目的：起搏电极导线的拔除是治疗起搏器置入术后顽固性感染的有效方法。本文采用血管内反推力牵引法对18例共28根起搏电极导线进行拔除治疗。

方法：18例(男14例，女4例，平均年龄56±12岁)，起搏器埋置术后反复囊袋或电极导线埋藏处感染破溃，起搏系统外露，感染病程：2.6±2.1年。经多次局部清创术和抗生素治疗，感染未能控制。9例患者曾行直接牵引法拔除电极导线，均失败。电极导线(心室17根，心房11根)置入时间：5.4±4.2年。X线下锁定钢丝插入电极导线内腔远端并卡牢，经上腔静脉双层套迭式扩张鞘管沿电极导管推送至电极附着的心肌处。手动牵引锁定钢丝和反向推动扩张鞘管，取出电极导线。

结果：24根电极导线被完全拔除；不完全拔除2根，远端电极留置于肝静脉和锁骨下静脉。1例2根电极导线(置入12年)拔除失败，后经外科开胸术取出。术中无并发症。平均随访11±7个月，感染被控制。

结论：起搏器术后感染是心脏起搏治疗的严重并发症，病死率达23%～66%。彻底根治的方法是将作为感染异物的整个起搏系统取出，其中电极导线的拔除最为关键。本文结果表明，血管内反推牵引法拔除起搏电极导线具有操作简便，成功率高(92.8%)和并发症低等特点，明显优于以往的直接牵引法和外科开胸手术方法。我们体会：①应选择与电极导线内腔相匹配的锁定钢丝；②扩张鞘管在分离心内电极导线的过程中，应与电极导线的方向一致，以免切断电极导线或穿破心脏。

Lead Extraction using Intravascular Countertraction Technique to Treat Refractory Infection of pacemaker Implantation (Abstract)

Department of Clinical electrophysiology, Cardiovascular Institute and Fu Wai Hospital, CAMS and PUMC, beijing (100037)

ma Jian, Wang Fangzheng, Yu Peizhen, et al.

objective: To present an intravascular countertraction technique of lead extraction for treatment of refractory infection after pacemaker implantation.

Methods: eighteen patients (14 men and 4 women, mean age 56±13 years) with 28 leads were presented for lead extraction, because of refractory pacemaker pocket infection and erosion. Eleven atrial and seventeen ventricular leads had been implanted for 5.4±4.2 years. A locking stylet was secured at the distal electrode by counterclockwise rotation to reinforce the lead and facilitate traction, and telescoping dilator sheaths were used to free the lead from adhesions in the venous system.

Results: twenty-four leads were completely removed and 2 partially removed, the distal electrodes of the latter 2 were detached during extraction and retained in the hepatic vein and subclavian vein, respectively. The other 2 leads in one patient failed to be extracted, which were finally taken out by surgical thoracotomy. A follow-up of 11±7 months, the infection was controlled in all patients.

Conclusion: with appropriate precautions and patient selection, intravascular countertraction technique allows successful extraction of up to nearly 90% of permanent pacemaker leads with a relatively low incidence of complications. The extraction of infected lead is an effective method for treating refractory infection of pacemaker implantation.