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高龄患者植入永久性心脏起搏器的临床观察
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DOI:
作者:
胡春燕1 李自强1 蒋庆渊1 朱军2 罗心平2 施海明2
HU Chun-yan,Li Zhi-qiang,Jiang Qing-yuan , Zhu Jun, Luo Xin-ping,Shi Hai-ming
作者单位:
1上海市浦东医院 上海复旦大学附属浦东医院 2 上海复旦大学附属华山医院
Shanghai Pudong Hospital, Fudan University Pudong Medical Center
关键词:
心脏起搏器; 高龄患者; 缓慢性心律失常
cardiac pacemaker; elderly patients bradyarrhythmia
摘要:
[摘要] 目的 观察合并缓慢性心律失常高龄患者永久性心脏起搏器植入情况及安全性。 方法 分析2005年1月 ~ 2013年4月收治的187例因缓慢性心律失常植入永久性心脏起搏器的高龄患者。植入单腔起搏器(VVI模式)125例(66.8%),双腔起搏器(DDD模式)62例(33.2%)。置入方法:起搏电极经锁骨下静脉穿刺置入者166例(88.8%)(其中左锁骨下静脉穿刺142例,右锁骨下静脉穿刺24例),经腋静脉穿刺置入者21例(11.2%)(其中经左腋静脉穿刺18例,右腋静脉穿刺3例)。分析手术完成情况、电极导管参数及术后并发症,随访患者出院后1 ~ 12月预后情况。结果 (1)手术完成情况:187例患者起搏器全部植入成功,电极导管参数:心房、心室起搏阈值均<1V,腔内R波振幅均>5mV,腔内A波振幅均>2mV。术中发生急性肺水肿1例,给予呋塞米治疗缓解,术中患者烦躁、不配合2例,肌肉注射安定完成手术,手术成功例100%。(2)手术并发症:术后发生气胸2例,均为双腔起搏器,术中有多次锁骨下静脉穿刺史。无心脏穿孔、电极脱位、囊袋血肿、囊袋感染、切口不愈合并发症。(3)随访结果:1年内死亡2例,1例植入单腔VVI起搏器患者出院后1月并发大面积脑梗死死亡,1例103岁植入单腔VVI起搏器患者术后2周急性肺水肿、急性肾功能衰竭死亡。植入单腔VVI起搏器术后发生心衰15例(12%),植入双腔DDD起搏器术后发生心衰9例(11.3%),其余患者自觉症状和活动能力均明显改善,晕厥、头晕、黒朦、乏力症状消失,胸闷、气急好转,无电极脱位、电极断裂、起搏器综合征并发症。结论 高龄患者植入永久性心脏起搏器是安全有效的,预后良好。采用采用腋静脉途径安置起搏电极,可降低锁骨下静脉途径的气胸和挤压综合征。该方法安全可行,值得推广。
[Absrract] Objective To investigate the status and safety of Implantation of permanent cardiac pacemaker in elderly patients with bradyarrhythmia. Methods We studied 187 elderly patients implanted permanent cardiac pacemaker because of bradyarrhythmia from January 2005 to April 2013. The 125 patients(66.8%) were implanted single chamber pacemaker(VVI model), the other 62 patients(33.2%) were implanted double chamber pacemaker(DDD model). Operation method: The 166 patients(88.8%) were inserted electrode catheter through subclavian vein puncture (including 142 through left subclavian vein and 24 right subclavian vein), the 21 patients(11.2%) through axillary vein(including 21through axillary subclavian vein and 24 axillary subclavian vein). Analyse the outcomes of operation completion, electrode catheter parameter, postoperative complications and prognosis of follow-up 1 ~ 12 months after discharged from hospital. Result (1) All the 187 patients were implanted cardiac pacemaker successfully. The pacing threshold of electrode catheter in atria and ventricles were all less than one volt. The R wave amplitude of heart chamber were all over 5 millivolt and the A wave amplitude over 2 millivolt. One patient occured acute pulmonary edema during operation, the symptom alleviated by intravenous injection of furosemide. Two patients were accomplished the operation by intramuscular injection of diazepam because of fidgets and ignoreing instructions. (2)Operative complications: Pneumothorax occurred in two patients that both implanted double dual chamber pacemaker and got multiple subclavian vein puncture. The other complications including cardiac perforation, electrode dislocation, pocket hematoma, pocket infections, operative incision disunion did not happended. The operation success rate was 100%. (3) Fllow-up result: Two patients died in a year. One 83 years old patient implanted with VVI pacemaker died for massive cerebral infarction one month after discharged from hospital, another 103 years old patient implanted with VVI pacemaker died for acute pulmonary edema and acute renal failure two weeks after discharged from hospital. 15 patients(12%) implanted with VVI pacemaker occurred heart failure and 9 patients(11.3%) implanted with DDD pacemaker occurred heart failure. The other patients felt their subjective symptoms and exercise capacity improved obviously, dizziness, amaurosis, syncope and feebleness disappeared, chest distress and dyspnea alleviated. Electrode dislocation, electrode fracture and pacemaker syndrome did not appeared. Conclusions: Implantation of permanent cardiac pacemaker in elderly patients was safe and effective and the prognosis was satisfactory. Inserting electrode catheter through axillary vein puncture could reduce the incidence of pneumothorax and crush syndrome caused by subclavian vein puncture.This method was safety ad practicable and should be applied.
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