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中华心脏与心律电子杂志 ›› 2023, Vol. 11 ›› Issue (02) : 65 -102. doi: 10.3877/cma.j.issn.2095-6568.2023.02.001

标准与规范

普通心脏起搏器和植入型心律转复除颤器手术操作规范中国专家共识(2023)
中华医学会心电生理和起搏分会, 中国医师协会心律学专业委员会   
  • 收稿日期:2023-03-16 出版日期:2023-06-25

Chinese expert consensus and practical guide on optimal implantation technique for conventional pacemakers and implantable cardioverter defibrillators(2023)

Chinese Society of Pacing and Electrophysiology, Chinese Society of Arrhythmas   

  • Received:2023-03-16 Published:2023-06-25
引用本文:

中华医学会心电生理和起搏分会, 中国医师协会心律学专业委员会. 普通心脏起搏器和植入型心律转复除颤器手术操作规范中国专家共识(2023)[J]. 中华心脏与心律电子杂志, 2023, 11(02): 65-102.

Chinese Society of Pacing and Electrophysiology, Chinese Society of Arrhythmas. Chinese expert consensus and practical guide on optimal implantation technique for conventional pacemakers and implantable cardioverter defibrillators(2023)[J]. Chinese Journal of Heart and Heart Rhythm(Electronic Edition), 2023, 11(02): 65-102.

心脏起搏器(PM)和植入型心律转复除颤器(ICD)的临床应用已多年,但植入手术操作本身尚无全面系统的指导性文件。本共识由中华医学会心电生理和起搏分会(CSPE)和中国医师协会心律学专业委员会(CSA)共同组织了多位国内该领域知名专家,查阅了大量的参考文献并结合丰富的临床经验及国内医院的实际情况编撰而成,就植入PM和ICD的手术流程,包括基本要求、详细的手术步骤、出院前管理、围术期并发症及处理、ICD植入特殊要点和脉冲发生器更换注意事项等多个方面通过详尽的文字和图片的形式对涉及手术的每个细节都进行了深入地解析。

表1 心血管植入型电子器械植入术前准备清单
表2 抗凝及抗血小板药物的围术期管理
表3 心血管植入型电子器械植入所需的设备、附件及作用
图1 起搏器植入手术常规消毒范围示意图(白色区域为消毒范围)
图2 制作起搏器囊袋切口示意图A为胸大肌-三角肌切口,B为水平切口,C为斜行切口
图3 胸大肌及胸小肌的解剖位置
图4 外周静脉及入路示意图[4A为静脉解剖位置,显示头静脉、锁骨下静脉及腋静脉位置,其中腋静脉以胸小肌上、下缘为标志分为3段;4B为头静脉切开、锁骨下静脉及腋静脉穿刺位置]
图5 通过肘静脉注射造影剂,X线透视下使腋静脉显影,有助于腋静脉穿刺
表4 起搏导线的分类、特点、优势和不足
图6 不同主动固定导线螺旋伸出方式[6A为美国美敦力公司5076型;6B为德国百多力公司Solia S型;6C为美国雅培公司2088TC型;6D为美国波士顿科学公司7740、7741、7742型]
图7 导线进入奇静脉[7A为前后位,显示导线在心影外,导线前端不能活动,僵硬;7B为左侧位,显示房室导线均在心影后方;7C为左侧位,调整位置后起搏导线植入右心耳和右心室心尖部]
表5 右心室起搏部位的优势和不足
图8 起搏导线通过三尖瓣的3种不同方法
图9 不同透视体位下右心室导线在心尖部的影像学位置[9A为右前斜位,显示心脏长轴;9B为后前位;9C为左前斜位,导线头端朝向间隔;9D为左前斜位,导线头端朝向心尖]
图10 塑形的鹅颈弯指引钢丝(钢丝头端10 cm处及远端1 cm处分别塑弯,为双弯3D形状)
图11 不同透视体位下导线在右心室间隔部的影像学位置[11A为后前位;11B为左前斜位,显示起搏导线头端朝向脊柱;11C为右前斜位,起搏导线头端位于九分法的第5区(中部间隔)]
图12 Selectra 3D鞘配合Solia S主动导线到位右心室间隔[12A为右前斜;12B为后前位;12C为左前斜]
图13 右心室心尖部和间隔部起搏形态[13A为右心室心尖部起搏,胸前导联左束支传导阻滞(LBBB)图形,Ⅱ、Ⅲ、aVF导联主波向下,QRS波宽大畸形;13B为右心室中位间隔部起搏,胸前导联LBBB图形,Ⅱ、Ⅲ、aVF导联主波向上,QRS时限较窄]
图14 不同张力下的右心室心尖部起搏导线[14A为正常张力;14B为张力过低;14C为张力过高]
图15 儿童先天性心脏病患者植入VVI起搏器(心腔内留有足够的导线)
图16 经永存左上腔静脉植入起搏导线[16A为前后位,经左侧静脉造影显示永存左上腔静脉;16B为前后位,经交通支造影发现无右上腔静脉;16C为前后位,经永存左上腔静脉植入心房和心室导线,分别位于右心房外侧壁和右心室心尖部]
图17 希氏束起搏(HBP)纠正左束支传导阻滞(LBBB)心电图及腔内电图[17A为自身;17B为HBP夺获传导束;17C为选择性HBP纠正LBBB;17D为非选择性HBP纠正LBBB]His为希氏束
图18 左束支(LBB)起搏导线旋入间隔过程中起搏心电图QRS波的变化
图19 术中腔内电图连续单极记录[在旋入过程中从小左束支(LBB)电位逐渐振幅增大,电位极性反转伴损伤电流(V-COI)改变,提示导线位置更深,靠近LBB。同时监测V-COI可保持导线头端未突破左心室内膜]
图20 左前斜位下经鞘管造影,显示导线进入室间隔的深度(箭头所示为造影剂)
图21 右心房导线植入右心耳前后位下的影像[前后位下导线顶端指向左前上,多位于12点到2点之间。21A:右心房导线位于右心耳窦部(12点左右);21B:右心房导线位于右心耳囊部(2点左右)。21C:患者在深吸气时,导线头端由J型变成L型]
图22 低位房间隔起搏影像[22A为前后位;22B为左前斜位;导线指向脊柱方向,与位于室间隔部的心室导线方向一致]
图23 低位房间隔起搏心电图(起搏P波在Ⅱ、Ⅲ和aVF导联倒置,且明显变窄)
图24 右心房被动导线X线影像,前后位下位于右心房下外侧壁
图25 过桥线与起搏导线的连接[25A为单极测试时,黑色鳄鱼夹夹在导线阴极(导线尾端的金属杆),红色鳄鱼夹夹在皮下组织;25B为双极测试时,黑色夹阴极(导线尾端的金属杆),红色夹导线阳极环]
图26 使用程控仪的起搏系统测试分析模块进行参数测试[以美国美敦力公司2290起搏系统分析仪为例,将起搏系统测试分析模块插入程控仪,连接测试线与过桥线,进入分析仪界面开始参数测试]
图27 在心房导线感知振幅测试时需注意观察腔内电图中远场R波振幅(建议<20% P波振幅)
图28 心房起搏测试与自身P波的关系[28A为心电监护上观察起搏P波形态与自身P波不同,房室呈1∶1下传;28B为前半部分为起搏前心电图,3∶2下传;后半部分,起搏心房后呈(4~6)∶1下传,心室自身频率比起搏前降低,说明心房被夺获]
图29 主动导线螺旋旋出前和旋出后的心室损伤电流变化
图30 损伤电流异常的可能情况[30A为在左束支(LBB)起搏导线拧入室间隔的过程中,原本抬高良好的损伤电流突然低平,提示导线穿孔可能;缓慢将导线回撤,损伤电流逐渐恢复;30B为过桥线鳄鱼夹的正负极连接错误导致腔内电图中出现负向波形]
图31 使用心电监护记录损伤电流及连接方法[用过桥线两端的同色鳄鱼夹(黑色或红色)分别连接起搏导线尾端金属柄(31A)和心电监护的V1(或V3)电极(31B),另一色鳄鱼夹旷置;31C为心电监护记录的损伤电流]
图32 导线固定方法的示意图[32A为将导线缝合套连同肌筋膜层一并缝扎(不推荐,导线固定不牢靠);32B为先在肌筋膜层缝扎一道死结,然后再绕过导线缝合套的沟槽打结(目前推荐的缝扎方法,导线固定牢靠)]
表6 围术期并发症类型和发生率(%)
图33 植入型心律转复除颤器术后胸部X线片提示左侧气胸(箭头提示气胸线)
图34 起搏器术后血胸[34A为右侧血胸;34B为选择性造影证实右乳内动脉损伤予以弹簧栓封堵(箭头处);34C为好转后胸部X线 片]
图35 导线穿孔胸部X线片(可见除颤导线穿出心脏)
图36 旋转综合征和棘轮综合征[36A为旋转综合征病例;36B为棘轮综合征的病例。两者心房、心室导线均移位,前者脉冲发生器沿自身横断面旋转且伴导线缠绕,后者导线类似于齿轮样滑动,但未盘绕脉冲发生器。此2种情况均由于导线固定不牢固所致]
图37 经未闭房间隔起搏左心室的左前斜位影像[37A为心室导线均似乎在右心室间隔部,但导线明显偏后,已到脊柱中间,提示导线已进入左心室;37B为重置导线位置,导线在心尖部,未达脊柱]
图38 起搏器植入术后囊袋并发症外观图[38A为囊袋血肿;38B为囊袋浅表皮肤感染]
图39 T-Shock方法行除颤阈值测试VF为心室颤动,ICD为植入型心律转复除颤器
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