经下腔静脉途径反推力牵引法拔除永久性起搏电极导线

采用经下腔静脉途径 ,对 11例起搏器术后顽固性感染和 2例电极导线断裂患者的电极导线进行血管内反推力牵引拔除术。需拔除电极导线共 17根 (心房和心室电极导线分别为 5和 12根 ) ,其中 15根因起搏器囊袋感染和破溃需拔除的电极导线置入时间为 11.5± 3.5 (8～ 2 0 )年 ,经上腔静脉途径拔除失败。结果 :经下腔静脉途径完全拔除电极导线 15根、不完全拔除 1根、失败 1根 ,无严重并发症。表明对置入年限长久和断裂电极导线 ,经下腔静脉途径的拔除成功率高 ,应作为首选拔除途径     

血管内反推力牵引术拔除感染性起搏电极导管

应用血管内反推力牵引术，经上腔静脉途径对９例病人的１４根感染性起搏电极导管进行拔除。１０根（７１．４％）电极导管被完全拔除，不完全拔除２根（１４．３％）。拔除失败的２根（１例）起搏电极导管经外科开胸术取出。平均随访９个月，感染被控制。提示血管内反推力牵引术是拔除感染性起搏电极导管和治疗起搏器植入术后顽固性感染的有效方法。     

经静脉途径拔除起搏电极导线的影响因素

目的探讨永久起搏器和埋藏式心脏转复除颤器(ICD)电极导线经静脉途径拔除的影响因素。方法对80例永久起搏器或ICD顽固性感染患者的157根电极导线进行拔除,先采用经上腔静脉途径拔除,未成功的换经下腔静脉途径拔除。分析电极置入时间长短、电极类型、患者年龄对拔除成功率的影响。结果拔除心房电极导线63根,右室电极导线75根,左室电极导线9根,ICD电极导线10根。拔除成功率100%。置入1年内、1～5年、5～10年、以及10年以上的电极导线经上腔静脉途径拔除的成功率分别为100%、86.4%、76.2%以及43.5%。不同电极类型及不同年龄患者经上腔静脉途径拔除电极导线的成功率无差异。结论经上腔静脉途径拔除永久起搏器或ICD电极导线的成功率较高,且不受电极类型及患者年龄影响,但随着电极置入时间的延长,其成功率降低。     

经静脉拔除114根永久性起搏电极导线

报道经静脉除 114根永久性起搏电极导线的结果。采用血管内反推力牵引技术和标准化器械 ,经上腔和 /或下腔静脉对 75例患者的 114根电极导线进行拔除。拔除指征为起搏系统顽固性感染 (97.3% )和电极导线断裂并脱入心腔 (2 .7% )。结果 :电极导线置入时间 5 .7± 5 .4 (0 .5～ 2 1)年 ,心房和心室电极导线分别为 35根和 78根。完全拔除电极导线 94根 (82 .4 % ) ,部分拔除 15根 (13.1% ) ,其余 5根拔除失败。术中一例因右心耳撕裂发生急性心包压塞。完全或部分拔除电极导线后 ,患者的感染症状被完全控制。结论 :经静脉拔除电极导线具有较高的成功率和安全性 ,是根治起搏器置入术后顽固性感染的有效方法。     

国内心律植入装置电极导线拔除的概况

对国内心律植入装置电极导线拔除的文献进行归纳或总结。电极导线拔除的原因有1感染;2电极导线断裂脱入心腔引起心律失常;3穿破心肌的电极导线;4精神症状;5体内多根电极导线。电极导线拔除的方法有1血管内反推力牵引法;2直接牵引法或加其他辅助措施;3机械扩张鞘;4体外循环下手术拔除;5杂交手术。拔除的电极导线主要为右室、右房电极导线。经上腔静脉途径拔除的成功率与电极导线植入的时间呈反向关系。拔除的并发症主要为心包压塞,与心房电极导线的拔除相关。还有肺栓塞、三尖瓣撕裂、下肢静脉血栓等并发症的发生。电极导线拔除的关键点为电极导线的头端与心肌的分离,以及电极导线体与血管或组织结构粘连的分离。因此,只要措施恰当,拔除则是安全、有效的,否则,并发症是致命的。     

新型"编织"技术应用于起搏导线拔除1例

常规使用的经上腔静脉途径拔除导线工具不能处理无腔实心导线。本文报道了1例植入9年的起搏器感染患者, 术中使用"编织"延长方法改良现有经上腔静脉拔除工具, 成功拔除导线, 为拔除这类导线提供1种可供选择的临床方法。     

经静脉途径拔除植入心律起搏装置导线25例临床体会

目的:回顾性分析和总结经静脉途径拔除植入心律起搏装置(CIED)导线的方法和体会。方法:25例CIED患者(导线断裂3例、感染22例)的47根导线经静脉途径成功拔除,其中6例导线徒手拔除,15例应用锁定钢丝和扩张鞘拔除,1例运用Evolution机械鞘拔除,3例经下腔静脉途径拔除;22例患者于对侧植入新的心律起博装置,2例患者无植入新的起搏装置指证,1例患者因感染性心内膜炎积极治疗无效死亡。结果:所有导线均完全拔除,术中术后均未发生严重并发症。结论:经静脉途径拔除CIED导线是根治心律起博装置导线相关问题的重要措施,科学、有效的运用多种器械和技术在复杂病例的应用中十分重要。     

经静脉拔除114根永久性起搏电极导线

目的我院自1996年起采用专业器械和血管内反推力牵引技术,共对114根电极导线进行了经静脉拔除,总结治疗结果和并发症.     

联合上下腔静脉途径心血管植入型电子器械导线拔除回顾性分析

目的回顾性分析单中心近年来联合上腔和下腔途径心血管植入型电子器械(CIED)导线拔除术(TLE)的病例特点,探究其与单纯上腔或下腔途径拔除CIED导线病例的不同之处。方法连续入选2011年1月至2018年9月于阜外医院心律失常中心行TLE患者159例。将其依据TLE时血管入路途径分成2组:A组为单纯经上腔或下腔途径拔除组(132例);B组为联合上腔和下腔途径拔除组(27例)。对比2组患者基线资料特点、CIED植入类型、导线拔除情况等。结果与A组相比,B组CIED植入时间更长、既往囊袋清创史和CIED更换史比例更高(P<0.05)。进一步统计学分析示,CIED植入时间对于需行联合上下腔静脉TLE者有独立预测价值;CIED植入时间≥5.25年时,其敏感度和特异度分别为74.1%和67.4%。2组患者共计拔除导线301根:A组拔除249根,B组拔除52根,总体临床成功率为95.2%;其中B组拔除成功率更低(86.7%对97.3%,P=0.002)、严重并发症率更高(18.5%对1.5%,P=0.002)。结论对于CIED植入时间≥5.25年者预示着其需要联合上下腔静脉途径行TLE。对于联合上下腔静脉途径行TLE患者,其成功率较单纯上腔或下腔途径更低,且严重并发症发生率更高。     

经静脉途径拔除植入心律起搏装置器械选择

目的:探讨多器械联合运用在经静脉途径拔除植入心律起搏装置中的安全性和有效性。方法:回顾性分析和总结2017-08-2019-05就诊于我院,应用多器械、综合管理成功治愈植入心律起搏装置感染或导线断裂患者的临床资料。结果:11例植入心律起搏装置患者的18根导线(导线断裂1例、起搏器综合征1例、感染9例)经静脉途径成功拔除,其中3根导线徒手拔除,15根导线运用锁定钢丝和扩张鞘拔除。4例患者运用Evolution机械鞘拔除,1例经下腔静脉途径拔除,2例患者经囊袋清创,加强抗感染后好转;6例患者于对侧植入新的心律起搏装置,3例患者无植入新的起搏装置指征。所有患者未发生严重并发症。结论:植入心律起搏装置科学管理至关重要,严格无菌操作是预防感染相关并发症的关键。综合运用多种器械,个体化制定拔除策略安全高效。     

Feasibility, safety, and determinants of extraction time of percutaneous extraction of endocardial implantable cardioverter defibrillator leads by intravascular countertraction method

Previous studies of the removal of implantable cardioverter defibrillator (ICD) leads have been restricted to case reports or small series. In this report, we describe our experience in ICD lead extraction by intravascular countertraction method using Cook's extraction kit. A total of 47 high-voltage (HV) leads, 3 rate sensing (S) leads, and 2 subcutaneous arrays were removed from 42 patients (33 men, 9 women; mean age 59 years [range 14 to 81]). One HV superior vena cava (SVC) lead and 11 HV right ventricular (RV) leads were explanted by manual traction only and defined in the "lead removal" category. One S lead was removed using a femoral venous approach. The remaining 37 leads were explanted by SVC approach using extraction sheaths and defined in the "lead extraction" category. Twenty leads were extracted for "infectious" (group A) and 17 leads for "noninfectious" (group B) etiologies for which extraction times of 27.0+/-18.0 and 27.0+/-15.0 minutes (mean+/-SD), respectively, were not different. Although extraction time, 34.0+/-11.0 minutes, for leads implanted for >48 months was longer than 23.0+/-16.0, 28.0+/-18.0, and 24.0+/-14.0 minutes, for leads with implant durations of 12, 24, and 48 months, respectively, such differences were not statistically significant. The extraction time, however, was directly related to the degree of fibrosis around the lead, 39.0+/-15.0 minutes for leads with severe fibrosis compared with 13.0+/-6.0 minutes for the leads with mild fibrosis (p<0.001). Patient's age, sex, or history of coronary artery bypass graft surgery did not significantly affect extraction time. All except the initial 2 lead extractions were performed in the electrophysiology laboratory. No mortality or serious complications associated with the procedure using these methods were observed.     

Case Reports: Radiofrequency Catheter Ablation of Typical Atrial Flutter and the Atrioventricular Junction via the Superior Vena Caval Approach in a Patient with a Congenital Absence of an Inferior Vena Cava

The absence of an inferior vena cava is a rare congenital condition often without clinical significance. Alternative venous approaches are often needed to treat these patients. We report a case of successful ablation of both isthmus dependent flutter and the AV junction using the superior vena cava in a patient with an inferior vena cava anomaly.     

Radiofrequency catheter ablation of the slow pathway for atrioventricular nodal reentry in a patient with an obstructed inferior vena cava

A 51-year-old man with an obstructed inferior vena cava underwent successful slow pathway catheter ablation using a superior venous approach. Two central venous sheaths were introduced into the right internal jugular vein using different approaches (anterior and posterior), so the two sheaths located away from each other could prevent the catheters from 'sticking' to one another. The transseptal long sheath enabled a stable positioning of the ablation catheter. A nonfluoroscopic mapping system could reduce radiation exposure to the ablator. These techniques may be useful to overcome the disadvantages of the superior venous approach compared to the inferior venous approach.     

Right ventricular pacing via left superior vena cava

Negotiating the pacing lead into the right ventricle via left superior vena cava, at times, can be difficult. We report two such cases in which pacing leads were introduced into the right ventricle via left superior vena cava, with the help of stylet tip shaped into a large pigtail loop.     

Hepatic autotransplantation with ex situ neoplasm extirpation and vena cava replacement

The treatment of a 64-year-old man with a retrohepatic neoplasm deemed not accessible by conventional in situ surgical techniques is presented to illustrate the potential benefit offered by techniques adapted from liver transplantation and vascular surgery. A computed tomography scan performed for uncharacteristic abdominal discomfort revealed a hepatic or retrohepatic tumor compressing the inferior vena cava. Biopsies were interpreted as probably leiomyoma or malignant schwannoma. The liver with neoplasm and retrohepatic inferior vena cava was removed en bloc and taken to the back table where the neoplasm invading the inferior vena cava wall was removed together with the inferior vena cava. The inferior vena cava was then replaced by a 22-mm polytetrafluoroethylene graft and the 3 hepatic veins were reconstructed with anastomoses to this graft. The liver was then autotransplanted by standard transplantation technique. The postoperative course was uneventful and the patient is in good health more than 2 years after surgery.     

Coronary Sinus Ostial Atresia and Persistent Left-Sided Superior Vena Cava: Clinical Significance and Strategies for Cardiac Resynchronization Therapy

A 48-year-old male patient underwent cardiac resynchronization therapy defibrillator implantation, and he was found to have atresia of the coronary sinus ostium with venous drainage occurring via a persistent left-sided superior vena cava, which was connected to the right-sided superior vena cava by the innominate vein. This is a rare benign cardiac anomaly that can pose problems when the coronary sinus needs to be cannulated. To identify the course of the coronary sinus, a coronary angiogram can be performed with attention directed to the venous phase of the angiogram. Although the technical difficulty of coronary sinus cannulation increases, various catheters, wires, and delivery systems can be utilized and this anomaly does not usually prevent successful left ventricular lead placement in cardiac resynchronization therapy via a left-sided superior vena cava approach. There however needs to be consideration regarding caliber of the left-sided superior vena cava being sufficiently large to avoid compromise of venous drainage after lead insertion.     

Long-term follow-up of right atrial ablation in patients with atrial fibrillation:

INTRODUCTION: The aim of this study was to evaluate the efficacy and the impact on quality of life of a new ablative approach to the right atrium in patients with atrial fibrillation (AF). METHODS AND RESULTS: Seventy-four symptomatic patients with paroxysmal (n = 49) or permanent (n = 25) refractory AF underwent radiofrequency ablation. A nonfluoroscopic electroanatomic mapping system was used to perform the following lesions: (1) an isthmus line between the tricuspid annulus and the inferior vena cava; (2) a posterior intercaval line from the superior vena cava and the inferior vena cava; (3) a septal line from the superior vena cava to the fossa ovalis, proceeding to the coronary sinus ostium where a circumferential line around the ostium was performed, and then on to the inferior vena cava; and (4) a transversal lesion connecting the posterior intercaval and the septal lesions. In addition, electrical disconnection of the superior vena cava was performed. There were no complications. Postablation remapping showed the absence of discrete electrical activity inside and just around the ablation lines. Electrical disconnection of the superior vena cava was obtained in all patients. After 21 +/- 6 months, 49 patients (66%) had stable sinus rhythm with continuation of the previous antiarrhythmic drug therapy, 13 patients (18%) were considered improved, and 12 (16%) received no benefit (unsuccessful procedure). After ablation, quality of life was significantly improved, reaching the levels of the general Italian population. Ejection fraction and the extent of the low-voltage area were found by multivariate analysis to be independent predictors of AF recurrence. CONCLUSION: The results of the present study suggest that this ablative approach in combination with antiarrhythmic drugs is safe and effective in treating AF, leading to a marked increase in quality of life in patients with refractory AF.