Le Bloa Mathieu, Thambo Jean-Benoît
CHU de Bordeaux, hôpital cardiologique Haut-Lévêque, unité médicochirurgicale des pathologies cardiaques congénitales du fœtus de l'enfant et de l'adulte, avenue de Magellan, 33600 Pessac, France.
CHU de Bordeaux, hôpital cardiologique Haut-Lévêque, unité médicochirurgicale des pathologies cardiaques congénitales du fœtus de l'enfant et de l'adulte, avenue de Magellan, 33600 Pessac, France; Université Bordeaux Segalen, l'institut de rythmologie et modélisation cardiaque LIRYC, Pessac, France; Université Bordeaux, Inserm U1045 CRCTB, 33000 Bordeaux, France.
Presse Med. 2017 Jun;46(6 Pt 1):594-605. doi: 10.1016/j.lpm.2017.05.015. Epub 2017 Jun 5.
The number of children and adult with congenital heart disease requiring implantation of cardiac pacemaker or cardioverter defibrillator is constantly increasing. The lead between stimulation/defibrillation site and the generator constitutes the main weakpoint of those devices despite the numerous recent technological advances: use of bipolar probes, corticoid elution electrodes, insulation improvement, magnetic resonance imaging (MRI) compatibility. Risk of device failure remains high in this population. Long term adverse events with endovascular devices remain high. That point leads us to review our implantation strategies. We try to favour an extravascular solution whenever possible. Subcutaneous defibrillators may be proposed to patients at high risk for severe ventricular arrhythmia without cardiac pacing indication. Patients should have a rigorous pre-implantation screening procedure to minimize the increased risk of inappropriate shock. New single chamber, VVIR-type, leadless pacemakers can be implanted directly into the right ventricle. Miniaturized implantable loop recorders help in management of palpitations and syncopes: it increases diagnosis yield and helps arrhythmias burden assessment. Development of remote monitoring (implantable loop recorder, pacemaker and defibrillator) helps to reduce the incidence of adverse clinical events by providing an early detection of clinically relevant events such as arrhythmias and device failure.
需要植入心脏起搏器或心脏复律除颤器的先天性心脏病儿童和成人数量正在不断增加。尽管近年来技术取得了诸多进步，如使用双极探头、皮质类固醇洗脱电极、改善绝缘、具备磁共振成像（MRI）兼容性，但刺激/除颤部位与发生器之间的导线仍是这些设备的主要薄弱环节。该人群中设备故障风险仍然很高。血管内装置的长期不良事件发生率也居高不下。这促使我们重新审视植入策略。我们尽可能倾向于采用血管外解决方案。对于有严重室性心律失常高风险且无心脏起搏指征的患者，可考虑植入皮下除颤器。患者应接受严格的植入前筛查程序，以将不适当电击风险的增加降至最低。新型单腔、VVIR型无导线起搏器可直接植入右心室。小型化植入式循环记录仪有助于心悸和晕厥的管理：它提高了诊断率，并有助于评估心律失常负担。远程监测（植入式循环记录仪、起搏器和除颤器）的发展通过早期检测心律失常和设备故障等临床相关事件，有助于降低不良临床事件的发生率。
