心脏再同步化治疗中经胸心外膜起搏导线的植入技术

The technique of epicardial lead implanted by thoracotomy in cardiac resynchronization therapy

目的探讨经胸心外膜左心室导线植入在慢性充血性心力衰竭心脏再同步化治疗中的意义。方法对1例经静脉植入左心室导线因冠状静脉窦开口畸形而放弃的患者行经胸植入左心室心外膜导线植入。结果右心房、右心室心内膜起搏导线植入及两根心外膜起搏导线缝合均顺利,术后未出现严重并发症。术后2周后临床症状逐渐改善,NYHA心功能分级从术前Ⅲ、Ⅳ级提高至Ⅱ级,LVEDD从72mm减至66mm,优化程控起搏器后超声心动图描记术检查室间隔基底部与左心室侧壁间失同步性改善,第3天心外膜起搏导线阈值从术中的2.0V降为0.5V且稳定。已随访12周临床症状、心功能改善,组织多普勒显像示左心室内恢复同步化。结论心脏再同步化治疗经胸心外膜左心室导线植入是安全、可行的,特别是对经静脉途径失败的患者,是可选择的方法之一;术中左心室导线的定位及术后的综合处理十分重要。

Objective To explore clinical value of left ventricular （LV） epicardial lead implanted by thoracotomy in cardiac resynchronization therapy （CRT） of chronic congestive heart failure. Methods LV epicardial leads were implanted by thoracotomy in a patient after failed coronary sinus implantation for abnormal ostium of coronary sinus. Results Right atrial and ventricular endocardial leads and two LV epicardial leads were implanted successfully without any serious complication. Pacing threshold of the epicardial leads decreased from 2.0V during operation to 0.SV at third day post operation. Clinical symptoms improved gradually, NYHA functional class reduced from Ⅲ～Ⅳ to Ⅱ, LV diastolic diameter decreased from 72mm to 66mm, and dyssynchrony between interseptal base and LV lateral wall ameliorated under optimum pacing parameters two weeks later. Tissue Doppler image displayed resynchronization of LV contraction during 12 weeks follow-up. Conclusion LV epicardial lead implanted by thoracotomy is safe and feasible in CRT after failed transvenous approach. LV epicardial lead positioning during operation and rational management after operation is very important.