心脏再同步化治疗充血性心力衰竭的护理

目的 总结16例应用心脏再同步化治疗慢性充血性心力衰竭患者的护理体会.方法 治疗前加强心理护理,完善各项准备;治疗中做好生命体征观察及护理配合;治疗后加强起搏器囊袋局部和全身情况的观察与护理,重视病情及并发症的观察与护理,认真做好出院指导、院外随访.结果 经治疗及护理,16例均取得满意效果.结论 良好的护理是取得上述效果的重要保证,特别要做好术前的评估、心理护理,术后加强心电监测、并发症的预防及随访指导.护理工作应配合电生理医生将心脏再同步化治疗结果更优化.     

心脏再同步化治疗充血性心力衰竭的术后护理进展

对心脏再同步化治疗充血性心力衰竭的机制及术后护理进行综述,提出重视术后并发症的观察.     

心脏再同步化治疗充血性心力衰竭的术后护理进展

对心脏再同步化治疗充血性心力衰竭的机制及术后护理进行综述,提出重视术后并发症的观察。     

心脏再同步化治疗慢性心力衰竭患者的护理

慢性心力衰竭（chronic heart failure,CHF）为各种器质性心脏病的终末阶段。随着对CHF病理生理学研究的深入,以及血管紧张素转化酶抑制剂、β受体阻滞剂、醛固酮拈抗剂等药物为代表的心脏修复治疗措施的广泛应用,CHF患者的生存期与生活质量已得到较大的改善,但美国纽约心脏病学会（NYHA）心功能Ⅲ～Ⅳ级患者的生存期短、病死率高,1年死亡率高达50％以上,5年存活率与恶性肿瘤相当,预后仍然很差。近年的临床研究发现,     

心脏再同步化治疗慢性充血性心力衰竭患者的护理

总结心脏再同步化治疗16例慢性充血性心力衰竭患者的护理.护理重点是治疗前做好心理护理及相关准备,治疗后监测生命体征,加强并发症的观察及护理,重视出院指导,是心脏再同步化治疗成功的重要保证.16例心脏再同步化治疗均获成功,随访3～12月,心力衰竭症状明显改善.     

心脏再同步化治疗慢性心力衰竭患者术后并发症的观察及护理

慢性心力衰竭是心血管治疗学上的难题,是一种具有较高患病率和病死率的严重疾患。心脏再同步化治疗（cardiac resynchronization therapy,CRT）作为抗心力衰竭治疗的一个有效手段逐渐被应用起来。但是由于操作复杂、技术难度大,术后除了普通起搏器植入术常见的并发症外,还具有一些独特的并发症。本院1999年在国内率先开展该项技术,     

心力衰竭心脏再同步化治疗指南的沿革

心力衰竭的心脏再同步化(CRT)或心脏再同步化并植入心脏复律除颤器(CRTD)治疗是新兴的卓有疗效的介入治疗方法,但是疗效差别非常显著,有的患者出现超反应,心功能和射血分数完全恢复正常,而有的患者则植入无效。由此派生出大量的临床试验,导致指南在不断更新细化,直接影响我们的临床治疗决策。本文针对国内外CRT指南的沿革和更新作一综述,明确最新的适应证和患者选择,以提高CRT在临床实践中的疗效。     

心脏再同步化治疗心力衰竭围手术期的护理

心力衰竭(简称心衰)是指由于各种心脏疾病造成的心脏收缩和(或)舒张功能异常,使心脏排血量不能满足机体代谢需求而导致的复杂病理生理过程和临床症候群[1].心脏再同步化治疗( cardiacresynchronization therapy,CRT)是借助于起搏技术使严重的房室传导阻滞或心室内传导功能障碍患者固有的心脏循环同步状态得以恢复的方法[1].通过改善电机械同步,提高心衰患者的心脏功能,改善运动耐力及生活质量,降低住院率和死亡率.成为现代心衰、特别是难治性和重度心衰治疗的重要策略.但有20％～30％的患者在接受CRT治疗后,临床症状、超声指标、心衰住院率和死亡率无明显改善,即所谓CRT无应答[2].我院于2005年2月开展CRT(D)置入技术,成功完成8例心衰患者的心脏再同步化治疗.由于CRT(D)置入技术复杂,手术难度、风险和并发症高于普通起搏器置入术,故对护理工作提出了更高要求.现将CRT治疗心衰围手术期的护理体会介绍如下.     

心脏再同步化治疗扩张型心肌病伴心力衰竭的护理

总结10例扩张型心肌病伴心力衰竭患者植入三腔双心室起搏器行心脏再同步化治疗的护理。起搏器植入前做好心理评估及护理,完善准备,起搏器植入后严密监测起搏器功能,观察心功能状况,加强切口护理和随访管理。10例患者起搏器功能良好,心功能得到改善。     

慢性心力衰竭患者行心脏再同步化治疗的围术期护理

报告12例慢性心力衰竭患者行心脏再同步化治疗的围术期护理.术前做好心理护理,改善患者的心功能,以便更好地耐受手术.术中备好各种用物及抢救器材,严密观察并及时处理病情变化.术后严密进行心电监护,预防切口感染,注重体位护理,及时观察和处理并发症.本组12例均康复出院.随访1-6个月,心衰症状明显改善,活动度增加.     

Relationship of baseline electrocardiographic characteristics with the response to cardiac resynchronization therapy for heart failure

Prospective identification of patients most and least likely to respond to cardiac resynchronization therapy (CRT) for congestive heart failure (CHF) will allow clinicians to target this intervention most efficiently. The authors hypothesized that ECG variables including RBBB and indicators of RV dysfunction and extensive prior myocardial infarction would correlate with diminished response to CRT. This study analyzed preimplantation ECGs in 110 patients with ICD indications and CHF due to left ventricular systolic dysfunction randomized to active biventricular pacing in the MIRACLE ICD trial. Clinical and ECG variables on the outcome of change in peak oxygen consumption from baseline to 6 months (Delta-VO2 ) were evaluated. For this cohort, average peak VO2 improved from 13.4 to 14.3 mL/kg per minute. Among clinical variables, the strongest predictors of increasing Delta-VO2 were reduced exercise time and peak VO2 at baseline. A dominant R wave in lead a VR, RBBB, and evidence of prior anterior infarction were each associated with significantly smaller average improvements in Delta-VO2 than their absence in univariate analysis. Alternative ECG criteria, including QRS duration, had no relationship with the outcome. In a multivariate model, only baseline VO2 (beta=-0.3, P=0.001) and ECG evidence of prior anterior infarction (beta=-1.3, P=0.03) were associated with the outcome. ECG markers of anterior infarction and RV dilation may help identify CHF patients unlikely to benefit from biventricular pacing. Further assessment is needed of these and other predictors of therapeutic response to CRT.     

Assessing reverse remodeling in heart failure patients treated with cardiac resynchronization therapy and its impact on prognosis

Cardiac resynchronization therapy (CRT) has become an alternative for patients with systolic dysfunction and persistence of heart failure symptoms despite optimal medical therapy. The role of noninvasive cardiac imaging before device implantation still remains controversial, but they are essential to provide an objective evidence of reverse remodeling of the heart which is, in turn, also related to the outcome of patients treated with CRT. The objective of this review is to highlight the acute and long-term CRT benefits as assessed by imaging, with special focus in cardiac reverse remodeling and its impact on prognosis.     

Living with cardiac resynchronization therapy: Challenges for people with heart failure

The number of people with heart failure requiring implantation of a cardiac resynchronization device is increasing in Iran. Although this intervention is an effective life‐saving treatment, several challenges are associated with patients’ lifestyle after insertion. This study identified the challenges and coping mechanisms of Iranians with heart failure living with cardiac resynchronization therapy. A qualitative approach using conventional content analysis was adopted. Seventeen people with heart failure and three nurses were recruited between December 2014 and November 2015 from a teaching hospital and a private clinic in Rasht, Iran. Participants were interviewed using semi‐structured interviews lasting 30–60 min. Five themes emerged: (i) fear of implantation, (ii) the panic of receiving a shock from the device, (iii) lack of control over life, (iv) inadequacies of the healthcare system, and (v) psychosocial coping. A heightened understanding of these challenges and coping strategies could prepare healthcare professionals to provide better routine care, education, and support to the recipients of cardiac resynchronization therapy prior to implantation, during the recovery period, and for long‐term management.     

Cardiac resynchronization therapy: predictors of failure and strategies to overcome

Evaluation of: Macias A, Garcia-Bolao I, Diaz-Infante E et al. Cardiac resynchronization therapy: predictive factors of unsuccessful left ventricular lead implant. Eur. Heart J. 28, 450–456 (2007).

Congestive heart failure (CHF) is a leading cause of morbidity, mortality and hospitalization in the elderly of industrialized nations. In CHF patients with moderate-to-severe left ventricular systolic dysfunction and significant dyssynchrony, cardiac resynchronization therapy (CRT) has been shown to improve functional status and decrease heart failure mortality and hospitalizations. Inability to transvenously implant a lead within a desired branch of the coronary sinus for CRT occurs in 5–10% of cases. The article under evaluation identifies two independent predictors of failed transvenous left ventricular lead implantation – the presence of permanent atrial fibrillation and an increased anteroposterior left atrial diameter.     

QRS duration and shortening to predict clinical response to cardiac resynchronization therapy in patients with end-stage heart failure

Despite current selection criteria (NYHA Class III-IV, LVEF < 35%, QRS > 120 ms with LBBB), 30% of patients do not benefit from cardiac resynchronization therapy (CRT). The use of QRS duration as selection criteria for CRT has not been evaluated systematically yet. Accordingly, the value of QRS duration at baseline (and reduction in QRS duration after CRT) to predict responders was studied. Patients were evaluated at baseline and after 6 months of CRT for NYHA Class, quality of life score, and 6-minute walk test. QRS duration was evaluated before, directly after implantation, and after 6 months of CRT. Sixty-one patients were included; 45 (74%) patients were classified as responders (improvement of NYHA Class, 6-minute walking distance and quality of life score) and 16 (26%) as nonresponders. QRS duration at baseline was similar between the two groups: 179 +/- 30 ms versus 171 +/- 32 ms, NS. Directly after implantation, QRS duration was reduced from 179 +/- 30 ms to 150 +/- 26 ms (P < 0.01) in responders; nonresponders did not exhibit this reduction (171 +/- 32 ms vs 160 +/- 26 ms, NS). After 6 months of CRT, QRS shortening was only observed in responders (from 179 +/- 30 ms to 159 +/- 25 ms, P < 0.01). ROC curve analysis showed that a reduction in QRS duration > 10 ms had a high sensitivity (73%) with low specificity (44%); conversely, a > 50 ms reduction in QRS duration was highly specific (88%) but not sensitive (18%) to predict response to CRT. No optimal cutoff value could be defined. QRS duration at baseline is not predictive for response to CRT; responders exhibit a significant reduction in QRS duration after CRT, but individual response varies highly, not allowing adequate selection of responders.     

Rate-dependent AV delay optimization in cardiac resynchronization therapy

BACKGROUND: During cardiac resynchronization therapy (CRT), cardiac performance is dependent on an optimized atrioventricular delay (AVD). However, the optimal AVD at different heart rates has not been defined yet during CRT. METHOD: The effects of an increase in heart rate by pacing or physical exercise on optimal AVD were studied in 36 patients with biventricular pacemakers/defibrillators. The velocity time integral (VTI) in the left ventricular outflow tract (LVOT) was measured with pulsed Doppler either at three different paced heart rates in the supine position or in seated position before and after physical exercise. RESULTS: The baseline AVD was optimized to 99 +/- 19 ms in the supine and 84 +/- 22 ms in the seated position. When the heart rate was increased by DDD pacing, there was a positive linear relationship between an increase in heart rate, in AVD and in VTI (LVOT-VTI + 0.047 cm/s per 10 beats per minute (bpm) heart rate increase per 20 ms increase in AVD, P = 0.007). A similar but more pronounced relationship was found after physical exercise in the seated position (LVOT-VTI + 0.146 cm/s per 10 bpm heart rate increase per 20 ms increase of AVD, P = 0.013). This effect was observed in patients with and without AV block and mitral regurgitation. CONCLUSIONS: In conclusion, the systolic performance of the dilated ventricle, which depends on an elevated preload, is critically affected by the appropriate timing of the AVD during exercise. In contrast to normal pacemaker patients, in CRT the relatively short baseline AVD should be prolonged at increased heart rates. Further studies with other means of measuring exercise cardiac performance are needed to confirm these unexpected findings.     

超声对充血性心力衰竭患者再同步化治疗术后舒张功能改善的评价

目的 应用常规超声及组织多普勒成像技术(TDI)探讨充血性心力衰竭(CHF)患者再同步化治疗(CRT)后左室舒张功能变化.方法 CHF患者31例,以CRT术后6个月左室收缩末容积降低≥10％为标准分为CRT有反应组(16例)和CRT无反应组(13例).所有患者均于CRT术前1～3 d、术后6个月接受超声检查.彩色M型超声测量二尖瓣口舒张期血流播散速度(Vp),计算E/Vp;TDI测量二尖瓣环四个位点的舒张早期运动速度(e),计算E/e;测量左室12节段心肌收缩期达峰时间(Ts-SD)、12节段Ts最大差值(Ts-Dif).结果 与CRT术前比较,CRT有反应组12节段Ts-SD、Ts-Dif均显著缩短,Vp显著增高,二尖瓣环各位点及4个位点平均E/e、E/Vp显著降低,而CRT无反应组上述参数均无显著差异;CRT有反应组二尖瓣环4个位点平均E/e、E/Vp与左室12节段Ts-SD呈显著正相关.结论 CRT治疗有反应患者的左室舒张功能也得到改善,其机制可能与左室充盈压降低及左室松弛改善有关.     

心脏再同步化治疗适应证的变迁

心脏再同步化治疗(CRT)慢性心力衰竭已走过20个春秋,其疗效已得到充分的肯定.随着系列临床研究结果的揭晓,其适应证也不断发生改变.从1998年最早的Ⅱb(C)类适应证,逐步发展到Ⅰ(A)类适应证;从纽约心脏病协会(NYHA)心功能Ⅲ或Ⅳ级拓展到Ⅰ～Ⅱ级;从窦性心律患者发展到心房颤动患者.对起搏依赖的心力衰竭患者其适应证变化也很大,从Ⅱb类适应证进展到Ⅰ(B)适应证,并且对左心室射血分数(LVEF)降低没有严格限制,其目的是为了防止大量右心室起搏给心力衰竭患者带来的危害,使患者达到最大获益.然而在QRS时限及形态的掌握上更加严格.目前认为,对QRS时限≥150 ms及完全性左束支传导阻滞(LBBB)患者,CRT治疗的获益最大,已经否定了对窄QRS时限(＜120 ms)的疗效.我们相信随着循证医学证据的积累,CRT治疗的目标人群会更加明确和具体,CRT应答率会进一步提高.     

Integration of automatic intrathoracic fluid content measurement into clinical decision making in patients with congestive heart failure

Background: Hospitalizations due to decompensation are a frequent problem in treating patients with congestive heart failure (CHF). Continuous impedance measurement via implantable devices may detect pulmonary fluid accumulation due to worsening CHF. An acoustic alert might allow an earlier treatment of impending decompensation. An algorithm that implemented impedance measurement into clinical decision making in treating CHF patients was evaluated.
Methods: Forty-two CHF patients (ejection fraction: 27 ± 6%; New York Heart Association 2.9 ± 0.6) with cardiac resynchronization therapy and automatic impedance measurements were included. Upon an alert, a stepped therapy was initiated: category (1) overt decompensation, hospitalization; category (2) worsened CHF, increase of diuretics; category (3) no CHF worsening, brain natriuretic peptide (BNP) measurement, elevated BNP: increase of diuretics, normal BNP: no specific treatment.
Results: During 18 ± 4 months, 45 alerts were treated according to the algorithm. Eleven category 1 alerts led to hospitalization; 21 category 2 and 11 category 3 patients (elevated BNP) were treated conservatively. Two category 3 alerts (normal BNP) received no treatment.
Conclusions: Automatic impedance measurement can be integrated into CHF management. BNP measurement restricted to patients with alert but without clinical signs of worsened CHF may prevent premature therapy escalation.     

心脏再同步化治疗对慢性充血性心力衰竭患者左心室舒张功能的影响

目的应用超声心动图评价左心室舒张功能,探讨心脏再同步化治疗对左心室舒张功能的影响。方法对组织多普勒提示有左心室非同步的慢性充血性心力衰竭患者12例进行心脏再同步化治疗,起搏前和起搏后1周行超声心动图检查,测量左室射血分数、Tei指数,同时测量二尖瓣血流E、A峰,E/A,左室舒张充盈时间占心动周期的比例,E峰减速时间,肺静脉血流S波、D波,二尖瓣环Em/Am。根据以上参数将舒张功能减退分为3期,应用组织多普勒测量心室机械不同步,比较起搏前后各参数的变化。结果起搏前,11例患者E峰和A峰融合,形似单峰,无法测量E、A峰值及E峰减速时间,所有患者左室舒张充盈时间缩短。起搏后1周,所有患者E峰和A峰分离,5例患者为第2期的舒张功能降低,7例患者为第1期的舒张功能降低。左室舒张充盈时间占整个心动周期的比例由起搏前的(34.5±2.9)%提高到(46.4±5.7)%(P<0.01)。左室射血分数由起搏前的(26.8±7.6)%提高到(37.7±10.1)%。左房内径在起搏后1周明显缩小(P<0.05),左室收缩非同步指数由起搏前的179.2±48.3下降到103.4±58.2(P<0.05)。结论在充血性心力衰竭患者中,由于心脏收缩的不同步,二尖瓣血流E、A峰融合较为常见。心脏再同步化治疗后,左室舒张充盈改善,体现了左室舒张功能的改善。