Epstein M R, Walsh E P, Saul J P, Triedman J K, Mayer J E, Gamble W J
Children's Hospital, Department of Cardiology, Boston, Massachusetts 02115, USA.
Pacing Clin Electrophysiol. 1998 May;21(5):1098-104. doi: 10.1111/j.1540-8159.1998.tb00156.x.
Bipolar epicardial leads are not yet widely available for atrial use. Since September 1986, we have used a bipolar active fixation endocardial lead (Cardiac Pacemakers model number's 4266, 4268, and 4269) as a bipolar epicardial atrial lead by attaching the corkscrew tip to the atrial surface and imbricating atrial tissue around the more proximal electrode. A total of 77 bipolar epicardial atrial leads have been implanted using this approach in 72 patients with congenital heart disease (ages 3 months to 38.7 years; mean 8.9 +/- 8.8 years). Indications for atrial pacing included AV block (n = 46), sinus node dysfunction (n = 17), and antitachycardial pacing (n = 9). Indications for epicardial pacing included the presence of an intracardiac right to left shunt (n = 33), concomitant cardiac surgery (n = 26), surgeon preference (n = 7), and lack of transvenous access to the atrial endocardium (n = 6). Follow-up (median 23 months; mean 28.0 +/- 23.1 months; range 1-78 months) data beyond 1 month postimplantation were available for 44 leads. Atrial sensing was > or = 2.0 mV for 26 leads (59%) with sensing possible at > or = 0.75 mV for 42 leads (95%). Threshold data were available at 5 V for 37 leads and at 2.5 V for 36 leads with mean pulse width thresholds measuring 0.21 +/- 0.33 ms and 0.34 +/- 0.34 ms, respectively. Two leads failed (high capture thresholds at 5 days [n = 1], lead fracture at 42 months [n = 1]; one of which was replaced. Four additional leads were replaced electively (marginal thresholds [n = 1], intermittent phrenic nerve stimulation [n = 1], damaged during subsequent surgery [n = 1], clinically irrelevant insulation break [n = 1]) concomitant with additional cardiac surgery. Until a commercially available lead is developed and released, improvisation with a bipolar active fixation endocardial lead as a bipolar epicardial atrial lead is a reasonable approach to providing bipolar atrial sensing and pacing in patients for whom endocardial pacing is contraindicated.
双极心外膜导联尚未广泛用于心房起搏。自1986年9月以来，我们通过将螺旋电极尖端固定于心房表面，并将心房组织包绕于较近端电极周围，将双极主动固定心内膜导联（心脏起搏器型号4266、4268和4269）用作双极心外膜心房导联。采用这种方法，共为72例先天性心脏病患者（年龄3个月至38.7岁；平均8.9±8.8岁）植入了77根双极心外膜心房导联。心房起搏的适应证包括房室传导阻滞（n = 46）、窦房结功能障碍（n = 17）和抗心动过速起搏（n = 9）。心外膜起搏的适应证包括心内右向左分流（n = 33）、同期心脏手术（n = 26）、外科医生偏好（n = 7）以及无法经静脉途径到达心房内膜（n = 6）。植入后1个月以上的随访数据（中位数23个月；平均28.0±23.1个月；范围1 - 78个月）可用于44根导联。26根导联（59%）的心房感知≥2.0 mV，42根导联（95%）在≥0.75 mV时可感知。37根导联可获得5 V时的阈值数据，36根导联可获得2.5 V时的阈值数据，平均脉宽阈值分别为0.21±0.33 ms和0.34±0.那么ms。两根导联出现故障（1根在5天时捕获阈值高，1根在42个月时导线断裂；其中1根被更换）。另外4根导联在同期心脏手术时被选择性更换（阈值临界[1根]、间歇性膈神经刺激[1根]、在后续手术中受损[1根]、临床无关的绝缘破损[1根]）。在开发并推出市售导联之前，将双极主动固定心内膜导联临时用作双极心外膜心房导联，对于心内膜起搏禁忌的患者而言，是提供双极心房感知和起搏的一种合理方法。
