单中心经静脉拔除感染起搏电极导线的回顾性分析

发布时间：2018-06-25 08:42

本文选题：心血管病学 + 电极拔除　；参考：《南方医科大学》2016年硕士论文

【摘要】：一、研究背景心律植入装置(cardiovascular implantable electronic device, CIED)是指永久心脏起搏器(PM)、埋藏式心脏复律除颤器(ICD)和心脏再同步化治疗(CRT,包括CRT-P/D)等辅助维持正常心律的器械装置。一项涉及全球多个国家的调查研究显示,全球CIED植入数量在逐年增长,2009年PM植入数量高达1002 664台,而ICD植入数量为328 027台。美国每年有300多万人植入CIED,植入总量超过了40万台。在挽救患者生命的同时,如此巨大的植入数量也带来了装置相关的感染问题。目前,CIED感染的发生率呈上升趋势,除了CIED植入率增加,可能还与高龄及合并多种疾病患者比例增高有关。美国一项调查显示,1996～2003年间CIED感染的住院率增加了3.1倍(PM为2.8倍,ICD为6.0倍),住院死亡风险也增加了2倍多,同时CIED感染的增加超过新装置植入的增长。来自美国出院调查处(NHDS)的资料显示,2004-2006年间美国CIED的年感染率分别为4.1%、4.8%和5.8%,2006年CIED感染比2004年增加了57%。荷兰的一项起搏器注册研究中,2000-2006年3410例CIED植入者中感染率高达2.2%,共75例(PM 36例,ICD 28例,CRT 11例)出现感染。丹麦多中心研究显示,1982-2007年新植入和更换患者共46299例,其中新植入和更换感染率分别为1.80/1000(起搏器·年)、5.32/1000(起搏器·年),更换感染率明显高于新植入率。国内开展人工心脏起搏技术已有40余年历史。在1997—-2005年间,感染、电极移位和导线折断等起搏器并发症的发生率为1.4%-1.9%,其中1997年感染的发生率为0.9%。在年植入50台以上的24家医院中,并发症发生率为1.0%,低于植入量少于50台的医院(1.8%)。然而,我国报道的起搏器相关感染并发症发生率较低,可能与缺乏全面的调查统计有关；此外,国内能够植入CIED的医师分散在全国不同级别医院,经验差异较大,起搏器的规范化培训也开展较晚,缺失规范的起搏器随访管理。CIED感染率的升高与众多因素相关。①植入率显著增加：美国1993—2008年间装置植入总量增加96%,而感染率却增长了210%,提示感染率的增加可能还有另外的原因。换言之,除了植入率增高,装置更换率以及ICD、CRT等复杂装置植入比例也在增加。②患者年龄偏高且合并多种疾病：社会老龄化的发展,在一定程度上影响了CIED患者的年龄。发展中国家CIED患者平均年龄65岁,而发达国家中年龄80岁的患者高达20%-30%。与年轻患者相比,高龄的患者无论是在身体条件还是合并症方面都要更差,因此感染的发生率也会相应的升高。另外,高龄患者常伴发多种疾病,如糖尿病、肾功能不全、心力衰竭等。③更换比率增高：植入装置更换比初次植入感染发生率明显增高。丹麦一项研究对3.6万例患者进行了跟踪随访,起搏器初次植入后发生感染的概率为0.75%,而更换后为2.06%。④术者经验与感染的发生密切相关。经验少的术者,装置感染的风险及机械并发症如心肌穿孔、脱位、心包压塞等并发症的发生率明显升高。⑤其他因素：围手术期增加感染风险的危险因素还包括植入2根以上的电极导线、未能预防性应用抗生素、术后早期再干预治疗、感染装置再植入及复杂装置的植入(如CRT-D)。一旦确诊囊袋感染、血行感染、感染性心内膜炎,应当尽早整体拔除感染装置。抗生素保守治疗失败率几乎达100%。如果感染装置未被及时取出,患者的死亡率明显增高,据报道半年内患者的死亡率高达18%。死亡相关的高危因素包括：右心功能障碍、肾功能异常,全身性血栓栓塞,中、重度二尖瓣反流等。因此囊袋及植入系统一旦确定感染时,无论是经皮下还是静脉植入(包括外科心外膜植入)的装置,即便患者正处在囊袋感染期无合并全身感染症状时,完整拔除整个植入系统也是必要的,因为囊袋感染时可能已经影响了整个系统,任何装置的遗留都会使感染的复发率大大增加。早期主要是通过徒手牵拉进行电极导线拔除,可成功解决多数导线植入时间较短的病例。但导线拔除的并发症偏高,而且拔除的成功率仍较低。况且早期病例电极导线植入数量少,而且植入时间相对偏短。但随着起搏器植入技术的进步,电极植入的部位及类型、导线的数量也已经发生改变,如ICD导线植入数量、起搏器升级病例均迅速增加,冠状静脉左室导线也在增加。起搏导线的植入时间越来越长,许多患者的起搏导线植入时间高达30-40年。起搏电极的拔除风险较高,有发生血胸、肺栓塞、心包压塞、电极游走、血管破裂甚至死亡等并发症的可能。除与患者自身的危险因素有关外,并发症的发生还与术者的经验和团队的协作密切相关。因此CIED植入医生必须经过适当的培训,即在经验丰富的医生(有100例以上起搏电极拔除的经验)指导下拔除20例以上电极的经历。术前的准备工作十分重要,包括经团队充分讨论协商后认可的心导管预案及心胸外科手术方案。起搏电极拔除前,起搏电极拔除所需的设备和辅助耗材需全部到位,确保高质量的球管透视装置在拔除手术时工作正常。经胸和经食管超声需到位随时可以参与工作、动脉测压系统到位,还需准备开胸手术包、心包穿刺包、临时起搏和除颤设备。心胸外科医师在场并随时可以开始紧急手术、麻醉医师在场和麻醉设备到位并随时可以麻醉。国外关于CIED感染处理的认识及技术水平已基本完善,而国内在该领域仍处于初步阶段。虽然制定了“心律植入装置感染与处理的中国专家共识”,但是区域医疗水平发展的不均衡性决定了其推广的艰巨性。如今,基层医院对于囊袋感染的处理仍倾向于应用大剂量抗生素、囊袋清创、脉冲发生器重置甚至剪短电极导线等保守治疗,大大增加了电极拔除的难度及风险。本文回顾了中心近年来电极拔除病例,分析各病例特点,总结了中心电极拔除经验,探讨影响电极拔除结果的影响因素。二、目的通过总结经锁骨下静脉或股静脉途径拔除的94根起搏电极导线结果,探讨电极拔除的影响因素并总结电极拔除的初步经验。三、方法回顾性分析2013年9月至2015年5月连续入院的42例囊袋感染或感染性心内膜炎的CIED植入患者。分析各病例的临床特点,总结经锁骨下静脉及股静脉途径拔除电极过程中的经验方法。探讨年龄、性别、体重指数、电极数目、植入时间、感染时间及静脉途径对电极拔除结果的影响。四、结果共拔除94根电极(心房电极45根,心室电极41根,除颤电极8根),平均植入时间8.97±7.24(0.30-33.00)年,感染时间0.94±1.83(0.10-12.00)年；完全拔除85根,部分拔除7根,残留2根,成功率97.9%,失败率2.1%。年龄、性别、体重指数、电极数目及静脉途径对电极拔除结果的影响无统计学差异；植入时间及感染时间对电极拔除结果的影响有显著的统计学差异。四、结论植入时间及感染时间的延长大大增加了电极拔除的难度,显著降低了成功率。锁骨下静脉是电极拔除的常规入路,股静脉是有效补充,两者结合可以有效的提高电极拔除的成功率。
[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.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R541.7

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