Szilágyi Szabolcs, Merkely Béla, Zima Endre, Kutyifa Valentina, Szucs Gábor, Fülöp Gábor, Molnár Levente, Szabolcs Zoltán, Gellér László
Department of Cardiology, Heart Center, Semmelweis University, Gaál J Street 9, H-1122 Budapest, Hungary.
Europace. 2008 Oct;10(10):1157-60. doi: 10.1093/europace/eun207. Epub 2008 Aug 14.
Phrenic nerve stimulation (PNS), which is often intolerable for the patient, is a known complication of resynchronization therapy. We describe a new, minimal invasive method for treating PNS.
Untreatable PNS was found in nine cardiac resynchronization therapy patients with distal coronary sinus (CS) lead position 6 +/- 6 (0.5-17) months after the implantation. Ablation catheter and Amplatz Left 2 type guiding catheter were introduced into the right atrium via the right femoral vein. Coronary sinus was cannulated with the Amplatz catheter, and on a normal guide wire, a coronary stent was introduced beside the lead into the side branch in seven cases or a bigger stent into the CS in two patients. The ablation catheter was looped around the CS lead in the atrium with bent tip and was drawn backward together with the CS electrode. New lead positions were evaluated with electrophysiological measurements, and the suitable position was stabilized with inflation of the stent. Pericardial effusion was not detected on post-operative echocardiography. After repositioning, suitable pacing parameters were registered (threshold: 1.6 +/- 1.1 V; 0.5 ms, impedance: 565 +/- 62 ohm). Phrenic nerve stimulation was not found with 7.5 V; 1.5 ms pacing. During follow-up (7.7 +/- 4.6 months), stable pacing threshold and impedance values were measured; transient and reprogrammable PNS was present in only one patient.
Coronary sinus electrode reposition using the femoral approach seems to be a safe and effective procedure, which means smaller burden for the patients compared with the established reposition operation. The technique can be used successfully if the CS lead is in a distal position.
膈神经刺激（PNS）是心脏再同步治疗已知的并发症，患者通常难以耐受。我们描述一种治疗PNS的新型微创方法。
在9例心脏再同步治疗患者中发现无法治疗的PNS，这些患者在植入后6±6（0.5 - 17）个月时远端冠状窦（CS）电极处于特定位置。通过右股静脉将消融导管和Amplatz Left 2型引导导管引入右心房。用Amplatz导管插入冠状窦，在正常导丝引导下，7例患者将冠状动脉支架引入电极旁的侧支，2例患者将更大的支架引入冠状窦。消融导管在心房中围绕CS电极弯曲尖端形成环，并与CS电极一起向后牵拉。通过电生理测量评估新的电极位置，通过支架膨胀稳定合适的位置。术后超声心动图未检测到心包积液。重新定位后，记录到合适的起搏参数（阈值：1.6±1.1 V；0.5 ms，阻抗：565±62欧姆）。在7.5 V；1.5 ms起搏时未发现膈神经刺激。随访期间（7.7±4.6个月），测量到稳定的起搏阈值和阻抗值；仅1例患者出现短暂且可重新程控的PNS。
采用股动脉途径重新定位冠状窦电极似乎是一种安全有效的方法，与既定的重新定位手术相比，对患者的负担更小。如果CS电极处于远端位置，该技术可成功应用。
