心脏再同步化治疗心力衰竭3例报告

目的:观察心脏再同步化治疗(CRT)对充血性心力衰竭患者心功能的影响。方法:对3例符合CRT适应证的充血性心力衰竭患者置入三腔起搏器,使心脏房室收缩趋向正常顺序、室间收缩同步化。3例患者均成功置入了三腔起搏器,左室电极靶血管2例位于左后侧静脉,1例右束支传导阻滞患者因为置入左后侧静脉膈肌跳动而改为心大静脉。结果:3个月时患者的胸闷气促症状明显改善,生活能够自理,心功能可达到NYHAⅡ级;QRS宽度均较术前缩短;术后3个月左室射血分数较术前提高,左室舒张末期内径减小;术后3个月程控仪测试参数显示,与置入三腔起搏器前相比夜间心率有所降低,活动度增加,心率变异性有所提高。结论:CRT通过改善心脏收缩的同步性,提高左室射血分数,从而改善心功能,提高生活质量和运动能力。     

心脏再同步化治疗晚期扩张型心肌病13例的效果

目的: 观察心脏再同步化治疗（CRT）晚期充血性心力衰竭的临床疗效。方法: 晚期扩张型心肌病患者13例接受CRT,NYHA心功能分级为Ⅲ～Ⅳ级,左室射血分数（LVEF）为（27.4±9.7）%,左室舒张末期内径（LVEDD）为(72.8±9.6)mm,QRS时限为( 137.8＋30.4)ms。术后观察QRS时限的变化,随访左室电极起博阈值、心功能分级、LVEF及LVEDD。结果: 术后QRS时限减少为（123.8±17.1）ms。所有患者随访3～38月,左室电极慢性阈值为（1.1±0.6）V/0.4 ms。与术前相比,NYHA心功能分级从(3.4±0.5)降低为(1.5±0.9); LVEF从(27.4±9.7)%上升至(43.5±18.5)%(P<0.05);LVEDD从(72.8±9.6)mm缩小为(65.5±11.6)mm（P<0.05）。结论: CRT可改善心功能,提高LVEF,并可逆转左心室重构。     

组织多普勒指导心脏再同步化治疗中左室电极导线的植入

目的运用组织多普勒技术指导心脏再同步化治疗(cardiac resynchronization therapy,CRT)中左室电极导线的植入并评价CRT短期疗效.方法选择拟行CRT的慢性充血性心力衰竭患者7例,起搏前行常规超声心动图和组织多普勒检查,计算LVEF、Tei指数、左右心室间不同步参数(T1-T2),QRS距左室各节段收缩峰值时间的标准差(Ts-SD),经心率校正的Ts-SD(Ts-SDC),并根据组织同步显像图(TSI)的色彩计算TSI指数.结合组织速度显像、组织追踪显像、组织同步显像3种方法判断左室延迟收缩的部位和程度,根据延迟的部位选择靶静脉及导线植入的深度,比较起搏前后各参数的变化.结果起搏前左室延迟收缩的部位存在较大的个体差异.在组织多普勒指导下,2例选择了左室后静脉,2例选择了左室侧静脉,3例选择了左室侧后静脉.起搏后7～10天,所有患者左心功能改善LVEF由起搏前的(27.3±7.4)%增高至(40.7±8.9)%(P＜0.01),Tei指数由1.23±0.70降低至0.83±0.33(P＜0.05),且心率较起搏前减慢(P＜0.05);左心室内收缩不同步改善TSI指数由起搏前的2.03±0.22降低至1.62±0.33(P＜0.05),Ts-SDC由191.39±47.35降低至119.45±62.02(P＜0.05);左右心室间收缩不同步改善T1-T2由起搏前(49.14±26.82)ms降低至(15.43±11.30)ms(P＜0.05);左房内径起搏后缩小(P＜0.01).结论组织多普勒可用于识别心室机械不同步的程度和部位,对于指导CRT中左室电极导线的植入和疗效的评价具有重要的实用价值.     

心脏再同步起搏治疗充血性心力衰竭初探

目的观察心脏再同步起搏（CRT）治疗慢性充血性心力衰竭（CHF）的临床疗效。方法选择心功能Ⅲ～Ⅳ级（NYHA分级）的患者12例,治疗前行心脏彩色多普勒检查及心电图检查,符合美国、中国心脏CRT指南的适应证,行CRT起搏器植入,术后第1周及第4周返院复查心脏彩色多普勒检查及心电图检查,观察CRT起搏器植入术前后患者心功能及病情变化。结果 CRT起搏器植入术治疗后12例患者心功能均明显改善,左室射血分数及左室充盈均增加,二尖瓣返流减少,NYHA心功能分级从Ⅲ～Ⅳ级提高到Ⅰ～Ⅱ级。结论心脏再同步起搏治疗慢性充血性心力衰竭近期疗效明显。     

心脏再同步化治疗慢性心力衰竭的疗效评价及无效原因分析

目的 评价心脏再同步化治疗(CRT)对慢性心力衰竭患者的临床和超声心动图疗效,总结CRT无效的原因.方法 研究施行CRT的患者53例,男37例,女16例,年龄41～82岁.患者术前均采用血流多普勒和组织多普勒的方法进行收缩不同步的评价,术前和术后6个月进行美国纽约心脏病学会(NYHA)心功能分级评价、心电图和超声心动图检查.临床有效者定义为术后6个月NYHA心功能分级改善1级以上的患者.超声心动图有效者定义为术后6个月左室收缩末容积缩小＞15%或左室射血分数绝对值增加＞5%的患者.结果 CRT术后6个月时,7例患者死亡,46例患者存活.其中NYHA心功能分级至少改善1级者40例,临床有效率为75.5%;超声心动图有效者37例(69.8%).术后6个月:左心室缩小;左室射血分数由(27.4±6.7)%增加到(40.4±10.0)%,P＜0.01;左心房内径缩小;二尖瓣反流减少;肺动脉收缩压由(49.6±13.6)mm Hg(1 mm Hg=0.133 kPa)降低为(38.7±14.5)mm Hg.窦性心律组(42例)的超声有效率显著高于心房颤动组(11例).在窦性心律患者中,与CRT无效组(10例)相比,有效组(32例)起搏前的QRS较宽(P＜0.05),肺动脉收缩压较低(P＜0.05),左室射血前时间较长(P＜0.05);起搏前两组间腔室大小、LVEF、二尖瓣反流面积和组织多普勒的各个收缩不同步参数的差异无统计学意义.结论 CRT能改善心力衰竭患者的左室收缩功能和左室重构,减少二尖瓣反流,降低肺动脉收缩压.窦性心律组的CRT疗效优于心房颤动组.在非缺血性心肌病和左束支传导阻滞患者占多数的研究中,QRS宽度、左室射血前时间和肺动脉收缩压可能预测CRT的疗效.     

氯沙坦对慢性充血性心力衰竭心功能作用的临床观察

目的观察氯沙坦对慢性充血性心力衰竭患者心功能的改善作用。方法选择慢性充血性心力衰竭患者64例,随机分为氯沙坦组和对照组,氯沙坦组在常规治疗基础上加服氯沙坦100mg,每日一次,总疗程8周;对照组采用常规治疗。以彩色多普勒超声心动图检测治疗前后以及组间心功能改变情况。结果慢性充血性心力衰竭患者经氯沙坦治疗后收缩压、舒张压均较治疗前和对照组治疗后下降。左室舒张末期容量(LVEDV),左室射血分数(EF),心输出量(CO)较治疗前和对照组治疗后改善。结论氯沙坦能明显改善慢性充血性心力衰竭患者心功能。     

心脏再同步化起搏治疗对慢性充血性心力衰竭患者心脏重构的影响

目的观察心脏再同步化起搏治疗(cardiac resynchronization therapy,CRT)对慢性充血性心力哀竭(chronic congestive heart failure,CHF)患者心脏重构的影响。方法入选21例CHF患者中扩张型心肌病13例,缺血型心肌病8例。所有患者符合CRT指南的Ⅰ类适应证。观察患者行CRT术后6个月及12个月左室射血分数(LVEF)、左室舒张末内径(LVDD)、左室收缩末内径(LVDS)、左室舒张末期容积(LVEDV)、左室收缩末期容积(LVESV)及左心房内径(LAD)的变化。结果 CRT术后6个月和12个月LVEF较术前显著增加(P0.05);LVDD、LVDS、LVEDV、LVESV及LAD较术前显著减少(P0.05)。术后12个月与术后6个月比较,以上指标差异均无统计学意义(P0.05)。结论 CRT术后6个月即可显著逆转CHF患者左室心肌重构,提高射血分数。     

心脏再同步化治疗起搏参数优化对心脏同步性及心功能的影响

目的 应用组织多普勒研究心脏再同步化治疗(CRT)术后A-V、V-V间期优化对心脏同步性能及心功能的影响,探索A-V、V-V间期优化在增强CRT临床疗效中的作用.方法 32例慢性心力衰竭患者接受CRT治疗,于术后7天、3个月、6个月进行A-V、V-V间期优化,观察心脏同步性和心功能变化.采用彩色超声诊断仪进行图像采集及下线分析.结果 经观察,术后7天、3个月、6个月的A-V间期需行优化的例数分别为28例、10例、6例,V-V间期需行优化的例数分别为29例、6例、5例.与CRT术前相比:CRT治疗术后未优化时的左室12节段组织速度达峰时间标准差明显改善[(68.8±26.4)ms与(41.6±23.1)ms,P＜0.01],左室射血分数增加[(28±4)%与(31±3)%,P＜0.05],主动脉瓣前向血流速度时间积分增加[(13.6±3.1)cm与(15.5±4.3)cm,P＜0.05],舒张早期跨二尖瓣血流峰速和舒张早期心肌组织运动峰速的比值下降(13.1±5.3与9.3±4.3,P＜0.05),左室舒张充盈时间延长[(313.2±93.6)ms与(368.6±97.1)ms,P＜0.05].与术后未优化时相比:术后7天优化心脏同步性指标进一步改善(P＜0.05),心功能指标无明显改变;术后3个月、6个月优化与术后7天优化相比,心脏同步性指标无明显改变,P＞0.05;术后6个月优化的左室射血分数增加,左室舒张充盈时间延长,P＜0.01.结论 CRT术后7天,A-V、V-V间期优化治疗改善心脏同步指标;术后6个月优化进一步改善心功能.     

充血性心力衰竭病人短期滴注多巴酚丁胺后心脏功能的持续改善

多巴酚丁胺具有β_1肾上腺素能活性,能加强心肌收缩力,而致心律失常及加快心率作用则较儿茶酚胺为小。近年报告心力衰竭病人短期滴注多巴酚丁胺后30分钟即有收缩功能、左室喷血分数及心排出量的改善,并可持续数月之久。本文以双盲对照法测定充血性心力衰竭患者静脉滴注多巴酚丁胺72小时对血流动力学及心血管功能的影响,以及其持续改善左室功能的作用。方法:15例特发性或酒精性心肌病并有Ⅲ或Ⅳ级稳定的充血性心力衰竭患者,所有病人均在用狄戈辛和利尿剂并给予低盐饮食(2克/日)。入院后     

右室感知触发左室起搏心脏再同步化治疗慢性充血性心力衰竭的疗效

目的 探讨给予慢性充血性心力衰竭患者右室感知触发左室起搏心脏再同步治疗的临床疗效.方法 选取慢性充血性心力衰竭患者30例作为研究对象,测定手术前后患者的舒张期二尖瓣(MVI)、二尖瓣反流(MR-VTI)、主动脉瓣前向血流速度平均积分(AVI)及左室射血分数(LVEF).结果 治疗后,MVI、MR-VTI、AVI及LVEF,两种模式比较均无统计学意义(P＞0.05);传统心脏再同步化模式的电池平均寿命短于右室感知触发左室起搏模式,并且右室感知触发左室起搏模式的QRS波时限优于传统心脏再同步化模式(P＜0.05).结论 右室感知触发左室起搏心脏再同步化治疗,能够有效改善慢性充血性心力衰竭患者的血流动力学,值得推广.     

心脏再同步化起搏治疗随访

目的探讨心脏再同步化起搏治疗(CRT)随访的相关技术细节。方法22例难治性充血性心力衰竭(简称心衰)患者(男14例、女8例),年龄59.5±7.8(47~74)岁,其中扩张型心肌病16例、高血压性心脏病6例。按常规方法置入双室起搏器后,按一定程序对起搏系统及患者的临床综合反应随访观察,根据患者反应及时对起搏系统参数进行优化。结果随访22±13.01(1~48)个月,双室起搏辅以优化的起搏参数及药物治疗。心衰临床症状改善,心功能提高,运动耐量增加,生活质量提高,心脏重塑进程延缓,因心衰住院事件减少。结论CRT必须从置入起搏器的即刻开始进行动态随访、优化起搏参数。     

心脏再同步化治疗对充血性心力衰竭患者内皮功能的影响

目的:探讨心脏再同步化治疗(CRT)对充血性心力衰竭(心衰)患者内皮功能的影响。方法:扩张型心肌病并发心衰患者分为药物治疗组(10例)和CRT+药物治疗组(12例),分别在治疗前、治疗12周末,检测心脏超声、血管内皮功能、脑钠肽(BNP)。结果:与药物治疗组比较,CRT+药物治疗组明显增加患者的心脏输出量[(4.32±1.50)L/min∶(3.41±1.00)L/min,P<0.05]及肱动脉内径的变化率(FMD)[(1 718±123)%∶(976±118)%,P<0.05],FMD和心输出量呈正相关(r=0.6,P=0.003)。结论:CRT可以提高内皮细胞的功能,其机制可能是通过增加心输出量来实现的。     

How many patients with heart failure are eligible for cardiac resynchronization? Insights from two prospective cohorts.

AIMS: To determine what proportion of patients with heart failure are eligible for cardiac resynchronization therapy (CRT). METHODS AND RESULTS: Eligibility criteria from the trials establishing the efficacy of CRT were applied to two prospective cohorts: the first enrolled patients with newly diagnosed heart failure discharged from 103 hospitals between April 1999 and March 2001 ('the hospital discharge cohort'); the second enrolled patients seen in a specialized clinic between August 2003 and January 2004 ('the specialty clinic cohort'). In the hospital discharge cohort, 73 patients (3% of the 2640 patients with ischaemic or dilated cardiomyopathy and 1% of all 9096 patients with heart failure discharged alive) met trial eligibility criteria: LVEF< or =0.35, QRS > or =120 ms, sinus rhythm, and NYHA class III or IV symptoms despite the treatment with ACE-inhibitor/angiotensin receptor blocker and beta-blocker. In the specialty clinic cohort, 54 patients (21% of the 263 patients with ischaemic or dilated cardiomyopathy and 17% of all 309 patients with heart failure) met these criteria. If persistent symptoms despite taking spironolactone were required for CRT eligibility, then the proportions qualifying dropped to 1% in the hospital discharge cohort and 18% in the specialty clinic cohort. CONCLUSION: Few heart failure patients meet trial eligibility criteria for CRT.     

Cardiac Resynchronization Therapy in Children

Cardiac Resynchronization therapy has become an important management tool in adults with heart failure and dilated cardiomyopathy. The role of CRT in children with CHF is still unclear. Evidence is slowly emerging in the pediatric cardiology literature that CRT may have an important and useful role in certain select populations with CHF. These include patients with complete heart block who develop pacing-induced cardiomyopathy, certain forms of congenital heart disease associated with systemic ventricular failure (even if the systemic ventricle is a morphologic RV) and in patients with idiopathic dilated cardiomyopathy. Studies in children supporting the use of CRT include many case reports, a few studies of CRT in post-operative patients, and one multi-center registry reporting the use of CRT in children. These papers will be summarized.     

Usefulness of cardiac resynchronization therapy in the management of Doxorubicin-induced cardiomyopathy

Doxorubicin is a widely used antineoplastic agent that may cause irreversible dilated cardiomyopathy. Doxorubicin-induced cardiomyopathy (DIC) can occur several years after exposure and carries a poor prognosis. Although cardiac resynchronization therapy (CRT) is a useful intervention in end-stage heart failure unresponsive to optimal medical therapies, its efficacy in DIC remains unknown. Four consecutive patients receiving CRT for DIC were evaluated before and after CRT. CRT resulted in improvements in the mean left ventricular ejection fraction at 1 month from 21+/-4.7% to 34+/-5% (p=0.03) and at 6 months (to 46+/-7.5%, p=0.01). CRT-induced reverse remodeling was observed, with a mean reduction in left ventricular internal diameter at end-diastole from 54.75+/-3.7 to 52.5+/-1.9 mm at 1 month (p=0.06) and further to 47+/-2.3 mm at 6 months (p=0.03). All patients experienced reductions in heart failure symptoms and improvements in New York Heart Association functional class (p<0.05). The impact of CRT was sustained over a follow-up of 18.5+/-3.5 months. In conclusion, this study suggests that patients with DIC, refractory to optimal pharmacologic therapy and meeting criteria for resynchronization device implantation, may achieve sustained benefit from CRT.     

心内膜电极心肌内埋置心脏再同步化治疗扩张型心肌病心力衰竭

目的探讨经胸心内膜电极心肌内埋置技术进行扩张型心肌病心力衰竭(简称心衰)的同步化治疗(CRT)效果。方法对1例置入冠状静脉窦电极困难导致心包压塞的扩张心肌病患者行经胸心内膜电极心肌内埋置技术进行电极置入,进行三腔起搏同步化治疗心衰。结果组织多普勒显示患者的房室、左室内存在明显收缩不同步,但在放置静脉窦电极时心脏穿孔出血。由于急诊条件无法使用心外膜电极,在开胸止血后右房、右室、左室均行心内膜电极心肌内埋置,未出现严重并发症。术后临床症状逐渐改善,NYHA心功能分级从术前Ⅲ-Ⅳ级提高至Ⅱ级,左室舒张末径从88mm减至68mm,优化程控起搏器后超声心动图描记原来收缩最延迟的左室侧壁和后壁中间段均有明显的达峰时间大幅缩短,分别缩短252ms和204ms。左室内最大收缩延迟由415ms缩短为163ms,左室收缩不同步指数由193ms缩短为65ms。随访3个月后电极的起搏阈值没有明显变化。结论经胸心内膜电极心肌内埋置技术进行扩张型心肌病心衰的CRT是安全、可行的,特别是静脉窦电极放置失败而无法选用心外膜电极时是可选择的方法。     

心脏再同步治疗的随访及疗效观察

目的探讨心脏再同步化起搏治疗（CRT）的长期疗效以及随访相关技术细节。方法15例慢性心力衰竭患者,男性13例,女性2例,平均年龄72．25岁,其中扩张性心肌病8例、缺血性心肌病5例、高血压性心脏病2例。按常规方法置入CRT后对起搏系统参数进行优化,观察长期疗效。结果随访12个月,经过双心室起搏辅以优化的起搏参数及药物治疗,左心室射血分数从29％提高至42％,差异有统计学意义（P〈0．01）;左心室舒张末内径从65．8mm缩小至59．6mm,差异有统计学意义（P〈0．01）;QRS波从144ms缩短至124ms,差异有统计学意义（P〈O．01）;心衰临床症状减轻,心功能改善,运动耐量增加,生活质量提高,心脏重塑进程延缓,因而心衰住院事件减少。结论CRT能够使心衰患者临床症状减轻,心功能改善,生活质量提高,心脏重塑进程延缓。随访优化起搏参数和药物治疗对提高疗效是十分重要的。     

心脏再同步治疗慢性心力衰竭随访疗效分析

目的探讨心脏再同步化治疗(CRT)对慢性充血性心力衰竭近远期治疗的效果。方法心力衰竭患者48例,男31例、女17例,年龄62.0±15.6(35～80)岁,其中扩张型心肌病28例,高血压性心脏病2例,缺血性心肌病l3例,Ⅲ度房室传导阻滞5例。心功能Ⅲ级(NYHA分级)34例、Ⅳ级14例。植入CRT系统(含CRTD),随访23.4±15.8个月。结果48例中有良好反应者32例,对治疗无明显反应者11例。死亡9例,其中2例猝死,4例死于心力衰竭恶化。结论CRT疗效肯定,定期随访和程控,将有助于减少无反应者。CRTD有助于降低猝死的发生。     

Unexpected and rapid recovery of left ventricular function in patients with peripartum cardiomyopathy: impact of cardiac resynchronization therapy

Aim Peripartum cardiomyopathy (PPCM) is a rare cause of dilated cardiomyopathy responsible for heart failure toward the end of pregnancy, which can lead to chronic heart failure in 50% of cases. In this short report, we assessed the benefit of cardiac resynchronization in patients with PPCM and chronic systolic dysfunction despite optimal medical treatment. METHODS AND RESULTS: For the last 10 years, we managed eight patients diagnosed with PPCM. Two of them presented severe systolic dysfunction, and medical treatment resulted in limited improvement from 10% to 25% and from 25% to 28% despite optimal treatment for 9 and 6 years, respectively. These two patients were porposed to receive an implantatable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT). Six months after ICD-CRT treatment, we observed a significant improvement in systolic function from 25% to 45% and 28% to 50%, respectively, and positive remodelling with reduction of left ventricular end-diastolic volume from 216 to 144 mL and from 354 to 105 mL, which represent a 34% and a 70% reduction, respectively. CONCLUSIONS: Physicians in charge of patients with PPCM should offer the opportunity of CRT for patients whose cardiac function has not significantly improved under standard medical treatment.     

Is “Hyper Response” to Cardiac Resynchronization Therapy in Patients with Nonischemic Cardiomyopathy a Recovery,a Remission,or a Control?

Background and Objectives: Some patients treated by cardiac resynchronization therapy (CRT) recover “normal” left ventricular (LV) function and functional status. However, whether this “normalization” persists or reverts over time remains unknown. The aim of the present study was to evaluate the long‐term outcomes of LV function in patients hyper responder to CRT. Methods: Eleven consecutive patients with nonischemic dilated cardiomyopathy, sinus rhythm, left bundle branch block (LBBB), New York Heart Association (NYHA) class III or IV, and optimal pharmacological treatment were hyper responder as they fulfilled concurrently the two following criteria: functional recovery (NYHA class I or II) and normalization of LV ejection fraction (LVEF). Results: After a mean follow‐up of 65 ± 30 months between CRT implantation and last evaluation LVEF improved from 26 ± 9 to 59 ± 6% (P < 0.0001). One patient died from pulmonary embolism 31 months after implantation. Three patients exhibited LVEF ≤ 50% at their last follow‐up visit (two at 40% and one at 45%). In eight patients, brief cessation of pacing was feasible (three were pacemaker‐dependent). Mean QRS duration decreased from 181 ± 23 ms to 143 ± 22 ms (P = 0.006). In one patient, pacing was interrupted for 2 years and LVEF decreased markedly (from 65% to 31%) but returned to normal after a few months when pacing was resumed. Conclusion: In hyper responder patients, “normalization” of LV function after CRT persists as long as pacing is maintained with an excellent survival. Ann Noninvasive Electrocardiol 2010;15(4):321‐327