生理性与非生理性起搏对术后房性心律失常的影响

探讨病窦综合征 (SSS)、房室阻滞 (AVB)患者安置生理性起搏器 (AAI/DDD)与非生理性起搏器 (VVI)对术后房性心律失常的影响 ,分别对 4 6例AAI/DDD与 6 1例VVI起搏患者进行术前及术后近 1年的心电图、动态心电图、心脏超声心动图检查随访。结果 :AAI/DDD组房性心律失常的发生率由术前的 5 0 %降至术后的 32 % ,VVI组发生率由术前的 4 4 .2 %上升至术后的 6 5 .5 % ,差异有显著性 (P <0 .0 1)。AAI/DDD组术后左室射血分数和心输出量改善 (P <0 .0 5 ) ,房室大小无明显变化 (P >0 .0 5 ) ;VVI组术后左室射血分数和心输出血下降 ,心房、心室扩大 (P <0 .0 1)。结论 :生理性起搏优于非生理起搏 ,前者有利于消除心律失常、改善心功能。     

不同起搏方式对病窦综合征患者房颤发生率的影响

目的　比较病窦综合征患者经心室按需起搏 (VVI)和心房起搏 [包括单心房起搏(AAI)、房室双腔起搏 (DDD)和双房起搏 ]治疗术后前 5年房颤的发生率。方法　对永久性人工心脏起搏器植入术后 5年以上、资料完整的 117例病窦综合征患者进行连续随访 ,平均随访时间(69.3± 6.7)个月 ,其中VVI起搏 83例 ,心房起搏 3 4例。随访内容包括临床表现、心电图和起搏器参数等 ,部分患者有Holter检查资料 ,分析 5年内两组病例房颤的发生率。结果　病窦综合征患者心脏起搏治疗前 5年内总的房颤发生率为 17.0 9% (2 0 /117) ,其中经VVI起搏的 83例患者房颤发生率为 2 2 .89% (19/83 ) ,经心房起搏的 3 4例患者房颤发生率为 2 .94% (1/3 4) ,后者房颤的发生率显著低于前者 (P <0 .0 1)。结论　在起搏治疗的病窦综合征患者中 ,术后前 5年心房起搏比心室起搏治疗有较低的房颤发生率     

病窦综合征患者心房起搏的随访结果

<正> 病窦综合征患者既可以选择心房起搏方式(AAI),也可以选择心室起搏方式(VVI),或双腔起搏(DDD).但DDD起搏费用偏高,而使部分病人难以接受,VVI起搏方式存在室房分离,因而难以保持心房收缩时对心室充盈的辅助泵作用,起搏器综合征,心房颤动,心力衰竭,血栓栓塞等并发症均较高,而且不能改善生存率.AAI起搏保持了房室顺序及心室同步功能,具有良好的血流动力学效应.是近年来病窦综合征患者主要的起搏方式之一.本文对45例心房起搏患者进行了随访,现报告如下.     

不同心室起搏策略对病窦综合征患者心室起搏百分比及心功能的潜在影响

目的观察不同心室起搏策略减少病窦综合征心室起搏百分比(Cum%VP)的效果以及潜在的心功能影响。方法将90例因病窦综合征植入美敦力Adapta系列起搏器的患者分为3组,分别程控为心室起搏管理(MVP)组、固定延长房室间期(LAVD)组和增强的房室间期自动搜索(Search AV+)组。随访12个月后,观察1不同起搏策略Cum%VP的差异;2血清脑利钠肽前体(NT-pro BNP)变化;3彩色超声心动图参数如左室射血分数(LVEF)、左室舒张末期内径(LVDd)及舒张早期的E峰/舒张晚期的A峰的E/A比值的变化。结果 MVP组Cum%VP为0.95%±0.44%,明显低于LAVD组的5.46%±0.23%及Search AV+组的6.74%±3.95%,P0.05。与MVP组比较,LAVD组及Search AV+组的血清NT-pro BNP、LVDd明显增加,LVEF较术前明显下降(P均0.05)。结论 MVP策略优于LAVD策略和Search AV+策略,能够显著减少病窦综合征患者Cum%VP,保护心功能。     

心脏起搏对心动过缓患者心功能及房性心律失常的影响

目的:评价不同起搏方式(DDD方式和VVI方式)对长期心脏起搏患者心功能及心律失常的影响。方法:分别对43例VVI起搏治疗和32例DDD起搏治疗患者进行临床、心电图、超声心动图的定期随访,随访时间平均为34±6.8个月和32±8.3个月。结果:与治疗前比较,R波抑制型起搏器(VVI)组随访期左房内径明显增大,左室射血分数(LVEF)显著减退(P均<0.05);房室全能型起搏器(DDD)组左房内径、LVEF无显著差异;与DDD组比较,VVI组左房内径明显增大(P<0.01),LVEF显著减退(P<0.01),房性心律失常明显增加(P<0.01),心功能显著恶化(级别显著增加),P<0.05。结论:DDD心脏起搏器可显著改善心功能,减少房性心律失常,比VVI起搏器为佳。     

不同起搏方式对病窦综合征患者的长期影响

本研究旨在比较生理性起搏(DDD)及非生理性起搏,(VVI)对病态窦房结综合征(SSS)患者的远期影响.     

生理性起搏对老年缓慢性心律失常伴心功能不全患者的作用

目的：探讨生理性及非生理性起搏对伴有心功能不全的老年缓慢型心律失常患的作用。方法：在常规强心药物治疗同时安置永久起搏器。非生理性起搏组54例,生理性起搏组36例（使用DDD起搏为12例）。于术术、术后1周及术后6个月时用超声多普勒分别测定心功能参数。结果：生理性起搏组术后1周时左室射血分数（LVEF）、每搏量（SV）及心排量（CO）均明显改善,血流加速时间（AT）缩短,主动脉峰值血流速度（PV）加快。6个月后上述参数进一步改善,左室舒张末期内径（LVd)亦显缩小,该组患术后1周及术后6个月心功能改善情况均明显优于非生理性起搏器。DDD起搏A－V间期为100ms时心功能参数最理想。结论采用物＋生理性水久起搏术治疗老年缓慢型心律失常的心功能不全,可取得满意的近期和远期效果。     

不同部位及不同方式心房起搏对心房激动的影响

目的 了解不同部位、不同方式心房起搏时P波、P－R间期以及心房激动顺序的特点，从而寻找最佳的心房单部位起搏方式。方法 对20例射频消融成功后的患者，分别放置高位右房、右心耳、Koch三角、希氏束以及冠状窦电极，若为左侧旁路则加置左心房电极，行不同部位、不同方式心房起搏。结果 Koch三角、Koch三角＋高位右房、左房、双房起膊时P波宽度、P－R间期无差异，但右心耳起搏时各导联P波增宽，P－R间期延长。从心房激动顺序分析，右心耳起搏时，激动传至希氏束区及冠状窦区的时间最长，而Koch三角、Koch三角＋高位右房及双房起搏时则较短，尤其是Koch三角、Koch三角＋高位右房起搏缩短更明显。另外，不同部位、不同方式起搏时右心房压力无差异。结论 Koch三角起搏在某种程度上可替代高位右房＋冠状窦起搏及双房起搏。     

起搏治疗对病窦综合征患者的影响

起搏治疗病窦综合征效果肯定。但不同心脏起搏模式能对病窦综合征患者的血流动力学,神经体液的活性,心脏的传导和节律以及组织病理学产生不同的影响,对病窦综合征患者,AAI起搏为最具有真正意义的生理起搏模式。     

AAI及DDD起搏对左心功能影响的远期效果评价

采用心脏超声观察病窦综合征 (SSS)AAI起搏 (n =2 9) ,DDD起搏 (n =3 3 ) ,术前 ,术后 1,2 ,5年的左室舒张末容积 (LVEDV)、左室收缩末容积 (LVESV)及左室射血分数 (LVEF)的变化 ,比较两种起搏方式对左心功能的影响。结果 :AAI起搏组术前 ,术后 1,2 ,5年随访的LVEDV、LVESV、及LVEF比较无显著性差异 ,DDD起搏组第 5年随访的LVESV明显增加 (P <0 .0 5 )、LVEF显著降低 (P <0 .0 5 )。结论 :长期DDD起搏可能对患者的左心功能造成损害     

Left Atrial Responses to Acute Right Ventricular Apical Pacing in Patients with Sick Sinus Syndrome

Chronic right ventricular apical (RVA) pacing can lead to an increased risk of heart failure and atrial fibrillation, but the acute effects of RVA pacing on left atrial (LA) function are not well known. Twenty‐four patients with sick sinus syndrome and intact intrinsic atrioventricular conduction were included. All patients received dual‐chamber pacemaker implants with the atrial lead in the right atrial appendage and the ventricular lead in the right ventricular (RV) apex. Transthoracic standard and strain echocardiography (measured by tissue Doppler imaging and speckle tracking image) were performed to identify functional changes in the left ventricle (LV) and LA before and after 1 hour of RVA pacing. The LA volume index did not change after pacing; however, the ratio of peak early diastolic mitral flow velocity (E) to peak early diastolic mitral annular velocity (Ea) was significantly increased and peak systolic LA strain (Sm), mean peak systolic LA strain rate (SmSR), peak early diastolic LA strain rate (EmSR), and peak late diastolic LA strain rate (AmSR) were significantly reduced after RV pacing. LV dyssynchrony, induced by RV pacing, had a significant correlation with E/Ea, Sm, and SmSR after pacing. E/Ea also had a negative correlation with Sm and SmSR after pacing. Multivariate regression analysis identified LV dyssynchrony and E/Ea as important factors that affect Sm, SmSR, EmSR, and AmSR after acute RVA pacing. Acute RVA pacing results in LA functional change and LV dyssynchrony and higher LV filling pressures reflected by E/Ea are important causes of LA dysfunction after acute RVA pacing.     

Selecting the Appropriate Pacing Mode for Patients with Sick Sinus Syndrome: Evidence from Randomized Clinical Trials

Several observational studies have indicated that selection of pacing mode may be important for the clinical outcome in patients with symptomatic bradycardia, affecting the development of atrial fibrillation (AF), thromboembolism, congestive heart failure, mortality and quality of life. In this paper we present and discuss the most recent data from six randomized trials on mode selection in patients with sick sinus syndrome (SSS). In pacing mode selection, VVI(R) pacing is the least attractive solution, increasing the incidence of AF and-as compared with AAI(R) pacing, also the incidence of heart failure, thromboembolism and death. VVI(R) pacing should not be used as the primary pacing mode in patients with SSS, who haven't chronic AF. AAIR pacing is superior to DDDR pacing, reducing AF and preserving left ventricular function. Single site right ventricular pacing-VVI(R) or DDD(R) mode-causes an abnormal ventricular activation and contraction (called ventricular desynchronization), which results in a reduced left ventricular function. Despite the risk of AV block, we consider AAIR pacing to be the optimal pacing mode for isolated SSS today and an algorithm to select patients for AAIR pacing is suggested. Trials on new pacemaker algorithms minimizing right ventricular pacing as well as trials testing alternative pacing sites and multisite pacing to reduce ventricular desynchronization can be expected within the next years.     

病窦综合征患者AAI和VVI起搏的远期随访分析

分析并比较病窦综合征 (SSS)患者AAI和VVI起搏的远期效果。对 1 4 0例AAI起搏、4 3例VVI起搏的SSS患者进行定期随访并行临床、心电图和Holter检查。结果 :随访 5 2± 4 .3(6～ 1 4 4 )个月 ,AAI组发生间歇性文氏型房室阻滞 (AVB) 1例。VVI起搏组阵发性房性心律失常、持续性心房颤动、脑栓塞、心源性死亡的发生率明显较AAI组高(分别为 39.5 3%vs 5 .71 %、1 8.6 0 %vs 1 .4 3%、9.3%vs 0 .71 %、1 1 .6 3%vs 0 .71 % ,P均 <0 .0 1 )。快速房性心律失常的发生率VVI组明显增加 (39.5 3%vs 1 8.6 0 % ,P <0 .0 1 ) ,AAI组明显减少 (5 .71 %vs 1 8.5 7% ,P <0 .0 1 )。无 1例近期和远期电极脱位。结论 :AAI起搏时远期AVB和电极脱位发生率很低 ,并且快速性房性心律失常、脑栓塞、心源性死亡事件的发生率低于VVI起搏     

双腔起搏器不同房室间期起搏对心功能影响的研究

探讨双腔起搏器不同房室间期 (AVD)起搏对即时心功能的影响 ,并观察根据即时心功能调定的最佳房室间期对CHF患者长期疗效的影响。用M型和B型超声心动图比较了 6例无心力衰竭DDD起搏者和 14例CHFDDD起搏患者 (其中 13例存在缓慢型心律失常 )不同AVD起搏时心功能参数的变化。 14例CHFDDD起搏患者常规起搏 3个月后随机分为常规起搏组 (7组 )和最佳房室间期起搏组 (7例 ) ,起搏 3个月后随访心功能 (NYHA分级 )和心室腔径的改变。结果 :CHF组和无心力衰竭组不同AVD起搏时各项心功能指标变化均无差异 (P >0 .0 5 ) ;常规起搏组和最佳AVD起搏组起搏 3个月后NYHA分级和心室腔径无显著变化 (P >0 .0 5 )。结论 :经调定的短AVDDDD起搏不能改善CHF患者的心功能和心室重构。不宜将双腔起搏器最佳AVD起搏作为CHF患者的常规非药物疗法 ,对因纠治心脏电学异常而安装DDD起搏器的CHF患者 ,在无其他证据之前仍宜采用常规AVD起搏     

VVI与DDD起搏对病窦综合征患者远期疗效的比较

比较VVI与DDD起搏方式对病窦综合征患者的临床疗效。研究病窦综合征患者212例,按不同起搏方式分为两组:VVI组105例、DDD组107例。研究终点:①在每次预定的随访中,以标准12导联ECG、Holter及心电监护诊断心房颤动(简称房颤);②卒中:当患者有大于24h脑缺血事件而产生神经系统症状或24h内死于脑血管事件,可确诊为卒中;③死亡:心血管事件死亡。患者出院后1,3,6个月定期随访,以后每隔半年随访一次。随访时,记录标准12导联ECG存档。每例患者至少有一份ECG,部分患者做Holter,了解有无阵发性房颤及术后发生持续性房颤的时间,患者的症状及体征。结果:①与VVI组比较,DDD组房颤发生率明显降低(10.3%vs24.8%,P<0.05);②VVI组患者6例出现脑卒中(5.7%),而DDD组无1人发生脑卒中,两组差异有显著性(P<0.05);③VVI组共有3例在术后3,4年发生慢性充血性心力衰竭,最后死于恶性心律失常,而DDD组患者均无因心力衰竭住院,随访至今无死亡。DDD组11例房颤均在2年内发生,其中第1年7例,而VVI组有26例房颤发生的时间较为弥散,2年内发生8例(30.8%),其余在3~8年内陆续发生。结论:病窦综合征患者安装双腔起搏器治疗发生房颤和脑卒中的机率明显减少。     

Adverse Effects of Continuous Ventricular Pacing in Patients with Slower Atrial Fibrillation and Normal Left Ventricular Systolic Function

Background: Both heart rate irregularity during chronic atrial fibrillation (AF) and ventricular desynchronization imposed by ventricular pacing may compromise ventricular function. We investigated whether heart rhythm regularization achieved through ventricular overdrive pacing (VP) gives additional benefit over rate control alone in patients with AF. Methods: We studied 27 patients (mean age 72 ± 7 years) with AF and normal left ventricular (LV) systolic function who were implanted with a common VVIR pacemaker. Cardiac function was assessed by using serial echocardiographic conventional, tissue Doppler imaging (TDI) and color M‐Mode (CMM) examinations, together with B‐type natriuretic peptide (BNP) measurements. Baseline data were obtained during AF (mean heart rate 58 ± 5 beats/minute) with the pacemakers programmed to ventricular mere back‐up pacing. These data were compared to the corresponding measurements following a 2‐week VP period after the devises had been programmed to a lower rate of 70 beats/min, ensuring most of the time continuing VP. Results: Continuous VP compared to AF, reduced the LV cardiac index (2.28 ± 0.44 l/min/m² vs 2.33 ± 0.39 l/min/m², P < 0.05), increased the LV end‐systolic volume (38 ± 14 mL vs 35 ± 11 mL, P < 0.05), and decreased the TDI‐derived systolic and diastolic mitral velocity (8.1 ± 1.8 cm/s vs 8.3 ± 1.6 cm/s, and 8.1 ± 1.8 cm/s vs 8.3 ± 1.6 cm/s, respectively, both P < 0.05) and the CMM‐derived transmitral early diastolic flow propagation velocity (37.6 ± 9.2 vs 41.5 ± 9.7, P < 0.05). Following VP, both ratios E/Ea and E/Vp showed a trend toward increase (P = NS), whereas BNP rose up to 25.5% (median value, from 111 pg/mL to 165 pg/mL, P < 0.01). Conclusion: VP may be considered disadvantageous compared to slower AF.     

不同部位起搏对心脏收缩功能的影响

通过不同部位起搏 ,观察房室同步和心室激动顺序对人体心脏收缩功能的影响及起搏体表心电图QRS波时限与心输出量 (CO)的关系。 1 5例射频消融术后的病人分别按顺序进行右房、右室心尖部和室间隔起搏 ,采用心导管法分别测定右房压 (RAP)、肺动脉压 (PAP)、肺毛细血管楔压 (PCWP)和CO ,并计算心脏指数 ,记录心电图。结果 :右室心尖部起搏和室间隔起搏较右房起搏时RAP、PAP升高。心尖部起搏时CO较右房起搏降低 1 9.1 5 % (P <0 .0 1 ) ,室间隔起搏时CO较右房起搏降低 7.86% (P <0 .0 5 ) ,而较心尖部起搏提高 1 2 .2 4 % (P <0 .0 5 )。心尖部起搏和室间隔起搏较右房起搏体表心电图QRS波时限明显延长 ,而室间隔起搏体表心电图QRS波时限比心尖部起搏平均缩短 1 8.6ms(P <0 .0 0 1 )。CO和△QRS波时限的相关性分析表明两者呈负相关关系 (r=- 0 .30 ,P <0 .0 5 )。结论 :起搏体表心电图△QRS波时限与CO呈负相关 ,不同部位起搏对心脏收缩功能的影响不同 ,其中室间隔起搏较心尖部起搏更符合生理性起搏     

病态窦房结综合征患者心脏变时功能不全的临床研究

目的探讨病态窦房结综合征患者心脏的变时功能。方法对60例病态窦房结综合征患者（观察组）和40例正常窦性心律者（对照组）作运动平板试验，测定静息心率、运动时的最大心率、运动时间、代谢当量；计算2级运动时的心率变时性指数（CRI）、运动后1min心率恢复值。结果观察组静息心率、最大心率、CRI明显低于对照组，差异有显著统计学意义（P〈0．01），观察组心率上升幅度、运动时间、代谢当量、运动后1min心率恢复值均低于对照组，差异有统计学意义（P〈O．05）；观察组心脏变时功能不全31例（517％），明显多于对照组4例（10％），差异有显著统计学意义（P〈0．01）。结论病态窦房结综合征患者常发生心脏变时功能不全。     

Dual Site Right Atrial Pacing can Improve the Impact of Standard Dual Chamber Pacing on Atrial and Ventricular Mechanical Function in Patients with Symptomatic Atrial Fibrillation: Further Observations from the Dual Site Atrial Pacing for Prevention of Atrial Fibrillation Trial

Background: The effects of atrial pacing mode on atrial and ventricular function in patients with atrial fibrillation (AF) and bradycardia have not been evaluated. We evaluated atrial and ventricular function during randomization to support pacing (SP), high right atrial pacing (HRA), and dual site right atrial pacing (DAP).Methods: Seventy-nine patients (66 ± 12 yr, 46 male) with standard pacing indications and symptomatic AF were randomized to each of three pacing modes (DAP, HRA, SP) for 6 months in a crossover design. Echocardiographic studies were performed at enrollment and the end of each mode. Paired comparisons of atrial and ventricular function parameters were performed between each pacing mode and baseline.Results: HRA pacing in DDDR mode resulted in increased left ventricular (LV) end systolic volume (78 ± 42 vs. 60 ± 31 ml, p = 0.001) and reduced LV ejection fraction (44 ± 14 vs. 50 ± 11%, p = 0.007) compared to baseline. These parameters did not change during DAP. DAP resulted in increased peak A wave velocity (75 ± 19 vs. 63 ± 23 cm/s, p = 0.003) and atrial filling fraction compared to baseline (0.47 ± 0.15 vs. 0.38 ± 0.13, p = 0.005). Atrial and ventricular function were similar between control and SP.Conclusion: DAP, but not HRA or SP, improved left atrial (LA) function in patients with AF and bradycardia. HRA pacing in DDDR mode resulted in LA dilatation and deterioration of LV function which was not observed with DAP.This study was supported by a grant from the Electrophysiology Research Foundation, Warren, NJ and Medtronic Inc., Minneapolis, MN. Drs. Delfaut and Prakash were supported by grants from the Electrophysiology Research Foundation during the term of this study. Drs. Saksena and Nanda were consultants to Medtronic during this study. Dr. Hettrick and Mr. Ziegler are employees of Medtronic.     

双腔起搏房室延迟优化对心功能及神经内分泌因子的影响

观察双腔起搏不同房室延迟(AVD)对即刻心功能的影响,并探讨以优化的AVD起搏对心功能及神经内分泌因子的影响。用SwanGanz导管和彩色多谱勒心脏超声仪分别测定20例心功能ⅡⅢ级患者不同AVD起搏时心功能参数的变化,将心排血量(CO)最大的和/或平均肺毛细血管楔嵌压(MPCWP)下降最明显的AVD定为优化AVD。其后,所有患者分别进行8周常规AVD及8周优化AVD起搏,分别在8周结束时对患者进行心脏B超测试及测定血浆内皮素(ET)、心钠素(ANP)、肾素活性(PRA)、血管紧张素Ⅱ(AngⅡ)、醛固酮(ALD)。结果:根据心导管及心脏B超测量的优化AVD分别为134±13ms及131±12ms。优化AVD组较常规AVD组对左室收缩功能指标有改善,但未达有统计学显著性差异。左室舒张功能指标在优化AVD组较常规AVD组明显改善。神经内分泌因子在优化AVD组较常规AVD组明显减低。结论:优化AVD起搏对心力衰竭患者远期心功能有改善作用,能明显降低有关神经内分泌因子。