超声心动图定量组织速度成像技术对心脏再同步治疗后右心室功能的判定价值

目的 应用超声心动图定量组织速度成像技术(QTVI)评价慢性心力衰竭(CHF)患者应用心脏再同步治疗(CRT)后右心功能及同步性变化.方法 接受CRT患者22例,在CRT术前、术后1周及6个月用常规超声心动图测量左心室功能、右心室功能及同步性参数,通过QTVI技术测量右心室游离壁的三尖瓣环处的右心室等容舒张时间(RVIRT)、等容收缩时间(RVICT)及射血时间(RVET),并计算右心室心肌功能指数(RV-MPI).结果 ①术后6个月右心室舒张末期面积(RVEDA)、右心室收缩末期面积(RVESA)较术前明显减小(P＜0.05);右心室面积变化率(RVFAC)及左心室射血分数(LVEF)在术后1周及6个月均不同程度提高(P＜0.05);②术后1周室间机械延迟时间(IVMD)明显减低(P＜0.05),表明术后1周左、右心室间同步性即明显改善;③术后1周及6个月右心室的RVICT、右心室等容舒张时间(RVIRT)明显缩短(P＜0.05),RVET明显延长(P＜0.01),RV-MPI明显改善(P＜0.01).结论 QTVI可应用于心力衰竭患者右心室功能评测,CRT可改善慢性心力衰竭患者的心室同步性及右心室功能.     

心脏再同步化治疗在射血分数降低的心力衰竭患者中超反应的预测因素分析

目的分析心脏再同步化治疗(CRT)在射血分数降低的心力衰竭患者中超反应的预测因素,并观察超反应对患者心功能及预后的影响。方法回顾性分析连续的因心力衰竭于本院植入CRT的患者,以术后6个月随访的左室射血分数(LVEF)测定值≥0.50为标准分为超反应组和非超反应组,通过组间比较以及多因素Logstic回归分析筛选出CRT超反应的独立预测因子。根据术前及术后第1,3和6个月的心脏超声指标LVEF、左室舒张末径(LVEDD)和左室收缩末径(LVESD)以及随访记录到的不良事件,观察超反应对患者心脏结构、心功能以及预后的影响。结果共有43例入选,其中13例(30.2%)出现超反应。与非超反应组相比,超反应组的非缺血性心肌病比例较高(100%vs 63.3%,P=0.032),心力衰竭病程较短[中位病程12(6~90)个月vs 66(24~108)个月,P=0.04],术前基线LVEF较高(0.32±0.04vs 0.27±0.06,P=0.008)。而非缺血性病因(OR=13.580,95%CI 1.154~160.055,P=0.038)和术前基线LVEF在0.30~0.35之间(OR=12.138,95%CI 1.492~80.597,P=0.01)是术后发生超反应的独立预测因子。超反应组术后LVEF、LVEDD和LVESD的改善整体优于非超反应组(P0.001)。超反应组复合终点事件(心力衰竭再住院、恶性心律失常、全因死亡)的发生率低于非超反应组(15.4%vs 56.7%,P=0.012),术后两年的无事件生存率高于非超反应组(log-rank P=0.028)。结论非缺血性心肌病以及术前LVEF相对较高的患者更容易从CRT治疗中获益,且获益主要来源于心脏结构与功能的改善以及不良事件发生率的降低。     

慢性心力衰竭合并持续性心房颤动患者心脏再同步治疗术后房室结消融及药物控制心室率疗效观察

目的观察慢性心力衰竭合并持续性心房颤动（房颤）患者心脏再同步治疗（CRT）的疗效,比较房室结消融术及药物控制心室率两种方法疗效的差异。方法慢性心力衰竭合并持续性房颤患者,符合CRT植入适应证并接受CRT或心脏再同步治疗除颤器（CRT—D）植入术,术后随机分为两组,房室结消融组以及药物治疗组,术后随访观察患者临床症状及心功能改善等情况,比较两组的疗效。结果共人选了26例患者,其中房室结消融组14例,药物控制组12例。术前两组患者间心功能,左心室舒张末期内径（LVEDD）,左心室射血分数（LVEF）及用药等基本情况差异无统计学意义。CRT术后随访结果,房室结消融组双心室起搏比例100％,药物治疗组双心室起搏比例72．0％±9．7％。与药物治疗组相比,房室结消融组LVEDD略有缩小[（61．0±6．9）mm对（62．0±7．8）mm],但差异无统计学意义（P=0．08）,LVEF改善明显（0．41±0．06对0．35±0．04）,差异有统计学意义（P=0．04）,提示房室结消融组疗效更佳。结论对慢性心力衰竭合并持续性房颤患者,CRT可以改善患者心功能,CRT术后行房室结消融可以提高有效的双心室起搏比例,进一步提高CRT疗效。     

左束支区域起搏在慢性心力患者中的应用(附7例报道)

目的:探讨慢性心力衰竭(CHF)患者行左束支区域起搏(LBBAP)的心电图特点、心室同步性改变及可行性。方法:入选7例因慢性心力衰竭且具有心脏再同步化(CRT)治疗指征,行左心室电极置入失败后改行LBBAP的患者。对其进行心电图、心脏超声及起搏器程控随访并对随访资料进行分析。结果:7例患者均试行LBBAP成功。术后心电图提示患者QRS波间期(QRSd)及左心室达峰时间(LVAT)均较术前缩短[QRSd:(165.23±9.13)vs.(125.19±6.03)ms;LVAT:(77.6±6.50)vs.(50.58±6.64)ms]。术后常规超声提示5例患者LVEF、LVIDd、NYHA心功能分级较前提升。6例患者双室间同步性较前好转,7例患者左心室内同步性均较前提升。结论:LBBAP对治疗慢性心力衰竭合并左束支传导阻滞的患者具有可行性,可作为常规CRT左心室电极置入失败后的备选方案。     

门控心肌灌注显像相位分析评价陈旧性心肌梗死患者左心室收缩同步性

目的 应用单光子发射计算机断层成像(SPECT)/CT门控心肌灌注显像(GMPI)相位分析技术评价陈旧性心肌梗死(OMI)患者的左心室收缩同步性,并探讨影响收缩不同步的独立危险因素.方法 选择2010年10月至2013年9月在常州市第一人民医院确诊的OMI患者76例作为OMI组,同时选择健康者74例作为对照组,对其临床资料进行回顾性分析.所有研究对象均进行静息GMPI检查,应用Cedars Sinai QGS软件相位分析技术获得左心室收缩同步性参数[相位直方图带宽(BW)和相位标准差(SD)]以及心功能参数,应用QPS软件获得心肌灌注缺损范围.分别比较OMI组与对照组、左心室射血分数(LVEF)≤35％与LVEF＞ 35％ OMI患者之间的BW和SD值.以对照组BW值的x-±2s为异常临界阈值,大于该阈值定义为左心室收缩不同步,分析其独立危险因素.结果 (1)OMI组的BW[(91.3 ±58.6)°比(37.2±11.7)°,P＜0.001]和SD值[(27.3±20.8)°比(1 1.8±5.4)°,P＜0.001]均高于对照组,LVEF低于对照组(P＜0.001).LVEF≤35％的OMI患者BW[(136.0±52.9)°比(51.0±24.0)°,P＜0.001]和SD值[(38.7±21.3)°比(17.1±14.0)°,P ＜0.001]均高于LVEF＞ 35％的OMI患者.(2)在OMI患者中,左心室收缩不同步(BW ＞60.6°)的比例为57.9％ (44/76).与左心室收缩同步性正常OMI患者比较,不同步患者的LVEF较低(P＜0.0O1),左心室舒张末期容积、收缩末期容积、室壁运动异常总积分、室壁增厚异常总积分和心肌灌注缺损范围均较高(P均＜0.001).(3)LVEF≤35％的OMI患者合并左心室收缩不同步的比例高于LVEF＞35％的患者[91.7％ (33/36)比27.5％ (11/40),P＜0.001].(4)Pearson线性相关分析显示,LVEF与BW呈负相关(r=-0.807,P＜0.001).(5)多因素logistic回归分析显示,心肌灌注缺损范围是导致OMI患者发生左心室收缩不同步的独立危险因素(OR=1.076,95％ CI:1.015 ～1.141,P=0.015).结论 GMPI相位分析可客观反映左心室收缩同步性;OMI患者左心室收缩同步性减低,左心室收缩不同步与LVEF相关;心肌灌注缺损范围是OMI患者发生左心室收缩不同步的独立危险因素.     

左心室电极位置对行心脏再同步化治疗的心力衰竭患者心功能的影响

目的探讨左心室电极位置对行心脏再同步化治疗(CRT)的心力衰竭患者心功能的影响。方法选取2013年1月—2017年6月贵州省人民医院心内科收治的行CRT的心力衰竭患者60例,根据左心室电极位置分为侧壁组(n=26)和后侧壁组(n=34)。比较两组患者术前及术后6个月心功能指标,包括左心室射血分数(LVEF)、左心室收缩末期内径(LVESD)、左心室舒张末期内径(LVEDD)、6分钟步行距离(6MWD)及血清脑钠肽(BNP)水平;比较两组患者术后6个月内因心力衰竭再入院率、病死率及不良心脏事件发生率。结果术前两组患者LVEF、LVESD、LVEDD、6MWD及血清BNP水平比较,差异无统计学意义(P0.05);术后6个月,侧壁组患者LVEF高于后侧壁组,LVESD、LVEDD短于后侧壁组,6MWD长于后侧壁组,血清BNP水平低于后侧壁组(P0.05)。两组患者术后6个月内因心力衰竭再入院率、病死率及不良心脏事件发生率比较,差异无统计学意义(P0.05)。结论左心室电极位置对行CRT的心力衰竭患者预后无明显影响,但将电极植入左心室侧壁者心功能改善效果优于将电极植入后侧壁者。     

心脏再同步治疗超反应的预测因子分析

目的 心脏再同步治疗（CRT）能明显改善患者临床症状,逆转心肌重构,称之为CRT超反应.本文主要分析CRT术后,患者超反应的预测因子.方法 采用回顾性研究,2005年1月至2010年6月共有124例随访资料完整的CRT或心脏再同步治疗除颤器（CRT-D）纳入分析,分为超反应组及其他反应组.并在CRT术后第6个月随访时,进行临床评估及超声心动图评价.心功能（NYHA分级）提高≥1级,左心室射血分数（LVEF） ≥0.45或增加2倍以上称为超反应.结果 两组患者在基线状态除QRS时限[（160.2±36.1）ms对（139.6±32.5）ms,P=0.01],完全左束支阻滞比例（95％对82％,P=0.02）、心力衰竭症状出现时间[（21.0±14.6）个月对（36.0±25.3）个月,P=0.02]差异有统计学意义外,其余参数在基线状态差异无统计学意义;有17％的患者出现超反应.6个月随访时超反应组与其他反应组在心功能分级、脑钠肽（BNP）、QRS时限、LVEF及因心力衰竭住院率方面有明显改善.结论 完全左柬支阻滞及心力衰竭症状出现较短的患者CRT反应较好.     

心脏再同步治疗前后血清胱抑素C的变化及临床意义

目的 了解心脏再同步治疗(CRT)前后血清胱抑素C(CysC)水平的变化,探讨CysC变化水平是否能反映CRT植入后心力衰竭患者心脏结构和功能改善程度.方法 对本院16例植入CRT/心脏再同步治疗除颤器(CRT-D)患者的随访资料进行分析,随访时间均＞6个月,平均随访(20.08±12.78)个月.根据治疗效果将患者分为有效组和无效组,有效定义为术后左心室收缩末容积缩小≥15％.结果 16例中有效10例(62.5％).有效组术后CysC水平明显降低[(1.54±0.38)对(1.22±0.29) P＜0.05];与临床及超声心动图指标比较,CysC在CRT术后1个月即出现明显变化且差异有统计学意义(P＜0.05).无效组术后各个时间点随访参数与术前相比均差异无统计学意义.而有效组术后6个月相关参数均明显优于无效组,但只有CysC在术后1个月即与无效组存在明显差异,且随时间延长,其差异越明显.随访时间≥6个月时,CysC水平的降低幅度(△Cys C％)与左心室舒张末期容积(LVEDV)缩小幅度(△LVEDV％)呈线性相关(R2=0.792,P＜0.05);无效组术后CysC与术前相比差别无统计学意义;CysC水平的变化与△LYEDV％无线性回归关系(P＞0.05).结论 血清CysC是一个有效地、较临床及超声心动图指标能更早的、可以常规用来监测CRT对于心力衰竭治疗效果的指标,可以更好地用于指导心力衰竭的再同步治疗.     

不同左束支阻滞型态的心力衰竭患者心脏再同步治疗效果比较

目的 验证符合左束支阻滞(LBBB)新诊断标准的慢性心力衰竭患者是否能从心脏再同步治疗(CRT)中更显著地获益.方法 入选2007年5月至2012年6月符合传统LBBB诊断标准且植入CRT患者,根据术前体表心电图形态分为“真性”LBBB组(真LBBB组:V1、V2导联负向波为主(QS或rS)；V1、V2、V5、V6、I、aVL导联中至少有2个以上的导联QRS波中间有切迹或顿挫；QRS时限,男≥140 ms、女≥130ms)和“假性”LBBB组(假LBBB组:符合传统的LBBB标准,但尚未达到“真性”LBBB诊断标准,具体包括上述6个导联中仅有1个或没有导联出现切迹或者顿挫,QRS时限,男＜140 ms、女＜130 ms).术后定期随访,比较两组患者QRS时限、左心室舒张末期内径(LVEDD)、左心室射血分数(LVEF)及心功能(NYHA分级)变化.结果 共入选32例患者(男13例),真LBBB组23例,假LBBB组9例,术前两组患者间性别、年龄、基础疾病、LVEF及心功能等基本情况差异无统计学意义.术后随访显示真LBBB组较假LBBB组LVEF增加显著(0.39±0.11对0.27±0.07,P=0.006),LVEDD缩小明显[(6.3±1.0)cm对(7.6±1.0) cm,P=0.003],提示真LBBB组对CRT治疗反应更佳.结论 符合LBBB新诊断标准的慢性心力衰竭患者从CRT中更显著获益.     

合并符合新诊断标准的左束支阻滞的慢性心力衰竭患者应用心脏再同步化治疗的疗效分析

目的:分析慢性心力衰竭患者合并符合新诊断标准的左束支阻滞(LBBB)(真性LBBB)能否从心脏再同步化治疗(CRT)中更能获益。方法:研究入选2005-06至2013-05接受CRT的19例患者,依据术前体表心电图QRS波的形态,符合新诊断标准即为真性LBBB组(n=13),符合传统诊断标准即为假性LBBB组(n=6);比较所有入选患者CRT术前与术后左心室射血分数(LVEF)、左心室舒张末内径(LVEDD)、QRS波时限(QRSd)及心室间机械延迟时间(IVMD);同时比较两组患者术后LVEF、LVEDD、QRSd、IVMD、16节段达最小收缩末容积时间标准差(Tmsv16-SD)及16节段达最小收缩末容积时间的最大差值(Tmsv16-Dif)有无差异。结果:两组患者在CRT术后的LVEF、LVEDD、IVMD及QRSd均较术前有明显的改善;而且与假性LBBB组比,真性LBBB组的LVEDD[(5.95±0.72)mm vs(7.13±0.78)mm,P0.01]、IVMD[(22.45±8.00)ms vs(27.63±13.09)ms,P0.01]及QRSd[(140.38±5.80)ms vs(153.68±14.38)ms,P0.01]改善更明显;术后两组患者的Tmsv16-SD、Tmsv16-Dif及LVEF的差异均无统计学意义。结论:合并真性LBBB和假性LBBB的心力衰竭患者均能从CRT中获益,合并真性LBBB的心力衰竭患者获益更明显。     

The cardiac component of cardiac cachexia

Background Recent evidence suggests the importance of noncardiac mechanisms in the genesis of the syndrome of cardiac cachexia. This raises the question of the relative role of the heart itself in this syndrome. This study sought to assess the cardiac dimensions, mass, and function and changes in these parameters over time in patients with chronic heart failure with and without cachexia. Methods Doppler echocardiography was performed in 28 patients with nonedematous weight loss (>7.5% over a period of >6 months) compared with 56 matched patients without weight loss in a ratio of 1:2 (age 71 ± 13 vs 67 ± 8 years, P = .07; New York Heart Association class 2.9 ± 0.7 vs 2.6 ± 0.6, P = .08). In 18 cachectic and 35 noncachectic patients with previous echocardiographic recordings, we analyzed the changes in left ventricular (LV) dimensions and mass over time. Results Cardiac dimensions including LV diastolic (69 ± 9 mm vs 67 ± 13 mm) and systolic cavity diameter (58 ± 11 mm vs 55 ± 15 mm), LV mass (480 ± 180 g vs 495 ± 190 g), and LV systolic and diastolic function including fractional shortening (16% ± 10% vs 18% ± 10%), isovolumic relaxation time (29 ± 22 ms vs 36 ± 27 ms), and E/A ratio (2.7 ± 1.6 vs 3.3 ± 2.9) did not differ between cachectic and noncachectic patients (all P > .1). By analyzing changes in LV mass over time, we found an increase (>20%) in 2 (11%) cachectic and 14 (40%) noncachectic patients and a decrease in LV mass (>20%) in 9 (50%) cachectic and 8 (23%) noncachectic patients (χ² test, P < .05). Conclusions Although no specific cardiac abnormality could be detected echocardiographically in cachectic patients compared with patients with noncachectic chronic heart failure in a cross-sectional study, over time a significant loss of LV mass (>20%) occurs more frequently in patients with cardiac cachexia. (Am Heart J 2002;144:45-50.)     

Analysis of cardiac symptoms preceding cardiac arrest

Prodromal symptoms and cardiac history were examined in 227 patients with coronary artery disease who were successfully resuscitated after out-of-hospital cardiac arrest. Cardiac arrest was sudden—with either no symptoms or symptoms for less than 1 hour—in 71% of the patients. Nonsudden death—death occurring after more than 1 hour of symptoms—occurred in 29% of the patients. A history of cardiovascular disease was present in 85% of patients with sudden cardiac arrest and in 83% with nonsudden arrest. Cardiac arrest occurred without symptoms in 38% of the patients with sudden cardiac arrest and was the first expression of coronary artery disease in 4% of the entire study group. This study indicates that cardiac arrest usually occurs with symptoms and almost always in the setting of a history of cardiovascular disease.     

External cardiac pacing during in-hospital cardiac arrest

External noninvasive cardiac pacing offers a rapid and simple method of pacing the heart during an emergency. It has been suggested that early use of cardiac pacing for bradycardia or asystole may improve survival in patients who have cardiac arrest. To investigate this possibility 58 consecutive episodes of cardiac arrest occurring on the medical wards or emergency room. Twenty-six episodes underwent external noninvasive pacing for bradycardia or asystole refractory to standard drugs. Only 2 patients survived, and survival could be directly attributed to pacing in only 1 of them. Of the 32 episodes not undergoing pacing, 23 had transient asystole or bradycardia, 13 of which rapidly responded to medications. The 17 cases (53%) not undergoing pacing survived. In conclusion, when bradycardia or asystole during cardiac arrest fails to respond to standard pharmacologic measures, it is an indicator of severe myocardial damage, and attempts at cardiac pacing rarely improve survival.     

Acute cardiac tamponade due to cardiac actinomycosis

Cardiac actinomycosis occurs in less than 2 percent of the patients with infections due to Actinomyces israelii. We describe the findings in a patient with acute cardiac tamponade who survived through pericardial drainage and aggressive medical therapy. Although uncommon, this disorder is important to recognize because it is curable with current medical and surgical therapy.     

心脏骤停和心脏性猝死

心脏性猝死(SCD)是目前社会关注的热点问题.2005年WHO的数据表明,在全球死于心脑血管疾病的约1700万人群中,40%～50%是SCD.SCD虽然有多种定义,但目前一般认为是在1 h内出现的由于心血管原因导致的非预期死亡事件或无目击者的死亡事件.心脏骤停(SCA)不等同于SCD,SCA如果救治失败会引起真正的SCD.     

Sodium-induced cardiac aldosterone synthesis causes cardiac hypertrophy

High sodium intake causes cardiac hypertrophy independently of increases in blood pressure. Aldosterone is synthesized in extraadrenal tissues such as blood vessels, brain, and heart. Effects of 8 weeks of high sodium intake on cardiac aldosterone synthesis, as well as cardiac structure, mass, and aldosterone production, levels of mRNA coding for aldosterone synthase (CYP11B2) and the angiotensin II AT1 receptor, were studied in normotensive Wistar-Kyoto (WKY) rats. Isolated rat hearts were perfused for 2 hr, and the perfusate was analyzed by high-performance liquid chromatography and mass spectrometry. Aldosterone synthase activity was estimated from the conversion of [14C]deoxycorticosterone to [14C]aldosterone. Levels of mRNA for CYP11B2 and AT1 receptor were determined by competitive polymerase chain reactions. A high sodium intake for 8 weeks produced left ventricular hypertrophy without elevation of blood pressure. Plasma aldosterone concentrations and plasma renin concentrations were decreased by high sodium intake. Aldosterone production, activity of aldosterone synthase, and expression of mRNA for CYP11B2 and AT1 receptor were increased in hearts of rats with high sodium intake. These results suggest that high sodium intake increases cardiac aldosterone synthesis, which may contribute to cardiac hypertrophy independently of the circulating renin-angiotensin-aldosterone system.     

Occult cardiac lymphoma presenting with cardiac tamponade

Subxiphoid pericardiostomy is the procedure of choice for treatment of a pericardial effusion with tamponade. We report a case in which this procedure not only failed to reveal the presence of an occult malignancy, but also resulted in a recurrent symptomatic effusion.     

Coronary angioscopy during cardiac catheterization and cardiac surgery

Summary Coronary angioscopy (CA) was performed in 30 patients (pts) during cardiac catheterization (Group 1) and in 11 pts during coronary bypass surgery (Group 2) using ultrathin fiberoptic angioscopes (Ø1.2–1.8 mm). For percutaneous CA (Group 1) the angioscope was introduced through a 9F guiding catheter from the femoral artery. The viewing field was cleared by flushing Ringer's solution and short-time occlusion of the coronary ostium by the guiding catheter. In Group 2 CA was performed retrogradely from the distal arteriotomy and through the bypass vein during flushing with cardioplegic solution. In Group 1 in 17/30 pts the coronary artery could be successfully examined by CA. In 13 pts the obstruction was eccentric and irregular shaped. In 2/5 pts, in whom CA was performed successfully pre and post balloon dilatation, CA after PTCA revealed an intimal rupture without clinical or angiographical signs of the intimal dissection. In Group 2 in 9/11 pts good visualization of stenoses could be achieved. At the obstruction site CA revealed thrombi in 3 pts and ulcer in 1 pts. In contrast to angiography, which estimates the lumen diameter of a segmental lesion, CA gives information about the luminal shape and the underlying substance of the obstruction (e.g. atheroma, thrombus, ulceration). The main problems in percutaneous CA are the insufficient intraluminal guidance, the insufficient depth of view of the angioscopes, and the limited examination time.     

心脏介入性治疗并发心脏压塞的处理策略

目的 探讨心脏介入治疗并发心脏压塞的处理策略。方法 12例心脏压塞患者，男性5例，女性7例，年龄28～52岁。其中经皮二尖瓣球囊扩张术8例，冠状动脉腔内成形术1例，先天性动脉导管未闭封堵术2例，右心室起搏1例。根据心脏穿孔的不同原因、可能的部位及心脏压塞情况，分别采用心包穿刺引流、心包穿刺引流与开胸修补或开胸置管引流等方法治疗。结果 3例单纯心包穿刺引流均痊愈；8例紧急心包穿刺引流后开胸修补有7例痊愈，1例主动脉根部破裂者因心源性休克时间过长，死于呼吸衰竭；1例冠状动脉腔内成形术者左回旋支穿孔，紧急心包穿刺引流后心包切开、胸腔置管引流痊愈。结论 根据心脏介入性治疗导致心脏压塞的不同原因、可能部位及心脏压塞进展情况，采取相应措施，可有效治疗此类并发症。