心室三部位起搏心脏再同步化治疗

心脏再同步化治疗(CRT)已成为治疗中重度心力衰竭的有效治疗手段。近年发展起来的心室三部位起搏CRT(Tri-V CRT)通过同时刺激左右心室壁多个延迟激动位点,最终可使心脏再同步化达到最佳的效果。一系列小规模临床研究已证实了Tri-V CRT的可行性、有效性及安全性,但由于缺乏大规模的随机对照临床试验且该技术存在一定的缺陷,故目前仅将其作为对传统CRT无应答且室内或室间仍然存在运动失同步心力衰竭患者的补救治疗措施。     

心脏再同步化治疗无反应者的治疗——升级为左室双部位起搏(附二例报道)

目的研究左室双部位起搏对心脏再同步化治疗(CRT)无反应者左室心肌收缩同步性及心功能影响。方法 2例CRT无反应、仍然存在左室收缩不同步、持续性心房颤动的患者植入第二根左室电极,尽量选择与原左室导线和右室导线间隔较远的静脉分支,原心房导线埋置于原囊袋中,术前术中进行心脏超声检查,用以选择最佳的导线与起搏器联接顺序。结果左室双部位起搏能改善左室收缩同步性,术后即刻和短期随访发现心脏功能均有改善。结论对CRT无反应、仍然存在左室收缩不同步的心力衰竭患者,左室双部位起搏是可行的选择。     

左室起搏电极部位对心脏再同步化治疗疗效的影响

目的探讨左室起搏电极部位对心脏再同步化治疗(CRT)效果的影响。方法 121例慢性心功能不全患者接受CRT,其中93例将左室电极植入侧后静脉、侧静脉或后静脉(A组),另16例植入心中静脉(B组)、12例植入心大静脉(C组);所有患者术前及术后6个月行纽约心功能(NYHA)分级,常规心电图及超声心动图检查。结果 A组患者术后NYHA分级得到显著改善,QRS波时限变窄,左室射血分数显著提高,左室舒张末内径、左室收缩末内径显著缩小(P<0.01);B组患者超声心动图部分指标及QRS波时限显著改善,但其NYHA分级无显著改变;而C组患者术后各项指标均无显著改善(P>0.05)。结论 CRT时应尽可能将左室电极置于左室侧壁或侧后壁。     

左室不同起搏部位对心脏再同步化治疗短期疗效的影响

目的探讨左室不同起搏部位对心脏再同步化治疗(CRT/D)患者术后短期(1周及6个月)疗效的影响。方法入选成功行CRT/D手术,且相关观察数据完整患者共36例。分析术中左室电极植入情况,左室起搏部位根据左室电极末端左前斜45度时的投影结合其相应心脏静脉的部位确定,分为靠近间隔部组(A组)和游离壁组(B组)。比较两组患者术后1周常规心脏超声变化,随访6个月CRT/D临床应答及并发症情况。结果术后1周,两组的左室射血分数均较术前明显提高;与A组相比,B组对心脏功能的改善更为明显,左房内径、左室收缩末期容积、二尖瓣返流情况仅在B组有所改善。术后随访6个月,35例有应答,B组中1例无应答,两组术后6个月无应答和并发症的发生率均无明显差别。结论 CRT/D治疗慢性心力衰竭在短期内即可使患者获益。左室电极位于游离壁可以更好的改善心脏功能,逆转心室重构。     

心脏再同步化治疗中的左室起搏部位

不同的心力衰竭患者其心脏收缩延迟的部位常存在差别,行心脏再同步化治疗时,目前普遍认为左室电极植入侧壁或后壁更有利于血流动力学的改善和左室重构。但仍强调根据心脏超声结果个体化选择植入部位。影响左室电极导线植入位置的因素,除了患者自身的血管条件外,与术者的技术、膈神经刺激、瘢痕组织有关。     

心脏再同步化治疗患者左室起搏位点的选择

左室电极的位置是决定心脏再同步治疗反应性的一个重要因素。传统方法是将左室电极放置在左室侧壁或侧后壁,但这对具体某一位患者来讲可能不是最佳位置。有研究表明,将电极放置在左室收缩延迟部位并避开心肌瘢痕可能是减少无反应的一个重要方法。大约有4%~8%的患者不能通过静脉途径植入左室电极。此外,受冠状静脉解剖、电极稳定性、膈肌刺激等因素的限制,左室电极经常不能到达理想目标位置。心内膜起搏、多点起搏、无导线起搏等方法提供了更多选择,为进一步减少心脏再同步化治疗无反应提供了可能。     

心脏再同步化治疗充血性心力衰竭

选取10例慢性心力衰竭伴室内传导阻滞患者进行双心室再同步化治疗(CRT)。观察术后NYHA心功能分级、QRS时限、左室射血分数(LVEF)、左室舒张末内径(LVEDD)和6min步行试验的变化。结果:CRT后,患者心功能分级、QRS时限、LVEF、LVEDD和6min步行试验较术前明显增加,LVEF与6min步行试验呈正相关(P均<0.05)。结论:CRT可明显改善慢性心力衰竭伴心室内传导阻滞患者的临床症状,提高患者的生活质量。     

无需临床试验证明左束支起搏的心脏再同步化作用

左束支传导阻滞(LBBB)是导致心力衰竭(HF)重要的可逆性因素,上世纪90年代初从恢复心脏收缩再同步角度提出双心室起搏(CRT)的方法,大规模临床试验最终证实CRT有效并成为HF伴LBBB一线治疗。然而CRT不仅操作复杂价格昂贵,且30%患者术后无反应。近5年来,左束支起搏(LBBP)受到越来越多的关注,治疗后QRS波时限<130 ms,已不再是CRT的指征;LBBP与LBBB相比除极速率增加大约1.55倍;临床报道显示LBBP治疗安全有效。HF合并LBBB首先选择CRT还是LBBP治疗,常纠结于前者有大规模临床试验证据而后者无,仍坚持有待于“大规模临床试验验证”,这种观点无法使更多具有适应证患者得到及时有效治疗。LBBP从物理电学层面精准地起搏左束支并纠正了LBBB,其与CRT有本质的区别,无需大规模临床试验来证明其心脏再同步化疗效。     

单左室起搏实现心脏再同步化治疗对左房结构及功能的影响

目的探讨分析单左室起搏(LUVP)实现心脏再同步化治疗(CRT)对左房结构功能的影响。方法 30例接受CRT治疗的慢性心力衰竭(简称心衰)患者,根据起搏模式不同分成两组,其中15例为LUVP,15例为双心室起搏(BVP),收集30例患者CRT术前及术后1、3、6个月内心功能、十二导联心电图及超声心动图临床资料,比较两组NYHA心功能分级,QRS波时限,左房容积指数(LAVI),左房射血分数(LAEF),左室射血分数(LVEF),心室间机械延迟时间(IVMD),室间隔与左室后壁收缩期轴向应变达峰时间差(SPWMD),二尖瓣返流面积(MRA),左室舒张末期内径(LVEED)指标的术前及术后变化。结果与术前相比,LUVP组及BVP组术后6个月NYHA心功能分级降低,QRS波时限、IVMD、SPWMD、MRA、LAVI、LVEED较术前减小,LAEF及LVEF增加(P均<0.05)。与BVP组相比,LUVP组术后6个月QRS波时限缩短[(133.8±9.1) ms vs(141.3±8.4) ms,P<0.05],MRA减小[(1.9±1.0) cm~2 vs (3.0±1.0) cm~2,P<0.05]。结论慢性心衰患者左室及左房结构、功能在CRT术后得到明显改善;同时,在缩短QRS波时限、减小二尖瓣返流面积方面LUVP较BVP更有优势。     

右室双部位双心室同步起搏治疗心力衰竭一例

心房颤动伴Ⅲ度房室传导阻滞患者，接受VVI型人工心脏起搏器置入术后出现心力衰竭。在保留原起搏器及导线的情况下，新置入2根电极导线分别至右事，及左室侧后静脉，与DDD起搏器心室及心房接口连接，行右室双部位双室同步起搏，临床疗效可。     

右心房左心室起搏对充血性心力衰竭患者急性血流动力学影响的研究

充血性心力衰竭 (CHF)为器质性心脏病终末阶段 ,病死率高。近年来 ,国内外学者进行了双心室同步起搏治疗CHF的实验研究和初步的临床应用 ,并取得了良好效果。但双心室起搏治疗CHF的费用昂贵 ,严重阻碍了这项技术的发展。自 2 0 0 1年 1 2月以来 ,对 6例需植入DDD起搏器且有不同程度CHF的患者行右心房左心室起搏时的急性血流动力学进行了研究。资料和方法　 6例患者均为经严格选择需植入DDD起搏器且有不同程度CHF患者 ,男性 4例、女性 2例。年龄49～ 72 (60 2± 9 6)岁 ,其中病态窦房结综合征 (SSS) 4例 ,2例合并有完全性左束支阻…     

Clinical and procedural characteristics of acute hemodynamic responders undergoing triple-site ventricular pacing for advanced heart failure

The advantages of triple-site ventricular pacing (Tri-V) compared to conventional biventricular site pacing (Bi-V) have been reported. We sought to identify the predictors of acute hemodynamic Tri-V responders. Acute hemodynamic studies were performed in 32 patients with advanced heart failure during Tri-V implantation. After the right ventricular (RV) and left ventricular (LV) leads were implanted for a conventional Bi-V system, an additional pacing lead was implanted in the RV outflow tract for Tri-V. The LV peak +dP/dt and tau were measured during AAI, Bi-V, and Tri-V pacing. A Tri-V responder was defined as a patient whose percentage of increase in the peak +dP/dt during Tri-V was >10% compared to of that during Bi-V. The baseline clinical variables and RV outflow tract lead location were analyzed to identify the characteristics of the Tri-V responders. Of the 32 patients, 10 (31%) were classified as Tri-V responders. The LV end-diastolic volume was greater (246 ± 48 vs 173 ± 53 ml, p <0.01), and the RV outflow tract lead was implanted at a greater outflow tract portion (p <0.05) in the Tri-V responders. Multivariate analysis revealed that only the baseline LV end-diastolic volume (per 50-ml greater) predicted the Tri-V response (odds ratio 2.87, 95% confidence interval 1.03 to 8.00, p <0.05). The area under the receiver operating characteristic curve for the LV end-diastolic volume was 0.84 (p <0.01) and an LV end-diastolic volume of >212 ml had a sensitivity of 80% and specificity of 77% to distinguish Tri-V responders. In conclusion, Tri-V provides greater hemodynamic effect for patients with a larger LV end-diastolic volume owing to its resynchronization effects on the LV anterior wall.     

心室再同步起搏治疗慢性心力衰竭的长期疗效分析

目的:观察心室再同步(CRT)起搏治疗慢性心力衰竭(CHF)的长期疗效及病死率.方法:49例CHF患者中,男40例,女9例,年龄31～82(56.3±11.0)岁.均有严重器质性心脏病,心功能(NYHA分级)Ⅲ～Ⅳ级,其中扩张型心肌病36例,缺血性心肌病9例,高血压性心脏病4例.所有患者心电图为窦性心律,ORS波>130 ms,左室舒张末期内径(LVEDD)>60 mm,左室射血分数(LVEF)<35%伴二尖瓣反流.49例中置入CRT40例,置入CRT心脏复律除颤器(CRT-D)9例.观察患者起搏器置入前,置入后1、3、6、12、24、36、48、60个月的心功能各项参数、生活质量(QOL)评分以及术后并发症、病死率与心血管事件.随访12～87(25.5±15.6)个月.结果:①并发症:电极脱位4例,囊袋出血2例;②病死率及死因:死亡15例(30.6%),其中CHF恶化死亡7例,心性猝死6例,非心源性死亡2例,49例患者中12例(24.5%)21次发生室性心动过速(VT)/心室颤动(Vf),其中3例CRT-D患者发生12次VT/Vf均被CRT-D成功纠治,3例CRT患者各发生1次VT/Vf经体外除颤纠治,6例CRT患者各因发生1次VT/Vf死亡;③心功能变化及QOL评分:37例(75.5%)患者LVEF、6 min步行距离、心功能NYHA分级等心功能评价指标术后持续改善,11例(22.4%)患者心功能评价指标术后改善后再次恶化,1例无明显变化;49例患者QOL评分均较术前提高,LVEDD术后12个月明显缩小.结论:CRT治疗CHF能明显改善患者心功能,提高生活质量、6 min步行距离、LVEF,缩小LVEDD,逆转左室重构;长期治疗,疗效巩固并能降低CHF导致的病死率,CRT-D可同时防治CHF及猝死事件的发生.     

Long-term left ventricular pacing: assessment and comparison with biventricular pacing in patients with severe congestive heart failure

OBJECTIVE

The purpose of this study is to report prospectively the results of six-month follow-up of permanent left ventricular (LV) based pacing in patients with severe congestive heart failure (CHF) and left bundle branch block (LBBB).

BACKGROUND

Left ventricular pacing alone has been demonstrated to result in identical improvement compared to biventricular pacing (BiV) during acute hemodynamic evaluation in patients with advanced CHF and LBBB. However, to our knowledge, the clinical outcome during permanent LV pacing alone versus BiV pacing mode has not been evaluated.

METHODS

Pacing configuration (LV or BiV) was selected according to the physician’s preference. Patient evaluation was performed at baseline and at six months.

RESULTS

Thirty-three patients with advanced CHF and LBBB were included. Baseline characteristics of LV (18 patients) and BiV (15 patients) pacing groups were similar. During the six-month follow-up period, seven patients died three BiV and four LV). In the surviving patients at 6 months, 8 of 14 patients in the LV group and 9 of 12 in the BiV group were in New York Heart Association class I or II (p = 0.39). No significant difference was observed between the two groups in terms of objective parameters except for LV end-diastolic diameter decrease (−4.4 mm in BiV group vs. −0.7 mm in LV group; P = 0.04).

CONCLUSION

At six-month follow-up, a trend toward improvement was observed in objective parameters in patients with severe CHF and LBBB following LV-based pacing. The two pacing modes (LV and BiV) were associated with almost equivalent improvement of subjective and objective parameters.     

Evaluation of left ventricular based pacing in patients with congestive heart failure and atrial fibrillation

Acute hemodynamic data of left ventricular based pacing were assessed in 2 groups of patients with severe cardiac failure: 11 patients with atrial fibrillation and 17 patients with sinus rhythm. Both biventricular and left ventricular pacing significantly improved acute hemodynamic findings to a similar degree in both groups, suggesting that left ventricular based pacing may be beneficial in patients with severe cardiac failure regardless of whether or not they are in sinus rhythm.     

双心室再同步起搏治疗宽QRS慢性心力衰竭患者的长期疗效及病死率分析

目的观察双心室同步起搏治疗慢性心力衰竭(心衰)患者的长期疗效及死亡率.方法 2001年3月至2005年2月住院患者25例,男18例,女7例,年龄34～75(61.42±10.36)岁;其中扩张性心肌病16例,高血压性心脏病3例,缺血性心肌病6例,心功能NYHA分级Ⅲ级10例、Ⅳ级15例.所有患者左室舒张末期内径(LVEDD)>60 mm,左室射血分数(LVEF)<0.40,QRS>130 ms.观察术前及术后3个月、6个月、1年、2年、3年的心功能各项参数及死亡率,平均随访时间为(20.88±11.51)个月.结果 (1)死亡率死亡5例,非心原性死亡3例,心原性猝死1例,急性心肌梗死1例.(2)术后3个月至3年,平均6 min步行距离明显增加(P<0.01).(3)NYHA心功能分级,术后3个月至3年,心功能明显改善(P<0.01),平均心功能降低1级以上.(4)LVEDD术后3个月至3年,LVEDD明显减小(P<0.05～P<0.01).(5)LVEF术后3个月至2年,LVEF明显增加(P<0.05～P<0.01);术后第3年 ,LVEF也改善,但差异无统计学意义.结论双心室同步起搏治疗宽QRS慢性心衰能明显改善患者的生活质量及心功能,减少LVEDD,逆转左室重构,长期治疗疗效巩固,并能降低心衰导致的病死率.     

双心室起搏治疗充血性心力衰竭的临床疗效

目的 :观察双室起搏治疗充血性心力衰竭 （CHF）的血流动力学及临床效果。方法 :CHF伴室内传导阻滞患者11例均植入双室起搏器 ,左室电极导线经冠状静脉窦插入抵达侧或后侧静脉 ,以达到左室起搏夺获。手术前、后应用 Swan- Ganz漂浮导管及超声心动图检查 ,观察双室起搏的血流动力学及临床效果。结果 :所有病例植入双心室起搏后临床症状改善 ,活动耐量增加。心输出量、心脏指数、射血分数均较术前明显改善。肺毛细血管嵌顿压下降 ,二尖瓣返流面积减少 ,治疗 3月后左心室舒张末期直径由 75± 8m m下降至 6 8± 6 m m（P<0 .0 5 ）。结论 :双心室起搏治疗 CHF伴心室内传导阻滞患者 ,可明显缓解临床症状 ,逆转左心室重塑 ,改善心功能。     

Right ventricular outflow versus apical pacing in pacemaker patients with congestive heart failure and atrial fibrillation

INTRODUCTION: Prior studies suggest that right ventricular apical (RVA) pacing has deleterious effects. Whether the right ventricular outflow tract (RVOT) is a more optimal site for permanent pacing in patients with congestive heart failure (CHF) has not been established. METHODS AND RESULTS: We conducted a randomized, cross-over trial to determine whether quality of life (QOL) is better after 3 months of RVOT than RVA pacing in 103 pacemaker recipients with CHF, left ventricular (LV) systolic dysfunction (LV ejection fraction < or = 40%), and chronic atrial fibrillation (AF). An additional aim was to compare dual-site (RVOT + RVA, 31-ms delay) with single-site RVA and RVOT pacing. QRS duration was shorter during RVOT (167 +/- 45 ms) and dual-site (149 +/- 19 ms) than RVA pacing (180 +/- 58 ms, P < 0.0001). At 6 months, the RVOT group had higher (P = 0.01) role-emotional QOL subscale scores than the RVA group. At 9 months, there were no significant differences in QOL scores between RVOT and RVA groups. Comparing RVOT to RVA pacing within the same patient, mental health subscale scores were better (P = 0.03) during RVOT pacing. After 9 months of follow-up, LVEF was higher (P = 0.04) in those assigned to RVA rather than RVOT pacing between months 6 and 9. After 3 months of dual-site RV pacing, physical functioning was worse (P = 0.04) than during RVA pacing, mental health was worse (P = 0.02) than during RVOT pacing, and New York Heart Association (NYHA) functional class was slightly better (P = 0.03) than during RVOT pacing. There were no other significant differences between RVA, RVOT and dual-site RV pacing in QOL scores, NYHA class, distance walked in 6 minutes, LV ejection fraction, or mitral regurgitation. CONCLUSION: In patients with CHF, LV dysfunction, and chronic AF, RVOT and dual-site RV pacing shorten QRS duration but after 3 months do not consistently improve QOL or other clinical outcomes compared with RVA pacing.     

Transoesophageal left ventricular pacing in heart failure patients with permanent right ventricular pacing.

BACKGROUND: Previous studies of biventricular (BV) pacing for treatment of heart failure (HF) patients with left bundle branch block (LBBB) evaluated responders to BV pacing with acute transvenous left ventricular (LV) pacing and arterial pulse pressure (PP). The aim of this study was to assess transoesophageal LV pacing in evaluation of the haemodynamic response with a view to upgrading responders from permanent right ventricular (RV) pacing to BV pacing. METHODS AND RESULTS: Ten HF patients (age 62+/-8 years; one female, nine males) in NYHA III, LV ejection fraction 24+/-9% and permanent RV pacing by means of an implanted pacemaker or ICD were tested using transoesophageal LV pacing and PP. Permanently RV-paced HF patients were analysed with transoesophageal atrial sensed LV pacing in VAT mode with a different AV delay (n = 6) and with transoesophageal LV pacing in V00 mode during atrial fibrillation (n = 4). In five responders, PP was higher during transoesophageal LV pacing than PP during RV pacing (74+/-42 versus 57+/-31 mmHg, P = 0.015). Responders were upgraded by means of an LV lead via the coronary sinus in the posterior (n = 1) or posterolateral (n = 4) walls and after attaining a high LV pacing threshold with an epicardial LV lead on the anterior (n = 1) or anterolateral (n = 1) walls. NYHA class improved from 3 to 2+/-0.3 (P = 0.003) during 204+/-120 days follow-up and cardiac output increased from 4.4+/-1.5 to 5.6+/-1.7 l/min (P = 0.027) when comparing BV pacing and optimal AV delay with RV pacing. In five nonresponders, PP was not higher during transoesophageal LV pacing than during RV pacing. CONCLUSION: Transoesophageal LV pacing may be a useful technique to detect responders to BV pacing in permanently RV-paced HF patients.