Management of a patient with an unusual trajectory of a temporary trans-venous pacing lead

Perforation of the right ventricle during placement of pacing wires is a welldocumented complication and can be potentially fatal.Use of temporary pacemaker,helical screw leads and steroids use prior to implant are recognised as risk factors for development of post-permanent pacemaker effusion.We reported an unusual case of pacing wire perforating interventricular septum into the left ventricle that occurred during the implant procedure performed in another institution.After the preoperative work-up and transfer to our tertiary cardiothoracic centre,the patient underwent successful surgical management.In conclusion,early recognition and timely diagnosis using advanced multimodality imaging can guide surgical intervention and prevent unfavourable consequences of device-related complications.

Inadvertent Lead Malposition in the Left Ventricle during Permanent Ventricular Pacing about One Case

Inadvertent Lead Malposition in Left Ventricle is a rare and underdiagnosed incident, which may occur during implantation of cardiac electronic devices and may remain asymptomatic. We reported the case of a 71-year-old man who was implanted with a ventricular single-chamber pacemaker for a slow atrial fibrillation with syncope and whose routine transthoracic echocardiography 23 months after implantation displayed a malposition of the pacemaker lead into the Left Ventricle through a patent foramen oval. The patient was asymptomatic. The electrocardiogram showed right bundle branch block QRS-paced morphology with a positive QRS pattern in V1, a median paced QRS axis on the frontal plane at -120°, a Precordial transition on V5. At the lateral Chest X-ray the lead curved backwards to the spine. Given the age of this old patient who already received oral anticoagulant for Atrial Fibrillation and the Lead malposition discovered 23 months after pacemaker’s implantation, we decided to maintain the lead in LV and continue anticoagulation.

Right Ventricular Outflow Tract Septal Pacing versus Apical Pacing: A Prospective, Randomized, Single-blind 5-Years Follow-up Study of Ventricular Lead Performance and Safety

Summary： Lead placement for ventricular pacing variably impacts the physiological benefit of the pa- tient. This study evaluated the ventricular lead performance and safety of right ventricular outflow tract septal pacing in patients with bradyarrhythmia in South China over 60-month follow-up. Totally, 192 patients （108 males, and 84 females, 63-4-21 years old） with bradyarrhythmia were randomly divided into two groups. The right ventricular outflow tract septum （RVOTs） group had lead placement near the sep- tum （n=97）, while the right ventricular apex （RVA） group had a traditional apical placement （n=95）. RV septal lead positioning was achieved with a specialized stylet and confirmed using fluoroscopic projec- tion. All patients were followed up for 60 months. Follow-up assessment included stimulation threshold, R-wave sensing, lead impedance and lead complications. The time of electrode implantation in both the ROVTs and RVA groups were significantly different （4.29±0.61 vs. 2.16±0.22 min; P=0.009）. No dif- ferences were identified in threshold, impedance or R-wave sensing between the two groups at 1 st, 12th, 36th and 60th month during the follow-up period. No occurrence of electrode displacement, increased pacing threshold or inadequate sensing was found. The long-term active fixation ventricular electrode performance in RVOTs group was similar to that in RVA group. RVOTs pacing near the septum using active fixation electrodes may provide stability during long-term follow-up period.

Implantation of Lumenless Pacing Leads at the Inter-atrial Septum and Right Ventricular Outflow Tract with Deflectable Catheter-sheath

Current permanent right ventricular and right atrial endocardial pacing leads are implanted utilizing a central lumen stylet. Right ventricular apex pacing initiates an abnormal asynchronous electrical activation pattern, which results in asynchronous ventricular contraction and relaxation. When pacing from right atrial appendage, the conduction time between two atria will be prolonged, which results in heterogeneity for both depolarization and repolarization. Six patients with Class Ⅰ indication for permanent pacing were implanted with either single chamber or dual chamber pacemaker. The SelectSecure 3830 4-French （Fr） lumenless lead and the SelectSite C304 8.5-Fr steerable catheter-sheath （Medtronic Inc., USA） were used. Pre-selected pacing sites included inter-atrial septum and right ventricular outflow tract, which were defined by ECG and fluoroscopic criteria. All the implanting procedures were successful without complication. Testing results （mean atrial pacing threshold： 0.87 V; mean P wave amplitude： 2.28 mV; mean ventricular pacing threshold： 0.53V; mean R wave amplitude： 8.75 mV） were satisfactory. It is concluded that implantation of a 4-Fr lumenless pacing lead by using a streerable catheter-sheath to achieve inter-atrial septum or right ventricular outflow tract pacing is safe and feasible.

Leadless Cardiac Pacemaker: Does Anatomical Position at Implant Affect Long-Term Electrical Performance?

Background: The Nanostim {trade mark, serif} Leadless Cardiac Pacemaker (LCP) has been shown to be safe and effective in human clinical trials. Since there is little information on the effect of implant location on LCP performance, the aim of this study was to determine whether anatomic position affects the long-term pacing performance of the LCP. Methods: Patients who enrolled in the Leadless II IDE Clinical Trial and had finished 6 months follow up (n = 479) were selected for the study. The implanting investigators determined the LCP final position under fluoroscope, which was categorized into three groups: RV apex (RVA, n = 174), RV apical septum (RVAS, n = 101), and RV septum (RVS, n = 204) (Figure 1). Data on capture threshold (at a 0.4 ms pulse width), R-wave amplitude and impedance were analyzed at implant, hospital discharge and 2 weeks, 6 weeks, 3 months and 6 months post-implant. Results: At implant, the mean capture thresholds in the RVA, RVAS and RVS were 0.77 ± 0.45, 0.81 ± 0.61 and 0.78 ± 0.59 volts, respectively. R-wave amplitudes were 8.0 ± 3.0 mV, 7.7 ± 2.9 mV and 7.6 ± 2.9 mV, respectively. Impedance values were 727 ± 311, 765 ± 333, and 677 ± 227 respectively. There were no differences among the 3 implant locations in capture threshold or R-wave amplitudes at 6 months (P > 0.06);however, all 3 performance parameters significantly improved over time (P < 0.001). Conclusions: The LCP implant location does not affect capture thresholds or R-wave amplitudes at 6 months, and there is little effect on impedance. Although implant location does not appear to be a predictor of electrical performance, additional long-term data will help guide optimal implant location.

Lead helix winding tricuspid chordae tendineae: A case report

BACKGROUND As left bundle branch pacing(LBBP)is more like physiological pacing,LBBP has emerged as a novel pacing strategy that uses the native conduction system to improve ventricular synchronization with stable pacing parameters.LBBP has been revealed associated with a significantly reduced risk of new-onset atrial fibrillation and heart failure compared with conventional permanent pacemaker implantation.CASE SUMMARY A 64-year-old man was admitted with a 24-h history of chest distress and shortness of breath,which continued unabated.The patient had no symptoms of chest pain,dizziness,syncope,nausea nor vomiting.There were no abnormalities found in routine examinations after admission.Twelve-lead electrocardiogram presented a result of 2:1 atrioventricular block.Coronary angiography was performed the next day and no abnormality was found.Finally,the patient agreed to received LBBP and signed the informed consent.During the process of withdrawing the Medtronic Model 3830 lead into sheath,we found the lead helix was wrapped around the chordae tendineae of the septal valve of tricuspid.Attempts to rotate the 3830 lead failed to release the lead helix from the chordae tendineae,and ultimately we used radiofrequency ablation to ablate the wrapped chordae tendineae.CONCLUSION Radiofrequency ablation effectively solved this problem without complications.It is an effective and reliable method to resolve lead winding chordae.

急性心脏电极穿孔的处理策略分析

目的:分析和总结心律置入装置置入术后急性心脏电极穿孔的处理策略。方法:回顾性分析2007年1月至2019年1月,于北京大学人民医院因急性心脏电极穿孔成功拔除穿孔电极患者的临床资料。结果:共25例急性心脏电极穿孔患者成功拔除穿孔电极,其中合并心包积液4例(16.0%);伴有周围器官损伤1例(4.0%),表现为穿孔电极导线由右心室流出道部穿出,并穿入左肺,同时造成左侧液气胸。25例患者术前血流动力学均稳定,收缩压(129.7±11.2)mmHg(1mmHg=0.133kPa),舒张压(70.8±9.8)mmHg。经静脉拔除24例(96.0%),经开胸手术成功拔除穿孔电极1例(4.0%)。经静脉拔除患者中,直接拔除22例(88.0%),经锁定钢丝拔除2例(8.0%)。1例经静脉拔除患者术后发生肺栓塞,经抗凝治疗后好转。结论:对于血流动力学稳定且不伴周围器官损伤的急性心脏电极穿孔患者,经静脉拔除穿孔电极是安全有效的处理策略。

“先跟后带”沟通模式在基层官兵思想教育中的应用探析

基层官兵思想教育是军队思想政治教育的重要组成部分,新时代基层官兵对说教式、批评式、质问式、命令式等沟通模式存在阻抗心理,导致个体思想政治教育效果不佳。“先跟后带”沟通模式是一种有效的沟通对话模式,通过“先跟”建立和谐关系,使受教育者愿意跟教育者敞开心扉说想法、谈感受,然后再运用“后带”让对方更愿意接受教育者传递的信息并做出改变,从而实现思想政治教育的目的。

Unexpected challenging case of coronary sinus lead extraction

An 84-year-old woman implanted with cardiac resynchronization therapy defibrillator underwent transvenous lead extraction 4 mo after the implant due to pocket infection. Atrial and right ventricular leads were easily extracted, while the attempt to remove the coronary sinus(CS) lead was unsuccessful. A few weeks later a new extraction procedure was performed in our center. A stepwise approach was used. Firstly, manual traction was unsuccessfully attempted, even with proper-sized locking stylet. Secondly, mechanical dilatation was used with a single inner sheath placed close to the CS ostium. Finally, a modified sub-selector sheath was successfully advanced over the electrode until it was free of the binding tissue. The postextraction lead examination showed an unexpected fibrosis around the tip. No complications occurred during the postoperative course. Fibrous adhesions could be found in CS leads recently implanted requiring nonstandard techniques for its transvenous extraction.

Bipolar Leads for Prevention of Phrenic Nerve Stimulation: Results from the ORPHEE Observational Study

Background: Up to one in three patients implanted with a cardiac resynchronization therapy-defibrillator (CRT-D) device experience phrenic nerve stimulation (PNS). Quadripolar leads are effective at reducing PNS, but compared to standard bipolar leads they have limitations related to maneuverability and high pacing thresholds. The ability of standard bipolar leads to overcome PNS is explored here. Methods: The French multicenter, observational study ORPHEE enrolled 90 CRT-D-eligible patients. Detection of PNS took place after satisfactory positioning of the LV bipolar lead (stable pacing threshold - LV ring, LV tip - RV ring and LV ring - RV coil) could prevent PNS from occurring in at least 90% of patients. Results: In 80 evaluable patients, PNS was reported in 12 patients (15%). Reprogramming overcame PNS in 10 patients: LV ring - RV coil in 8 patients;LV tip - LV ring in 1;and LV tip- RV ring in 1. As PNS was avoided in 78 of 80 patients (97.5%), the primary endpoint was significant (97.5% vs. 90%, p = 0.01). Conclusion: During CRT-D implantation, PNS occurred in 15% of patients. In most (97.5%) implanted patients, PNS could be avoided by vector reprogramming using a bipolar LV lead. For patients whose coronary sinus anatomy precludes the implantation of multi-electrode leads, bipolar leads are a suitable, reliable alternative.

Hemothorax induced by cardiac perforation resulting from two active screw-in leads: A case report

We describe the case of a 77-year-old female who underwent dual-chamber permanent pacemaker implantation using two active screw-in leads for complete atrioventricular block. The two active screw-in leads perforated the atrial and ventricular walls causing cardiac tamponade and a left hemothorax associated with ventricular perforation. An emergency sternotomy was performed to facilitate drainage and hemostasis. Although hemothorax due to pacing lead perforation is very rare, such a possibility should always be considered.

心室主动电极体外临时持续起搏的安全性及有效性

目的:评价心室主动电极体外临时持续起搏的安全性及有效性。方法:回顾性分析2014年1月至2022年1月于北京大学人民医院因起搏器感染行电极拔除术且起搏器依赖患者共415例,均使用心室主动电极体外桥接临时持续起搏。收集临床资料及随访结果,分析其安全性及有效性。结果:415例患者平均年龄(63.8±11.7)岁,男性315例(75.9%)。局部囊袋感染310例(74.7%),菌血症75例(18.1%),感染性心内膜炎30例(7.2%),病态窦房结综合征185例(44.6%),高度或完全性房室阻滞30例(55.4%)。穿刺点位于同侧锁骨下或腋静脉315例(75.9%),右侧颈内静脉入路100例(24.1%)。405例(97.6%)为右心室间隔部临时起搏,10例(2.4%)由于不耐受单腔起搏模式而选择了右心房+右心室双腔体外临时起搏。临时起搏电极保留时间为(15.3±11.6)d,4例(0.9%)出现与临时起搏相关的并发症。中位随访24.5(7.8,51.3)个月期间,1例(0.3%)患者再次出现起搏器感染。结论:对于起搏器依赖患者在感染装置拔除后,心室主动电极体外临时持续起搏安全、有效,临时起搏相关并发症发生率低。

老年病人起搏器植入术后三尖瓣反流的影响因素分析

目的分析老年病人心脏起搏器植入术后三尖瓣反流(tricuspid regurgitation,TR)发生或发展的影响因素。方法回顾分析2012年1月至2021年1月在我科行心脏起搏器植入的264例老年病人术后TR的情况。术后出现新的TR或TR程度较术前加重的病人为加重组,其余为未加重组。比较2组病人的术前临床资料及二维超声心动图参数,并对病人术后TR的影响因素行多因素Logistic回归分析。结果264例植入起搏器的老年病人中,新发TR或TR加重共87例,发生率为33.0%。加重组年龄,术前三尖瓣轻度反流、右室心尖起搏比例及植入年限高于未加重组(P<0.01);左心房内径(LAD)、右心房内径(RAD)大于未加重组(P<0.01)。Logistic回归分析表明,RAD增大、术前三尖瓣轻度反流、右室心尖起搏、植入年限是植入心脏起搏器术后TR发生或发展的独立影响因素(P<0.05)。结论老年病人术前RAD增大、起搏电极位于右室心尖部、心脏起搏器植入年限长是术后TR发生或发展的危险因素,术前三尖瓣轻度反流是术后TR发生或发展的保护因素。

紧急床旁临时心脏起搏173例分析

对两种临时心脏起搏方法的效果和并发症作一分析。１７３例严重心律失常患者分别采用两种床旁临时起搏方法：即用球囊飘浮电极经静脉心内膜起搏１６９例，用钢丝电极剑突下经皮穿刺心内膜起搏４例。结果：用球囊飘浮电极经静脉心内膜起搏全部成功，起搏７（１～３１）天，电极脱位６例经重新安置电极后恢复起搏；穿刺损伤胸导管１例。用钢丝电极剑突下经皮穿刺心内膜起搏４例，１例成功；３例因心脏停搏时间太久而失败。结论：两种临时心脏起搏方法急救不宜搬动的严重心律失常病人均有效。

电极导线在右室心尖部和右室流出道起搏的随访观察

目的评价螺旋电极导线行右室流出道(RVOT)间隔部起搏的可行性。方法连续入组195例具有植入起搏器适应证患者,术前随机分为螺旋主动固定电极导线的RVOT间隔起搏组(A组)和翼状被动固定电极导线的右室心尖部(RVA)起搏组(B组),两组中每例入选患者均分别行RVA和RVOT两个部位起搏测试,最后固定于相应的位置。比较两组术中手术时间、起搏参数、起搏QRS波宽度、手术成功率及起搏3个月、1年和2年后电极导线参数的变化。结果 A组99例,B组96例。两组起搏后QRS波宽度明显大于起搏前,B组起搏QRS波时限长于A组(176.46±24.54 ms vs 165.45±22.78 ms,P=0.001)。用于固定RVOT间隔部的曝光时间长于RVA。两组术中及术后并发症相似,R波振幅术后2年内及两组间无差别。术中A组起搏阈值高于B组(0.71±0.30 V vs0.56±0.19 V),术后2年内起搏阈值两组内及组间无差异。术后3个月时阻抗下降,A组的阻抗低于B组并持续整个随访期间。术后2年内超声心动图参数组内及组间无差别。结论采用螺旋主动固定电极导线进行RVOT起搏是安全可行的。

主动固定电极导线脱位的临床特点及处理措施

目的主动固定电极导线广泛应用于临床,电极导线脱位是心脏起搏器置入术的严重并发症,文中旨在探讨主动固定电极导线脱位的临床特点及处理措施。方法回顾性分析1341例起搏器植入患者中,电极导线脱位的临床资料及处理措施。结果电极脱位患者12例,有13根电极导线脱位。其中9根主动固定电极导线脱位,包括心房主动电极2根及心室主动电极7根;3根主动固定电极导线脱位发生于术后1个月内,6根发生于术后1个月后。4根被动电极导线脱位,包括心房电极2根及心室电极2根,均发生于术后1个月内。所有脱位主动固定电极均被安全拔除。结论主动固定电极导线脱位发生率与被动电极相似,但远期脱位率呈增多趋势。在起搏器安装时要采取必要的措施预防电极脱位。

右室中位间隔起搏的可行性与安全性

目的评价中位右室间隔起搏(RVSP)方法的可行性和安全性。方法选择101例行RVSP,右室心尖部起搏(RVAP)126例作对照。在X线指导下将室间隔分四区,分别为His束区、右室流出道间隔区、低位前间隔区和右室流入道间隔区,精确定位RVSP的主动导线在中位间隔位置。记录术中曝光时间、电极导线植入参数、心电图和术后第3,6,12个月随访资料。结果两组手术曝光时间无差异。RVSP组起搏前后的QRS波形态有稳定的特征性变化,可结合X线用于指导导线定位。RVSP组起搏后的QRS波时限明显小于RVAP组(98.19±22.30 msvs 120.80±24.14 ms,P<0.01),术中两组的心室导线的起搏阈值、电流、阻抗均存在明显差异(0.76±0.30 V vs0.39±0.10 V,0.98±0.52 mA vs 0.36±0.19 mA,690.67±141.64Ωvs 867.16±201.23Ω,P<0.01)。在随访中两组心室起搏阈值和阻抗较稳定。结论在X线指导下将室间隔分区,主动导线能精确、快捷地固定于右室中位间隔部。该部位是较理想的起搏部位,安全可行。

主动电极右心室间隔部起搏损伤电流、起搏参数和电极稳定性的关系

目的探讨主动电极右心室间隔部(RVS)起搏损伤电流(COI)、起搏阈值、R波感知阈值、电极阻抗和被植入电极稳定性的关系。方法选取主动电极RVS起搏患者82例,术中或术后根据电极是否发生脱位分为A组(无脱位组)76例和B组(脱位组)6例,分别测试电极固定即刻损伤电流(COI0 min)和10 min后损伤电流(COI10 min),测试电极固定术后10 min和3个月后起搏阈值、R波感知阈值和电极阻抗。结果术中A组COI0 min、COI10 min均高于B组,两组比较差异均有统计学意义(P <0.01);电极固定10 min后测试A组起搏阈值低于B组,A组R波感知阈值高于B组,两组比较差异均有统计学意义(P <0.01)。结论主动电极RVS起搏植入术中损伤电流大、起搏阈值低、R波感知阈值高提示主动电极固定的稳定性好。

起搏器更换时原起搏电极导线参数及更换指标分析

目的：分析74例更换起搏器时电极导线的各项参数的变化并探讨导线更换指标。方法：本组年龄12—87（62．8±18．4）岁，其中病窦综合征45例，房室传导阻滞29例，均为单腔VVI起搏。结果：至测量时原心室起搏电极导线的埋置时间60—148（97．4±22．8）月，首次埋置时起搏阈值为（0．48±0．24）V，更换时为（1．29±0．64）V（P〈0．01），增加0．81V，增幅为168％，首次植入时R波幅为（7．8±3．6）mV，更换时为（5．9±3．4）mV（P〈0．05）。植入时电极导线阻抗为（664±122）n，更换时阻抗为（726±148）n，增幅9．3％（P〉0．05）。7例因起搏阈值大于2．0V或阻抗大于125Ω而重新植入电极导线。原电极导线使用率为90．5％。结论：埋置起搏电极导线8—9年后，90．5％原电极导线仍在可使用的范围内，能否支持到再次更换需进一步随访。

经永存左上腔静脉植入起搏电极导线9例分析

目的:回顾性分析经永存左上腔静脉植入起搏电极导线患者的临床资料,为临床医生提供参考。方法 :本研究入选了2009~2019年在中国医学科学院阜外医院经永存左上腔静脉植入起搏电极导线的患者9例,其中男性2例,女性7例,平均年龄为(47±25)岁。分析患者基线特征、导线类型、导线植入成功率、术中起搏参数等。术后3个月和6个月常规随访,以后每6~12个月随访。测试起搏阈值、感知及导线阻抗等参数,并随访观察并发症发生情况。结果 :9例患者中3例合并先天性心脏病,7例患者为孤立性永存左上腔静脉,2例为双上腔静脉,其中1例患者因右侧锁骨下静脉闭塞,被迫经左上腔静脉植入起搏导线,另1例患者因右锁骨下静脉留置深静脉管,选择经左上腔静脉植入起搏导线。术中2例病态窦房结综合征患者心室导线植入失败,选择植入心房单腔起搏器;1例病窦综合征患者心房导线植入失败,选择植入心室单腔起搏器。随访期间,1例患者于术后2周发现心室导线脱位,选择经右侧重新植入,其余患者未见并发症。随访中位时间1.8(1.1,4.3)年,随访期间心房、心室导线参数稳定。结论:经永存左上腔静脉植入心房、心室起搏电极导线均存在一定难度,短期内存在导线脱位风险,但远期导线参数稳定。双上腔静脉患者应避免经永存左上腔静脉植入导线。