微创胸腔镜心外膜电极技术和冠状静脉窦电极技术进行心脏再同步治疗的比较研究

目的 探讨微创胸腔镜心外膜电极导线技术和冠状静脉窦电极导线技术完成心脏再同步治疗(CRT)的效果.方法 回顾性总结北京安贞医院2007年4月至2009年6月的28例进行CRT治疗的心肌病心力衰竭的病例资料.治疗前所有患者均经心电图和超声心动图明确诊断心力衰竭伴心脏不同步.所有患者右心房和右心室电极导线均在X线引导下植入,左心室电极导线植入中,10例采用微创胸腔镜心外膜电极导线技术(组1),其中有3例因为冠状静脉窦电极无法植入而转入外科.18例采用冠状静脉窦电极导线技术(组2).组1患者在术中经食管超声心动图监测下测试左心室侧壁不同位置,寻找同步效果最理想的位置,并使用无损伤缝线固定左心室心外膜电极.围术期和随访5～24个月监测心脏结构、功能和同步效果.结果 所有患者术中电极导线放置顺利.组1患者术后顺利拔除气管插管,除1例发生肺炎外无明显并发症.2组患者术后均临床症状改善顺利出院.随访结果显示:组1左心室最大收缩延迟时间由术前(390.7±42.1)ms缩短为(135.7±37.2)ms,左心室不同步指数(Ts-SD)由术前的(143.7±30.1)ms降为(50.3±22.3)ms,心室间机械延迟(IVMD)由术前(57.7±24.9)ms降为(27.0±10.8)ms.左心室射血分数(LVEF)由术前0.320±0.007升到0.400±0.006,左心室舒张末内径(LVEDD)由术前(71.3±12.8)mm降低为(62.3±6.5)mm.组2结果显示:左心室最大收缩延迟时间由术前(396.7±36.1)ms缩短为(293.7±119.2)ms,Ts-SD由术前的(147.7±22.1)ms降为(96.3±34.3)ms,IVMD由术前(59.7±35.9)ms降为(27.0±25.8)ms.LVEF由术前0.281±0.077升到0.330±0.076,LVEDD由术前(71.3±9.8)mm降为(67.3±9.5)mm.其中组1在改善左心室最大收缩延迟时间和Ts-SD方面优于组2,差异有统计学意义(P＜0.05).结论 两种同步治疗技术均可以获得较好的心力衰竭治疗效果,其中微创胸腔镜心外膜电极技术完成心力衰竭CRT治疗对于非严重心功能不良者安全可行,而且由于心外膜电极导线在左心室侧后壁位置的良好选择性,使其可以更好地纠正左心室内部的不同步运动.     

微创胸腔镜心外膜电极技术和冠状静脉窦电极技术进行心脏再同步治疗的比较研究

Objective To compare the minimally invasive surgical implantation of left ventricular epicardial electrode technique and coronary vein sinus endocardial electrode technique for cardiac resynchronization therapy(CRT) in cardiomyopathy heart failure. Methods During April 2007 to May 2009 total 28 patients were diagnosed as advanced heart failure with cardiac dysynchronization through ECG and Tissue Doppler Echos. Ten received surgical epicardial electrode implantation ( group 1 ) and 18 received coronary sinus electrode implantation ( group 2). For the group 1 patients, the electrodes were placed in right atrial and ventricle guided by X ray under the general anesthesia. The right atrial and ventricle electrodes were connected with the three chamber pacemaker. The Tissue Doppler Echo TEE technique was used to search suitable left ventricle place for the ideal CRT therapy. Then the epicardial electrode was fixed at the ideal place. The resynchronization features were examined after surgery during the follow of 5 ～ 24 months. Results The endocardial and epicardial electrodes were implanted successfully without any serious complication in group 1 patients. All patients were discharged without any adverse cardiac episodes. For the group 1 patients during the 5 ～ 24 months follow-up the left ventricle maximize delay time decreased from ( 390. 7 ± 42.1) ms to ( 135.7 ± 37.2 ) ms, the left dysynchronization index (Ts-SD) decreased from ( 143.7 ±30. 1 ) ms to (50. 3 ±22. 3) ms,the inter-ventricle mechanical delay time (IVMD) decreased from (57.7 ±24. 9) ms to (27.0 ± 10. 8) ms,left ventricle end-dilation diameters (LVEDD) increased from (71.3 ± 12. 8) mm to (62. 3 ±6. 5) mm and the left ventricle ejection fraction (LVEF) increased from 0. 320 ±0. 007 to 0. 400 ±0. 006. For the group 2 patients during the follow up period the left ventricle maximize delay time decreased from (396. 7 ± 36. 1 ) ms to (293.7 ± 119. 2)ms,Ts-SD decreased from ( 147.7 ± 22. 1 ) ms to (96. 3 ± 34.3) ms,IVMD decreased from ( 59.7 ± 35.9 ) ms to (27.0±25.8) ms,LVEDD increased from (71.3 ±9.8) mm to (67.3 ±9.5) mm and LVEF increased from 0. 281 ±0. 077 to 0. 330 ±0. 076. The left ventricle resynchronization results were better in the group 1 cases. Conclusion Cardiac resynchronization results were good in both groups and the surgical epicardial therapy could improve the left ventricle resynchronization.     

微创胸腔镜心外膜电极同步化技术治疗心肌病心力衰竭十例

目的探讨微创胸腔镜心外膜电极技术完成心力衰竭(简称心衰)同步化治疗的效果。方法 10例心肌病心衰患者经心电图和组织多普勒技术明确诊断心衰伴心脏不同步运动。患者在全麻双腔气管插管放射线引导下行左锁骨下静脉穿刺放置右房和右室心内膜电极。然后利用微创胸腔镜和心外膜电极技术,在术中组织多普勒食管监测下测试左室侧壁不同位置,寻找同步化效果最理想的位置,并使用无损伤缝线固定左室心外膜电极。围术期监测心脏结构、功能和同步化效果。结果所有患者术中电极放置顺利,一般心外膜电极尝试贴附3～4次可以找到合适的位置,位置均在左室的侧后面。右房和右室电极起搏阈值为0.5～0.8V,左室心外膜电极阈值为0.5～1.5V,术后顺利拔除气管插管。除1例发生肺炎外,无膈肌刺激、电极脱位等并发症。术后临床症状改善顺利出院。术后随访3～24个月,左室最大收缩延迟时间缩短,左室不同步指数降低,心室间机械延迟。左室射血分数升高,左室舒张末径降低(P均0.05)。结论应用微创胸腔镜心外膜电极技术完成心衰同步化治疗安全可行,可获得良好的同步化效果。     

植入心外膜电极心脏再同步化治疗一例

38岁男性,诊断为扩张型心肌病,左室射血分数0.24;心电图示完全左束支传导阻滞,QRS波时限180 m s;最佳药物治疗基础上心功能NYHA仍为Ⅲ级。逆行冠状静脉窦造影示冠状静脉窦中远段狭窄和扭曲,左室电极无法通过,随后心外科医生在全麻下植入心外膜电极。术后即刻血流动力学和6个月临床随访效果满意。     

心外膜电极导线在心脏再同步化治疗中的应用

随着心脏再同步化治疗(cardiac resynchronization therapy,CRT)治疗的广泛开展,应用心外膜电极导线起搏左心室逐渐增多。现介绍这方面的相关问题。     

无鞘置入冠状静脉窦-左心室电极导线在心脏再同步治疗中的应用

慢性心力衰竭（心衰）是心内科治疗学上的难题,具有较高的患病率和病死率。我国35～74岁人群中约有心衰患者400万人,其5年病死率可达30％～50％。与此同时,因心衰引起的医疗花费相当巨大。尽管药物治疗取得很大进展,     

心外膜电极导线在心脏再同步左室起搏中的应用(附二例报道)

目的报道2例心外膜电极导线在心脏再同步治疗(CRT)左室起搏中的应用及结果。方法2例均因心脏靶静脉解剖结构问题不能经心脏静脉途径置入左室电极,其中1例为右室双部位(心尖部+流出道间隔)起搏3个月后无效的患者。全麻后气管插管,在左第4肋间腋前线处切口,进胸后切开心包,用缝线将心外膜电极固定于左室侧后下壁,通过皮瓣下隧道把左室电极送入囊袋并与脉冲发生起搏器左室孔相联。结果2例手术顺利,无并发症。术后左室同步性明显好转,射血分数增加,心功能改善。结论心外膜导线在CRT左室起搏中的应用是安全、可行的,术后短期随访可获得良好的临床疗效。     

左室心外膜电极导线在心脏再同步化除颤器治疗中的应用一例

患者男性,68岁,因"反复劳力性胸闷、气促10年"入院,诊断为冠心病、陈旧性心肌梗死、缺血性心肌病,心功能Ⅲ～IV级。24h动态心电图检查为室性早搏、非持续性室性心动过速。心电图检查示完全性左束支传导阻滞。入院后给予规范化药物治疗后行心脏再同步化起搏除颤器(CRT-D)植入术,首次经静脉左室电极导线植入失败后改经心外膜途径行左室心外膜电极导线植入,并最终完成了CRT-D植入术。术后随访1年,患者活动能力明显增强,心功能和心脏超声检查各项参数明显改善,提示经心外膜途径植入左室电极导线是经静脉途径左室电极导线植入失败时的可靠选择。     

心外膜起搏导线在心脏再同步治疗中的临床应用

心脏再同步治疗（CRT）药物难治性扩张性心肌病心力衰竭临床疗效已得到肯定,不仅可以改善临床症状,而且可明显降低病死率.但经心脏静脉左心室导线的植入亦存在着一定的脱位率（发生率6%～14%）、慢性阈值增高（发生率13%～18%）及由于先天或后天的各种原因造成心脏静脉左心室导线植入失败（发生率10%～30%）.     

心脏再同步治疗冠状静脉窦夹层的原因探讨

心脏再同步治疗（CRT）能够有效地改善药物治疗无效的心力衰竭患耆和心事传导和／或室内传导异常患者的心脏功能和症状。CRT早在2005年已经被欧洲心脏病协会列入心力衰竭伴心室收缩不同步患者I类适应汪,证据级别为A级。     

Middle-term stability of epicardial left ventricular electrodes for cardiac resynchronization therapy

IntroductionCardiac resynchronization therapy (CRT) is currently considered an effective and safe way to treat patients with severe heart failure. Unsuccessful attempts at endovascular insertion of the left ventricular (LV) electrode should prompt a consideration of having the electrode implanted by a cardiac surgeon.AimsThe aims of our work were to evaluate the electric parameters of CS-implanted LV electrodes and to compare them with transvenous implanted electrodes, identify the causes of endovascular implantation failure, compare the clinical and echocardiographic resynchronization effects, and compare the safety of both approaches.Methods and resultsPatients indicated for CRT had the LV electrode implanted either endovascularly (“endo” group) or epicardially (“epi” group; in cases of endovascular approach failure or as a part of another CS procedure). The trial was planned as a case–control study. Each group comprised 92 patients (26 females, 66 males) with an average age of 69 (epi) and 68 (endo) years, respectively. LV stimulation was effective at the 3-year follow-up in 98.1% of patients in the epi group and in 96.6% of patients in the endo group (p = NS). The groups were comparable with respect to the stimulation threshold both before discharge and at the 3-year follow-up. At the 1-month follow-up, this threshold was significantly higher in the epi group (1.62 V vs. 1.06 V, p < 0.001) and the same was true for the 1-year and 2-year follow-ups (1.57 V vs. 1.09 V and 1.54 V vs. 1.21 V, respectively; p < 0.001). Energetic output during LV stimulation was significantly higher in the epi group at all time points. The overall procedural effectiveness of endovascular implantation was 94.6%. Clinical response to CRT was noted in 71.4% of epi group patients and in 68.1% of endo group patients (p = NS). The average absolute increase in LV ejection fraction was comparable in both groups (6.0% vs. 7.2%, p = NS). Significantly higher 1- and 3-year mortality was noted in the epi group (19.0% vs. 5.5% and 21.7% vs. 6.5%, respectively; p < 0.001).ConclusionEpicardial electrodes are capable of effective LV stimulation, as shown during middle-term follow-up. Epicardial LV stimulation is more demanding energetically. Resynchronization effects are similar in patients with epicardial and endocardial LV electrodes; however, the mortality of patients with epicardial LV electrodes seems to be significantly higher.     

心力衰竭再同步治疗中小切口心外膜左心室电极置入的补救技术

目的 探讨小切口心外膜左心室电极置入行心脏再同步化治疗.方法 6例心力衰竭患者拟行心脏再同步化治疗,冠状窦途径失败后采用小切口心外膜置入左心室电极,同时经静脉置入右心房、右心室电极.术后随访1年,评价心功能和左心室电极参数.结果 经小切口心外膜途径,所有患者均成功将左心室电极置入到理想部位.无术中并发症,无住院期间死亡,无膈肌刺激征.术中,左心室起搏阈值为(1.2±0.5)V;术后12个月,左心室起搏阈值为(1.1±0.4)V.12个月随访时,6 min步行[(327±77)m比(267±68)m,P=0.001]明显增加,纽约心功能分级明显改善,左室射血分数明显增加[(26.1±6.0)%比(38.2±4.7)%,P:0.004],左心室舒张末期内径明显减少[(72.2±6.8)mnl比(84.1±7.2)mm,P=0.001].结论 小切口心外膜置入左心室电极安全、有效,可以作为经冠状窦途径置人失败患者的替代治疗.     

Totally epicardial cardiac resynchronization therapy system implantation in patients with heart failure undergoing CABG

BACKGROUND: Systolic dyssynchrony is present in a considerable number of patients with heart failure (HF) undergoing coronary artery bypass grafting (CABG). Surgical revascularization offers an optimal setting for totally epicardial cardiac resynchronization therapy (CRT) system implantation. AIM: To assess the efficacy of totally epicardial CRT implantation during CABG, in patients with HF. METHODS: Twenty three patients with HF and dyssynchrony underwent totally epicardial CRT system implantation during CABG. This randomised, single-blind, cross-over study compared clinical and echocardiographic parameters during two periods: 3 months of active CRT (CRT+) and 3 months of inactive CRT (CRT-) pacing. RESULTS: Twenty two patients underwent randomisation and completed both study periods. In the CRT+ group more patients improved by two NYHA classes (p=0.028), had a longer 6-minute walk test distance (p=0.047) and better quality of life (p=0.003) compared with the CRT- group. Echocardiography revealed an improved LV ejection fraction (p<0.001), smaller LV end-systolic volume (p=0.04), reduced mitral regurgitation (p=0.026) and improved LV synchrony in the CRT+ group compared with the CRT- group. CONCLUSION: CRT delivered by a totally epicardial system implanted during CABG is associated with additional improvement of clinical and echocardiographic parameters in patients with HF and systolic dyssynchrony.     

心脏再同步治疗慢性心力衰竭患者细胞因子浓度变化及其与左室射血分数的关系

目的探讨心脏再同步治疗（CRT）1个月、3个月对慢性心力衰竭患者血清细胞因子水平的影响及其与左室射血分数（LVEF）的关系。方法入选心功能Ⅲ～Ⅳ级的患者30例,分为CRT组15例,对照组15例。两组于治疗前、治疗后1个月及3个月分别测定肿瘤坏死因子-α（TNF-α）和白细胞介素-6（IL-6）浓度,超声测量LVEF。结果CRT组治疗3个月后TNF-α、IL-6浓度与治疗前相比明显下降。治疗后1个月及3个月,CRT组LVEF均较治疗前明显改善。细胞因子（TNF-α、IL-6）浓度与LVEF呈显著负相关。结论CRT治疗3个月后心功能改善的同时细胞因子浓度降低,提示血清TNF-α、IL-6浓度可作为慢性心力衰竭患者心功能的预测指标。     

慢性心力衰竭患者心脏再同步治疗疗效观察

目的随访慢性心力衰竭患者心脏再同步治疗（CRT）的临床疗效。方法入选1999年至2008年行CRT的慢性心力衰竭患者,收集这些患者基线和最后一次临床资料。采集数据包括临床心功能评估,心脏超声学指标和体表心电图QRS时限宽度。结果95例患者行CRT治疗,分为早期组和近期组。早期组随访时间（57±17）个月,随访生存率为66．6％;近期组随访时间（18±10）个月,生存率为89．1％。两组患者CRT治疗后心功能显著提高,但自身状态下体表心电图QRS时限宽度变化差异无统计学意义。随访中患者药物治疗变化明显。结论中长期和短期随访均证实CRT治疗在一部分慢性心力衰竭患者中能提高心功能,但缺乏预测疗效的敏感指标。     

Cardiac resynchronization therapy in heart failure patients with less severe left ventricular dysfunction

Cardiac resynchronization therapy is beneficial in heart failure patients with LVEF ≤35% and electrical dyssynchrony. However, its effects among patients with less severe LV dysfunction have not been established. Recent post‐hoc analyses of landmark CRT trials suggest that CRT benefit may be present in patients with LVEF >35% and is associated with improvement in cardiac reverse remodelling, all‐cause mortality, and need for heart failure hospitalizations. This review summarizes the currently available literature regarding the potential impact of CRT in patients with more modest reductions in LVEF.     

Comparative effects of ventricular resynchronization therapy in heart failure patients with or without coronary artery disease

In patients with advanced heart failure, intraventricular conduction delay (IVCD) and left ventricular systolic dysfunction (LVSD), multisite cardiac pacing can be proposed as an additive treatment. The aim of this study was to assess the clinical effectiveness of atrioventricular pacing according to the etiology of LVSD, by comparing the outcome of patients with and without coronary artery disease. Between August 1997 and November 1998, 103 patients were included in the InSync trial and received a biventricular pacemaker and a specifically designed left ventricular pacing lead. Baseline evaluation (12 lead ECG, New York Heart Association Class, quality of life (QOL) and distance walked during the 6 min walk test) was repeated in survival patients at 1, 3, 6 and 12 months after pacemaker implantation. Patients were split in two groups, ischemic (N = 48) and non-ischemic (N = 55), according the result of a recent coronary angiography, the existence of coronary angioplasty or coronary artery bypass or the history of a prior myocardial infarction. RESULTS: The mortality rate was similar in the two groups with a mean 12 months actuarial survival rate of 78%. Nevertheless, the delay between the death and the pacemaker implantation was significantly higher in the non-ischemic group. A significant reduction in QRS duration and a significant improvement in NYHA class (-1.5). QOL score (-50%) and 6 min walking test (+18%) were observed similarly in the two groups. CONCLUSION: This study shows that biventricular pacing improves significantly functional status of patients with LVSD, IVCD and advanced heart failure, regardless the etiology of the cardiomyopathy, ischemic or not, without over-mortality in ischemic patients.