Nunain S O, Roelke M, Trouton T, Osswald S, Kim Y H, Sosa-Suarez G, Brooks D R, McGovern B, Guy M, Torchiana D F
Cardiac Arrhythmia Service, Harvard Medical School, Boston, MA, USA.
Circulation. 1995 Apr 15;91(8):2204-13. doi: 10.1161/01.cir.91.8.2204.
This study examines the limitations and complex management problems associated with the use of tiered-therapy, implantable cardioverter-defibrillators (ICDs).
The study group comprises the first 154 patients undergoing implantation of tiered-therapy ICDs at our institution. Pulse generators from three different manufacturers were used. In 39 patients, a complete nonthoracotomy lead system was used. The perioperative mortality was 1.3%. Of these 154 patients, 37% experienced late postoperative problems. Twenty-one patients required system revision within 36.5 months (mean, 8.57 +/- 11.3) of surgery. Reasons for revision were spurious shocks due to electrode fractures (3) or electrode adapter malfunction (2), inadequate signal from endocardial rate-sensing electrodes (3), superior vena cava or right ventricular coil migration (5), failure to correct tachyarrhythmias due to a postimplant rise in defibrillation threshold (5), or pulse generator failure (3). One of these patients required system removal for infection after revision of an endocardial lead. A further 32 patients received inappropriate shocks for atrial fibrillation with a rapid ventricular response or sinus tachycardia. Two of these patients also received shocks for ventricular tachycardia initiated by antitachycardia pacing triggered by atrial fibrillation. Ventricular pacing for bradycardia was associated with inappropriate shocks due to excessive autogain in 2 patients.
Despite the major diagnostic and therapeutic advantages of tiered-therapy ICDs, a significant proportion of patients continue to experience hardware-related complications or receive inappropriate shocks.
本研究探讨了分层治疗植入式心脏复律除颤器（ICD）使用过程中的局限性及复杂的管理问题。
研究组包括在我们机构接受分层治疗ICD植入的首批154例患者。使用了来自三个不同制造商的脉冲发生器。39例患者使用了完全非开胸导联系统。围手术期死亡率为1.3%。在这154例患者中，37%出现术后晚期问题。21例患者在术后36.5个月（平均8.57±11.3个月）内需要对系统进行修订。修订原因包括电极断裂（3例）或电极适配器故障（2例）导致的误放电、心内膜心率感知电极信号不足（3例）、上腔静脉或右心室线圈移位（5例）、植入后除颤阈值升高导致无法纠正快速心律失常（5例）或脉冲发生器故障（3例）。其中1例患者在心内膜导联修订后因感染需要移除系统。另有32例患者因房颤伴快速心室反应或窦性心动过速接受了不适当的电击。其中2例患者还因房颤触发的抗心动过速起搏引发室性心动过速而接受电击。2例患者因自动增益过高，导致用于治疗心动过缓的心室起搏与不适当电击有关。
尽管分层治疗ICD具有主要的诊断和治疗优势，但仍有相当一部分患者继续经历与硬件相关的并发症或接受不适当的电击。
