起搏器导线绝缘层破损表现及初步处理与随访

Clinical manifestation and preliminary management of pacemaker lead insulation damage.

目的总结起搏器导线绝缘层破损病例表现及初步处理方法。方法回顾性分析2014年1月至2021年7月,646例行动态心电图监测起搏器功能,发现与导线绝缘层破损相关的病例10例,且导线绝缘层破损经X线检查证实。出现异常时间在植入起搏器后(63.73±36.64)个月,10例破损导线均为翼状、心室双极导线。运用程控检查、动态心电图监测,结合患者临床表现,通过调整起搏器参数进行初步处理及随访。结果 10例患者,其中4例因间断胸闷、头晕、黑矇就诊,1例因左胸壁明显搏动感就诊,其余5例为常规随访时发现导线绝缘层破损。9例表现为心室导线阻抗降低,1例为阻抗升高,10例单极阻抗为(275.1±92.60)Ω。感知参数发现异常时,导线感知极性均为双极。起搏参数发现异常时,6例导线起搏极性为单极,4例为双极,心室起搏阈值与电极极性有关。动态心电图均表现为间歇性过感知(其中2例为单纯过感知),8例合并间歇性感知不良,6例合并间歇性起搏不良。1例随访2年后,因导线损坏程度加重,进展为持续感知、起搏不良。10例均将心室导线极性由双极改为单极,根据不同表现,通过降低感知灵敏度、调整起搏电压、程控DDD为AAI、关闭自动阈值测试功能等措施,能使起搏器起搏功能正常运行。结论绝缘层破损,通过动态心电图定期跟踪监测,可协助分析不适原因、评估风险性、精准指导参数动态调整,并评价调整后效果。

Objective To summarize the manifestations and preliminary management of pacemaker lead insulation damage. Methods From January 2014 to July 2021, 646 cases of dynamic ECG monitoring pacemaker function were analyzed retrospectively. 10 cases related to the damage of wire insulation were found, and the damage of wire insulation was confirmed by X-ray examination. The abnormal time was(63.73 ± 36.64) months after pacemaker implantation. The damaged leads in 10 cases were wing and ventricular bipolar leads. Using program-controlled examination, dynamic ECG monitoring, combined with the patient′s clinical manifestations, the pacemaker parameters were adjusted for preliminary management and follow-up. Results Among the 10 patients, 4 cases seek medice advice for intermittent chest tightness, dizziness and amaurosis, 1 case got to a doctor for obvious pulsation of the left chest wall, and the other 5 cases were found to be damaged during routine follow-up. The impedance of ventricular leads decreased in 9 cases and increased in 1 case;The single-stage impedance of 10 cases was(275.1 ± 92.60) Ω. When the sensing parameters were abnormal, the sensing polarities of the wires were bipolar. When abnormal pacing parameters were found, the lead pacing polarity was unipolar in 6 cases and bipolar in 4 cases. The ventricular pacing threshold was related to the electrode polarity. Ambulatory ECG showed intermittent over perception(2 cases were simple over perception), 8 cases were complicated with intermittent poor perception, and 6 cases were complicated with intermittent poor pacing. One case was followed up for 2 years and progressed to poor continuous sensing and pacing due to the aggravation of lead damage. In 10 cases, the polarity of ventricular lead was changed from bipolar to unipolar. According to different manifestations, the pacing function of pacemaker can be operated normally by reducing sensing sensitivity, adjusting voltage output, programmed DDD as AAI and turning off automatic threshold test function. Conclusion The insulation layer damage can be tracked and monitored regularly by dynamic electrocardiogram,which can help to analyze the causes of discomfort, evaluate the risk,accurately guide the dynamic adjustment of parameters,and evaluate the effect after adjustment.