心房静止伴巨大心房起搏器更换一例

患者男,以"反复黑嚎12年余,胸闷气短1个月"为主诉入院.12年前无明显诱因出现晕厥,略胸闷、气短,入院行ECG检查示:交界区逸搏心律,心率40次/min,超声心动图未发现异常.行永久起搏器(VVI)植入术治疗.4年前再次出现黑朦,于医院检查,发现短暂性脑缺血发作(椎基底动脉系统).     

房颤状态下应用X线影像定位植入心房电极的随访

目的在永久起搏器心房电极的植入过程中,某些患者心房处于房颤状态.此时仅能通过X线下心房电极的位置确定心房电极植入是否成功.本研究对此类患者术后心房电极的状态进行随访,以揭示此种方法的安全可靠性.方法对植入心房电极过程中心房处于房颤状态的患者进行术后随访6～72个月.记录常规12导联心电图, 部分患者记录心房腔内心电图,1例患者记录食管心电图.对维持窦性心律的患者,测定心房电极的阻抗、感知以及脉宽设定为0.37～0.40 ms时的阈电压.超声心动图测量的左心房、心室的内径和EF值.结果 39例患者心房电极植入中心房处于房颤状态.对27例患者进行了随访.维持窦性心律者14例(51.9%),心房静止1例(3.7%),心房颤动12例(44.4%).14例维持窦性心律者心房电极起搏感知参数良好.比较窦律与心房颤动、静止者的左房内径(37.3±4.95) mm vs (42.9±5.62) mm,左室舒张末内径(48.7±4.62) mm vs (53.92±8.23) mm;左室射血分数(67±6.8)% vs (51±14.9)% 均有显著差异P≤0.05.结论起搏器植入术中心房如处于房颤状态,以X线透视下心房电极达到良好的部位作为心房电极放置成功的标准是安全可靠的方法.为使术后心房电极持续发挥作用,术前应考虑左房内径,左室舒张末内径和左室射血分数.     

心房纤维化致右房电极植入失败病例1例

1例长期房性心动过速患者射频消融术中出现心脏停搏,并在三维标测系统指导下行右心房基质标测,后行双腔起搏器植入。三维标测系统指导下标测右心房游离壁及前壁发现大片低电压及疤痕区。起搏器植入术中多次调试右心房电极,起搏阈值参数均不理想,右心房电极植入失败。长期房性心动过速可能导致心房电重构、心房纤维化,从而导致右心房电极植入失败。     

心房颤动病人植入永久性心脏起搏器的护理

心房颤动(房颤)是常见的快速性心律失常之一,它一般无需植入永久性心脏起搏器,但在某些特殊情况下如房颤出现规整的长R-R间期,尤其是伴有头晕、黑蒙甚至晕厥等症状时仍需植入起搏器;另外,病人在必须使用减慢传导的药物情况下也应安装起搏器。起搏器对改善病人因血流动力学障碍引起的症状及预防猝死起到了重要作用,而手术的顺利实施与术前、术后有效的护理措施及健康指导密不可分。     

心脏起搏器植入患者的临床护理体会

目的探讨临床护理在心脏起搏器植入患者的应用。方法回顾性分析2006年3月至2008年2月我院对29例患者植入永久性心脏起搏器的临床资料。分析如何采用合理的护理方法以患者提高手术成功率，减少术后并发症。结果29例手术均成功安装固定起搏器，其中3例在术后出现电极脱位，其余未发生手术并发症。结论积极的综合临床护理可有效提高手术成功率，减少术后并发症。     

永久性心脏起搏器植入后的随访管理

近年来，心脏起搏技术不断完善，起搏治疗在心血管病治疗领域得到了越来越广泛的应用。而植入起搏器只是起搏治疗的开始，后续的随访管理直接关系到起搏治疗的效果。成立起搏中心或建立起搏随访门诊，设专人进行档案管理，由起搏电生理专业的医生直接对安装起搏器的病人进行随访是很有必要的，可以早期发现和解决问题，也可以排除一些由于起搏器引起的症状。我院自2003年12月正式成立心脏起搏中心以来，从完善档案管理，健全随访管理制度，来保障心脏起搏器安全有效的工作，使植入心脏起搏器病人的生活质量明显提高。     

埋藏式起搏器植入173例临床随访分析

目的 回顾性分析23年共置入173例埋藏式人工心脏起搏器,评价不同电极植入路径,不同类型电极的临床效果及安全性.方法 将173例患者按起搏部位及植入路径随机分组,比较起搏参数、手术时间及X光照射时间,观察植入手术成功率及并发症.结果 173例患者中,锁骨下静脉穿刺植入电极119例,其中应用翼状电极98例,应用螺旋电极21例;头静脉植入途径48例;颈外静脉植入途径6例.3例(1.7%)患者植入电极1年内发生电极折断现象;2例(1.5%)患者在植入1周内发生电极脱位;3例(1.7%)患者发生反复性囊袋坏死现象;3例(1.7%)患者废弃残留电极脱落至右心腔,未给特殊处置,随访12年至今;10例(6%)患者发生起搏综合征,经重新调整心率后,均起搏良好.螺旋电极应用至今6年,未见不良并发症发生.结论 埋藏式人工心脏起搏术是一种安全、有效的治疗方法.锁骨下静脉穿刺植入电极途径,螺旋电极的应用,是目前临床的主要方法.     

开展安装心脏起搏器术后健康教育方法探讨

我病区1998年6月-2006年6月共安装心脏起搏器91例，其中单腔起搏器41例，双腔起搏器50例．男性60例。女性31例．其中50岁以上人员占70％。现报告健康教育方法如下。     

关于老年人植入心脏起搏器术后疗养康复的体会

目的避免或减少老年人植入心脏起搏器术后疗养康复过程中起搏器故障和相关疾病的发生。积极治疗基础疾病,改变其不良症状,并通过心理治疗改善不良心理情绪,使其增强自信,提高生活质量。方法入院后,详细了解安置起搏器的时间、类型及工作情况,全面掌握其身体状况和心理特点,为其制定合理的疗养计划。结果疗养期结束后,疗养员无一例出现起搏器故障和发生相关疾病;基础疾病及不良症状得到进一步控制,心理不良情绪得到进一步控制,基本达到了疗养的目的。结论疗养院医务人员应全面了解起搏器的类型及特性;掌握安置起搏器的适应症和容易出现的病症;掌握此类疗养员的身体情况和心理特点,制定合理的疗养计划并按计划认真予以实施,是保证老年人植入心脏起搏器疗养员能够顺利完成疗养生活的有效措施。     

植入心脏起搏器与抗心律失常设备患者的生活指导

目的 使植入起搏器后的患者掌握应避免接触的设备，掌握接触后应采取的应对措施。方法 对住院17例行起搏器植入术的患者采取讲解与文字相结合的方法，对其进行相关知识宣教，通过提问及考试了解其掌握情况。结果 知识覆盖率由0上升到100％。结论 患者应掌握植入起搏器后应避免接触的设备，并掌握接触此类设备后应采取的措施，以保证起搏器功能的正常。     

安装起搏器腹腔镜手术的护理12例

当今，由于外科ICU和手术、麻醉方法的不断完善，手术指征逐渐放宽，合并心脏疾病的病人越来越多地被纳入非心脏手术范围。2000年5月以来，我科为12例胆囊结石合并严重心律失常病人安装起搏器后实施了腹腔镜胆囊切除术(LC)，疗效满意，现将围手术期的护理体会报告如下。     

人工心脏起搏器安装术后病人足底推拿的效果评价

目的探讨足底推拿对人工心脏起搏器安装术后病人便秘、体位性低血压、伤口愈合时间、睡眠时间、伤口疼痛的作用效果。方法将60例人工心脏起搏器安装术后病人,采用分层随机抽样法分为对照组30例和实验组30例,对照组予常规护理(止血、心电监护、皮肤护理、心理疗法等),实验组在对照组的基础上应用足底推拿护理技术。结果两组病人采用不同的护理方法对病人术后伤口疼痛、睡眠时间、便秘、体位性低血压、伤口愈合时间有显著性差异(P<0.01)。结论足底推拿能有效疏通全身经络,加速血液循环,改善全身症状,减少术后病人伤口疼痛和改善失眠,防止便秘,减少下床活动时体位性低血压等并发症,有利于提高病人的生活质量,加快了术后康复。     

二尖瓣返流病人收缩期左房内前向性血流的研究

本研究应用彩色多普勒超声心动图检测了31例收缩期左房内前向性血流。将脉冲多普勒取样容积置于二尖瓣口左房侧,在与负向性返流相并行的一侧出现收缩期正向性血流频谱时,定为前向性血流,彩色多普勒血流显示为红色血流。全部病人均经心血管造影及/或手术证实。结果表明,收缩期左房内前向性血流是由于大量、高速、偏心的血流在左房内折返形成漩涡而产生,此血流常发生于连枷样二尖瓣病人,阳性率为93.5％,也可以发生于非FMV严重的二尖瓣返流病人。     

The Treatment of Septicemia in Pacemaker Patients

The authors analyzed the data of seven patients who had undergone open heart surgery because of pacemaker endocarditis in the past 4 years. Repeated surgical interventions on the pacemaker system were found to be the most common predisposing factors. Staphylococcus aureus and Staphylococcus epidermidis were the most common causative organisms. Two-dimensional echocardiography was important in the diagnosis of cases with atypical clinical picture and negative blood cultures. We concluded that: (1) any pacemaker patient with fever should be considered to have a pacemaker endocarditis; (2) all of these patients should be examined by two-dimenensional echocardiography; and (3) the total removal of the infected hardware seems to be the only way to achieve complete recovery.     

The Etiology of Syncope in Pacemaker Patients

A total of 46 patients with syncopal episodes after VVI pacemaker implantation were studied. Of these, 92% had one to three syncopal episodes and 8% more than three. All underwent a thorough clinical examination, which included chest X ray, echocardiogram, neurological exam, and the following protocol: 24-hour Holter monitoring, EEG, blood pressure (BP) measurement in three positions, Doppler exam of the carotid vessels, fasting blood glucose, and head-up tilt table test (60 minutes, 60 degrees). Holter monitoring showed exit block in two patients (4.3%) and failed sensing in one (2.1%). In two patients there was unilateral slowing on EEG. Orthostatic hypotension was found in four patients (8.6%), and hypoglycemia in three insulin-dependent diabetics. An occlusive atherosclerotic plaque in the carotid artery was found in three patients (6.5%). Syncope was induced in 17 patients (36.9%) by the tilt table test, after a mean standing time of 47 +/- 11 minutes. The mean resting systolic BP of these patients was 140 +/- 24 mmHg, and fell to a mean level of 56 +/- 8 mmHg (mean systolic BP drop was 79 +/- 8 mmHg). Sixteen of these 17 patients with positive tilt table were being paced at the time of syncope and one had a spontaneous heart rate of 73 beats/min. In 14 cases (30.4%) the cause of syncopal episodes after this extensive workup remained unexplained. These results indicate that pacemaker dysfunction is not a major cause of syncopal episodes in pacemaker patients and that these are most often due to vasovagal syncope. Long-term follow-up is warranted to determine the prognostic significance of various types of syncope in pacemaker patients.     

术后随访在永久性心脏起搏器植入患者中的应用

目的探讨术后随访在永久性心脏起搏器植入患者中的应用效果。方法 2009年1月至2010年1月在哈尔滨医科大学附属第二医院心内科住院行永久性心脏起搏器植入的患者86例,患者出院后每3个月对其进行1次电话随访,为期2年;采用Zung焦虑自评量表(self-rating anxiety scale,SAS)和Zung抑郁自评量表(selfratingdepression scale,SDS)分别在患者出院前和出院后1及2年对其进行评估与比较。结果出院前、出院后1及2年,存在焦虑或抑郁症状的患者人数,差异有统计学意义(P<0.05或P<0.01)。结论术后长期、定期的随访,有利于减轻植入永久性心脏起搏器患者的焦虑及抑郁症状,有利于促进患者的术后康复。     

心室起搏管理功能对房室传导阻滞患者的近期疗效观察

目的观察具备心室起搏管理（MVP）功能的起搏器（Adapta）在Ⅱ度或间隙性Ⅲ度房室传导阻滞患者的近期效果。方法29例患者入选,分别置入具有MVP功能的Adapt起搏器（实验组,n=17）和其他类型双腔起搏器（对照组,n=12）。并分别在置入前和置入后1、3个月进行随访。随访中观察上述两组的右室起搏比例、心功能（纽约心功能分级、血脑钠肽）、左房内径、左室舒张末内径、左室射血分数等变化。结果置入双腔起搏器（Adapta）术后1个月及3个月,与对照组比较,实验组心室起搏比例明显降低（39．89％±41．21％vs96．48％±3．52％;40．91％±43．49％vs94．53％±4．62％,P均〈0．05）。其他指标两组间无明显差异。结论起搏器心室起搏管理功能可以在短期内降低心室起搏比例。     

Incidence and Significance of Chronotropic Incompetence in Patients with Indications for Primary Pacemaker Implantation or Pacemaker Replacement

This prospective study was undertaken to evaluate the incidence and significance of chronotropic incompetence in 211 patients [age 71.1 6 10.6 years (mean 6 SD)] by means of maximum exercise test in order to determine the indication for rate-responsive pacing before primary pacemaker implantation (147 patients) or pacemaker replacement (64 patients). There were 112 (53%) patients with second- or third-degree AV block, 63 (30%) with sick sinus syndrome, and 36 (17%) with chronic atrial fibrillation. Chronotropic incompetence was defined as maximum heart rate lower than age-adjusted norm calculated by the formula: 0.7x(220 - age) and its significance as the difference between the two rates. The overall incidence of chronotropic incompetence was 42%. The incidence was significantly higher in patients with atrial fibrillation (67%, P<0.0005) and sick sinus syndrome (49%, P<0.012) than in those with AV block (30%). The mean difference between maximum heart rate and the age-adjusted norm was 18% (range 2%-63%). The mean difference was significantly higher in patients with atrial fibrillation (27%, range 8-63%) than in those with sick sinus syndrome (19%, range 2%-45%, P<0.01), or with AV block (12%, range 6%-26%, P<0.000001). The rate-responsive pacemakers were implanted in 44% of 211 patients studied and in 43% of 196 patients excluded from the study due to the apparent (contra)indication of rate-responsive pacing (NS). Thus, chronotropic incompetence seems to be common in the pacemaker patient population. The highest incidence and significance was found in patients with chronic atrial fibrillation. Systematic evaluation of chronotropic competence can double the rate of implantation of rate-responsive pacemakers; however, further studies are needed to clarify relation between the significance of chronotropic incompetence and functional benefit of rate-responsive pacing.     

老年人应用心脏起搏器原因探讨

目的：了解老年人植入埋藏式心脏起搏器的病因。方法：将1987－1998年间270例首次入院植入心脏起搏器的临床资料进行回顾性分析。结果：①270例中，老年退行性心脏瓣膜病（SDHVD）占71．5％，是老年患者植入心脏起搏器的首要病因；②无论合并或不合并其他器质性心脏病而需植入起搏器的SDHVD患者中，传导阻滞的发生均多于病态窦房结综合征。结论：老年患者已成为心脏起搏治疗的主要人群且以SDHVD引起的心脏传导系统障碍为最常见。