【作者】 杨艳；

【导师】 刘凡；

【作者基本信息】 河北医科大学 ， 内科学， 2015， 硕士

【摘要】 目的:心脏起搏器起搏电极的发展经历了被动电极到主动电极的飞跃,主动电极的出现改善了被动电极脱位率高,固定后位置不便调整等诸多不便。主动电极植入后短期起搏阈值可出现较大变化,以主动电极植入即刻及植入后5-10分钟的起搏阈值定义为短期起搏阈值,探究心脏起搏器主动电极植入后患者一般情况及既往史对短期起搏阈值的影响情况。并分析主动电极植入后心肌损伤标记物的变化,了解主动电极的应用是否存在肌损伤及损伤程度的评价。方法:1对象入选2012年09月至2014年09月于我院心血管内科接受心脏起搏器治疗并植入单根或双根主动电极的患者192例,其中男性93例,女性99例,平均年龄67.61±8.91岁(41~88岁)。病态窦房结综合征156例,Ⅱ°房室传导阻滞9例,Ⅲ°房室传导阻滞18例,以及变时性功能不良9例。其中应用单根主动电极的患者136例,应用双根主动电极的患者56例。并收集临床资料,以上患者均完全符合2008年ACC/AHA/HRS心脏节律异常的装置治疗指南的Ⅰ类及Ⅱa类适应证。2所有患者均进行术前心电图、胸片、心脏超声、心肌酶、BNP、生化全项等检查,所有患者心功能均在60%以上。患者均于术前停用抗血小板药物;所有患者术中均为一次性植入主动电极导线成功。记录患者一般情况包括性别、年龄、吸烟、饮酒及伴有的既往疾病如高血压、糖尿病、冠心病、高脂血症等,术中监测主动固定电极导线植入后心房和心室短期的起搏阈值并记录。3统计方法采用多因素Logistic回归分析心脏起搏器主动电极植入后在短期内一般情况对起搏阈值的影响。并于起搏器术前及术后24h、48h、甚或72h监测心肌酶并记录,各心肌酶水平不同时间及两组间的比较使用重复测量设计的方差分析,了解主动固定电极导线对心肌细胞的损伤程度,评判其临床安全性及手术可行性。结果:1以性别、年龄,既往疾病高血压、冠心病、糖尿病、高脂血症及嗜好吸烟及饮酒史为自变量,以心室主动固定电极螺旋旋出后即刻的起搏阈值为因变量做logistic回归分析,结果显示,冠心病、糖尿病、高脂血症、吸烟及饮酒为心室即刻起搏阈值的影响因素;以心室主动固定电极螺旋旋出后5-10分钟时的阈值为因变量做logistic回归分析,结果显示,女性、年龄、糖尿病、饮酒为心室5-10分钟起搏阈值的影响因素;以心房主动电极螺旋旋出后即刻的起搏阈值为因变量做logistic回归分析,结果显示,冠心病、吸烟为心房即刻起搏阈值的影响因素;以心房主动电极螺旋旋出后5-10分钟的起搏阈值为因变量做logistic回归分析,结果显示,糖尿病、吸烟为心房5-10分钟起搏阈值的影响因素。2不同时间心肌酶水平的比较入选患者术前测定血清肌红蛋白(MYO)水平为58.11±23.70ng/ml,肌酸激酶(CK)浓度为66.02±33.02U/L,肌酸激酶同工酶(CK-MB)浓度为16.03±9.49 U/L,乳酸脱氢酶(LDH)浓度为193.00±49.94 U/L,肌钙蛋白I(c Tn I)浓度为0.01±0.01ng/ml。心肌酶血清肌红蛋白(MYO)水平起搏器术前及术后不同时间差异均有统计学意义(F=36.196,P<0.001),术后24小时较术前升高(P<0.05);肌酸激酶(CK)浓度起搏器术前及术后不同时间差异均有统计学意义(F=39.075,P<0.001),术后24小时及48小时较术前升高(P<0.05);肌酸激酶同工酶(CK-MB)浓度起搏器术前及术后不同时间差异均有统计学意义(F=11.469,P<0.001),术后24小时较术前升高(P<0.05);乳酸脱氢酶(LDH)浓度起搏器术前及术后不同时间差异均有统计学意义(F=25.430,P<0.001),术后24小时及48小时较术前升高(P<0.05);肌钙蛋白I(c Tn I)浓度起搏器术前及术后不同时间差异均有统计学意义(F=21.456,P<0.001),术后24小时及48小时较术前升高(P<0.05)。3不同分组心肌酶水平的比较血清肌红蛋白(MYO)水平单根组与双根组间比较差异无统计学意义(F=0.758,P=0.385);血浆肌酸激酶(CK)浓度单根组与双根组间比较差异无统计学意义(F=0.453,P=0.502);血浆肌酸激酶同工酶(CK-MB)浓度单根组与双根组间比较差异无统计学意义(F=3.740,P=0.055);血浆乳酸脱氢酶(LDH)浓度单根组与双根组间比较差异无统计学意义(F=0.865,P=0.354);血浆肌钙蛋白I(c Tn I)浓度单根组与双根组间比较差异无统计学意义(F=0.054,P=0.816)。结论:本组研究显示:心脏起搏器主动固定电极导线植入后,女性、年龄、吸烟、饮酒、冠心病、糖尿病、高脂血症在短期内对可对起搏阈值的造成一定影响。植入主动电极导线后患者的心肌酶MYO、CK、CK-MB、LDH、c TNI水平逐渐升高,24小时可达到高峰,并明显高于术前水平(P<0.05),但72小时均能有统计学意义的下降,故主动固定电极导线的植入对心肌的损伤无明确作用,主动固定电极导线单根组与双根组间心肌酶水平差异无统计学意义(P>0.05),心肌损伤与应用主动固定电极导线的数目无明显相关。更多还原

【Abstract】 Objective: The development history of cardiac pacemaker pacing lead go through from passive to active pacing lead.Emergence of active pacing lead reduce passive pacing lead high dislocation rate and improve fixed position inconvenient adjustment.After active pacing lead implantation,short-term pacing threshold can be a big change.Instant pacing threshold and pacing threshold of active fixed pacing lead 5-10 minutes after implantation is defined as short-term pacing threshold. To explore the influence factor of active fixed pacing lead after implantation of cardiac pacemaker in short-term pacing threshold.Analysis change of myocardial injury markers after the active pacing lead implanted.To know whether the application of active pacing lead with myocardial injury and evaluation of damage degree.Methods:1 Object: From sep 2012 to sep 2014 in our hospital cardiovascular internal medicine cardiac pacemaker therapy(cardiac pacemaker) and active fixed pacing lead implanted in 192 patients, 93 cases of male, female 99 cases, average age 67.61 ± 8.91(41 to 88 years). Sick sinus syndrome in 156 cases, Ⅱ°atrioventricular block 9 cases, Ⅲ°atrioventricular block 18 cases, and change the 9 cases of sexual function. 136 patients with one active fixed pacing lead used in it, the two leads of 56 patients with active fixed pacing lead. And collect the clinical data of all patients were in line with the 2008 ACC/AHA/HRS abnormal heart rhythm of plant treatment guidelines Ⅰclasses and class a indication.Ⅱ2 All patients were examined before electrocardiogram, chest X-ray, echocardiogram, myocardial enzyme, BNP, biochemical examination such as whole, drugs to patients in preoperative antiplatelet discontinuation; All of the patients are all one-time active fixed pacing lead implanted successfully. Intraoperative monitoring of active fixed pacing lead implanted atrial or ventricular after short-term pacing threshold, and record the patient general condition including gender, age, smoking, drinking and associated with diseases such as hypertension, diabetes, coronary heart disease, hyperlipidemia, etc.3 Statistical method: Using multiariable Logistic regression analysis of cardiac pacemaker after active fixed pacing lead implanted in the short term, in general, the impact on the threshold of the wrestle since. And in preoperative and postoperative 24 h, 48 h, or even 72 h monitoring myocardial enzymes, the myocardial enzyme levels in different time and the comparison between two groups using repeated measures design analysis of variance, evaluation of active fixed pacing lead for myocardial damage degree, understand its security.Result:1 By gender, age, hypertension, coronary heart disease, diabetes, hyperlipidemia, smoking and drinking as independent variables, with ventricular active fixed pacing lead spiral spin out immediately after pacing threshold do logistic regression analysis for the dependent variable, the results showed that coronary heart disease, diabetes, hyperlipidemia, smoking and drinking to the influence factors of ventricular instant pacing threshold; With ventricular active fixed pacing lead spiral spin out 5-10 minutes after the threshold for the dependent variable of logistic regression analysis, the results showed that women, older age, diabetes, alcohol as the influence factors of ventricular 5-10 minutes pacing threshold; With atrial active fixed pacing lead spiral spin out immediately after pacing threshold do logistic regression analysis for the dependent variable, the results showed that coronary heart disease, smoking, the influence factors of atrial pacing immediate threshold; With atrial active fixed pacing lead spiral spin out 5-10 minutes after pacing threshold do logistic regression analysis for the dependent variable, the results showed that diabetes, smoking, 5-10 minutes for atrial pacing threshold of influence factors.2 Different time of myocardial enzyme levels. Preoperative serum myoglobin(MYO) level was 58.11 ± 23.70 ng/ml, creatine kinase(CK) concentration was 66.02 ± 33.02 U/L, creatine kinase isoenzyme(CK-MB) concentration was 16.03±9.49U/L,lactate dehydrogenase(LDH) concentration was 193.00±49.94 U/L, troponin I(c Tn I) concentration was 0.01±0.01 ng/ml. Serum myocardial enzyme myoglobin(MYO) concentration of preoperative and postoperative different time difference was statistically significant(F=36.196, P<0.001),concentration of 24 hours after the operation elevated(P<0.05); Creatine kinase(CK) concentration of preoperative and postoperative different time difference was statistically significant(F= 39.075, P<0.001), concentration of 24 hour and 48 hours after the operative elevated(P<0.05); Creatine kinase isoenzyme(CK-MB) concentration of preoperative and postoperative different time difference was statistically significant(F =11.469, P<0.001), concentration of 24 hours after the operation elevated(P<0.05); Lactate dehydrogenase(LDH) concentration of preoperative and postoperative different time difference was statistically significant(F=25.430).Troponin I(c Tn I) concentration of preoperative and postoperative different time difference was statistically significant(F=21.456).concentration of 24 and 48 hours after the operation elevated(P<0.05).3 Myocardial enzyme levels, different groups are compared. Serum myoglobin(MYO) level of the one and two leads group and there was no statistically significant difference between two groups(F=0.758, P=0.758). Creatine kinase(CK) concentration difference between the one lead and the two leads groups has no statistical significance(F=0.453, P=0.502); Creatine kinase isoenzyme(CK-MB) concentration difference between the one lead and the two leads groups has no statistical significance(F=3.740, P=3.740). Lactate dehydro- genase(LDH) concentration of the one and two leads group and there was no statistically significant difference between two groups(F=0.865, P=0.354); Troponin I(c Tn I) concentration difference between the one lead and the two leads groups has no statistical significance(F=0.054, P=0.054).Conclusions: this study shows that: female, age, smoking, drinking, coronary heart disease, diabetes, hyperlipidemia, heart pacemakers is influence factors of pacing threshold active fixed pacing lead in the short term after implantation.After active fixed pacing lead implanted in patients,myocardial enzyme MYO,CK,CK-MB,LDH,c TNI can be increased peak on 24 hours a day and significantly higher than preoperative(P<0.05), but 72 hours can drop to normal or below the preoperative level. There is no statistically significant significant difference of myocardial enzyme levels active pacing leads between single and two leads group(P>0.05).There is no clear effect on myocardial injury active pacing leads implanted.Myocardial injury and the number of active pacing lead have no obvious correlation.更多还原