本文選題：心血管病學 + 電極拔除　； 參考：《南方醫(yī)科大學》2016年碩士論文

【摘要】：一、研究背景心律植入裝置(cardiovascular implantable electronic device, CIED)是指永久心臟起搏器(PM)、埋藏式心臟復律除顫器(ICD)和心臟再同步化治療(CRT,包括CRT-P/D)等輔助維持正常心律的器械裝置。一項涉及全球多個國家的調(diào)查研究顯示,全球CIED植入數(shù)量在逐年增長,2009年PM植入數(shù)量高達1002 664臺,而ICD植入數(shù)量為328 027臺。美國每年有300多萬人植入CIED,植入總量超過了40萬臺。在挽救患者生命的同時,如此巨大的植入數(shù)量也帶來了裝置相關的感染問題。目前,CIED感染的發(fā)生率呈上升趨勢,除了CIED植入率增加,可能還與高齡及合并多種疾病患者比例增高有關。美國一項調(diào)查顯示,1996～2003年間CIED感染的住院率增加了3.1倍(PM為2.8倍,ICD為6.0倍),住院死亡風險也增加了2倍多,同時CIED感染的增加超過新裝置植入的增長。來自美國出院調(diào)查處(NHDS)的資料顯示,2004-2006年間美國CIED的年感染率分別為4.1%、4.8%和5.8%,2006年CIED感染比2004年增加了57%。荷蘭的一項起搏器注冊研究中,2000-2006年3410例CIED植入者中感染率高達2.2%,共75例(PM 36例,ICD 28例,CRT 11例)出現(xiàn)感染。丹麥多中心研究顯示,1982-2007年新植入和更換患者共46299例,其中新植入和更換感染率分別為1.80/1000(起搏器·年)、5.32/1000(起搏器·年),更換感染率明顯高于新植入率。國內(nèi)開展人工心臟起搏技術已有40余年歷史。在1997—-2005年間,感染、電極移位和導線折斷等起搏器并發(fā)癥的發(fā)生率為1.4%-1.9%,其中1997年感染的發(fā)生率為0.9%。在年植入50臺以上的24家醫(yī)院中,并發(fā)癥發(fā)生率為1.0%,低于植入量少于50臺的醫(yī)院(1.8%)。然而,我國報道的起搏器相關感染并發(fā)癥發(fā)生率較低,可能與缺乏全面的調(diào)查統(tǒng)計有關；此外,國內(nèi)能夠植入CIED的醫(yī)師分散在全國不同級別醫(yī)院,經(jīng)驗差異較大,起搏器的規(guī)范化培訓也開展較晚,缺失規(guī)范的起搏器隨訪管理。CIED感染率的升高與眾多因素相關。①植入率顯著增加：美國1993—2008年間裝置植入總量增加96%,而感染率卻增長了210%,提示感染率的增加可能還有另外的原因。換言之,除了植入率增高,裝置更換率以及ICD、CRT等復雜裝置植入比例也在增加。②患者年齡偏高且合并多種疾�。荷鐣淆g化的發(fā)展,在一定程度上影響了CIED患者的年齡。發(fā)展中國家CIED患者平均年齡65歲,而發(fā)達國家中年齡80歲的患者高達20%-30%。與年輕患者相比,高齡的患者無論是在身體條件還是合并癥方面都要更差,因此感染的發(fā)生率也會相應的升高。另外,高齡患者常伴發(fā)多種疾病,如糖尿病、腎功能不全、心力衰竭等。③更換比率增高：植入裝置更換比初次植入感染發(fā)生率明顯增高。丹麥一項研究對3.6萬例患者進行了跟蹤隨訪,起搏器初次植入后發(fā)生感染的概率為0.75%,而更換后為2.06%。④術者經(jīng)驗與感染的發(fā)生密切相關。經(jīng)驗少的術者,裝置感染的風險及機械并發(fā)癥如心肌穿孔、脫位、心包壓塞等并發(fā)癥的發(fā)生率明顯升高。⑤其他因素：圍手術期增加感染風險的危險因素還包括植入2根以上的電極導線、未能預防性應用抗生素、術后早期再干預治療、感染裝置再植入及復雜裝置的植入(如CRT-D)。一旦確診囊袋感染、血行感染、感染性心內(nèi)膜炎,應當盡早整體拔除感染裝置�？股乇Ｊ刂委熓÷蕩缀踹_100%。如果感染裝置未被及時取出,患者的死亡率明顯增高,據(jù)報道半年內(nèi)患者的死亡率高達18%。死亡相關的高危因素包括：右心功能障礙、腎功能異常,全身性血栓栓塞,中、重度二尖瓣反流等。因此囊袋及植入系統(tǒng)一旦確定感染時,無論是經(jīng)皮下還是靜脈植入(包括外科心外膜植入)的裝置,即便患者正處在囊袋感染期無合并全身感染癥狀時,完整拔除整個植入系統(tǒng)也是必要的,因為囊袋感染時可能已經(jīng)影響了整個系統(tǒng),任何裝置的遺留都會使感染的復發(fā)率大大增加。早期主要是通過徒手牽拉進行電極導線拔除,可成功解決多數(shù)導線植入時間較短的病例。但導線拔除的并發(fā)癥偏高,而且拔除的成功率仍較低。況且早期病例電極導線植入數(shù)量少,而且植入時間相對偏短。但隨著起搏器植入技術的進步,電極植入的部位及類型、導線的數(shù)量也已經(jīng)發(fā)生改變,如ICD導線植入數(shù)量、起搏器升級病例均迅速增加,冠狀靜脈左室導線也在增加。起搏導線的植入時間越來越長,許多患者的起搏導線植入時間高達30-40年。起搏電極的拔除風險較高,有發(fā)生血胸、肺栓塞、心包壓塞、電極游走、血管破裂甚至死亡等并發(fā)癥的可能。除與患者自身的危險因素有關外,并發(fā)癥的發(fā)生還與術者的經(jīng)驗和團隊的協(xié)作密切相關。因此CIED植入醫(yī)生必須經(jīng)過適當?shù)呐嘤?即在經(jīng)驗豐富的醫(yī)生(有100例以上起搏電極拔除的經(jīng)驗)指導下拔除20例以上電極的經(jīng)歷。術前的準備工作十分重要,包括經(jīng)團隊充分討論協(xié)商后認可的心導管預案及心胸外科手術方案。起搏電極拔除前,起搏電極拔除所需的設備和輔助耗材需全部到位,確保高質(zhì)量的球管透視裝置在拔除手術時工作正常。經(jīng)胸和經(jīng)食管超聲需到位隨時可以參與工作、動脈測壓系統(tǒng)到位,還需準備開胸手術包、心包穿刺包、臨時起搏和除顫設備。心胸外科醫(yī)師在場并隨時可以開始緊急手術、麻醉醫(yī)師在場和麻醉設備到位并隨時可以麻醉。國外關于CIED感染處理的認識及技術水平已基本完善,而國內(nèi)在該領域仍處于初步階段。雖然制定了“心律植入裝置感染與處理的中國專家共識”,但是區(qū)域醫(yī)療水平發(fā)展的不均衡性決定了其推廣的艱巨性。如今,基層醫(yī)院對于囊袋感染的處理仍傾向于應用大劑量抗生素、囊袋清創(chuàng)、脈沖發(fā)生器重置甚至剪短電極導線等保守治療,大大增加了電極拔除的難度及風險。本文回顧了中心近年來電極拔除病例,分析各病例特點,總結了中心電極拔除經(jīng)驗,探討影響電極拔除結果的影響因素。二、目的通過總結經(jīng)鎖骨下靜脈或股靜脈途徑拔除的94根起搏電極導線結果,探討電極拔除的影響因素并總結電極拔除的初步經(jīng)驗。三、方法回顧性分析2013年9月至2015年5月連續(xù)入院的42例囊袋感染或感染性心內(nèi)膜炎的CIED植入患者。分析各病例的臨床特點,總結經(jīng)鎖骨下靜脈及股靜脈途徑拔除電極過程中的經(jīng)驗方法。探討年齡、性別、體重指數(shù)、電極數(shù)目、植入時間、感染時間及靜脈途徑對電極拔除結果的影響。四、結果共拔除94根電極(心房電極45根,心室電極41根,除顫電極8根),平均植入時間8.97±7.24(0.30-33.00)年,感染時間0.94±1.83(0.10-12.00)年；完全拔除85根,部分拔除7根,殘留2根,成功率97.9%,失敗率2.1%。年齡、性別、體重指數(shù)、電極數(shù)目及靜脈途徑對電極拔除結果的影響無統(tǒng)計學差異；植入時間及感染時間對電極拔除結果的影響有顯著的統(tǒng)計學差異。四、結論植入時間及感染時間的延長大大增加了電極拔除的難度,顯著降低了成功率。鎖骨下靜脈是電極拔除的常規(guī)入路,股靜脈是有效補充,兩者結合可以有效的提高電極拔除的成功率。
[Abstract]:First, cardiovascular implantable electronic device (CIED) is a device for permanent cardiac pacemaker (PM), embedded cardiac cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT, including CRT-P/D) to support the normal rhythm of the rhythm of the heart. The number of CIED implantation is increasing year by year. In 2009, the number of PM implants was up to 1002664, and the number of ICD implanted was 328027. In the United States, about 3000000 people implanted CIED in the United States each year more than 400 thousand. While saving the lives of the patients, the number of such huge implants also brought about the related infection problems. At present, the occurrence of CIED infection The increase in rate is associated with an increase in the CIED implantation rate, which may be associated with a higher proportion of older and multiple disease patients. An American survey showed that the rate of hospitalization for CIED infection increased by 3.1 times in 1996~2003 years (PM 2.8 times, ICD was 6 times), and the risk of hospitalization increased by more than 2 times, and the increase of CIED infection exceeded the new device implantation. Data from the NHDS (NHDS) showed that the annual infection rate of CIED in the United States was 4.1%, 4.8% and 5.8% respectively. In 2006, CIED infection increased in a pacemaker registration study in 57%. Holland, 3410 cases of CIED implanted in 2000-2006 years were 2.2%, 75 cases (PM 36 cases, ICD 28 cases, CRT 11 cases). Infection. The Danish multicenter study showed that 46299 patients were newly implanted and replaced in 1982-2007 years. The new implantation and replacement rates were 1.80/1000 (pacemaker year) and 5.32/1000 (pacemaker year). The rate of replacement infection was significantly higher than that of the new implantation rate. The domestic development of human cardiac pacing technology has been over 40 years. In 1997 - -2005 years. The incidence of pacemaker complications, such as infection, infection, electrode displacement and wire broken, was 1.4%-1.9%, in which the incidence of infection in 1997 was 0.9%. in 24 hospitals with more than 50 stations. The incidence of complications was 1%, lower than that of less than 50 hospitals (1.8%). However, the incidence of complications related to pacemaker related infections reported in our country was low. It may be related to the lack of comprehensive survey statistics; in addition, physicians who can be implanted with CIED in the country are scattered in different levels of hospitals in the country, the experience is different, the standardized training of pacemakers is also carried out later, and the increase of the rate of.CIED infection is related to many factors. (1) the rate of implantation is significantly increased: 1993 The total number of plant implants increased by 96% in 2008, and the infection rate increased by 210%, suggesting an increase in the infection rate. In other words, the rate of implant replacement and the proportion of ICD, CRT and other complex devices are increasing. The average age of CIED patients is affected. The average age of the CIED patients in developing countries is 65 years old, while the age of 80 years in the developed country is up to 20%-30%. and the younger patients are worse, and the incidence of infection will rise accordingly. A variety of diseases, such as diabetes, renal insufficiency, heart failure, and so on. (3) the rate of replacement increased: the replacement rate of the implant was significantly higher than the initial infection rate. A Danish study was followed up for 36 thousand patients, the probability of infection after the initial pacemaker implantation was 0.75%, and the replacement was the experience of the 2.06%. 4 patients. Closely related to infection. Less experienced operators, risk of infection, and complications such as myocardial perforation, dislocation, pericardial plug, and other complications are significantly higher. 5. Other factors: the risk factors for increasing infection risk in the perioperative period include more than 2 electrodes implanted, and the failure to prevent the use of antibiotics Early intervention treatment, infection device reimplantation and complex device implantation (such as CRT-D). Once the bag infection, blood infection, infective endocarditis, the infection device should be removed as early as possible. The failure rate of the conservative treatment of antibiotics is almost 100%. if the infection device is not taken out in time and the mortality rate of the patient is obviously increased, it is reported that the death rate of the patient is obviously higher. The high risk factors associated with 18%. mortality in half a year are as follows: right heart dysfunction, abnormal renal function, systemic thromboembolism, severe mitral regurgitation, and so on, as soon as the capsule and implantation system determine infection, whether by subcutaneous or venous implantation (including surgical epicardial implantation), even if the patient is It is also necessary to completely remove the entire implant system when there is no systemic infection in the bag infection period, because the bag infection may have affected the whole system, and the remnants of any device will greatly increase the recurrence rate of the infection. In the early stage, most of the wires could be successfully solved by removing the electrode wire by hand pulling. The complications of wire removal were high, but the success rate of the extraction was still low. Moreover, the early case electrode wire implantation was less and the implantation time was relatively short. However, with the progress of the pacemaker implantation technology, the number of electrodes implanted and the number of lead lines had changed, such as ICD wire implantation. The number of pacemaker escalation cases increased rapidly and the coronary vein left ventricular traverse increased. The implantation time of pacing wires grew longer and the pacing wire was implanted in many patients for up to 30-40 years. The extraction risk of pacing electrodes was higher, and there were complications such as hemothorax, pulmonary embolism, pericardial tamponade, electrode travel, vascular rupture and even death. In addition to the risk factors of the patient's own, the occurrence of the complications is closely related to the experience of the operator and the teamwork of the team. Therefore, the CIED implant must be properly trained, that is, the experience of removing 20 above electrodes under the guidance of an experienced doctor (with 100 above pacing electrodes removed). The preparation work is important, including the cardiac catheterization plan and the cardiothoracic surgery plan approved by the team after the negotiation and consultation. Before the pacing electrode is removed, the equipment and auxiliary materials needed for the pacing electrode are all in place to ensure that the high quality tube fluoroscopy device works normally when the operation is removed. In order to participate in the work, the arterial pressure measurement system is in place, and the chest surgery bag, pericardium puncture bag, temporary pacing and defibrillation equipment are required. The cardiothoracic surgeon is present and can start the emergency operation at any time. The anesthesiologist is present and the anesthesia equipment is in place and can be anaesthetized at any time. The knowledge and technical level of the treatment of CIED infection abroad have been basic. It is still at a preliminary stage in the field. Although the "Chinese expert consensus" of "infection and treatment of cardiac implantable devices" is formulated, the uneven development of regional medical level determines the difficulty of its promotion. The difficulty and risk of the electrode extraction was greatly increased by the replacement of the pulse generator and even the cutting of the electrode wire. This paper reviewed the cases in the center of the electrode extraction in recent years, analyzed the characteristics of each case, summed up the experience of the extraction of the central electrode, and discussed the influencing factors of the removal of the electrode. Two, the purpose was to sum up the subclavian vein. The results of 94 pacing electrode wires removed from the femoral vein were used to investigate the influence factors of the electrode extraction and to summarize the preliminary experience of the electrode removal. Three. Methods a retrospective analysis of 42 cases of sack infection or infective endocarditis from September 2013 to May 2015 was retrospectively analyzed. The clinical characteristics of each case were analyzed, and the clavicle was summed up by the clavicle. An empirical method in the process of removing electrodes through the inferior veins and femoral veins. The effects of age, sex, body mass index, electrode number, implantation time, infection time and venous pathway on the removal of the electrode were investigated. Four, 94 electrodes were removed (45 atrium electrodes, 41 ventricular electropoles, 8 defibrillation electrodes), and the average implantation time was 8.97 + 7.24 (0.30). In -33.00), the infection time was 0.94 + 1.83 (0.10-12.00) years, 85 were removed completely, 7 were extracted and 2 were extracted, the success rate was 97.9%, the failure rate was 2.1%. age, sex, body mass index, electrode number and vein approach had no significant difference between the electrode extraction results and the effect of implantation time and infection time on the electrode extraction results. Four. Conclusion the time of implantation and the prolongation of the time of infection greatly increase the difficulty of the removal of the electrode and significantly reduce the success rate. The subclavian vein is the conventional approach of the electrode extraction, the femoral vein is an effective supplement, and the combination of the two can effectively improve the success rate of the electrode extraction.
【學位授予單位】：南方醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2016
【分類號】：R541.7

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