The Study On Approaches And Efficacy Of Optimizing The Pacing Therapy And In The Patients Whose Right Atrium Couldn't Be Captured

Objectives To study on the individualized approaches of pacing therapy and efficacy in the patients whose right atrium couldn't be capturedMethods 18 cases were selected from the department of cardiology in Fujian Provincial Hospital during the period from April 2013 to March 2015, which right atrium couldn't be captured. There were 5 cases with atrial standstill(AS) implanted the dual pacemaker and 8 cases of chronic atrial fibrillation with long R-R interval(CAFLRRI) with His pacing and 5 cases of CAFLRRI with CRT indication among them. The atrial active leads were implanted into the CSO to achieve the DDD pacing mode in the 5 cases with AS. 8 patients with CAFLRRI were received the His bundle pacing: to fix the Medtronic 3830 lead onto His bundle or near. 5 patients of CAFLRRI with CRT indication were implanted the lead into left ventricular through the coronary sinus,and the right ventricular leads were implanted into right ventricular interval. The left ventricular lead in one of the 5 with CRT indication was linked into a general dual pacemaker's atrial interface and the right ventricular lead was linked into its ventricular interface. Then we set the AV interval into 25 ms to make left ventricle shrink precedently so that we can ensure the bi-ventricular pacing. Other 4 cases were linked with the CRT pulser. To Follow- up their symptom and ECG and cardiac function after 3 months.Results 1. 5 cases whose right atrium couldn't be captured were all diagnosed AS by EP study. We successfully implanted the atrial lead onto the CSO and ventricular lead on right ventricular septum and tested the leads parameters was in the normal range. The P wave duration after pacing was between 50~80(64.0±10.9)ms which was in the normal range. The ECG shows that P waves were inverse in the II, III, AVF lead. Compared with the postoperative duration of QRS complex to the preoperative,there was no statistical difference [(74.0±15.2)ms vs.(97.2±17.3)ms, T=1, P>0.05]. We realized the physiological pacing in DDD mode. Their fatigue symptoms were significantly improved after operation and syncope or amaurosis didn't reappear.Those pacemakers all worked well and didn't appear the situation of electrode loss, the pouch hemorrhage or infection. 2. 8 patients with CAFLRRI were received His-pacing. Compared with the postoperative duration of QRS complex to the preoperative, there was no significantly statistical difference[(80.5±14.5)ms vs.(91.8±22.7)ms,T=5, P>0.05].The interval of postoperative His-pacing signal to the starting of QRS complex had no significantly statistical difference compared with the preoperative H-V interval [(44.0±6.3)ms vs.(42.8±5.5)ms,T=10.5, P>0.05]. To follow-up those patients after 3 months, their fatigue symptoms were significantly improved after operation and syncope or amaurosis didn't reappear.Those pacemakers all worked well and didn't appear the situation of electrode loss, the pouch hemorrhage or infection. 3. 5 patients with CAFLRRI, their cardiac function were between class II~III(NYHA). Their ECG presented a CLBBB graphics and the QRS complex duration ?120ms. The UCG showed the whole heart cavity expanded. So they had the CRT implanting indication. The postoperative ECG presented a IRBBB graphics and the QRS complex duration was narrower compared with the preoperative.It had statistical difference[(113.6±5.2)ms vs.(140.0±12.3)ms,T=15, P< 0.05)]. We followed-up them after 3 months. Although the UCG showed the whole heart cavity expanded, the LVED was more shrunken compared with the preoperative [(5.1±0.2)ms vs.(5.6±0.3)ms,T=15, P<0.05], and the LVEF was increased compared with the preoperative [(41.2±3.1)% vs.(33.2±1.6)%, T=15, P<0.05]. They both had statistical difference. Their fatigue symptoms were significantly improved after operation and syncope or amaurosis did not reappear.Those pacemakers all worked well and didn't appear the situation of electrode loss, the pouch hemorrhage or infection.Conclusions To realize the physiological pacing for the patients whose right atrium couldn't be captured, we must follow the individualized principle. We can choose CSO-pacing for the patients with AF and His-pacing for the patients with CAFLRRI and biventricular pacing for the patients of CAFLRRI with CRT indication so that to optimize the pacing program and realize the physiological pacing for the patients whose right atrium cannot be captured?These methods are safety and efficiency.