Block M, Hammel D, Borggrefe M, Scheld H H, Breithardt G
Medizinische Klinik und Poliklinik, Innere Medizin C (Kardiologie und Angiologie), Westfälische Wilhelms-Universität Münster.
Herz. 1994 Oct;19(5):259-77.
For years the high efficacy of implantable cardioverter-defibrillators (ICD) to prevent sudden cardiac death was impaired by the substantial perioperative mortality of the therapy. With the introduction of transvenous-subcutaneous defibrillation leads, thoracotomy could be abandoned and perioperative mortality was reduced to less than 1%. Despite frequent lead complications as dislocations, conductor fractures and isolation failures, long-term efficacy in termination of ventricular tachyarrhythmias remained approximately 98% and prevention of sudden cardiac death was not impaired. All nonthoracotomy defibrillation lead systems involve an endocardial right ventricular lead usually introduced from the left cephalic vein or directly via the subclavian vein. This lead has a pace/sense tip and at least one defibrillation electrode located in the right ventricle. Additionally, a second transvenous electrode and/or a subcutaneous patch or array electrode or the pulse generator shell has to be used for defibrillation. In combination with the biphasic defibrillation waveform, virtually all patients can be defibrillated using a combination of these electrodes. In most patients defibrillation is possible with transvenous electrodes alone and there is no need for an additional subcutaneous electrode. Smaller pulse generators have already been implanted in a subpectoral position--in many patients allowing a single incision approach as used for pacemaker implantation. Ultimately, with even smaller pulse generators ICDs should be implantable like present pacemakers in local anesthesia. This overview covers the history, models, practical aspects of implantation and testing, efficacy and complications of transvenous/subcutaneous defibrillation leads. Figures show the impact of the surgical approach on the frequency of de novo ICD implantations, X-rays of nearly all current bipolar and tripolar transvenous subcutaneous ICD lead systems, transvenous-epicardial hybrid systems and various complications. Additional figures cover lead complications not visible on X-rays. Defibrillation thresholds are compared for various lead configurations. Sensing amplitudes and pacing thresholds are compared for bipolar and pseudobipolar sense/pace leads as well as for different cardiac diseases. Tables summarize the main characteristics of current transvenous and subcutaneous ICD leads and external devices for intraoperative testing of ICD leads as well as the complications of transvenous/subcutaneous leads in three multicenter studies.
多年来，植入式心脏复律除颤器（ICD）预防心源性猝死的高效能因该治疗显著的围手术期死亡率而受损。随着经静脉-皮下除颤导线的引入，开胸手术得以摒弃，围手术期死亡率降至1%以下。尽管导线并发症频发，如脱位、导线断裂和绝缘故障，但终止室性快速心律失常的长期效能仍保持在约98%，且预防心源性猝死的能力并未受损。所有非开胸除颤导线系统都包含一根通常从左头静脉或直接经锁骨下静脉引入的右心室内膜导线。该导线有一个起搏/感知头端，且至少有一个除颤电极位于右心室。此外，还必须使用第二个经静脉电极和/或一个皮下贴片或阵列电极或脉冲发生器外壳进行除颤。结合双相除颤波形，几乎所有患者都可通过这些电极的组合进行除颤。在大多数患者中，仅用经静脉电极就能进行除颤，无需额外的皮下电极。更小的脉冲发生器已被植入胸大肌下位置——在许多患者中允许采用与起搏器植入相同的单切口方法。最终，随着脉冲发生器甚至更小，ICD应能像目前的起搏器一样在局部麻醉下植入。本综述涵盖经静脉/皮下除颤导线的历史、型号、植入和测试的实际情况、效能及并发症。图展示了手术方式对初次植入ICD频率的影响、几乎所有当前双极和三极经静脉皮下ICD导线系统、经静脉-心外膜混合系统的X线片以及各种并发症。其他图涵盖了X线片上不可见的导线并发症。比较了各种导线配置的除颤阈值。比较了双极和伪双极感知/起搏导线以及不同心脏疾病的感知幅度和起搏阈值。表格总结了当前经静脉和皮下ICD导线以及用于ICD导线术中测试的外部设备的主要特征，以及三项多中心研究中经静脉/皮下导线的并发症。
