为左上腔静脉永存合并右上腔静脉缺如患者植入起搏导线

目的 对左上腔静脉永存合并右上腔静脉缺如患者的心室起搏导线植入方法作初步探讨,方法 为3例病态窦房结综合征,2例三度房室阻滞患者植入VVI起搏系统,导线经左上腔静脉、冠状静脉窦、右心房、三尖瓣口而固定于右心室心尖部（4例）或至心大静脉远段（1例）,靠近心外膜左缘。结果 5例患者的导线均成功放置分别随访3个月-7年,起搏功能良好。结论 对左上腔静脉存伴右上腔静脉缺如患者植入心脏起搏系统,通过适当地操作,一般可将导线定侠于右心室心尖部;而经冠状静脉窦作左心室心外膜起搏亦是可以选择的。     

Case report of fatal complication of superior vena cava tear from balloon dilatation of iatrogenic superior vena cava narrowing

The treatment options for superior vena cava (SVC) obstruction depends on the cause and severity of SVC narrowing. It ranges from conservative medical management to more elaborate endovascular and surgical repair of obstruction. There has always been a concern regarding the possibility of rupture of SVC during balloon dilatation, if the obstruction is secondary to the surgical cause. Very few cases are reported in the literature. We report a case of fatal complication of SVC tear in a 2-month-old child who had iatrogenic SVC narrowing.     

Percutaneous treatment of superior vena cava obstruction following transvenous device implantation.

The aim of this study is to assess the feasibility and safety of percutaneous treatment of superior vena cava (SVC) obstruction following transvenous device implantation. SVC obstruction is an uncommon but serious complication that can occur following permanent pacemaker or cardioverter defibrillator implantation utilizing transvenous endocardial leads. The treatment has traditionally been surgical but with the advent of stents, percutaneous approach is becoming popular. We report on the prevalence of SVC obstruction and the safety of its percutaneous catheter-based treatment. This is a retrospective study of SVC obstruction following device implantation in our institution from January 1993 through November 2003. A total of 1,850 permanent pacemaker and 1,200 implantable cardioverter defibrillator initial implants were performed during that period. Three patients developed SVC obstruction following implant (prevalence, 1/1,000 implant). Two patients were males and the mean age at implant was 57 +/- 13 years. Laser lead extraction and SVC angioplasty with or without stenting were performed in all patients. In two of them, this was followed by reimplantation of new systems. There were no procedural complications or mortality. The patients remain free of SVC obstruction symptoms 24 +/- 19 months after treatment. SVC obstruction prevalence after device implantation is low. Percutaneous treatment of SVC obstruction can be safely performed and appears to be effective in maintaining medium-term patency.     

经永存左上腔静脉植入起搏电极体会

目的总结经永存左上腔静脉（PLSVC）植入起搏电极体会。方法总结4例PLSVC植入双腔起搏器的患者。患者出院前及出院后3个月、6个月进行随访,了解起搏器工作状态。结果4例患者术前均常规行经胸超声心动图检查,结果显示冠状静脉窦开口扩大,提示PLSVC存在可能。第1例患者因术前发现PLSVC可能,首先穿刺右侧锁骨下静脉;造影显示右上腔静脉缺如,右侧锁骨下静脉汇入PLSVC。第2、3例患者因双腔起搏器植入前反复出现心动过缓相关症状,在术前经右侧锁骨下静脉植人临时起搏器,术中造影显示PLSVC与右侧上腔静脉无交通。第4例患者在置入导丝时直接经PLSVC进入右心房。患者术后3个月、6个月常规行起搏器程控并调整起搏器出厂设置参数,此后每6—12个月行起搏器程控,程控时测量心房电极和心室电极的起搏阈值、感知和阻抗。均在满意范围。第1例患者两次随访时心律均为窦性心律,心房电极感知大于2mV,起搏阈值小于1V,阻抗小于1000Q。结论PLSVC能够顺利完成起搏电极植入。     

经下腔静脉途径拔除起搏导线的初步体会

目的 介绍应用血管内反推力技术经下腔静脉途径拔除起搏导线的初步临床体会。方法 对１８例患者的２８根导线应用血管内反推力牵引技术拔除导线,其中１６例（２５根导线）首选经上腔静脉途径,失败后改用经下腔静脉途径;２例（３根导线）直接用经下腔静脉途径拔除。结果 １６例患者的２５根导线,经上腔静脉途径完全拔除２２根（８８％）,３根经此途径拔除失败后改用下腔静脉途径,其中２根完全拔除。２例患者的３根导线直接先     

支架置入术治疗上腔静脉综合征

目的　观察支架置入治疗上腔静脉综合征的临床疗效。方法　采用经皮静脉内支架置入术治疗 12例上腔静脉综合征患者 (男 11例 ,女 1例 ,平均年龄 5 1岁 )。结果　上腔静脉综合征缓解率为 92 % (11 12 ) ,无早期血管堵塞、支架移位等临床并发症 ,复发率 16 7%。结论　经皮静脉内支架置入术治疗上腔静脉综合征缓解率高 ,相对安全简单 ,并发症少。     

Acute superior vena cava syndrome after insertion of implantable cardioverter defibrillator

We describe a rare case of superior vena cava syndrome that occurred a few hours after insertion of an implantable cardioverter defibrillator through the right subclavian vein in a patient with previous dual chamber DDD pacemaker. The patient was successfully treated with anticoagulant therapy showing a fast clinical and instrumental improvement.     

Pacemaker implantation in patients with persistent left superior vena cava

Implantation of a permanent pacemaker system is most commonly performed by puncturing the left subclavian vein and introducing the pacemaker lead(s) through the superior caval vein to the right atrium and/or ventricle. Occasionally, a persistent left superior caval vein is encountered peroperatively, complicating the procedure. This article describes three such patients and provides a review of the literature regarding one of the most common anomalies of the thoracic vessels.     

Clinical implications of left superior vena cava persistence in candidates for pacemaker or cardioverter-defibrillator implantation

Persistence of a left superior vena cava (LSVC) has been reported in 0.3%–0.4% of candidates for pacemaker (PM) or cardioverter-defibrillator (ICD) implantation. The aim of the study was to evaluate the clinical implications of LSVC persistence for proper device performance. We observed the prevalence of LSVC during a 15-year period. A total of 2077 consecutive patients underwent PM implantation over a 15-year period: 7 had persistent LSVCs (0.34%). Among 599 patients undergoing ICD implantation, 4 LSVCs (0.66%) were observed. Overall LSVC persistence was found in 11/2676 (0.41%) patients. The right superior vena cava was absent in 4/11 (36%) patients. The leads were placed from the left subclavian approach in 5/7 PM patients: 2 received an elective right sided approach due to physician preference. All ICD patients had the device placed left pectoral with a single-coil lead: defibrillation therapy was effective in the long term in all but one patient, who required the addition of a subcutaneous array. Left superior vena cava persistence in PM/ICD patients is similar to the general population (0.41% in our study). The left-sided implant may be skill-demanding during lead placement; however, this task can be accomplished in the majority of cases, with a reliable outcome in the short term and appropriate device performance at follow-up.     

永存左上腔静脉畸形患者行起搏器植入术研究分析

目的 对永存左上腔静脉畸形患者行起搏器植入方法及术后起搏功能作初步探讨.方法 分析13例永存左上腔静脉畸形植入心脏起搏器患者的导线植入路径、方法、导线植入位置、手术与X线曝光时间.结果 13例患者中5例经左锁骨下静脉径路,8例经右锁骨下径路植入导线,均获成功.右侧血管径路与左侧血管径路植入起搏器X线曝光及手术时间比较差异有统计学意义：（593.61±70.03）s对（948.45±69.06）s,P＜0.001及（53.49±5.11） min对（81.25±13.39） min,P＜0.001.随访4～89个月,起搏功能良好.结论 对左上腔静脉永存伴（或不伴）右上腔静脉缺如的患者植入起搏器,通过选择合适的路径、恰当的起搏模式、操作手术均能获得成功,近期和远期随访结果满意.     

Effects of verapamil on superior vena cava electrical remodeling induced by short-term pacing from right atrium and superior vena cava in human

BackgroundAlthough the superior vena cava (SVC) may be involved in the triggering or maintenance of atrial fibrillation (AF), the electrophysiological properties of SVC in human are ill-defined.MethodsThe baseline effective refractory periods (ERPs) of high right atrium (HRA), SVC and the conduction time (CT) between HRA and SVC were measured at pacing cycle lengths (PCL) of 600 and 400 ms respectively in 20 patients (12 females, age 46 ± 13 years) with paroxysmal supraventricular tachycardia. Immediately after acute electrical remodeling (ER) induced by constant HRA or SVC pacing at PCL of 400 ms for 5 min, ERPs of HRA, SVC and the CT between HRA and SVC were determined. After verapamil was administered, the same protocols for determining ERPs of HRA, SVC and the CT between HRA and SVC were repeated.ResultsThe baseline ERP of SVC was significantly longer than that of HRA. The CT from SVC to HRA was significantly longer than that from HRA to SVC. After acute ER, both the ERPs of HRA and SVC were significantly shortened. However, no significant changes of the CT between HRA and SVC could be demonstrated. After verapamil infusion, significant shortening of the ERP of HRA and SVC still occurred following acute ER and the ERP of SVC was still longer than that of HRA.ConclusionsIn human, ER can occur both in HRA and SVC after a short and moderately rapid heart rate pacing either from HRA or SVC. Verapamil cannot prevent such ER from occurring.     

人上腔静脉心肌袖的形态学观测

目的观察人上腔静脉心肌袖的大体解剖及形态特征，为心房颤动（房颤）的临床研究与治疗提供依据。方法20例非心脏原因死亡的尸检标本，取出心脏，置于4％的多聚甲醛溶液中固定1周以上进行取材。取上腔静脉，经酒精脱水，石蜡包埋，分别作纵向和横向连续切片，常规HE染色。选取部分标本进行Masson染色和PGP9．5单克隆抗体S-P免疫组化染色。结果（1）HE染色结果，上腔静脉壁内有心肌细胞的延伸。（2）Masson染色结果显示，上腔静脉肌袖组织中，纤维结缔组织呈蓝色，心肌细胞、神经纤维和神经节呈棕红色。（3）免疫组化染色结果，上腔静脉的肌袖细胞处存在PGP9．5免疫组化染色阳性的神经纤维和神经节。结论人上腔静脉壁内有心肌袖的存在，是发生心律失常的结构基础。上腔静脉有丰富的自主神经纤维分布，可能引起肌袖细胞的电生理特征发生改变。     

Bidirectional superior vena cava: right atrial conduction delay during tachycardia.

The superior vena cava, like all the thoracic veins, has myocardial sleeves and plays a role in initiation and perpetuation of atrial fibrillation. Conduction delay between it and the right atrium has been shown previously. This case study shows delay in both directions during different arrhythmias in the same patient.     

Sinus node injury as a complication of superior vena cava isolation

We report a case with SVC ectopy initiating AF; the origin and breakout point of the sinus node was inside the SVC, and the SVC ectopy was conducted through the same path as the sinus node activation to depolarize the right atrium. Injury to the sinus node happened after successful isolation of SVC.     

二代冷冻球囊消融犬上腔静脉有效性和安全性研究

目的通过二代冷冻球囊消融隔离犬上腔静脉(SVC),探讨其有效性和安全性,为临床开展冷冻球囊消融SVC提供证据。方法本研究共选取14只犬,通过二代冷冻球囊消融SVC,根据冷冻球囊消融时间用随机数字表法随机分为2组:90 s组和120 s组。术前行SVC造影显示SVC-右心房交界处,将28 mm冷冻球囊放置于SVC-右心房交界处进行冷冻。术后观察40~60 d后再次行电生理检查,之后处死行组织学病理检查。比较术中冷冻参数、并发症及术后窦房结恢复时间等指标。结果2组犬均成功隔离SVC。90 s组与120 s组犬在SVC隔离时间[(24.3±8.1)s对(22.7±9.0)s,P=0.297]、隔离温度[(-23.4±12.5)℃对(-21.5±11.1)℃,P=0.370)]及最低温度[(-51.2±6.2)℃对(-53.3±7.0)℃,P=0.195]均差异无统计学意义。术中90 s组1只犬出现暂时性膈神经损伤,120 s组1只犬出现一过性窦性心动过缓。术后平均观察51 d,90 s组有1只犬出现SVC电位恢复,120 s组全部犬SVC电位均保持隔离(85.7%对100.0%,P=0.299)。术后组织病理显示所有隔离的SVC均达到环形冷冻透壁损伤,高倍镜下未发现窦房结及膈神经损伤。结论二代冷冻球囊可安全有效的消融SVC,且有效冷冻剂量为90 s。     

Superior vena cava syndrome after implantation of a transvenous cardioverter defibrillator

Superior vena cava syndrome is a rare, but nevertheless wellknown complication of permanent pacemaker implantation. Nowadayscardioverter defibrillators are also routinely implanted transvenously. A superior vena cava syndrome occurred in a 48-year-old female2 years after implantation of cardioverter defibrillator. Theclinical problem, in the presence of a predisposing thrombophiliccondition (circulating lupus anticoagulant), resolved only partiallyafter treatment with thrombolytics and oral anticoagulation.This syndrome should be recognized as a possible important complicationof defibrillator therapy and requires lifelong anticoagulation.