束支阻滞图形心电图改变。     

永久心脏起搏治疗对儿童患者长期预后的影响

目的 了解儿童患者接受永久心脏起搏治疗的安全性及有效性,并评价其长期预后.方法 收集1977年4月1日至2011年4月1日在阜外心血管病医院接受永久心脏起搏治疗的所有患儿（≤14周岁）的临床资料.了解儿童起搏患者的基础心脏疾病、起搏器植入适应证、并发症情况以及长期预后.结果 85例患儿（男52例,女33例）接受永久心脏起搏治疗,年龄2个月～14岁,平均（8.1＆#177;4.2）岁;最常见的基础心脏疾病为先天性心脏病50例（58.8％）,其次为病毒性心肌炎8例（9.4％）,4例（4.7％）患儿合并其他基础心脏疾病（长QT综合征,室性心动过速和肥厚型心肌病）,23例（27.1％）患者无伴发疾病.起搏治疗适应证分别为房室阻滞（67例,78.8％）、病态窦房结综合征（16例,18.8％）、长QT综合征（2例,2.4％）,房室阻滞的患儿绝大多数（43例,64.2％）为外科修补术后.患儿随访1～291（73＆#177;62）个月,18例患儿失随访,随访率为78.8％.随访期间,20例（29.9％）患儿因电池耗竭更换起搏器.并发症的发生率为11.9％（13例次/109次手术）,包括导线移位（5例,4.6％）、囊袋内感染（5例,4.6％）、血肿（2例）和导线断裂（1例）.3例患儿死亡,基础心脏病均为结构性心脏病.结论 儿童患者植入永久心脏起搏器治疗是安全、有效的.应根据患者的年龄、基础心脏病等情况选择合适的导线植入途径和起搏方式.儿童患者接受起搏治疗的长期预后主要与基础心脏疾病相关.     

不适当的心室起搏频率致儿童起搏器术后心功能受损二例

2例患儿,年龄分别为3岁、3岁6个月,均因运动耐力下降就诊,患儿分别于2.5年和1年前因先天性心脏病外科手术后出现高度房室传导阻滞,植入心外膜电极(1例植入单腔起搏器,电极放置于右室心尖部;另1例植入双腔起搏器,起搏位点为右房+右室心尖部),术后分别设置起搏频率为100～140次/分和110～180次/分。入院后心脏B超示左室舒张未期内径增大,左室射血分数分别为0.45～0.50和0.35～0.40。考虑为心室起搏频率过快所致的心功能受损,均予其下调起搏频率为70～140次/分。经上述处理后1个月随访时2例患儿心功能恢复正常。     

心脏瓣膜术后Ⅲ度房室传导阻滞的临床分析

目的 探讨心脏瓣膜术后Ⅲ度房室传导阻滞（Ⅲ°AVB）的发生原因、影响因素及相关治疗措施.方法 回顾性分析我院2000年1月至2008年12月3674例心脏瓣膜术后9例发生持续性Ⅲ°AVB并行永久性起搏器置入术患者的临床资料.心脏病因：风湿性心脏瓣膜病2例,感染性心内膜炎2例,主动脉瓣二叶畸形2例（其中合并感染性心内膜炎1例）,退行性主动脉瓣病变1例,先天性房室管畸形1例（既往有心脏手术史）,二尖瓣脱垂及非对称性肥厚性心肌病各1例.行主动脉瓣置换4例、二尖瓣置换2例、二尖瓣置换及三尖瓣成形1例、Bentall术1例、左室流出道疏通及二尖瓣置换1例.结果 本组9例患者,术后早期出现Ⅲ°AVB 7例,术后24～48 h出现Ⅲ°AVB 1例,术后4年出现Ⅲ°AVB 1例.出现Ⅲ°AVB持续时间超过2～3周不能恢复者,均行永久性起搏器置入术,其中采用DDD起搏器4例、VVI起搏器5例.无晚期死亡患者.结论 心脏瓣膜术后出现Ⅲ°AVB大多发生于术后早期,与手术部位有一定关系.术中注重心脏瓣膜结构与房室结及传导束的解剖关系,是预防术后出现Ⅲ°AVB的关键.Ⅲ°AVB持续时间超过2～3周者需行永久性起搏器置入术.     

Bloqueo auriculoventricular en pacientes en tratamiento con fármacos bradicardizantes. Variables predictoras de la necesidad de implante de marcapasos

Introduction and objectivesAtrioventricular block (AVB) in the presence of bradycardic drugs (BD) can be reversible, and pacemaker implantation is controversial. Our objective was to analyze the pacemaker implantation rate in the mid-term, after BD suspension, and to identify predictive factors.MethodsWe performed a cohort study that included patients attending the emergency department with high-grade AVB in the context of BD. We studied the persistence of AVB after BD discontinuation, recurrence in patients with AVB resolution, and the predictive variables associated with pacemaker requirement at 3 years.ResultsOf 127 patients included (age, 79 [71-83] years), BAV resolved in 60 (47.2%); among these patients, recurrence occurred during the 24-month median follow-up in 40 (66.6%). Pacemaker implantation was required in 107 patients (84.3%), despite BD discontinuation. On multivariable analysis, the variables associated with pacemaker need at 3 years were heart rate < 35 bpm (OR, 8.12; 95%CI, 1.82-36.17), symptoms other than syncope (OR, 4.09; 95%CI, 1.18-14.13), and wide QRS (OR, 5.65; 95%CI, 1.77-18.04). Concomitant antiarrhythmic treatment was associated with AVB resolution (OR, 0.12; 95%CI, 0.02-0.66).ConclusionsMore than 80% of patients with AVB secondary to BD require pacemaker implantation despite drug discontinuation. Predictive variables were wide QRS, heart rate < 35 bpm, and clinical presentation other than syncope.     

单根电极导线心室起搏双腔感知双反应方式起搏器远期效果分析

目的　探讨单根电极导线心室起搏双腔感知双反应方式起搏器 (VDD起搏器 )的远期临床使用效果。方法　 1993- 0 3～ 2 0 0 2 - 0 5共植入单根电极导线的VDD起搏器 16例 ,其中男性 12例 ,女性 4例 ,年龄 4 9～ 75岁 ,平均年龄 ( 6 4 4± 7 8)岁。均为窦性心律正常伴完全性房室传导阻滞或高度房室传导阻滞者。常规采用穿刺锁骨下静脉方法植入电极导线 ,起搏器植入电极导线插入的同侧。结果　随访时间 112～ 1个月 ,平均 ( 6 8 8±6 3)个月。全部患者植入后 ,心功能提高 ,临床症状消失 ,长期随访生活质量明显改善 ,无心房感知不良者。 1例因冠心病合并心衰于随访 4 2个月死亡外 ,其余均健在 ,无失访者。结论　只要适应证选择合适 ,使用VDD起搏器手术简单易于操作 ,又可减轻病人负担并能取得最佳的治疗效果 ,心内科同道应重视这类起搏器的选用 ,特别是对于经济不发达地区更为重要     

心脏起搏术后患者发生心绞痛的情况分析

目的分析心脏起搏术后患者心绞痛的发生情况。方法 35例起搏器术后一年内并发心绞痛的为心绞痛组,选取同期的495例永久心脏起搏患者为非心绞痛组,比较两组的一般情况。并对不同起搏原因及不同起搏方式的心绞痛发作情况进行比较。结果与非心绞痛组比较,心绞痛组年龄、吸烟、性别构成无差异,但合并高血压、糖尿病、高脂血症比例较高。因房室传导阻滞(AVB)行心脏起搏者较因病窦综合征起搏者术后发生心绞痛比例高(15.4%vs 1.8%,P<0.001),而安置VVI者与DDD者心绞痛发生率相似(6.7%vs 6.3%,P>0.05)。结论起搏术后发生心绞痛患者多合并多种冠心病危险因素,AVB者术后心绞痛发生率高。     

Pediatric cardiac pacing: indications, implant techniques, pacing mode

Over the last years, pacing leads design and pacemaker (PM) generator size, reliability, and longevity have markedly improved, so that reliable paediatric implant can now be performed at any age with a low complication rate. Main indications include congenital and postoperative atrioventricular block (AVB) and postoperative sick sinus syndrome. Implantation of a PM is mandatory for children who are symptomatic from syncope or congestive heart failure and for those who have advanced block persisting more than 10 days after cardiac surgery. Criteria for pacing have been established in relation with the bradycardia and prophylactic pacing is recommended in children with congenital AVB and a mean heart rate <50 beats/minute. The majority of paediatric cardiologists recommend epicardial pacing in children less than 10 kg and when venous access to the heart is limited by congenital anomalies or prior operation; for older children, transvenous implantation has become the technique of choice. As heart rate is the main determinant of cardiac output at exercise in children with normal heart structures, the VVI-R mode is an alternative to dual chamber transvenous pacing in young patients. Patients with isolated sinus failure are paced in the atrium. Although the majority of patients are doing well, late complications within the paediatric population include venous thrombosis and difficulties in lead extraction. Myocardial dysfunction in children with congenital AVB is increasingly reported, but it is not determined whether it is due to the underlying disease or to right ventricular apical pacing and adverse remodelling.     

Complete heart block in late presentation of inferior STEMI successfully treated with percutaneous coronary intervention

A 55-year-old female presented with 4-day history of fatigue and exertional shortness of breath. A late presentation inferior ST elevation myocardial infarction (STEMI) was diagnosed based on ST elevation in the inferior leads of electrocardiography and elevated cardiac troponin T (TnT). She developed complete heart block 1 day after admission to the hospital and remained hemodynamically stable. She was taken to the catheterization laboratory for a temporary pacing wire insertion. Coronary angiogram at the same time showed an occluded right coronary artery at the mid-section. The lesion was successfully opened. Within 24 hours, the patient's heart rhythm returned to sinus with first-degree atrioventricular block (AVB), thus avoiding the need for a permanent pacemaker. Current guidelines recommend medical management for late presentation hemodynamically stable STEMI of more than 72 H onset. Current ACC/AHA/HRS Pacemaker Guidelines recommend reperfusion strategy for acute presentation inferior STEMI associated with AVB. However, no clear strategy exists in the case of late presentation inferior STEMI with advanced AVB. Our case report suggests that late coronary intervention could be a management strategy in such a scenario in order to avoid a permanent pacemaker.     

Infranodal chronic auriculo-ventricular block in subjects under 50 years of age

The aetiology and evolution of chronic infranodal atrioventricular block (AVB) of young patients are not well known: are they the first sign of subclinical myocardial disease which can only be diagnosed by long term follow-up or do they represent isolated degenerative disease of the conduction tissue (Lenegre's disease)? Eighteen patients (15 men, 3 women) aged 25 to 49 years (average 41.5 years) were followed up for periods of 2 to 20 years (average 7.33 years) after pacemaker implantation for syncopal AVB. Follow-up was focused on the evolution of the conduction defects and the cardiovascular status. The patients were divided into two groups at the initial assessment: Group I: 15 patients with documented AVB; Group II: 3 patients in whom all basal recordings showed sinus rhythm (SR). Apart from one patient with an early non-ischaemic dilated cardiomyopathy, there was no previous cardiovascular disease. There was no history of ischaemic heart disease, drug effects, infection or inflammation in favour of an acute AVB. Three patients had permanent AVB, either 2nd degree with bundle branch block (N = 2) or 3rd degree block (N = 1). The other 15 patients were in sinus rhythm with bundle branch block: left bundle branch block (LBBB) in 5 cases, right bundle branch block (RBBB) in 3 cases; RBBB with left anterior hemiblock in 5 cases, RBBB and left posterior hemiblock in 2 cases. Paroxysmal AVB was recorded in 12 of these 15 patients on at least one occasion.(ABSTRACT TRUNCATED AT 250 WORDS)     

Early-Onset Cardiomyopathy After Pacemaker Implanted in a Preterm Infant With Congenital Complete Heart Block and Anti-Ro/SSA Antibodies

Congenital complete heart block is a potentially fatal complication that can occur in neonates whose mothers have autoimmune disorders; it has rarely been reported in the presence of Sjögren syndrome. Pacemaker implantation is recommended to treat rhythm abnormalities in these neonates. We report the case of a late-preterm infant with Sjögren-syndrome-antibody–induced complete heart block who underwent temporary bipolar epicardial pacing as a bridge to permanent pacemaker implantation. Soon after the pacemaker was implanted, takotsubo cardiomyopathy developed. To our knowledge, this is the first report of reversible cardiomyopathy after pacemaker implantation in an infant.     

Pacemaker therapy in infants (author's transl)

Since April 1974 until January 1978 permanent pacemakers were implanted in 21 children. The patient age at the time of operation averaged 4.5 years; the youngest patient was 3 months old. Indications for pacemaker implantation were: congenital total a-v block (TAVB) (n = 4), sick syndrom (S-S-S) (n = 4), postoperative TAVB (n = 13). Cardiac failure was present in all patients despite optimal medical treatment. Pacemakers were implanted under general anesthesia and intubation. The stimulation electrodes were positioned by the transvenous route in 16 subjects and by direct fixation upon the ventricle and the atrium in 5 patients. 5 children obtained an atrial triggered, 14 patients R-inhibited demand pacemaker and 2 subjects an asynchronous pacemaker. After a mean observation time of 16.4 months mean pacemaker function is normal in 14 patients. 6 children died 1 to 33 months after implantation despite functioning pacemakers because of congestive heart failure. Pacemaker malfunction was observed in 4 patients. The type of malfunction induced: failure of the impulse generator (n = 2), dislodgement of the electrode (n = 2), threshold increase (n = 1). In 5 children generators were changed 9 to 36 months (m = 23 plus or minus 10) after implantation because of battery depletion. The use of the pacemakers in small children is connected with several specific problems: 1. Application of large generators is hazardous because of impending perforation and secondary infection. 2. Until now miniaturization of pacemakers decreases function time and therefore implies frequent surgical intervention. 3. Stretching and dislodgement of transvenous electrodes may occur due to growth of the child. 4. Threshold increase may limit the life-span of myocardial electrodes. 5. Physiological changes in natural frequency requires changes in stimulation rate. 6. To guarantee normal physical activity demand related adaptation of heart rate is necessary. Because of these reasons a pacemaker system for children should have the following criteria: low weight, small wolume, high energy capacity, atrial or programmable stimulation, a thin elastic perhaps coiled electrode.