右位心植入DDDR永久起搏器1例

右位心是一种少见无分流的先天性心血管疾病,发病率约为2/10万。右位心植入心脏永久起搏器极为少见,国内仅见几例植入VVI型起搏器的报道,植入DDDR起搏器仅见徐桂萍等的1例报道。1病例报道患者男性,58岁,因“反复胸闷20余年,头晕、乏力2年,再发2周”入院。入院前5天经24小时动态     

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...     

高龄与非高龄患者永久性起搏器植入的比较分析

目的探讨老年高龄患者植入永久起搏器的安全性及有效性。方法回顾性分析我院2014年1月至2015年12月接受心脏永久起搏器植入治疗的125例患者,分为高龄组与非高龄组,比较分析其基线资料、起搏器适应征、起搏电极参数、并发症情况。结果 125例患者分为高龄组31例和非高龄组94例。基线资料比较提示高龄组冠心病患病率明显高于非高龄组。在起搏器适应征和起搏电极参数方面高龄组与非高龄组比较均无统计学差异。高龄组发生1例起搏器相关并发症,非高龄组发生4例并发症,两组无差别。结论老年高龄患者植入心脏永久起搏器是安全有效的。     

罕见右位心的心电图采集分析一例

右位心是心脏在胸腔的位置移至右侧的总称.心脏无其他先天性畸形的单纯右位心不引起明显的病理生理变化,也不引起症状,以后和常人一样可能也患后天性心脏病.但右位心常和较严重的先天性心血管畸形同时存在.右位心发生概率很低,根据X光检查资料的分析与统计,右位心者约占正常人的万分之一.根据解剖部位不同可分为镜像右位心、右旋心和心脏右移.诊断可依据体征和X线片很容易确立,进一步的分型应结合心电图、超声心动图确定,部分诊断困难者以及合并复杂畸形者往往需要选择心血管造影确诊.心电图常有其特征性改变,但是对于特殊部位的右位心需要结合病史、体征及影像学检查才能确定.本文报道一例特殊部位右位心患者.     

低位房间隔起搏与右心耳起搏的临床对比研究

目的 探讨低位房间隔起搏与右心耳起搏在植入操作时间、起搏参数方面的差异.方法 选取40例因窦房结功能障碍或成人获得性房室传导阻滞导致的缓慢型心律失常行起搏治疗的患者分为两组.其中,房间隔组20例,采用主动固定螺旋电极行低位房间隔起搏;右心耳组20例,采用被动固定翼状电极行右心耳起搏.对比两组电极植入操作时间,电极植入时、术后1个月、3个月的起搏参数（阈值和阻抗）.结果 房间隔组与右心耳组比较,心房电极植入操作时间和起搏参数在术中、术后1个月、3个月差异均无统计学意义（P＞0.05）.结论 低位房间隔起搏与右心耳起搏具有相似的电极植入操作时间以及相同的起搏参数,为临床起搏治疗的有效部位.     

不同部位起搏对起搏器植入患者急性凝血功能的影响

目的 探讨不同部位起搏对永久心脏起搏器植入患者手术前后机体凝血功能的影响.方法 40例缓慢型心律失常经静脉永久心脏起搏器植入患者(起搏器组),分为右室心尖部起搏和间隔部起搏各20例,20名健康体检者作为正常对照组.检测血浆凝血酶原时间(PT)、部分活化凝血酶原时间(APTT)、凝血酶时间(TT)及血浆D-二聚体(D-D)含量.起搏器组在植入起搏器前及植入后7 d对上述指标进行比较分析.结果 起搏器组与正常对照组各项比较术前差异无统计学意义(P>0.05).心尖部起搏组术后7 d D-D较术前升高,TT较术前降低(P<0.05),右室间隔部起搏组术后7 d D-D较术前升高,TT较术前降低,差异有统计学意义(P<0.05).心尖部起搏组与右室间隔部起搏组术后比较差异无统计学意义(P>0.05).结论 植入起搏器手术后患者处于高凝状态,应加强术前术后凝血功能的监测,防止并发血栓性疾病.     

起搏心电图问答

<正>按起搏心电图回答问题:患者因Ⅲ度房室传导阻滞植入永久起搏器(SJ Medical 5356),起搏器参数:上限跟踪频率110次/分,下限频率60次/分,PAV/SAV 200/175 ms,PVARP(心室后心房不应期)275 ms。请根据心电图分析起搏器的心房、心室电极起搏和     

心内高右房超速起搏转复永久起搏器术中并发的心房扑动

目的 评价心内高右房超速起搏转复永久起搏器术中并发心房扑动的有效性和安全性.方法 回顾性分析我院应用心内高右房超速起搏转复20 例永久起搏器术中并发Ⅰ型心房扑动患者的临床资料.结果 20例中19例转复成功, 总成功率95%.所有患者未出现并发症.结论 心内高右房超速起搏转复永久起搏器术中并发的心房扑动是一种简便、安全和有效的方法.     

解剖矫正大动脉异位合并病窦综合征的永久起搏器治疗一例

患者女性,36岁,晕厥1次。经心电图、胸部X线片、腹部B超及右心系统造影后临床诊断:先天性心脏病,解剖型矫正大动脉异位,下腔静脉肝下段缺如,奇静脉开放,右位心,窦性心动过缓、窦性停搏、结性逸搏。成功行VVI永久起搏器置入术。正确判断心脏方位、解剖结构及大动脉空间关系和穿刺左锁骨下静脉是此患者起搏器置入术成功的关键和难点。     

主动与被动电极植入右室心尖部或右室间隔部即刻起搏参数的比较

目的比较主动与被动电极(AE与PE)植入右室心尖部(RVA)或右室间隔部(RVS)对即刻起搏参数的影响。方法回顾植入永久起搏器的患者资料,比较AE和PE植入RVA时即刻起搏参数的差异,比较AE植入RVA或RVS即刻起搏参数的差异。结果入选399例,283例右室起搏电极植入RVA,AE 155例,PE 128例。AE者的起搏阈值高于PE者,而阻抗、感知低于PE者,电极类型是影响差异的唯一因素。271例右室起搏电极为AE,植入RVA 155例,RVS 116例。两部位仅阻抗有差异,起搏部位是影响差异的唯一因素。结论 AE和PE在植入RVA时起搏阈值、感知和阻抗的差异由电极类型不同所引起,而AE植入RVA和RVS即刻阻抗的差异归咎于起搏部位的不同。     

Incidentally Found Situs Inversus with Dextrocardia: Inferior Myocardial Infarction in an 86‐Year‐Old Woman

Situs inversus with dextrocardia is a rare condition. Yet, the incidence of atheroclerosis and myocardial infarction in patients with dextrocardia is similar to that in general population. The diagnosis of acute myocardial infarction is somewhat tricky and difficult if the dextrocardia is not recognized. We present the electrocardiogram, coronary angiograms, and chest radiogram of a patient with incidentally found situs inversus with dextrocardia.     

Long-term results of endocardial pacing with Autocapture threshold tracking pacemakers in children.

AIM: We aimed to evaluate the long-term results of endocardial pacing with Autocapture threshold tracking pacemakers in children. METHODS AND RESULTS: Implantation and follow-up data of 20 children with these pacemakers were retrospectively evaluated. The pacemakers were implanted subpectorally in five and subcutaneously in 15 patients. The indication for pacing was high-grade atrioventricular block in 18 cases. The mean age at implantation was 7+/-4.8 years. Four patients were pacemaker dependant (heart rate < 30 bpm). At implantation, the mean pacing threshold was 0.5 V at 0.5 ms. The mean evoked response (ER) signal was 8.5+/-3.6 mV, and the polarisation signal (PS) was <1 mV in 15 patients and 1-2 mV in five patients. During the mean follow-up period of 60 months, mean ER signal decreased significantly to 7.7+/-6.3 mV at 24 months and 6.5+/-2.5 mV at 60 months (P < 0.05). In four of 15 patients (26.6%), with a predischarge PS value of <1 mV, it increased between 1 and 2 mV over time. During follow-up, autocapture function was deactivated in six (30%) patients; due to inappropriate ER/PS values in four and due to severe muscle twitching in two with subpectoral implants. These problems occurred during a median period of 21 months after implantation. Generators were replaced in three patients with Microny pacemakers because of battery depletion at 54, 66 and 78 months. In two of them autocapture function had been working since implantation. In seven of 10 patients, who completed > or = 60 months of follow-up, battery impedances were still at the predischarge level. CONCLUSIONS: Autocapture function works well in most children at implantation. Mean ER signal significantly decreases over time despite stable pacing parameters. Autocapture function may become nonoperational due to decreased ER signal in some patients. Muscle twitching may be an important problem that may result in discontinuation of autocapture function in children with subpectoral implants.     

间隔部主动固定电极对老年患者心功能的影响

目的探讨右室间隔部（RVS）主动固定电极对植入永久起搏器的老年患者心功能的影响。方法入选78例植入永久起搏器的老年患者,分为RVS起搏组（实验组,植入主动固定电极,n=42）和右室心尖部（RVA）起搏组（对照组,植入被动固定电极,n=36）,以超声心动图评价两组术前、术后6个月左室缩短率（FS）、每搏输出量（SV）、心输出量（CO）、左室射血分数（LVEF）、E／AI：L值的差异。结果术前两组心功能状况无明显差异（P〉0．05）。术后6个月,RVS起博组与术前相比较,FS、SV、CO、EF、E／A虽有下降趋势,但差异无统计学意义（P〉0．05）;RVA起博组在术后6个月FS与对照组差异无统计学意义（P〉0．05）,但SV、CO、EF、E／A均高于RVS起博组（P〈0．05）。两组起搏阈值、感知、阻抗起搏比例及平均心率等差异均无统计学意义（P〉0．05）。结论RVS起搏对患者心功能的影响优于右室心尖部起搏。     

Inadvertent permanent ventricular pacing from the coronary vein: an electrocardiographic, roentgenographic, and echocardiographic assessment

The incidence of inadvertent permanent ventricular pacing from the coronary vein is not known. In a retrospective analysis of 69 patients in whom transvenous pacemakers were implanted between 1979 and 1986, 12 patients were discovered to have right bundle-branch block pattern to the paced complexes on electrocardiogram. In this group, three patients were considered to have inadvertent placement of pacing lead in the coronary vein by two-dimensional echocardiographic criteria. No complications were noted in follow-up of 2-79 months. Monitoring of surface electrocardiogram, frontal and lateral fluoroscopy, and pacing threshold and sensing parameters (during implantation of pacemaker) were found to offer no absolute protection against malplacement of the lead. Placement of the lead into the lung field via the main pulmonary artery and then withdrawing with eventual positioning into the right ventricular apex will avoid malposition into the coronary vein. Two-dimensional echocardiography is useful for the diagnosis of pacing lead malplacement and should be performed in any patient with right bundle-branch block pattern in the surface electrocardiogram following pacemaker implantation.     

Long-term follow-up of pacemakers with an Autocapture pacing system

The aim of this study was to evaluate the safety and performance of the Autocapture pacing system during a 5-year follow-up period. The study was conducted retrospectively between May 1996 and May 2001. Sixty consecutive patients who had undergone VVI pacemaker implantation using an Autocapture program with leads 1402T (n: 31) and 1452T (n: 29) were included in the study. Intraoperative measurements including a ventricular stimulation threshold test, sensing of intrinsic R wave (mV), and lead impedance (W) were done by a standard pacing system analyzer. Evoked responses (ER, mV) and polarization signals (PS, mV) were measured after the pocket was closed. Pacing thresholds by Autocapture (AC thrd, V) and Vario (Vario thrd, V), battery current (mA), and battery impedance (kW) were also repeated during predischarge and 1, 6, 12, 18, 24, 30, 40, 50, and 60 months after discharge. According to the ER and PS values an Autocapture algorithm could be activated in 49 patients (88%). The Autocapture algorithm remained active during the follow-up in all of these patients. In patients with inappropriate ER and PS values (11 patients, 12%), pacemakers were programmed to a VVIR pacing mode and Autocapture algorithm was inactivated. ER and PS values did not reach appropriate values to activate the Autocapture algorithm in any of these patients in consecutive follow-ups. Twenty-four-hour Holter monitoring could be conducted in 32 patients (53%). In all recordings, when the loss of capture occurred, it was confirmed that back-up pacing continued. When the first measurements recorded during implantation were compared to approximately the 5th year measurements; ER (9.2 mV vs 9.6 mV), PS signal (1.13 +/- 0.30 mV vs 1.15 +/- 0.72 mV), AC thrd (0.4 V vs 1.2 V), Vario thrd (0.7 V vs 1.3 V), and lead impedance (502 ohm vs 620 ohm) were not changed significantly. Battery impedance increased 1 kOhm between 30-40 months of the implantation. Seven deaths occurred during follow-up. Three patients had fatal myocardial infarction, one died due to a non-cardiac event, and the remaining three died due to progressive heart failure. Conclusion: ER, R wave amplitude, and PS, which are the main parameters for the continuation of Autocapture function, did not change significantly during long-term follow-up. High output back up pacing provided additional safety for sudden rises in threshold. The Autocapture pacing algorithm was found to be effective and reliable during long-term follow-up.     

心脏再同步治疗难治性心力衰竭的临床应用

目的评价心脏再同步治疗（CRT）难治性心力衰竭的临床疗效。方法21例难治性心力衰竭患者接受CRT治疗;左心室导线采用经心脏静脉血管径路植入或开胸直接缝合左心室心外膜导线。植入术后定期随访,分析患者心功能、活动耐量、生活质量评分、QRS时限、左心室射血分数（LVEF）、左心室舒张末内径（LVEDD）等指标的变化,评价CRT的临床疗效,测试起搏参数并在超声心动图指导下优化AV间期和VV间期。结果21例患者成功植入CRT,其中3例患者因心脏静脉血管畸形而采用开胸植入左心室心外膜导线。平均随访（9．8±9．5）个月,死亡3例;2例患者因心力衰竭症状复发再住院;其余患者心功能分级、生活质量评分、活动耐量较植入术前有显著改善;植入术后1个月LVEF明显提高（0．31±0．06对0．37±0．05,P〈0．01）;二尖瓣反流程度[（2．24±0．89）级对（1．43±0．75）级,P〈0．01];LVEDD植入术后6个月明显减小（（71．91±8．38）mm对（68．82±10．80）mm,P〈0．05];QRS时限分析显示CRT治疗有效组术后明显变窄（（162．50±24．08）ms对（142．50±19．15）ms,P〈0．05],无效组变化不明显[（148．00±10．95）ms对（138．00±4．47）ms,P〉0．05]。1例患者左心室导线脱位。右心房和右心室起搏导线的阈值、感知灵敏度及阻抗均在正常范围,左心室导线各参数,除1例患者阈值升高外余均正常。3例开胸植入心外膜导线患者除1例于植入术后第5个月心脏性猝死,余2例分别随访18个月和26个月,左心室导线阈值分别为0．5V／0．4ms和1．0V／0．4ms。CRT治疗的总临床有效率为76．2％。结论CRT治疗难治性心力衰竭有效,能恢复患者心脏电活动和机械活动的同步性,显著改善心功能。QRS时限变窄是CRT疗效的重要预测指标。     

生理性起搏器治疗缓慢型心律失常的临床观察

目的探讨生理性起搏器在缓慢型心律失常中的临床疗效与安全性。方法共85例患者,起搏器包括双腔起搏器DDD[心房＋心室（起搏心腔）;心房＋心室（感知心腔）;双重（1抑制＋T触发）（感知后反应方式）]60例,双腔起搏器VDD[心室（起搏心腔）;心房＋心室（感知心腔）;双重（1抑制＋T触发）（感知后反应方式）]3例,双腔起搏器VVIR[心房＋心室（起搏心腔）;心房＋心室（感知心腔）十（1抑制）（感知后反应方式）;R频率调整（程控功能）]22例。结果85例患者均手术成功,术中测得心室起搏阈值为（0．42±0．13）V／0．5ms,阻抗（560±130）Ω,R波振幅（9．8±2．2）mV;右心房起搏阈值为（0．89±0．27）V／0．5ms,阻抗（670±180）Ω,P波振幅（2．8±1．2）mV,P波感知灵敏度（0．48±0．3）mV。A—V间期程控在140-160ms,频率适应参数程控为反应时间和恢复时间取中档值,增益取低档值,下限频率程控为60-70次／min,上限频率程控于110-130次／min,感知阈值取中档,频率适应档次取4～5。随访4-50个月,所有患者的生活质量明显提高,无起搏器并发症发生。结论生理性起搏可产生较好的血液动力学效应,改善心功能,提高运动耐量,对有适应证的起搏器患者应首先推荐使用各类生理性起搏器。     

Safety and effectiveness of single-lead VDD pacing

INTRODUCTION AND OBJECTIVES: Single-lead VDD pacing provides the physiological benefits of atrioventricular synchrony with the convenience of a single-lead system. However, concern remains about the method's safety and effectiveness. METHOD: In total, 700 patients with single-lead VDD pacemakers were evaluated retrospectively. The following parameters were recorded: age, sex, etiology, the symptoms and electrocardiographic diagnosis that justified pacemaker implantation, the venous access route used for implantation, atrial sensing at implantation, atrial undersensing at follow-up, the occurrence of supraventricular tachyarrhythmias, and final pacing mode. RESULTS: Third-degree atrioventricular block was the main indication for pacemaker implantation (66.4%). The most commonly used venous access route was via the right cephalic vein (49.1%). At implantation, the mean atrial signal was 1.8 (4 1.15) mV. During follow-up, significant atrial undersensing occurred in 7.7% of patients; in 1.9%, it could not be corrected by device reprogramming. Uncontrollable supraventricular arrhythmias were observed in 6.4% of patients. Symptomatic sinus node disease was rare. By the end of follow-up, 91.4% of patients were still on VDD pacing, while, in 8.3%, the pacemaker had to be reprogrammed to the VVI mode. Only 0.3% required atrial lead implantation for DDD pacing. Left-side venous access during implantation was a independent predictora of atrial undersensing at follow-up. Low values of atrial detection at implant did not reach statistical signification although it showed a remarkable trend. CONCLUSIONS: Single-lead VDD pacing seems to be safe and effective when appropriately indicated. Our findings are consistent with those of previously published studies.     

Coronary stent deployment in situs inversus

Situs inversus with dextrocardia occurs in approximately one in 10 000 patients. Successful stent deployment for the treatment of unstable angina and situs inversus is presented. Three technical challenges associated with the procedure are highlighted. Firstly, the successful choice of diagnostic and interventional catheters is based on an understanding of the orientation of the aortic arch. With a right sided aorta Judkins catheters should be successful. Secondly, image reversal is not necessarily required for image interpretation. Thirdly, successful coronary engagement with catheters requires rotation in a direction opposite to that normally used.


Keywords: dextrocardia; situs inversus; stenting; unstable angina     

右心室流出道间隔部起搏的可行性和稳定性

目的:本研究通过右心室流出道间隔部(RVOT)起搏与右心室心尖部(RVA)起搏的比较,评价RVOT起搏在目前植入技术条件下的可行性和稳定性.方法:42例无器质性心脏病患者,平均年龄(63.5±10.4)岁,随机分到RVA组(n=14)和RVOT组(n=28),所有患者均植入主动固定电极导线和带有自动起搏阈值测试功能的起搏器.通过手术时间、术中X线曝光时间及术中电极导线的各项参数评价RVOT起搏的可行性;通过急、慢性期起搏阈值及并发症评价RVOT起搏的稳定性.结果:RVA组和RVOT组的手术时间、曝光时间、术中电极导线各项参数等指标差异均无统计学意义(P均>0.05);RVOT组急性期起搏阈值稳定性与RVA组相近(P=0.23);两组术后6个月时起搏阈值分别为(0.55±0.11)V和(0.54±0.09)V(P=0.787),差异无统计学意义;随访期中,两组并发症发生率亦相近.结论:在目前的起搏技术条件下,RVOT起搏的可行性和稳定性与传统的RVA起搏相近.