CAJ | 학술논문

目的观察长期置入起搏/除颤导线相关的慢性病理学改变.方法本研究共包括3部分,第一对2008年3月至2011年3月38例应用准分子激光消融拔除的患者的83根起搏/除颤导线的病理学观察,第二对1例应用准分子激光消融拔除起搏/除颤导线死亡患者的尸体进行解剖研究,第三对10例既往置人起搏/除颤导线后因各种原因死亡患者的尸体进行解剖研究.结果导线在血管内和心腔内可以形成广泛的纤维结缔组织包裹和粘连.上腔静脉近右心房处常粘连较为严重,且此处较薄弱,外侧为胸膜腔,易穿孔且穿孔后局部不能产生压迫止血作用,是本研究中1例拔出导线致死的原因.导线与三尖瓣和腱索的粘连往往较严重.位于心尖部右心室游离壁的导线尖端离心外膜较近.导线及血管、心腔内壁的血栓较常见,甚至有较大的血栓(尤其心耳内).结论经静脉置入的起搏/除颤导线在血管内和心腔内可形成广泛的纤维结缔组织包裹和粘连,导线和三尖瓣及腱索形成复杂的解剖关系和严重的粘连,有些心室导线的顶端已经进入肌层、接近心外膜,导线及血管、心腔内壁的血栓较常见.上腔静脉近心房处组织薄弱且粘连严重,导线拔出操作可导致透壁性损伤而致患者死亡.
목적 관찰장기치입기박/제전도선상관적만성병이학개변.방법 본연구공포괄3부분,제일대2008년3월지2011년3월38례응용준분자격광소융발제적환자적83근기박/제전도선적병이학관찰,제이대1례응용준분자격광소융발제기박/제전도선사망환자적시체진행해부연구,제삼대10례기왕치인기박/제전도선후인각충원인사망환자적시체진행해부연구.결과 도선재혈관내화심강내가이형성엄범적섬유결체조직포과화점련.상강정맥근우심방처상점련교위엄중,차차처교박약,외측위흉막강,역천공차천공후국부불능산생압박지혈작용,시본연구중1례발출도선치사적원인.도선여삼첨판화건색적점련왕왕교엄중.위우심첨부우심실유리벽적도선첨단리심외막교근.도선급혈관、심강내벽적혈전교상견,심지유교대적혈전(우기심이내).결론 경정맥치입적기박/제전도선재혈관내화심강내가형성엄범적섬유결체조직포과화점련,도선화삼첨판급건색형성복잡적해부관계화엄중적점련,유사심실도선적정단이경진입기층、접근심외막,도선급혈관、심강내벽적혈전교상견.상강정맥근심방처조직박약차점련엄중,도선발출조작가도치투벽성손상이치환자사망.
Objective Widely pacemaker/implantable cardioverter defibrillator (ICD) implantation is also related to an increasing need for transvenous lead extraction.Understanding the location and extent of pathological changes,including adhesions and fibrous tissue formation along the course of chronic pacemaker/ICD leads,are essential for operators performing lead extraction operations in order to reduce the potential life threatening complications.Methods Three parts are included in the research,pathological examination on 83 extracted pacemaker/ICD leads using excimer laser technique from March 2008 to March 2011,autopsy examination of one died patient during lead extraction for lead-related infective endocarditis,and anatomical analysis on pacemaker/ICD leads from 10 patients died of other non-cardiac causes.Results Extensive encapsulated fibrous tissue around the leads and extensive adhesion/fibrosis along the course of the leads from venous entry site to the lead/myocardial interface could be detected on transvenous pacemaker/ICD leads.Since the tissue at the junction between superior vena cava (SVC) and right atrium (RA) is very thin,free of pericardium,thus,this is a common place for extensive adhesion/fibrosis and myocardial perforation/tear during lead extraction,which accounted for one death during extraction in our cohort.Extensive adhesion and fibrosis were also observed at the tricuspid valve and subvalvular structures.Leads implanted to the right ventricular apex were close to the epicardial surface and prone to perforation through myocardium.It is common to observe thrombus on the leads or at the interface between leads and myocardial tissue,especially at right atrial appendage (RAA) at the site of lead insertion.Conclusion Extensive adhesions and fibrosis can be commonly seen along the course of pacemaker/ICD leads,and at SVC to RA junction,the tricuspid valve/subvalvular structures,and RA/RV lead interface.The tissue at SVC to RA junction is very thin,making it vulnerable for myocardial perforation/tear during lead extraction.Thrombus is commonly seen along the leads or at the lead-tissue interface.