心腔内多根废弃导线要警惕!阜外医院华伟等病例报告

2020-02-17 顾敏,华伟 中国循环杂志

起搏导线脱入肺动脉是较为罕见的并发症。近期阜外医院华伟、顾敏通过检索近 10 年来在该院就诊的起搏器植入患者的病历资料,共发现 3 例这样的患者,并均经 X 线胸片和 CT 证实。

起搏导线脱入肺动脉是较为罕见的并发症。近期阜外医院华伟、顾敏通过检索近 10 年来在该院就诊的起搏器植入患者的病历资料,共发现 3 例这样的患者,并均经 X 线胸片和 CT 证实。

这 3 例患者均为起搏器尾端脱位肺动脉:其中 2 例导线脱入右肺动脉;1 例导线脱入左肺动脉。


图1  66岁男性患者(病例1)X线胸片和肺动脉CT图像


图2  66岁男性患者(病例2)X线胸片和肺动脉CT图像


图3  44岁女性患者(病例3)X线胸片和肺动脉CT图像

3 例中有两例患者同时合并肺血栓栓塞。病例 2 和病例 3中脱入肺动脉的导线为废弃导线,病例 1 因在我院就诊时间短,未获知外院手术过程,考虑为废弃导线可能性大。

华伟、顾敏指出,随着导线植入时间延长,废弃导线往往与周围心肌及血管组织广泛粘连而导致拔除困难,故术者常常选择旷至废弃导线。通常做法是将废弃导线尾端固定于囊袋中。

尽管多数废弃导线因与周围心肌、血管组织粘连,不易发生移位,但可能有少数废弃导线与周围导线粘连较轻。此时,如未将位于囊袋中的导线尾端固定牢靠,则可能会发生导线尾端移位。

导线尾端可随血流漂入肺动脉及其分支,并常常合并肺血栓栓塞。除发生肺血栓栓塞,飘动的导线可机械刺激心室而发生心律失常。

比如Stein 等报道的一例起搏导线尾端脱入肺动脉的病例。该患者 3 年前被发现导线脱入肺动脉,未作特殊处理,后因恶性室性心律失常入院。

排除其他原因所致心律失常后,考虑心律失常与导线机械刺激有关,拔除导线后未再发生室性心动过速。

Polewczyk 等9年期间对 1 767 例患者进行经静脉途径导线拔除,其中 19 例(占 1.1%)患者导线脱入肺动脉。研究显示:拔除脱入肺动脉的导线与拔除其他部位导线同样安全有效。

华伟、顾敏报道的这的3 例患者中除病例 1患者失访外,另外 2 例均建议行导线拔除,但患者拒绝。对合并肺血栓栓塞的患者进行长期抗凝治疗,并密切随访。随访期间血栓消失,未发生其他不良事件。

华伟、顾敏强调,预防导线脱入肺动脉更为重要。

对于心腔内多根废弃导线,尤其是年轻患者,即使未合并感染,也应考虑行导线拔除。如不能拔除导线,需仔细固定导线尾端,避免导线坠入血管和心腔,以免发生肺血栓栓塞或者恶性心律失常等严重并发症。

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    2021-03-30 我要当大牛

    现在无导线起搏器的兴起可以有效防止此类事件的发生

    0

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    2020-02-26 南山梯

    很值得学习

    0

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    2020-02-21 南山梯

    学习了

    0

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    2020-02-20 南山梯

    真是难得一见,长见识了

    0

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