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临床资料 患者男性,63岁.持续性胸骨后压榨性疼痛,心电图示急性下壁、正后壁和右室梗塞,相继出现 I°A-VB、Ⅱ°和Ⅲ°A-VB,频发室性早搏.静注阿托品和滴注异丙肾上腺素无效,行右心室临时起搏器安装术.住院第三周仍存在高度A-VB,暂时关闭起搏器时最长6s内无心室电活动,即起搏依赖现象.故行右心室永久起搏器安装术.术中见J型钢丝经锁骨下静脉不能送达上腔静脉.给76%泛影葡胺,见造影剂滞留于锁骨下静脉内,部分逆流到颈内静脉.上腔静脉上端周围较细,静脉呈网状分布,由此侧支引流至上腔静脉下段.上腔静脉上端造影呈细线状不规则狭窄.狭窄段长约3cm,最狭处腔内直径仅0.1cm,导引钢丝不能通过.右侧锁骨下静脉几乎完全闭塞.遂放弃上腔静脉途径,改为右髂外静脉进路.于腹股沟上方2cm处沿韧带走行方向作切口,分离皮下组织,造囊袋放置起搏发生器(VVI、PCI公司445型).在髂外动脉内侧穿刺股静脉(实为髂外静脉)插入电极起搏导管,经下腔静脉达右心室.调整电极位置、满意后测得阈值0.6V,脉宽0.6ms,阻抗800Ω,R波高度5.7mV,起搏频率70次/min.固定电报导管和起搏发生器.局
Clinical data Patients Male, 63 years old Persistent post-sternal pain, electrocardiogram showed acute inferior wall, posterior wall and right ventricular infarction, I ° A-VB, Ⅱ ° and Ⅲ ° A-VB appeared one after another, Premature premature beats. Atropine intravenous and instillation of isoproterenol ineffective right ventricular temporary pacemaker installation .Ath three weeks of hospitalization there is still a high degree of A-VB, temporary closure of the pacemaker when the maximum within 6s no ventricular electrical activity , That is dependent on the phenomenon of pacing, so the right ventricular permanent pacemaker installation surgery see J-type wire through the subclavian vein can not be delivered to the superior vena cava, to 76% of diatrizoate, see contrast agent retention in the subclavian Venous, part of the counter-current to the jugular vein.The upper superior vena cava around the upper thin, veins reticular distribution, which leads to the drainage of the superior vena cava inferior vena cava superior vena cava angiography showed thin linear irregular stenosis. About 3cm, the narrowest cavity diameter of only 0.1cm, the guide wire can not pass.The right subclavian vein is almost completely occluded.Will give up the superior vena cava route, change to the right external iliac vein approach .In the inguinal area 2cm along Ligament walking direction of the incision, the subcutaneous tissue, sac placement bag placement generator (VVI, PCI 4 45 type.) In the external iliac artery puncture femoral vein (actually external iliac vein) into the electrode pacing catheter, the ventricle to the right ventricle.Adjustment of the electrode position, the satisfaction of the measured threshold 0.6V, pulse width 0.6ms, Impedance 800Ω, R wave height 5.7mV, pacing frequency 70 beats / min. Fixed Telegraph Catheter and Pacing Generator.