心电图在CRT治疗VV间期优化中的应用

目的比较心脏再同步治疗(CRT)VV间期的超声心动图优化方法与心电图优化方法的相关性。方法入选36例CRT植入术后大于3个月的病例,选择左室领先30ms、双室同步、右室领先30ms、60ms5种VV间期,用超声心动图VTI替代每搏输出量,并设立相应VV间期为最佳VV间期。两种心电图优化方法同时进行。第1种为QRS波时限法:描记出最窄QRS波为最佳VV间期。第2种为心室间激动延迟法:即分别在胸前导联(最好V1或V2导联)记录从起搏信号到QRS波形态最早出现变化的间期,仅左室起搏时所获得的间期记为T1,仅右室起搏时获得的间期记为T2。T2-T1代表最佳VV间期。结果超声优化的最佳VV间期左室领先为负值,左室与在后第1种心电图优化方法与VTI符合率64%(r=0.61,p<0.01);第2种心电图优化方法符合率为86%(r=0.82,p<0.001);联合上述两种心电图方法,其符合率达92%(r=0.90,p<0.0001)结论 CRT的VV间期优化中,与超声心动图优化对比,联合两种心电图方法其相关性最高。     

定期超声心动图引导下AV及VV间期优化在心脏再同步治疗中的长期疗效观察

目的 探讨定期超声心动图引导下优化AV及VV间期在长期心脏再同步治疗(CRT)中的临床价值.方法 回顾分析2002年6月至2012年10月新疆医科大学第一附属医院心脏中心成功植入CRT或心脏再同步治疗除颤器(CRT-D)的慢性心力衰竭患者108例.根据AV及W间期优化频率分为定期系统优化组(n=35)及非定期系统优化组(n=73).经过长期随访比较2组患者长期疗效.非致命心血管事件或因心力衰竭进展死亡为主要终点事件,左心房内径(LAD)、左心室舒张末期内径(LVEDD)、左心室收缩末期内径(LVESD)、左心室射血分数(LVEF)作为次要终点事件.结果 2组患者基线特征、随访时间(P=0.122)及应答率(P=0.524)差异无统计学意义.定期系统优化组非致命性心血管事件或因心力衰竭进展死亡较未定期优化组发生率更低(P=0.035).多因素Cox分析中,未定期系统优化显著提高患者非致命性心血管事件或因心力衰竭进展死亡发生风险(风险比3.192,95％ CI l.536 ～5.176,P=0.012).定期系统优化显著提高患者心功能(NYHA分级,P＜0.001),生存质量评分(P=0.001)及6min步行试验(6-MWT,P=0.002).此外定期系统优化组LAD较未定期优化组显著缩小(P=0.009),LVEF(P=0.039)显著提高.结论 定期超声心动图引导下AV及VV间期优化能够提高CRT长期疗效.     

肺心病右心室肥厚128例心电图与超声心动图对比观察

1999年10月～2003年10月笔者对确诊的128例肺心病人进行了心电图与超声心动图对照检查，以观察和比较两项检查对肺心病早期右室肥厚诊断的敏感性。现将结果报告如下。     

宽QRS与超声心动图心室结构改变的关系

心脏再同步治疗作为治疗心力衰竭一种手段,效果是肯定的。但是,仍有近1/3的病人不能从中获益。如何早期、准确及可靠的判断心脏的同步性成为心脏再同步治疗的前提。传统观点认为电机械不同步是其主要指标,但越来越多的实验数据提示机械不同步在此方面更显优越性。其主要包括了三个方面的内容：宽QRS在单独判断心脏不同步的局限性,超声心动图判断心脏不同步的新旧方法以及宽QRS与心脏结构改变关系。     

58例肺心病右心室肥厚心电图与超声心动图对比观察

对确诊的58例肺心病人进行心电图和超声心动图对照检查,结果说明超声心动图对肺心病右室肥厚的诊断具有明显的敏感性,对肺心病的早期诊断有较大的诊断价值。     

心脏再同步治疗中超声心动图的应用

超声心动图（尤其是组织多普勒显像技术）能有效地评估心脏机械失同步、评价心脏再同步治疗的效果和指导左室电极放置。文中对超声心动图在心力衰竭心脏再同步治疗中的应用作一概述，主要是其在评估机械失同步、评价CRT的治疗效果和指导左室电极放置中的应用。     

老年心脏瓣膜病的超声心动图与心电图表现

老年退行性心脏瓣膜病（senile degenerative valvular heart disease，SDVHD）的发生率较高，国外该病尸检检出率为60％-70％，超声检出事为74％，国内该病尸检检出率为46．1％，超声检出率为38．8％-60．2％。本病病理变化为瓣膜结缔组织退行性变、纤维化、增厚及钙化，从而引起瓣膜及支架功能异常。但对于SDVHD的超声心动图与心电图改变之间关系报道较少。本文旨在探讨心脏瓣膜病变超声心动图与心电图改变之间的规律。     

心电图和超声心动图诊断原发性高血压价值的对比研究

目的 探讨心电图（ECG）和超声心动图（UCG）对诊断原发性高血压（EHT）的意义。方法 对EHT患121例（Ⅰ期31例,Ⅱ期53例,Ⅲ期37例）分别作ECG、UCG和X线检查。结果 ECG诊断EHTⅠ期阳性率为29．03％;Ⅱ期阳性率为64．15％;Ⅲ期阳性率为72．97％。UCG诊断EHTⅠ期阳性率为83．87％;Ⅱ期阳性率为96．22％;Ⅲ期阳性率为86．48％。UCG、ECG和X线诊断EHT阳性率之间的比较有显性差异（P＜0．005）。结论 UCG诊断EHT的阳性率较高,如ECG诊断标准中加上P波的改变可以提高诊断率。ECG、UCG2种方法对EHT的诊断均有意义。     

超声心动图与心电图诊断左房扩大的对比分析

对 117例心血管疾病患者以超声心动图 (ＵＣＧ)为标准 ,分析心电图诊断左房扩大的价值 ,心电图的敏感性较低 ,其敏感性和心房颤动 (Ａｆ)的发生率随心房扩大程度而增加 ,风心病Ａｆ的发生率明显高于其它心血管疾病 ,机理尚不十分明确。本文以ＵＣＧ和心电图对心血管患者进行对比检查 ,现报告如下。1　资料与方法2 0 0 1年 4月～ 2 0 0 1年 8月住院者117例 ,均经ＵＣＧ诊断为左房扩大。男性 62例、女性 5 5例 ,年龄 14～ 86(平均60 7)岁。其中高血压病 3 1例、冠心病2 7例、风心病 18例、冠心病合并高血压病 12例、扩张性心肌病和心肌炎 16…     

心脏再同步治疗中超声心动图的应用

超声心动图(尤其是组织多普勒显像技术)能有效地评估心脏机械失同步、评价心脏再同步治疗的效果和指导左室电极放置.文中对超声心动图在心力衰竭心脏再同步治疗中的应用作一概述,主要是其在评估机械失同步、评价CRT的治疗效果和指导左室电极放置中的应用.     

Temporal variation in optimal atrioventricular and interventricular delay during cardiac resynchronization therapy

BackgroundTailored atrioventricular delay (AVd) and interventricular delay (VVd) combination improves hemodynamics in patients treated with cardiac resynchronization therapy (CRT). Whether tailored AVd-VVd combination changes over time is not known.Methods and ResultsTwenty-two patients (18 M, aged 69.9 ± 12.5 years, New York Heart Association class III, QRS ≥ 130 ms, ejection fraction 29.6 ± 8.8%) were implanted with a biventricular device with programmable VVd. Myocardial performance index (MPI) was evaluated during pacing at different VVds and AVds at baseline and after 6 and 12 months. The optimal AVd-VVd combination was identified by the minimum MPI. After optimization, the appropriate AVd-VVd combination was programmed in each patient. MPI at 6-month follow-up after optimization was significantly higher compared with baseline (.79 ± .21 vs. .59 ± .15, P < .05). Re-optimization of AVd-VVd combination was required after 6 months in 21 of 22 (95%) patients. Re-optimization significantly reduced MPI compared with the value prior to re-optimization (.56 ± .15 vs. .79 ± .21, P < .05). The MPI remained unchanged at 12-month compared with 6-month follow-up (.59 ± .19 vs. .56 ±.15, P = NS). Clinical symptoms and reverse left ventricular remodeling were sustained at 6-month and 12-month follow-up.ConclusionOptimal AVd and VVd combination changes over time in patients with heart failure. Sustained improvement in clinical symptoms and reverse left ventricular remodeling after CRT are not temporally associated with improvement in MPI.     

心脏再同步治疗起搏参数优化对血流动力学的影响及随访

目的应用超声心动图观察心脏再同步治疗（CRT）后不同时期AV、VV间期优化对心力衰竭血流动力学的影响,探讨AV、VV间期优化在增强CRT临床疗效中的作用。方法扩张性心肌病心力衰竭患者32例接受CRT治疗,并于植入术后7d,3、6个月在超声心动图指导下进行AV、VV间期优化,观察优化后不同时间起搏参数、血流动力学指标。结果32例入选患者均一次成功植入三腔起搏器,术后1、3、6个月随访起搏阈值、感知、阻抗的改变差异无统计学意义（P〉0．05）。CRT植入术后7d,87％（28／32）、90％（29／32）患者分别需要AV、VV间期优化,植入术后6个月仍有18％（6／32）、16％（5／32）患者分别再次需要AV、VV间期优化。植入术后7d、3个月优化起搏与术后未优化相比,舒张期充盈时间（DFT）延长、Tei指数下降（P〈0．05）。植入术后6个月优化起搏与植入术后即刻相比DFT延长、主动脉瓣前向血流速度时间积分（V11）增加、Tei指数下降、E／Em比值下降、左心室射血分数（LVEF）明显增加（P〈0．05）。结论CRT植入术后AV、VV间期优化改善心力衰竭患者的血流动力学,可以带来良好的临床疗效。     

Electrocardiographic versus echocardiographic optimization of the interventricular pacing delay in patients undergoing cardiac resynchronization therapy

Electrocardiographic VV Optimization. Introduction: Echocardiographic optimization of the VV interval may improve CRT response, but it is time‐consuming and not routinely performed. The aim of this study was to compare the response to cardiac resynchronization therapy (CRT) when the interventricular pacing (VV) interval was optimized by Tissue Doppler Imaging (TDI) to CRT response when it was optimized following QRS width criteria. Methods and Results: The study included 156 consecutive CRT patients with severe heart failure and left bundle‐branch block configuration. Atrioventricular interval was selected according to a pulsed Doppler assessment, and VV optimization was randomly assigned to echocardiography (ECHO group, n = 78) or electrocardiography (ECG group, n = 78). Optimal VV was defined for the ECHO group as producing the best LV intraventricular synchrony according to TDI displacement curves and for the ECG group as resulting in the narrowest QRS measured from the earliest deflection. At 6‐month follow‐up, percentage of echocardiographic responders (defined as neither death nor heart transplantation and a LV end‐systolic volume reduction >10%) was higher in the ECG optimized group (50.0% vs 67.9%; P = 0.023), whereas clinical response (defined as neither death nor heart transplantation and >10% improvement in the 6‐minute walking test) was similar in both groups (71.8% vs 73.1%; P = 0.858). Conclusions: VV optimization based on QRS width obtained a higher percentage of responders in terms of LV reverse remodeling compared to the TDI method. (J Cardiovasc Electrophysiol, Vol. 22, pp. 1129‐1134, October 2011)     

The role of electrocardiography in the elaboration of a new paradigm in cardiac resynchronization therapy for patients with nonspecific intraventricular conduction disturbance

Cardiac resynchronization therapy (CRT) is associated with a favorable outcome only in patients with left bundle branch block (LBBB) pattern and in patients with a QRS duration > 150 ms, in patients with non-LBBB pattern with a QRS duration of 120–150 ms usually is not beneficial. After adjusting for QRS duration, QRS morphology was no longer a determinant of the clinical response to CRT. In contrast to the mainstream view, we hypothesized that the unfavorable CRT outcome in patients with non-LBBB and a QRS duration of 120–150 ms is not due to the QRS morphology itself, but to less dyssynchrony and unfavorable patient characteristics in this subgroup, such as more ischemic etiology and greater prevalence of male patients compared with patients with LBBB pattern. Further, the current CRT technique is devised to eliminate the dyssynchrony present in patients with LBBB pattern and inappropriate to eliminate the dyssynchrony in patients with non-LBBB pattern. We also hypothesized that electrocardiography may also provide information about the presence of interventricular and left intraventricular dyssynchrony and the approximate location of the latest activated left ventricular (LV) region. To this end, we devised new ECG criteria to estimate interventricular and LV intraventricular dyssynchrony and the approximate location of the latest activated LV region. Our preliminary data demonstrated that the latest activated LV region in patients with nonspecific intraventricular conduction disturbance (NICD) pattern might be at a remote site from that present in patients with LBBB pattern, which might necessitate the invention of a novel CRT technique for patients with NICD pattern. The application of the new interventricular and LV intraventricular dyssynchrony ECG criteria and a potential novel CRT technique might decrease the currently high nonresponder rate in patients with NICD pattern.     

Effects of cardiac resynchronization therapy on coronary blood flow: evaluation by transthoracic Doppler echocardiography

BACKGROUND: Relatively limited and conflicting data are available on the effects of cardiac resynchronization therapy (CRT) on coronary blood flow (CBF). AIMS: To investigate changes in the left anterior descending coronary artery (LAD) flow under different CRT pacing modes by means of transthoracic Doppler echocardiography (TTE). METHODS: Twenty-two responders to CRT (67+/-11 years) with idiopathic dilated cardiomyopathy underwent TTE assessment of LAD flow and Tissue Velocity Imaging during 4 programming modes: intrinsic conduction (IC), right ventricular pacing (RV), simultaneous biventricular pacing (BVP), BVP with left ventricular (LV) pre-activation. RESULTS: Mean coronary flow velocity (CFV) was increased by simultaneous BVP (p=0.0063 vs. IC) and BVP with LV pre-activation (p<0.0001 vs. IC; p=0.027 vs. simultaneous BVP). Peak CFV and LAD flow velocity/time integral were highest during BVP with LV pre-activation. A reduction in septal-to-lateral delay and an increase in peak systolic velocity in the basal septum were observed during simultaneous BVP and BVP with LV pre-activation. CONCLUSIONS: In CRT responders with idiopathic dilated cardiomyopathy, an increase in LAD flow, assessed by TTE, was observed during simultaneous BVP and BVP with LV pre-activation. This was associated with an improvement in regional myocardial contraction and a decrease in intraventricular dyssynchrony.     

Prospective comparison of echocardiographic atrioventricular delay optimization methods for cardiac resynchronization therapy

BACKGROUND: Atrioventricular (AV) delay optimization can be an important determinant of the response to cardiac resynchronization therapy (CRT) in patients with medically refractory heart failure and a ventricular conduction delay. OBJECTIVES: The purpose of this study was to compare two Doppler echocardiographic methods of AV delay optimization after CRT. METHODS: Forty consecutive patients (age 59 +/- 12 years) with severe heart failure, New York Heart Association class 3.1 +/- 0.4, QRS duration 177 +/- 23 ms, and left ventricular ejection fraction 26% +/- 6% referred for CRT were studied using two-dimensional Doppler echocardiography. In each patient, the acute improvement in stroke volume with CRT in response to two methods of AV delay optimization was compared. In the first method, the AV delay that produced the largest increase in the aortic velocity time integral (VTI) derived from continuous-wave Doppler (aortic VTI method) was measured. In the second method, the AV delay that optimized the timing of mitral valve closure to occur simultaneously with the onset of left ventricular systole was calculated from pulsed Doppler mitral waveforms at a short and long AV delay interval (mitral inflow method). RESULTS: The optimized AV delay determined by the aortic VTI method resulted in an increase in aortic VTI of 19% +/- 13% compared with an increase of 12% +/- 12% by the mitral inflow method (P <.001). The optimized AV delay by the aortic VTI method was significantly longer than the optimized AV delay calculated from the mitral inflow method (119 +/- 34 ms vs 95 +/- 24 ms, P <.001). There was no correlation in the AV delay determined by the two methods (r = 0.03). CONCLUSION: AV delay optimization by Doppler echocardiography for patients with severe heart failure treated with a CRT device yields a greater systolic improvement when guided by the aortic VTI method compared with the mitral inflow method.     

改良腔内图法与心脏超声优化心脏再同步化治疗室间间期的比较

目的 比较改良腔内图（IEGM）法与心脏超声优化心脏再同步化治疗（CRT）的室间间期（VV间期）及相应心脏超声参数。方法 入选20例符合CRT植入I类适应证的慢性充血性心力衰竭患者,植入具有IEGM法优化功能的CRT/CRT-D; 术后1、3、6个月对每一例患者进行随访,随访时分别按传统IEGM法 、 改良IEGM法及超声法优化VV间期,比较两种IEGM法与超声法的一致性,并评估改良IEGM法获得的急性血流动力学效果[左室射血分数（LVEF）、二尖瓣返流面积（MRA）、主动脉前向血流速度时间积分（VTIAo）]是否优于传统IEGM法。 结果摇与传统IEGM法比较,改良IEGM法获得的VV间期与超声优化获得的VV间期一致性更好,改良IEGM法获得的LVEF1、3、6个月分别较传统IEGM法改善[（0.31±0.07） vs （0.29±0.08）,（0.37±0.07） vs （0.34±0.08）,（0.45±0. 07） vs （0.42依±0.08）,P均〈0. 05],MRA术后6个月较传统IEGM法减少[（2.1±1.8） cm^2vs （2.6±2.4） cm^2,P〈0. 05],但VTIAO及术后1、3个月MRA与传统IEGM法比较没有差异（P〉0. 05）。 结论 改良IEGM法与传统IEGM法相比,其与超声优化获得的VV间期一致性更好。