Department of Cardiovascular Surgery, Heart Institute (InCor)-Clinics Hospital of the University of Sao Paulo Medical School, Sao Paulo, Brazil.
Heart Rhythm. 2013 Nov;10(11):1646-52. doi: 10.1016/j.hrthm.2013.08.002. Epub 2013 Aug 3.
Limited venous access in certain patients increases the procedural risk and complexity of conventional transvenous pacemaker implantation.
The purpose of this study was to determine a minimally invasive epicardial approach using pericardial reflections for dual-chamber pacemaker implantation in patients with limited venous access.
Between June 2006 and November 2011, 15 patients underwent epicardial pacemaker implantation. Procedures were performed through a minimally invasive subxiphoid approach and pericardial window with subsequent fluoroscopy-assisted lead placement. Mean patient age was 46.4 ± 15.3 years (9 male [(60.0%], 6 female [40.0%]). The new surgical approach was used in patients determined to have limited venous access due to multiple abandoned leads in 5 (33.3%), venous occlusion in 3 (20.0%), intravascular retention of lead fragments from prior extraction in 3 (20.0%), tricuspid valve vegetation currently under treatment in 2 (13.3%), and unrepaired intracardiac defects in 2 (13.3%).
All procedures were successful with no perioperative complications or early deaths. Mean operating time for isolated pacemaker implantation was 231.7 ± 33.5 minutes. Lead placement on the superior aspect of right atrium, through the transverse sinus, was possible in 12 patients. In the remaining 3 patients, the atrial lead was implanted on the left atrium through the oblique sinus, the postcaval recess, or the left pulmonary vein recess. None of the patients displayed pacing or sensing dysfunction, and all parameters remained stable throughout the follow-up period of 36.8 ± 25.1 months.
Epicardial pacemaker implantation through pericardial reflections is an effective alternative therapy for those patients requiring physiologic pacing in whom venous access is limited.
在某些患者中，有限的静脉通路会增加常规经静脉起搏器植入的程序风险和复杂性。
本研究旨在确定一种微创心外膜方法，通过心包反射在心外膜上进行双腔起搏器植入，适用于静脉通路有限的患者。
2006 年 6 月至 2011 年 11 月期间，15 例患者接受了心外膜起搏器植入。通过微创剑突下途径和心包窗进行手术，随后进行透视引导的导丝放置。患者平均年龄为 46.4±15.3 岁（9 例男性[60.0%]，6 例女性[40.0%]）。由于 5 例患者（33.3%）有多处废弃的导丝、3 例患者（20.0%）静脉闭塞、3 例患者（20.0%）先前提取的导丝碎片血管内滞留、2 例患者（13.3%）三尖瓣有当前正在治疗的赘生物、2 例患者（13.3%）未修复的心脏内缺损，这些患者被认为静脉通路有限，采用了新的手术方法。
所有手术均成功完成，无围手术期并发症或早期死亡。单纯起搏器植入的平均手术时间为 231.7±33.5 分钟。在 12 例患者中，可将心房导线放置在右心房的上腔，通过横窦。在其余 3 例患者中，将心房导线植入左心房，通过斜窦、后下腔静脉隐窝或左肺静脉隐窝。所有患者均未出现起搏或感知功能障碍，且所有参数在 36.8±25.1 个月的随访期间均保持稳定。
通过心包反射进行心外膜起搏器植入是一种有效的替代治疗方法，适用于那些静脉通路有限但需要生理性起搏的患者。
