What Can I Expect During Defibrillator Surgery?

The surgical technique of placing an implantable defibrillator is nicknamed the surgical technique of placing an implantable defibrillator; the surgical technique of placing an implantable cardioverter defibrillator; the automatic cardiac defibrillator implantation. The main classifications are cardiovascular surgery / surgical arrhythmia / surgical ventricular tachyarrhythmia / ischemic ventricular tachyarrhythmia.In recent years, the use of implantable cardioverter defibrillators has been limited to ventricular tachyarrhythmias. Drug therapy is not effective, but can not be surgery or antiarrhythmic surgery, but at the end of surgery or postoperative electrophysiological examination can still induce ventricular tachycardia.

Surgical technique of implantable defibrillator

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The surgical technique of placing an implantable defibrillator is nicknamed the surgical technique of placing an implantable defibrillator; the surgical technique of placing an implantable cardioverter defibrillator; the automatic cardiac defibrillator implantation. The main classifications are cardiovascular surgery / surgical arrhythmia / surgical ventricular arrhythmia / surgical ventricular arrhythmia Drug therapy is not effective, but can not be surgery or antiarrhythmic surgery, but at the end of surgery or postoperative electrophysiological examination can still induce ventricular tachycardia.

Chinese name

Surgical technique of implantable defibrillator

nickname

Surgical technique of implantable cardioverter defibrillator

Surgical technique of implantable defibrillator

Surgical technique of implantable cardioverter defibrillator; surgical technique of implantable cardioverter defibrillator; automatic cardioversion implantation

Cardiovascular Surgery / Surgical Treatment of Arrhythmia / Surgical Treatment of Ventricular Tachyarrhythmia / Ischemic Ventricular Tachyarrhythmia

37.9401

In recent years, the use of implantable cardioverter defibrillators has been limited to ventricular tachyarrhythmias. Drug therapy is ineffective and cannot be performed with surgery or antiarrhythmic surgery, but electrophysiological examination can still induce ventricularity at the end or after surgery Tachycardia.

The surgical technique of placing an implantable defibrillator is suitable for:

In recent years, the surgery for ischemic ventricular tachyarrhythmia has made great progress. Surgical treatments include surgical procedures, intraoperative cryoablation, and implantable cardioverter defibrillators. The surgical indications are also expanding. According to and analyze various clinical factors, a corresponding individualized surgical plan should be formulated for each case.

1. There are recurrent monomorphic ventricular tachycardia, drug treatment is not effective, left ventricular function is better, surgery should be performed.

2. Polymorphic ventricular tachycardia, due to its complex characteristics and difficult to map intraoperatively, was considered to be a contraindication for surgery. Recently, the use of an electronic computer to support the mapping system during multi-point electrode array surgery can identify one or more parts of the ventricular muscle that cause arrhythmia, even identify the type of ventricular tachyarrhythmia, and measure the origin of arrhythmia in a short time. Since then, polymorphic ventricular tachycardia is also suitable for surgical treatment.

3. Idiopathic ventricular fibrillation without any surgery can be done, all implanted cardioverter defibrillator.

The main contraindication for surgery is severe left ventricular dysfunction. If the application of drugs is not effective, implantable cardioverter defibrillator can be used. This operation has little trauma and low surgical mortality. Left ventricular function is extremely poor, and cardioverter defibrillator placement is ineffective, and heart transplantation should be considered.

In addition to the routine preparation for general open-heart cardiac surgery, the following points should be noted:

1. The purpose of preoperative electrophysiological examination is to prove that the arrhythmia is ventricular, not supraventricular tachycardia; application of stimulation techniques can induce and terminate ventricular tachycardia; determine the origin of ventricular tachycardia Site; identify and record the slow conduction area of the reentrant loop and the range of abnormal potentials.

2. Application of endocardial mapping method before surgery Endocardial electrophysiological mapping method is to use a grade 4 catheter or a multipolar catheter to place the right atrium, His bundle and left and right ventricles, and record the atrium, His bundle and Two-ventricular bipolar electrogram and activation time are used as a reference; a large-head catheter is used as a detection electrode, and the left and right ventricles are moved forward and backward at a predetermined sequence point under perspective, while performing sinus rhythm and inducing ventricular tachycardia Mapping.

(1) Pacing mapping method: During sinus rhythm, perform multi-point endocardial pacing at a frequency 10 to 20 times / min faster than your own heart rate. The electrocardiogram recorded at each point and the body surface during tachycardia Compare the 12 leads and locate the origin of ventricular tachyarrhythmias. The accuracy of this method is only 20% to 50%.

(2) Excited sequence mapping method: Find the earliest excited site during ventricular tachycardia. This potential occurs before the QRS complex on the surface electrocardiogram. However, the ventricular tachycardia reentry loop is more complicated after myocardial infarction, and the earliest activation point is not necessarily a component of the reentry loop. In this case, the earliest activation point is often located at the distal end of the block, that is, at the exit of the reentrant loop.

(3) Mapping of the slow conduction area: The slow conduction area is the basis for reentry, and it is also an ideal target for surgery and catheter ablation. Its electrophysiological characteristics are: abnormal or low amplitude fragmentation potentials can occur during local depolarization; pacing in the slow conduction zone can produce occult tow ventricular tachycardia; occult tow is accompanied by post-stimulation QRS complexes Prolongation indicates that the pacing site may be located in the slow conduction zone.

3. Preoperative echocardiography showed the size of the left ventricle, the presence or absence of wall tumors, and calculation of left ventricular function indicators. Is there any other heart disease?

4. Preoperative coronary angiography and left ventricular angiography can show the scope and severity of coronary artery stenosis, as well as the location and function of left ventricular infarction, in order to choose left ventricular cryoablation and coronary artery bypass grafting or implantable heart rhythm Turn over the defibrillator.

5. It is still controversial that the application of amiodarone can increase surgical mortality and postoperative complications. This problem depends in part on the design of the surgery, as postoperative low cardiac output is limited to cases where certain operations are performed with cardiac arrest. Cox proposes that ventricular tachycardia is performed under an extracorporeal heartbeat at room temperature, and amiodarone has no effect on the postoperative course. In the case of simultaneous coronary artery bypass grafting or heart valve surgery, first perform ventricular tachycardia under the heart beat, and then perform other operations while the heart is beating. In this case, Stop amiodarone for at least 4 weeks.

1. Through epicardial and endocardial mapping under cardiac pulsation during operation to determine the origin of the arrhythmia, local endocardial resection and cryoablation must be performed until the ventricular tachycardia cannot be induced. Avoid the use of cardiac arrest surgery, so this method has a high recurrence rate. A cardiac pacing lead was placed at the end of the operation.

2. Sub-endocardial resection cannot be performed on the aortic and mitral valve annulus and the muscles around the papillary muscle. Only cryoablation can be applied to avoid valve insufficiency.

3. After repeated tachycardia and subendocardial resection and cryoablation, 5% ~ 10% of cases still can induce ventricular tachyarrhythmia, and implantable cardioverter defibrillation should be placed during the operation. Device system. If this system is not installed, amiodarone should be applied after surgery.

4. Before the application of amiodarone, it is necessary to perform antiarrhythmic surgery under cardiac beat during operation to prevent low cardiac output syndrome after operation. In cases where cardiac arrest is accompanied by coronary artery bypass grafting or heart valve surgery, amiodarone should be stopped for at least 4 weeks before surgery.

5. Early repair of ventricular aneurysm by Jatine and Dor without intraoperative mapping. Recently, Dor and Rasteger reported that the medial wall angioplasty under the guidance of mapping has received satisfactory results. In the future, we must pay attention to accurate intraoperative mapping so that the effect of this operation can be further improved.

6. Of the patients who placed an implantable pacing defibrillator, about 12% of the cases had an extremely high defibrillation threshold, and 25J could not terminate the arrhythmia. Some patients with high defibrillation thresholds are related to hypokalemia or taking amiodarone. After correcting electrolytes and adjusting drugs, the threshold can be lowered. The threshold can also be lowered by replacing a large sheet electrode or changing the superior vena cava spring electrode to a sheet electrode or adjusting the position of the lead. For a few particularly difficult patients, a high-output pulser needs to be implanted.

After returning to the monitoring room, the ECG, arterial pressure, left atrial pressure, right atrial pressure, and pulmonary arterial pressure, and arterial oxygen saturation were continuously monitored. Blood gas analysis and cardiac output were performed intermittently. Most of the patients undergoing surgery were elderly, with poor lung compliance and muscle tone. They maintained mechanical assisted breathing for 2 to 3 days and sucked sputum in time. After disabling the ventilator, intermittently atomize and turn your back to help expel sputum and prevent respiratory infections. When the venous transfusion reaches a hematocrit of 35%, plasma is input to prevent blood viscosity from affecting hemodynamics and complications such as thromboembolism, and control the amount of blood. Low-dose dopamine and / or dobutamine and nitroglycerin are routinely applied after surgery. Apply powerful antibiotics to prevent infection. Digitalis and diuretics were used to treat heart failure, and drugs such as dopamine and dobutamine were gradually stopped.

1. Low cardiac output syndrome In the past, circular endocardium ventriculotomy was used, and the incidence of this complication was very high. At present, the scope of surgery is reduced, and subendocardial resection or cryoablation is used under the guidance of mapping. This syndrome gradually decreases. Postoperative application of dopamine and / or dobutamine to support myocardial contractility and timely application of sodium bicarbonate to correct metabolic acidosis can cure most low cardiac output syndromes. A few cases require intra-aortic capsule counterpulsation.

2. Heart failure patients have heart dysfunction before surgery, and often have different degrees of heart failure after surgery. Digitalis and diuretics were routinely applied after surgery. Check the blood potassium concentration intermittently to prevent hypoarrhythmia from causing arrhythmia.

3. Ventricular tachycardia occurs in about 2% to 38% of patients with recurrent ventricular tachyarrhythmias after surgery. Early after surgery, antiarrhythmic drugs such as amiodarone can be used. Immediate or late recurrence of ventricular tachyarrhythmias requires implantable cardioverter defibrillators.

4. Some complications can occur in the early and late stages of a buried implantable cardioverter defibrillator.

5. Early postoperative complications

(1) The pulse generator sac can produce effusion or blood, which can usually subside on its own. It is not recommended to use puncture pumping to increase the chance of infection. Perform puncture drainage.

(2) Placement of the sheet electrode of the implantable cardioverter defibrillator, such as near the anastomosis of coronary artery bypass graft surgery, can cause vascular rupture. Such serious complications should be urgently re-operated.

(3) After placement of an implantable cardioverter defibrillator, femoral artery embolism and cerebral infarction can occur. The patient had a history of atrial fibrillation for more than 2 years, and the defibrillation was converted to sinus rhythm during the operation. Anticoagulation was applied after the operation.

(4) When endocardial spring electrodes and frequency sensing electrodes are used, thrombus formation of the subclavian vein may occasionally occur.

6. Late complications The most common late complications are infections. Bag infection requires removal of all implantable cardioverter-defibrillator defibrillators, and the manufacture of a bag into a new device. If the infection is not serious, you can also try to remove the pulse generator, keep the lead, and give a sufficient amount of antibiotic treatment.