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

doi:10.3877/cma.j.issn.2095-6568.2023.02.001

Abstract

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.

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References 78

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双联抗血小板治疗		DOAC		VKA		DOAC+抗血小板
是否因ACS行PCI或合并其他高危因素		CHA₂DS₂-VASc评分 <3分）、无脑卒中史		CHA₂DS₂-VASc评分 <3分）、无脑卒中史		PCI+CHA₂DS₂-VASc评分<3分）、无脑卒中史
否	是	否	是	否	是	否	是
<1个月继续使用DAPT	<6个月继续DAPT	根据术者的经验和/或血栓栓塞风险继续或中断	可暂停	根据术者的经验和/或血栓栓塞风险继续或中断	可暂停，无需肝素桥接	PCI<6个月继续SAPT+低剂量DOAC	PCI>6个月DOAC
>1个月继续服用阿司匹林+停用P2Y12	>6个月停用P2Y12抑制剂	根据术者的经验和/或血栓栓塞风险继续或中断	可暂停	根据术者的经验和/或血栓栓塞风险继续或中断	可暂停，无需肝素桥接	PCI<6个月继续SAPT+低剂量DOAC	PCI>6个月DOAC

双联抗血小板治疗		DOAC		VKA		DOAC+抗血小板
是否因ACS行PCI或合并其他高危因素		CHA₂DS₂-VASc评分 <3分）、无脑卒中史		CHA₂DS₂-VASc评分 <3分）、无脑卒中史		PCI+CHA₂DS₂-VASc评分<3分）、无脑卒中史
否	是	否	是	否	是	否	是
<1个月继续使用DAPT	<6个月继续DAPT	根据术者的经验和/或血栓栓塞风险继续或中断	可暂停	根据术者的经验和/或血栓栓塞风险继续或中断	可暂停，无需肝素桥接	PCI<6个月继续SAPT+低剂量DOAC	PCI>6个月DOAC
>1个月继续服用阿司匹林+停用P2Y12	>6个月停用P2Y12抑制剂	根据术者的经验和/或血栓栓塞风险继续或中断	可暂停	根据术者的经验和/或血栓栓塞风险继续或中断	可暂停，无需肝素桥接	PCI<6个月继续SAPT+低剂量DOAC	PCI>6个月DOAC

项目	作用
设备
公司专用的起搏分析仪	起搏测试和脉冲发生器程控
可提供>40°透视X光机	导线定位
电灼止血。优选等离子电灼（非必需）	止血及游离导线时避免导线损坏
监测心律、袖带血压和脉搏血氧	生命体征监测
供氧、吸氧、袋式通风设备	处理呼吸紧急情况
备有药物和插管材料的急救设备	处理心血管和心律紧急情况
超声心动图（现场可快速使用）	诊断心脏压塞
呼吸机	用于全身麻醉
附件
长鞘（7~9 F），如23 cm	协助通过静脉扭曲、狭窄处
亲水性0.035导丝	帮助进入、通过狭窄、迂曲血管
加硬0.035导丝	帮助通过迂曲血管
封堵硅胶帽	对废弃的导线头进行封盖
心包穿刺所需器械及配件	处理紧急心脏压塞

项目	作用
设备
公司专用的起搏分析仪	起搏测试和脉冲发生器程控
可提供>40°透视X光机	导线定位
电灼止血。优选等离子电灼（非必需）	止血及游离导线时避免导线损坏
监测心律、袖带血压和脉搏血氧	生命体征监测
供氧、吸氧、袋式通风设备	处理呼吸紧急情况
备有药物和插管材料的急救设备	处理心血管和心律紧急情况
超声心动图（现场可快速使用）	诊断心脏压塞
呼吸机	用于全身麻醉
附件
长鞘（7~9 F），如23 cm	协助通过静脉扭曲、狭窄处
亲水性0.035导丝	帮助进入、通过狭窄、迂曲血管
加硬0.035导丝	帮助通过迂曲血管
封堵硅胶帽	对废弃的导线头进行封盖
心包穿刺所需器械及配件	处理紧急心脏压塞

导线分类	特点	优势	不足
刺激方式
单极导线	导线头端为阴极，脉冲发生器外壳为阳极。现已不再作为常规使用	寿命较长，两极间距较大，起搏心电图上脉冲信号清楚	仅提供单极起搏、感知模式，抗干扰能力较差，膈神经刺激多，不能用于ICD感知
双极导线	导线顶端为阴极，距离头端1.0~2.5 cm的环状导线为阳极	可提供单极或双极起搏、感知模式；双极工作模式下抗干扰能力强，可减少远场感知，无胸大肌刺激；可用于ICD感知	相对较粗、结构更复杂
固定方式
被动固定导线	头端有固定装置（翼状头、叉状头等），能使导线固定于肌小梁	对心内膜创伤较小，心肌穿孔概率低	只能固定在肌小梁丰富部位，如右心耳、右心室心尖部等；有一定的脱位发生率；导线移除困难
主动固定导线	通过头端螺旋固定于心内膜，其长度为1.5~2.0 mm，分可导电或不导电。螺旋结构分为可伸缩和不可伸缩，不可伸缩螺旋分为裸露（需配合鞘导入）和甘露醇包裹	可于任何部位植入，移除导线时相对容易	当植入于心耳、心室游离壁或心尖时有一定穿孔风险

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

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导线电极位置	优势	不足
右心室心尖部	技术成熟，易于定位，并存在方便固定被动导线的肌小梁	对左心室功能、心力衰竭和死亡有远期负面影响，导线拔除风险高于间隔部起搏
右心室间隔部	虽尚存争议，仍认为是比右心室心尖部起搏更生理的方案，可减少潜在的起搏诱导的心脏收缩非同步化，并减少导线穿孔风险	解剖定位不明确，不能实现生理性起搏。其对右心室收缩功能、三尖瓣反流的影响以及起搏参数与心尖部起搏相似
右心室流出道	目前暂无证据证实该起搏部位起搏的优势	目标区域更小，壁薄易穿孔。高位时固定并不可靠

并发症类型	发生率
操作相关的死亡	0~0.1
30 d死亡	0.6~1.4
气胸	0.4~2.8
导线穿孔	0.1~1.5
心包积液	10.2
心脏压塞	0.5~1.5
导线脱位	1.2~3.3
囊袋血肿	0.2~16.0
感染	0.6~3.4
其他	<0.5

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

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