心脏再同步治疗难治性心力衰竭的临床应用

目的评价心脏再同步治疗（CRT）难治性心力衰竭的临床疗效。方法21例难治性心力衰竭患者接受CRT治疗；左心室导线采用经心脏静脉血管径路植入或开胸直接缝合左心室心外膜导线。植入术后定期随访，分析患者心功能、活动耐量、生活质量评分、QRS时限、左心室射血分数（LVEF）、左心室舒张末内径（LVEDD）等指标的变化，评价CRT的临床疗效，测试起搏参数并在超声心动图指导下优化AV间期和VV间期。结果21例患者成功植入CRT，其中3例患者因心脏静脉血管畸形而采用开胸植入左心室心外膜导线。平均随访（9．8±9．5）个月，死亡3例；2例患者因心力衰竭症状复发再住院；其余患者心功能分级、生活质量评分、活动耐量较植入术前有显著改善；植入术后1个月LVEF明显提高（0．31±0．06对0．37±0．05，P〈0．01）；二尖瓣反流程度[（2．24±0．89）级对（1．43±0．75）级，P〈0．01]；LVEDD植入术后6个月明显减小（（71．91±8．38）mm对（68．82±10．80）mm，P〈0．05]；QRS时限分析显示CRT治疗有效组术后明显变窄（（162．50±24．08）ms对（142．50±19．15）ms，P〈0．05]，无效组变化不明显[（148．00±10．95）ms对（138．00±4．47）ms，P〉0．05]。1例患者左心室导线脱位。右心房和右心室起搏导线的阈值、感知灵敏度及阻抗均在正常范围，左心室导线各参数，除1例患者阈值升高外余均正常。3例开胸植入心外膜导线患者除1例于植入术后第5个月心脏性猝死，余2例分别随访18个月和26个月，左心室导线阈值分别为0．5V／0．4ms和1．0V／0．4ms。CRT治疗的总临床有效率为76．2％。结论CRT治疗难治性心力衰竭有效，能恢复患者心脏电活动和机械活动的同步性，显著改善心功能。QRS时限变窄是CRT疗效的重要预测指标。

Clinical application of cardiac resynchronization therapy for refractory heart failure

Objective To evaluate the chnical effectiveness of cardiac resynchronization therapy (CRT) for refractory heart failure.Methods Twenty-one patients with refractory heart failure received CRT device implantation.The left ventricular electrode lead was implanted via cardiac vein through coronary sinus or by epicardial suture.The effectiveness of CRT was evaluated in terms of NYHA class,exercise tolerance,quality of life,QRS width,LVEF and LVEDD during follow-up period.Pacing parameters were tested,and AV/VV interval was optimized by the guidance of echocardiography.Results CRT devices were successfully implanted in 21 patients.Left ventricular epicardial electrode lead was implanted by suture due to deformation of coronary vein in three patients.The mean Follow-up duration was(9.8 ± 9.5 )months.Three patients died and two patients reinhospitalized during follow-up period.The heart function classification,quality of life and distance of 6 minutes hall walk improved significantly after CRT implantation.The LVEF increased from 0.31 20.06 to 0.37 20.05(P<0.01) ,and improved mitral regurgitation was seen in grade 2.24 ±0.89 to 1.43±0.75(P<0.01)one month after CRT implantation.LVEDD decreased from(71.91 ±8.38 )mm to (68.82 ± 10.80) mm (P<0.05 )at 6 month after-implantation.QRS duration decreased significantly after CRT implantation among CRT responsers[(162.50 ± 24.08 ) ms vs( 142.50 ±19.15 ) ms,P <0.05] ,but not in CRT non-responsers[ ( 148.00 ±10.95)ms vs( 138.00 ±4.47) ms,P>0.05].One patient had left ventricular electrode lead dislocation after 2 months.Pacing parameters of electrode leads were within normal range except one patient with high pacing threshold(6.0 V/1.2 ms).The threshold of epicardial electrode lead in two patients was 0.5 V/0.4 ms and 1.0 V/0.4 ms at 18-month and 26-month follow-up,respectively.Atrio-ventricular,inter-ventricular and intraventricular synchrony was achieved by optimizing AV and VV interval by the guidance of echocardiography for all patients.The total clinical effectiveness of CRT was 76.2%.Conclusion CRT is beneficial to patients with refractory heart failure by recovering the cardiac electric and mechanical synchronization.QRS duration is an important predictive index for CBT effectiveness.