植入型心律转复除颤器不适当治疗的原因分析及处理

Cause and treatment of inappropriate therapy of implantable cardioverter defibrillators

目的分析植入型心律转复除颤器（ICD）误诊断和误放电治疗的原因，寻找解决方法。方法34例住院病人，男性24例，女性10例，平均年龄（62．54±11．17）岁。植入单腔ICD（VVI）21例，双腔ICD（DDDR）3例，三腔ICD（CRT—D）10例，平均随访（20．72±16．98）个月。结果（1）ICD的误诊断和误放电治疗6例（占17．6％），其中单腔ICD3例，三腔ICD3例。（2）原因：1例（单腔ICD）对噪音误识别；4例患者是对心房颤动（AF）伴快速心室率的误识别，由于AF的心室率达到心室颤动（VF）检测区的标准，将其识别为VF。1例（V350型，ST．Jude公司）CRT-D患者因室上性心动过速（SVT）误电击7次，原因是ICD能正确识别SVT，但出厂设置了对SVT的最长诊断时间为60s，SVT持续60S后不消失，ICD自动按室性心动过速设置程序进行治疗，行3阵ATP治疗未转复继续电转复。（3）2例患者在VF区设立了快速室性心动过速（FVT）区，4次AF的心室率达到FVT检测区频率，经1阵抗心动过速起搏（ATP）治疗后转复。（4）共误放电40次。单腔ICD患者14次，三腔ICD患者26次。6例患者均发生在短时间内连续电击事件，1例患者曾在3h内发生7次电击事件。结论AF伴快速心室率（达到VF区的频率）是各种ICD误识别的主要原因，因此控制AF的心室率是减少ICD不适当治疗的基础。过多的电击治疗会给患者很大的痛苦和恐惧，建议加强药物治疗，必要时行射频消融治疗。

Objective The purpose of this study was to analyze the causes of inappropriate therapy and explore the treatment measure in patients with implantable cardioverter defibrillators （ICD）. Methods Thirty four patients 24 men and 10 women, mean age （62. 54 ± 11.17） years received ICDs. Among these patients, 21 received single-chamber ICD, 3 received double-chamber ICD and 10 received triple-chamber ICD （ CRTD）. The mean follow-up duration were （20. 72 ± 16. 89 ） months. Results Six （ 17.6% ） patients （3 singlechamber ICD, 3 CRT-D） experienced inappropriate detections and therapies of ICD during follow-up. One patient with single-chamber ICD received an inappropriate shock due to myopotential interference （noise）. The inappropriate shocks were caused by atrial fibrillation （AF） with rapid ventricular response reaching into ventricular fibrillation （VF） detect-zone in 4 patients. Device in the sixth patient with CRT-D （V350, ST. Jude Medical） detected supraventricular tachycardia （SVT） for 7 times. SVT were terminated by shocks after failed in ATPs when the lasting time of SVT was more than 60 seconds, because the longest time of discriminating SVT in device was 60 seconds. AF for 4 times in 2 patients is successfully terminated by ATP in FVT detectzone. Forty shocks 6 patients were caused by inappropriate detections, of which 14 occurred in single-chamber ICD and 26 occurred in triple-chamber ICD. The frequently shocks in a short time occurred in 6 patients. A patients received 7 shocks within 3 hours. Conclusions The rapid ventricular rate of AF in VF detect-zone was the main cause of inappropriate detections of ICD. Therefore control the ventricular rate of AF with medicine is important was patients with ICD. If the fast ventricular rate of AF is not controlled by medicine, the radiofrequency ablation of AF is the choice.