三维电解剖指导下极低射线的起搏器植入

Implantation of pacemakers using electro-anatomical mapping

目的 起搏器植入术是常见的X线透视下介入手术,但是这项技术也使患者和医生承受辐射风险.本研究分析使用三维电解剖标测（three-dimensional electro-anatomical mapping,3D-EAM）系统植入起搏器的可行性及优势.方法 回顾性分析2016年7月至2017年2月在温州医科大学附属第一医院行起搏器植入的45例患者.其中22例使用EnSite系统（原美国圣犹达公司）进行起搏器植入术,24例患者接受传统起搏器植入术.研究比较两组患者的手术指征、血清肌酐（Scr）、射血分数（EF）、总手术时间,X线曝光时间,起搏参数和并发症.结果 与常规组相比,3D-EAM组的X线曝光时间[（104±83）s对（754.2±452.0）s,P〈0.001]和X线曝光量[（6.79±4.46）mGy对（59.32±40.94）mGy,P〈0.001]显著减少,但手术时间稍长于对照组[（64±12）min对（56±24）min,P=0.090],两组间起搏器参数相似.在两组患者的手术中均没有并发症.术后随访6～12个月.随访时无并发症发生.心室阈值和感测振幅均在正常范围.结论 X线可用于指导起搏器导联在心室中的位置,然而一些特殊的患者,如儿童、育龄妇女、怀孕妇女必须避免曝光于射线.与X线透视相比,3D-EAM技术避免接触辐射,而且在放置心脏起搏器上同样有效.进一步研究3D-EAM技术的可行性和优势是必要的.

Objective The implantation of pacemakers is a common interventional procedure that is usually carried out under fluoroscopic control. There is an irreducible radiation risk for both the patient and doctors performing the procedure. Three-dimensional （ 3D ） electro-anatomical mapping （ EAM ） is a new technique for identifying anatomical structures of the heart that avoids any risk of radiation.We investigated the benefits and risks of implantation of pacemakers guided only by an electroanatomic navigation system compared to traditional,fluoroscopic techniques. Methods Twenty two patients[mean age（73±9. 6） years,40. 9% were males] underwent pacemaker implantation using the EnSite, electroanatomical mapping. Twenty four patients （45. 8% males,age 72±10. 3 years old） undergoing traditional pacemaker implantation served as controls.The procedure indication, serum creatinine （ Scr ） , ejection fraction （ EF ） , total procedure time, total fluoroscopy time, pacing and sensing parameters and complications were compared between the ESM technique and fluoroscopic controls. Results EAM implants resulted in significant reductions in fluoroscopy time [ （ 104 ± 83） s,vs. （754. 2±452）s,P〈 0. 001]and radiation exposure [（6. 79±4. 46） mGy vs.（59. 32±40. 94） mGy, P 〈 0. 001] compared to conventional implantation. While the procedure time was slightly longer than that in the controls [（64±12） min vs.（56±24） min, P=0. 09],pacing and sensing parameters obtained at the implantation were similar in both groups. No complications were recorded during the procedure in any patient. Patients were followed up six months to one year in the outpatient clinic after implantation. No complications were seen at follow-up.Ventricular threshold and sensing amplitudes were in normal ranges. Conclusions EAM techniques avoid exposure to radiation,and,are equally effective,in experienced hands,in placing pacemakers, compared to fluoroscopy. Further studies will be necessary to investigate the scope and utility of EAM techniques.