心动过缓是心脏外科手术后的常见并发症,心脏外科的手术类型及其与心脏传导系统的解剖毗邻关系导致术后心动过缓发生率和需要植入永久起搏器的比例不同,多见于瓣膜外科手术和肥厚型心肌病手术术后.目前心脏外科术后房室传导阻滞的患者多在5～7 d行永久起搏器植入治疗,部分中心在早期(＜72 h)或者晚期(＞14 d)行起搏器植入术.窦房结功能障碍的患者植入起搏器的时机需要结合临床症状观察一定时间后进行判断.本文就目前文献中不同种类心脏外科手术后心动过缓植入起搏器治疗患者的发生率及植入时机进行了汇总分析,有助于了解心脏外科术后发生心动过缓的危险预测和治疗措施.

1病例资料 患者,男,32岁,以主诉运动中意识丧失3次来诊.患者首次晕厥发生于20年前运动过程中,伴摔倒;4年前运动5分钟后自觉心悸,伴晕厥前兆,未处理;20天前运动过程中再发晕厥,伴小便失禁,救护车入院,血压、血糖未见异常,心电图示QT间期延长至542 ms,心率48次/分,考虑晕厥为长 Q-T综合征(long Q-T syndrome,LQTS)所致.入我院心电图示QTc 472 ms,动态心电图未捕捉到室性心动过速或心室颤动,心脏超声和计算机体层血管成像(computed tomography angiography,CTA)未见异常,无家族史,未服用引起Q-T间期延长的药物.

目的:探讨心脏移植术后患者无创心电检测中的心率减速力(DC)、心率加速力(AC)、心率变异性(HRV)等自主神经功能指标与健康人群的差异.方法:回顾性收集 2017 年 1 月至 2021 年 12 月于中国医学科学院阜外医院就诊的心脏移植术后患者 89 例(心脏移植术组),所有患者均于移植术后 1 个月以上行 24 小时长程动态心电图和超声心动图检查.另选取 100 例同期体检有动态心电图和超声心动图检查结果的健康人作为对照组.比较分析两组患者的DC、AC、HRV[包括主要指标全部窦性心搏RR间期标准差(SDNN)]等自主神经功能指标.结果:心脏移植术组患者年龄(50.6±13.7)岁,男性 72 例(80.9％);对照组年龄(41.9±10.2)岁,男性 70 例(70.0％).心脏移植术组患者平均心率[(85.3±12.6)次/min vs.(74.1±7.5)次/min]、最慢心率[(69.5±14.9)次/min vs.(49.9±5.5)次/min]均高于对照组,最快心率低于对照组[(110.2±18.9)次/min vs.(123.1±9.9)次/min],DC[(2.8±1.0)ms vs.(7.4±1.4)ms]、AC[(-3.0±1.2)ms vs.(-8.0±1.6)ms]绝 对 值、SDNN[(64.6±28.9)ms vs.(141.4±33.2)ms]也均低于对照组,差异均有统计学意义(P均<0.05).心脏移植术组中 10 例(11.2％)患者SDNN正常,4 例(4.5％)DC值正常.心脏移植术组患者SDNN与术后随访时长(月)呈正相关(P<0.05),与DC、AC无明显相关性.结论:心脏移植术后患者心率较健康人增快,DC、AC、HRV等自主神经功能指标明显降低.SDNN随着术后生存时间延长呈增加趋势,DC和AC则无明显变化.

目的 探讨左束支区域起搏(LBBAP)在持续性心房颤动(简称房颤)合并心动过缓患者中治疗的临床效果.方法 连续纳入自2019年10月至2020年4月的持续房颤合并心动过缓需要起搏治疗且超声评估左室射血分数≤0.35并接受LBBAP的患者.术中记录导线参数,术后3个月、6个月及1年随访起搏器程控参数和起搏相关并发症,以及术后1年超声心动图评估,对比基线、术后1年各项参数的变化.结果 连续入选共41例患者,年龄为(68.9±11.0)岁,其中男性占比73.2％(30/41).LBBAP的手术成功率为97.6％(40/41).术后起搏QRS波时限较术前基线心电图QRS波时限无明显变化[(115.2±9.6)ms vs(110.8±20.3)ms,P=0.145].LBBAP的心室电极中位植入时间为12(6.0,25.0)min,中位X线暴露时间为4.6(3.0,7.8)min.心室起搏平均阈值为(0.7±0.2)V.随访(13.3±7.0)个月,起搏比例达83.3％(48.3％,96.5％),随访心室起搏阈值(0.8±0.3)V.围手术期有2例在电极拧入过程中出现室间隔穿孔,经回撤起搏电极调整植入位点后均成功施行LBBAP且患者无临床症状,余患者在围手术期和随访期间均未出现任何起搏相关并发症.术后1年随访与基线对比左室射血分数(0.60±0.07vs0.60±0.06,P=0.243)和左室舒张末直径[(51.6±6.7)mmvs(52.1±6.6)mm,P=0.449]均无明显变化,但左房前后径较术前显著缩小[(50.1±10.9)mm vs(47.6±1.4)mm,P=0.013].结论 持续性房颤心动过缓患者接受LBBAP治疗1年随访起搏参数稳定,维持窄QRS波时限,且可能有助于逆转左房重构.

目的 应用实时三维超声心动图评价左束支区域起搏(LBBaP)和右心室间隔部起搏(RVSP)术后右心室功能,并进行比较.方法 回顾性分析2020年11月至2022年1月行永久性心脏起搏器植入术的95例患者的临床资料,其中50例患者采用LBBaP(LBBaP组),45例患者采用RVSP(RVSP组).所有患者术前及术后6个月均进行二维和实时三维超声心动图检查,获取图像并评估右心室大小及功能参数,比较手术前后两组患者上述参数的变化.结果 术前两组患者右心室大小及功能参数差异均无统计学意义(P＞0.05).术后6个月RVSP组患者右心室舒张末期容积较术前增加,且差异有统计学意义(P＜0.05);反映右心室功能的三尖瓣环收缩期位移、右心室射血分数、右心室间隔纵向应变、游离壁纵向应变及三尖瓣环舒张早期运动速度(e')也均较术前降低,且差异均有统计学意义(P＜0.05).术后6个月RVSP组患者三尖瓣环e,较LBBaP组患者降低,且差异有统计学意义(P＜0.01).然而,LBBaP组患者右心室大小及功能参数与术前比较差异均无统计学意义(P＞0.05).结论 应用实时三维超声心动图评价不同部位起搏方式术后右心室功能具有重要的临床价值.RVSP对患者术后右心室功能有一定影响,而LBBaP则未见显著影响,安全性及有效性更高.

目的:探讨埋藏式心律转复除颤器(ICD)的除颤电极在右心室不同植入位置与三尖瓣反流进展的相关性.方法:回顾性纳入2016年1月至2019年12月于中国医学科学院阜外医院心律失常中心植入ICD或心脏再同步治疗除颤器(CRT-D)患者198例.所有患者在术前及术后均完善超声心动图,根据三尖瓣反流面积分为无、轻、中、重度四级.术后三尖瓣反流进展定义为:随访超声心动图评估的三尖瓣反流程度较术前基线提高至少一个等级.按除颤电极植入部位分为间隔部电极组和心尖部电极组.采用Kaplan-Meier曲线生存分析及Cox比例风险模型评估除颤电极植入部位对于三尖瓣反流进展是否存在影响.结果:198例患者平均年龄(57.1±12.1)岁,其中125例患者植入ICD,73例患者植入CRT-D.间隔部电极组115例(58.1％),心尖部电极组83例(41.9％),基线存在中-重度三尖瓣反流的患者共28例(14.1％).中位随访12(9,16)个月,共有48例(24.2％)患者出现三尖瓣反流进展,其中间隔部电极组28例(24.3％),心尖部电极组20例(24.1％),两组发生率差异无统计学意义(P=0.97).进一步分析显示,24例(12.1％)患者在随访期间进展为中-重度三尖瓣反流,其中间隔部电极组16例(13.9％),心尖部电极组8例(9.6％),两组发生率差异无统计学意义(P=0.36).同时,两组患者随访时的三尖瓣舒张期流速和三尖瓣舒张期跨瓣压差的差异均无统计学意义(P均>0.05).Kaplan-Meier曲线生存分析显示两组三尖瓣反流进展发生率差异无统计学意义(log-rank P=0.141).多因素Cox回归分析提示,除颤电极植入间隔部并未增加三尖瓣反流进展的发生风险(HR=0.55,95％CI:0.29～1.02,P=0.07).结论:ICD除颤电极的植入位置与术后三尖瓣反流进展可能并不相关.

患者,男性,44岁,因"气短2个月"入院.患者2月前无明显诱因于上楼时出现气短,无下肢水肿、腹胀、尿量减少,无胸痛、心悸,无头晕、黑矇等不适.家中自测心率偏慢,波动在30～50次/分,于当地医院完善动态心电图提示最慢心率36次/分,合并一度房室传导阻滞、二度房室传导阻滞、完全性右束支传导阻滞,为求进一步诊治于2021年2月24日收入中国医学科学院阜外医院.既往溃疡性结肠炎病史20年,对牛奶制品过敏.个人史、家族史无特殊.入院查体:血压 136/83 mmHg(1 mmHg=0.133 kPa),心率48次/分,全身浅表淋巴结无肿大,心、肺、腹及神经系统查体均未见明显异常,双下肢不肿.

Objective:To investigate risk factors for appropriate therapy of ventricular arrhythmias (VA) and all-cause mortality in implantable cardioverter defibrillator (ICD) or cardiac resynchronization defibrillator (CRT-D) with reduced ejection fraction non-ischemic heart failure.Methods:This study retrospectively analyzed data from Study of Home Monitoring System Safety and Efficacy in cardiac implantable electronic device-implanted patients.From February 2009 to December 2014, a total of 234 patients were included with ICD/CRT-D from 79 hospitals according to the inclusion and exclusion criteria.According to whether the ICD/CRT-D had appropriate treatment VA events during the follow-up period, the patients were divided into no appropriate treatment group ( n=93) and VA appropriate treatment group ( n=141). The average age of the patients was (58.8±13.4) years old.Among them, men accounted for 76.1% (178/234). The primary endpoint was the first appropriate ICD/CRT-D therapy.The secondary endpoint was the first appropriate ICD/CRT-D shock and all-cause mortality.Cox proportional hazard models were used to identify risk factors for appropriate ICD/CRT-D therapy and all-cause mortality. Results:During a mean follow-up period of (55.2±21.6) months, 141 (60.3%, 141/234) patients experienced the first appropriate ICD/CRT-D therapy, and, 103 (44.0%, 103/234) patients experienced the first appropriate ICD/CRT-D shock therapy.There were 70 (29.9%, 70/234) patients died.In multivariate Cox model, left ventricular end-diastolic dimension(LVEDD)and patients with syncope or presyncope symptoms were independent predictive factors of the first appropriate therapy for VA.Male gender, patients with syncope or presyncope symptoms, and those taking amiodarone were independent risk factors of the first appropriate shock for VA.Larger LVEDD, comorbid hypertension, and low mean activity of patients at 30 days were independent predictors of all-cause mortality.Compared patients with ICD, those with CRT-D had significantly lower risks of first appropriate therapy or shock for VA.Conclusion:In patients with reduced ejection fraction non-ischemic heart failure, LVEDD and syncope or presyncope symptoms were independent risk factors of appropriate therapy for VA.Larger LVEDD, comorbid hypertension, and low mean patient activity were independent predictors of all-cause mortality.The results of this study can be used to guide the risk stratification of high-risk sudden cardiac death(SCD)in patients with reduced ejection fraction non-ischemic heart failure.

目的:探讨近5年来非瓣膜性心房颤动(房颤)射频导管消融术围术期抗凝治疗状况及卫生经济学特点,分析华法林与新型口服抗凝药物(NOAC,包括利伐沙班及达比加群酯)的有效性及安全性.方法:连续性入选2015年1月至2019年8月中国医学科学院阜外医院一病区住院的1936例非瓣膜性房颤患者,其中男性1406例(72.60％),女性530例(27.40％),平均年龄(56.4±10.4)岁.根据患者服药情况分为华法林组(n=660),利伐沙班组(n=620),达比加群酯组(n=656).对其围术期抗凝方案、药物构成比例、治疗费用及出血、栓塞事件进行回顾性分析,随访期限为术后3个月.结果:1936例患者房颤病程中位时间为3(1,6)年.2015～2019年华法林使用比例呈明显下降(2015年vs.2019年:79.80％vs.20.24％,P<0.001),利伐沙班及达比加群酯使用比例均呈明显上升(P均<0.001);2015～2017年年化人均药物费用[元/(年·人)]呈显著上升趋势(2609.9 vs.6096.4 vs.10339.4,P<0.001);成本效果分析显示华法林较利伐沙班、达比加群酯具有更优的成本效果比(217.8 vs.13158.7 vs.12142.1,P<0.001).3个月随访期间无死亡事件,共发生大出血9例(0.46％)及栓塞事件17例(0.88％),包括中枢神经系统栓塞15例;华法林组与利伐沙班组、达比加群酯组的栓塞发生率(1.20％vs.0.65％vs.0.76％,P=0.35)及大出血并发症发生率(0.76％vs.0.32％vs.0.30％,P=0.40)差异均无统计学意义.1936例患者中1439例患者为间断性抗凝治疗,497例连续性抗凝治疗,亚组分析显示,华法林与NOAC抗凝药使用后患者并发症发生差异均无统计学意义.结论:非瓣膜性房颤患者射频导管消融术围术期抗凝治疗中,华法林与NOAC的安全性及有效性相当;成本效果分析显示华法林较NOAC有明显的效价优势.

Objective:To investigate the association between big endothelin-1 and major adverse cardiovascular events in heart failure patients.Methods:From March 2013 to November 2015, a total of 220 patients with heart failure who were hospitalized in Fuwai Hospital and met the inclusion criteria were selected and analyzed retrospectively. The patients were divided into three groups according to the levels of big endothelin-1: group 1 (<0.4 pmol/L, n=73) , group 2 (0.4-0.8 pmol/L, n=73) and group 3 (>0.8 pmol/L, n=74) . The primary endpoint was sudden cardiac death (SCD) or ventricular arrhythmia (VA) .Secondary endpoints were heart failure readmission, and composited endpoint of all-cause mortality or heart transplantation. Results:During a mean follow-up period of (25.1±14.3) months, 34 patients (34/220, 15.5%) experienced SCD/VA. Ninety-eight patients (98/220, 44.6%) were hospitalized due to heart failure. And 98 patients (98/220, 44.6%) died (84/220, 38.2%) or underwent heart transplantation (14/220, 6.4%) . In multivariate Cox regression models, big endothelin-1 was an independent risk factor for SCD/VA ( HR=3.207, 95% CI 1.115-9.233, P=0.031, T2 vs. T1; HR=3.598, 95% CI 1.146-11.300, P=0.028, T3 vs. T1) , heart failure readmission ( HR=1.707, 95% CI 1.001-2.912, P=0.049, T2 vs. T1; HR=2.666, 95% CI 1.507-4.715, P=0.001, T3 vs. T1) , and all-cause mortality or heart transplantation ( HR=1.964, 95% CI 1.021-3.780, P=0.043, T2 vs. T1; HR=3.853, 95% CI 2.007-7.398, P< 0.001, T3 vs. T1) . Conclusion:Big endothelin-1 level showed good predictive value for SCD, heart failure readmission and all-cause mortality in heart failure patients, and therefore can be used as a risk stratification factor for SCD risk and prognosis in patients with heart failure.

目的:对比有无合并糖尿病的急性主动脉夹层(AAD)患者的临床特征,探讨糖尿病对AAD患者短期和中期预后的影响.方法:入选2008年1月至2010年12月就诊于中国医学科学院阜外医院急诊科,经CT确诊为AAD的患者.采集患者的基线资料,记录患者的治疗方案和住院期间预后,并对患者进行中期随访.结果:本研究共纳入994例AAD患者,其中Stanford A型AAD 520例,Stanford B型AAD 474例.Stanford A型AAD患者中有16例(3.1％)患者合并糖尿病,Stanford B型患者中有24例(5.1％)患者合并糖尿病.合并糖尿病的AAD患者平均年龄、合并高血压、冠心病和高脂血症的比例均高于未合并糖尿病的AAD患者(P<0.05).合并和未合并糖尿病的AAD患者30 d死亡率分别为2.5％和8.2％,两者之间差异无统计学意义(P>0.05).多因素Cox回归显示糖尿病不是影响AAD患者短期预后(HR=0.251,95％CI:0.027～2.372,P>0.05)或中期预后(HR=0.233,95％CI:0.030～1.819,P>0.05)的独立因素.结论:合并糖尿病的AAD患者的平均年龄较大,合并高血压、冠心病和高脂血症的比例高,但糖尿病不是AAD患者短期或中期预后的影响因素.

目的 研究发现,microRNA-31(miR-31)可能在血管紧张素Ⅱ(AngⅡ)诱导的主动脉瘤/夹层小鼠的发病中起重要作用.本文探究了β-氨基丙腈(β-aminopropionitrile monofumarate,BAPN)诱导的主动脉瘤/夹层小鼠中miR-31的表达水平.方法 选取3周龄的C57BL/6野生型雄性小鼠(n=40),随机分为BAPN组(n=20)和对照组(n=20),BAPN组小鼠饮用0.4％浓度BAPN的饮用水,对照组小鼠饮用普通饮用水,实验周期为28天.造模结束后测量小鼠的主动脉直径和血压,统计小鼠生存率和主动脉瘤/夹层发生率.分离两组小鼠主动脉组织并提取总RNA,应用加尾法、茎环法逆转录和实时定量PCR对比分析两组小鼠主动脉组织miR-31的表达水平.结果 存活曲线显示BAPN组小鼠生存率显著降低(45％∶100％,P＜ 0.01).BAPN组小鼠主动脉瘤/夹层的发生率为75％,主动脉瘤/夹层破裂死亡率为55％.与对照组相比,BAPN组小鼠升主动脉最大直径[(1.86±0.51) mm比(1.18±0.11) mm,P＜0.01]和主动脉弓最大直径[(1.95±0.50)mm比(1.16±0.17) mm,P＜0.01)]显著大于对照组;两组之间收缩压[(101.20±5.26) mmHg比(100.60±7.56) mmHg,P=0.891)]和舒张压[(59.40±9.94) mmHg比(62.00±5.76) mmHg,P=0.600)]差异无统计学意义.使用加尾法逆转录和实时定量PCR检测BAPN诱导的小鼠主动脉瘤/夹层主动脉组织中miR-31的表达水平,主动脉瘤/夹层主动脉组织中miR-31的表达水平对比对照组有升高趋势,但差异无统计学意义(1.11±1.41比1.00±1.26,P=0.686).扩大样本量,使用茎环法逆转录和实时定量PCR检测小鼠主动脉组织miR-31的表达水平,BAPN诱导的主动脉瘤/夹层小鼠主动脉组织中miR-31表达水平对比对照组有升高趋势,但差异依旧无统计学意义(1.73±1.69比1.00±2.65,P=0.328).结论 BAPN诱导的主动脉瘤/夹层小鼠对比对照组小鼠主动脉组织中miR-31的表达水平有升高趋势,但无显著差异.基于miR-31在AngⅡ诱导产生的小鼠主动脉瘤/夹层中可能起到的重要作用,需要扩大样本量进一步探讨BAPN诱导对比AngⅡ诱导产生的小鼠主动脉瘤/夹层组织中miR-31表达水平的差异及意义.

目的:探讨左束支区域起搏(LBBAP)对三尖瓣反流(TR)的影响.方法:前瞻性入选2019年9月至2020年12月在中国医学科学院阜外医院本团队行LBBAP的缓慢性心律失常患者,术后定期随访超声心动图.按反流束面积/右心房面积比值的半定量法评估TR级别为无、轻、中、重度TR.TR进展定义为随访超声心动图评估的TR程度较术前进展至少一个等级.TR改善定义为随访超声心动图评估的TR程度较术前改善至少一个等级,中度或重度TR判断为有临床意义TR.结果:入选331例患者,303例患者完成随访,平均随访时间(6.63±4.57)个月.303例完成随访患者平均年龄(62.5±14.3)岁,男性167例(55.1％).术前轻度以上TR患者137例(45.2％),包括102例轻度TR、26例中度TR和9例重度TR;术后随访发生TR患者126例(41.6％),包括97例轻度TR、24例中度TR和5例重度TR.术后TR无进展患者260例(85.8％),术后TR改善患者57例(41.6％),TR进展患者43例(14.2％),包括TR进展1级42例(13.9％)、进展2级1例(0.3％).术后14例(4.6％)患者进展为有临床意义TR,术后出现新发TR患者29例(9.6％).Logistic回归分析发现心房颤动是LBBAP后TR进展的危险因素(OR=2.749,95％CI:1.404～5.380,P=0.003);持续性心房颤动是导致术后出现有临床意义TR的危险因素(OR=7.212,95％CI:1.928～26.969,P=0.003).结论:LBBAP可改善部分患者术前TR,少部分患者LBBAP后发生TR进展.心房颤动可能是LBBAP术后TR进展的影响因素.

Objective:To investigate the predictive value of home monitoring data for appropriate therapy and all-cause mortality of implantable cardioverter defibrillator (ICD) for primary prevention.Methods:This study retrospectively analyzed data from Study of Home Monitoring System Safety and Efficacy in Cardiac Implantable Electronic Device-implanted Patients. A total of 305 patients were included from 79 hospitals from Feb 2019 to Dec 2014. Data of patient activity and mean rest heart rate during the first 30-60 days recording by home monitoring system were collected and the average of 30-day patient activity (APA) and the average of 30-day mean rest heart rate (AMRHR) were calculated. The main endpoint was the first appropriate ICD therapy.The secondary endpoint was all-cause mortality.Results:During a mean follow-up period of (44.9±24.9) months, 117 (38.4%, 117/305) patients experienced the first appropriate ICD therapy and 55 (18%, 55/305) patients died. In univariate and multivariate Cox model, AMRHR was an independent predictive factor for the appropriate therapy in addition to NYHA class and left ventricular ejection fraction (LVEF) . Age, left ventricular end-diastolic diameter (LVEDD) , NYHA class and APA were independent risk factors for all-cause death. The predictive value of age, LVEDD, LVEF, APA, AMRHR for all-cause mortality was evaluated by ROC curve, and the results showed that APA had the best predictive value on all-cause death (AUC=0.703) .Conclusion:AMRHR and APA collected by home monitoring system have good predictive values for appropriate therapy or all-cause mortality in ICD patients for primary prevention.

Objective:This study aimed to evaluate the safety and practical concerns of 3.0 tesla (3.0 T) magnetic resonance imaging (MRI) scan for patients with magnetic resonance (MR) -conditional pacemakers.Methods:Fourteen patients with MR-conditional pacemaker who were referred for medically necessary MRI scanning from January 2017 to December 2018 in Fuwai hospital were included. A rigorous standardized workflow was performed in collaboration with electrophysiologists, pacemaker engineers and radiologists. Pacemaker interrogation was performed immediately before and after MRI scan. Significant changes in parameters including sense, impedance and threshold were recorded. Scan related adverse events were documented and imaging qualities were evaluated by radiologists.Results:Among the 14 patients, 6 were men and the age was (59±18) years old (17-81 years old) . Sixteen MRI examinations on different body regions (brain=8, cervical spine=2, lumbar spine=3, heart=3) were successfully completed. There were 11 patients who had their pacemakers implanted in the right chest wall and 3 patients in the left chest wall. Four patients had spine or cardiac MRI exams before pacemaker implantation. No significant changes in interrogation parameters such as sense [atrial: (3.3±1.2) ?mV vs. (2.6±1.5) ?mV, P=0.29; ventricular: (9.1±3.7) ?mV vs. (6.8±4.7) ?mV, P=0.39] , impedance [atrial: (578±162) ?Ω vs. (587±88) ?Ω, P=0.41; ventricular: 584±200 Ω vs. (578±66) ?Ω, P=0.63] and threshold [atrial: (0.6±0.2) ?V/0.4 ms vs. (0.8±0.1) ?V/0.4 ms, P=1.0; ventricular: (0.8±0.3) ?V/0.4 ms vs. (0.8±0.3) ?V/0.4 ms, P=0.76] were noted during or after MRI scanning. None of the patients complained of palpitations, heating sensation, pain or syncope. No pacing inhibition, pacemaker reset or arrhythmia were detected. Artifacts related to pulse generator and leads were observed in 3 cardiac MRI reports, with 2 pacemakers in the right pectoral and 1 in the left pectoral, but quality of cardiac image adequately allowed interpretation of diagnostic value. Conclusion:This study made an effective attempt to demonstrate that 3.0 T MRI scanning on different body regions for patients with MR-conditional pacemakers can be safely applied in the conditions of standardized workflow. The artifacts of pulse generators and leads in cardiac MRI scan had no adverse impact on diagnostic value.

经典抗凝药物华法林也有局限 药物治疗包括华法林与非维生素K拮抗剂口服抗凝药.其中,华法林是经典的抗凝药物,在临床应用已数十年,其抗凝疗效确切,可有效预防卒中;而且华法林价格便宜,购买途径方便,是房颤患者的“老朋友”.

目的:总结过去21年间中国医学科学院阜外医院致心律失常性右心室心肌病的诊疗情况.方法:选取1996年7月至2017年12月间就诊的全部致心律失常性右心室心肌病(ARVC)患者共522例.根据患者首次就诊时间分为2010年前就诊患者(简称2010年前,n=141)和2010年及以后就诊患者(简称2010年及以后,n=381).回顾患者的病历资料,分析不同时间段就诊的ARVC患者接受的诊断和治疗方式.结果:在522例患者中,男性患者373例(71.5％),确诊时平均年龄(39.0±15.1)岁.1996～2017年新就诊患者随时间的变化而增多(P<0.01).(1)患者首次就诊至确诊间隔时间中位数为277(30,1096)d,2010年及以后较2010年前时间缩短[244(30,984)d vs.357(31,1400)d,P<0.01].(2)所有患者均接受了心电图和经胸超声心动图检查,137例(26.2％)的患者接受了基因检测,360例(69.0％)患者接受了心脏磁共振成像(CMR)检查,11例(2.1％)患者接受了心内膜活检.患者行CMR和心内膜活检的比例2010年及以后高于2010年前(74.5％vs.53.9％,P<0.01;2.9％vs.0,P<0.05),行基因检测的比例低于2010年前(22.8％vs.35.5％,P<0.01).(3)患者接受 β 受体阻滞剂、索他洛尔和胺碘酮治疗的比例分别为28.5％、35.6％ 和10.9％,2010年及以后较2010年前高(分别为36.5％vs.7.1％、39.9％vs.24.1％、14.4％vs.1.4％,P均<0.01).(4)接受导管消融术、埋藏式心律转复除颤器(ICD)植入以及心脏移植的患者比例分别为62.3％、19.5％、10.0％,但2010年及以后较2010年前无明显变化(分别为62.7％vs.61.0％、20.5％vs.17.0％、9.4％vs.11.3％,P均>0.05).结论:ARVC的诊断和治疗水平在过去的20余年中得到了长足的提高,导管消融术成为重要的治疗手段,但在基因检测及心肌活检、规范药物治疗等方面仍存在提升空间.

Objectives:To investigate whether the gender differences exist in distribution of bradyarrhythmia and implantation age among patients with pacemaker.Methods:We retrospectively enrolled consecutive patients for pacemaker implantation from January 2015 to December 2017 in Center of Arrhythmia Fuwai Hospital Ward 1. The clinical data were collected, including age, sex, types, of bradyarrhythmia and complication, etc. The type of bradyarrhythmia and the average of pacemaker implantation in young and middle-aged group (18-59 years old) and the elderly group (≥60 years old) were compared.Results:A total of 1 431 adult patients with pacemaker implantation were finally enrolled with 47.5% (680/1 431) male cases, the age of all patients ranging from 19 to 96 years old with average (68.1±13.1) years old.①The distribution of various bradyarrhythmia was significantly different between male and female patients. In overall patients, the prevalence of sick sinus syndrome in female patients was significantly higher than that in male patients[60.1% (451/751) vs. 41.2% (280/680) , P<0.001], while the prevalence of atrioventricular block[23.3% (175/751) vs. 32.5% (221/680) , P<0.001] and atrial fibrillation with long interval or low heart rate[9.6% (72/751) vs. 14.6% (99/680) , P=0.004] were significantly lower than that in male patients. This gender differences were also found in the young and middle-aged group as well as in the elderly group.②In the young and middle-aged group, the mean age of pacemaker implantation of female patients with sick sinus syndrome was significantly older than that of male patients[ (53.0±7.1) years old vs. (49.7±10.3) years old, P=0.037]. In the elderly group, the age of pacemaker implantation of male patients was older than that of female patients with second-degree atrioventricular block[ (75.9±7.0) years old vs. (72.2±6.4) years old, P=0.012] and atrial fibrillation with long interval or low heart rate[ (74.5±8.4) years older vs. (70.8±6.9) years old, P=0.007]. Conclusion:Gender differences were found in the distribution of various bradyarrhythmia in patients with pacemaker. The age of pacemaker implantation was also different between sex in some type of bradyarrhythmia.

Objective:To determine the durability and long-term performance of St Jude Riata defibrillation leads in clinical practice.Methods:This was a retrospective study of patients with implantation of a Riata or Durata lead and then underwent generator replacement between January 2010 and December 2019. The prevalence of lead defect and long term pacing parameters (including pacing threshold, sensing and impedance) of Riata defibrillation leads were compared to Durata leads.Results:Seventy-six patients who underwent ICD implantation and then replacement of generators with a Riata ( n=29) or Durata ( n=47) lead in Fuwai Hospital were included. Median lead age in Riata group was 7.4±2.1 (3.0-12.2) years and in the Durata group was 5.2±1.9 (1.7-9.3) years. Four Riata leads failed with the prevalence of lead defect of 13.8% (4/29) , including 3 leads fracture and 1 insulation defect which occurred at median lead ages of 8.2±2.0 (6.5-10.9) years. No lead defect was identified in Durata group. Riata lead had a higher incidence of lead defects than Durata leads (13.8% vs. 0, P=0.019) . Twenty-five Riata leads and 47 Durata leads continued to be used normally. Compared to the parameters at the initial implantation, the mean pacing threshold during generator replacement (1.1 V/0.5 ms vs. 0.7 V/0.5 ms, P>0.05) and R wave amplitude (11.8 mV vs. 12.7 mV, P>0.05) showed no difference, with impedance decreased from 630 Ω to 519 Ω ( P<0. 01) . Conclusion:The lead defect rate of Riata leads was 13.8% over the course of 7.4 years follow-up. For those leads without defect, long-term pacing parameters were stable.

目的:评估植入型心律转复除颤器(ICD)/心脏再同步除颤器(CRT-D)更换脉冲发生器时,经静脉除颤导线的稳定性和长期起搏参数.方法:研究入选2010年1月至2019年12月在中国医学科学院阜外医院行ICD/CRT-D脉冲发生器更换术的患者.比较首次植入时、脉冲发生器更换时的经静脉除颤导线的起搏参数(包括起搏阈值、感知和阻抗).结果:共308例患者成功施行ICD/CRT-D脉冲发生器更换术,男性205例,平均年龄(59.05±14.45)岁,脉冲发生器使用时间为68.0(54.2～83.3)个月.除6例除颤导线因绝缘层破裂或不完全断裂而追加了新导线外,302例(98.1％)均继续应用原除颤导线.应用原除颤导线的302例患者除颤导线的起搏阈值首次植入时为(0.71±0.49)V/0.50 ms,更换时升高至(1.01±0.88)V/0.50 ms,R波感知振幅由首次植入时(15.38±6.46)mV下降至(12.13±6.48)mV,阻抗由首次植入时(867.66±318.21)Ω降低至(702.05±260.87)Ω,P均<0.001.以导线固定方式进行分组,主动固定导线组的起搏阈值在首次植入时[(0.93±0.84)V/0.50 ms vs.(0.64±0.25)V/0.50 ms,P=0.008]和更换时[(1.15±0.98)V/0.50 ms vs.(0.90±0.72)V/0.50 ms,P=0.036]均略高于被动固定导线组.两组在更换时的起搏阈值均表现为升高趋势,增幅为0.2 V/0.50 ms,但主动固定导线组的起搏阈值变化未达到统计学意义(P=0.228).结论:98％的除颤导线在平均应用5.67年后仍参数良好,数值变化幅度小,脉冲发生器更换时可继续应用.