心脏再同步治疗术后QRS时限变化对长期疗效的影响

目的：通过分析植入心脏再同步治疗（ CRT）术后QRS时限（ QRSd）的变化,评估术后不同的QRSd对CRT长期预后的影响。方法2001年4月至2012年3月来自沈阳军区总医院及白求恩国际和平医院住院并植入CRT的心力衰竭患者164例,按术后QRSd变化分为3组：Ⅰ组：107例（ QRSd术前〉术后）,Ⅱ组：30例（ QRSd术前〈术后）,Ⅲ组：27例（ QRSd术前=术后）。观察术后3组病死率及心功能指标变化。结果随访48个月,3组患者的病死率及死因差异无统计学意义（ P〉0．05）。Ⅰ组和Ⅲ组术后心功能及左心室射血分数（LVEF）较Ⅱ组明显改善（P〈0．05-0．01）,且左心室舒张末期内径（ LVEDD）明显缩小（ P〈0．05-0．01）。Ⅱ组术后心功能及 LVEF也明显改善（ P〈0．05-0．01）,但LVEDD无明显缩小（P〉0．05）。术后QRSd较术前变宽或变窄与术前QRSd的基础值有关,术前QRSd〈140 ms是术后QRSd变宽的影响因素。结论术后QRSd变化对预后影响不同,QRSd变窄患者不但临床心功能恢复的较好,而且还可有明显的左心室逆重构,更奠定了长期心功能改善的基础。术后QRSd变化与术前QRSd有明显关系,术前QRSd〈140 ms时,术后QRSd变窄的几率小,因此,术前QRSd越宽,术后QRSd变窄的效果越好。     

心力衰竭患者心脏再同步化疗效的多因素分析

目的：探讨影响心力衰竭患者心脏再同步化治疗（CRT）效果的因素. 方法：入选因慢性心功能不全接受CRT的患者25例.CRT应答定义为术后6个月左室收缩末期容积（LVESV）减少＞15％以及纽约心功能改善1级以上（包括1级）,不达上述标准以及因心力衰竭死亡者定义为CRT无应答.对所有患者随访（26.0±15.9）个月,17例表现为CRT应答,8例表现为CRT无应答,分析两组患者的临床基线特征及治疗前后心功能分级、基线QRS波时限（QRSd）等指标,并作logistic回归分析. 结果：慢性心力衰竭患者对CRT的反应与QRSd（r=1.19,P=0.01）、术后QRSd缩短时间（ΔQRSd,r=1.28,P=0.01）相关.ROC曲线分析显示,基线QRSd＞135 ms预测CRT应答的敏感性为70.6％0、特异性为62.5％,ΔQRSd缩短25 ms预测CRT应答的敏感性为64.7％、特异性为90.9％. 结论：QRS波基线值和ΔQRSd是CRT应答的预测因子.     

心脏再同步治疗前后QRS波时限与疗效相关性

目的探讨QRS波时限对心脏再同步治疗（CRT）临床疗效的预测价值。方法入选心功能Ⅲ～Ⅳ级（NYHA分级）、左心室射血分数≤0．35、QRS波时限〉120ms患者,CRT治疗前后1周行心电图检查。随访6～12个月,以心功能分级改善I级以上或6rain步行试验距离增加25％以上作为临床有效的标准,死亡患者定义为无效,分析CRT治疗前后QRS波时限及QRS波时限缩短值对CRT临床疗效的预测价值。结果（1）共79例患者人选,57例（72．2％）临床有效;（2）CRT治疗后1周QRS波时限,治疗前后QRS波时限差值,治疗前舒张压、左心室收缩末内径和左心房内径,有效组和无效组之间差异有统计学意义（P〈0．05）;（3）受试者工作特征曲线显示CRT治疗后1周QRS波时限、治疗前后QRS波时限差值能预测CRT的疗效（P〈0．01）。结论CRT治疗后1周QRS波时限、治疗前后QRS波时限差值可以预测宽QRS波患者的CRT疗效。     

二维斑点追踪显像技术预测心脏再同步治疗的疗效

目的旨在比较二维斑点追踪显像技术与现有的超声心动图技术对心脏再同步治疗（CRT）疗效的预测价值。方法施行CRT的患者50例,每个患者植入术前均采用血流多普勒、组织多普勒和二维斑点追踪显像的方法进行收缩不同步的评价,有效者定义为术后6个月左心室收缩末容积缩小〉15％或左心室射血分数（LVEF）绝对值增加〉5％的患者。结果CRT有效组起搏前左心室射血前时间显著长于无效组[（146．0±34．5）ms对（123．5±32．0）ms,P〈0．05],其余常规超声心动图参数和组织多普勒参数在两组间差异无统计学意义。二维斑点追踪显像技术示CRT有效组和无效组的左心室应变达峰时间标准差（Tstrain—SD）的差异无统计学意义（P〉0．05）,而CRT有效组的应变率结束时间标准差（Tsr—SD）显著高于无效组（P〈0．05）。两组间左心室应变均值（Strain-12）的差异亦无统计学意义（P〉0．05）,而CRT有效组的左心室12节段纵轴反向应变总和（Pstrain-12）显著高于无效组[（12．5±7．9）％对（7．1±8．4）％,P〈0．05]。将140．5ms作为截点值,左心室射血前时间预测超声心动图有效的敏感性和特异性分别为63％和79％,将70．7ms作为截点值,Tsr—SD预测CRT有效的敏感性和特异性分别为73％和65％。结论常规超声心动图参数中仅左心室射血前时间能预测CRT疗效,二维斑点追踪显像技术的部分参数预测CRT疗效优于组织多普勒。     

心脏再同步治疗后心室电重构和室性心律失常与左心室逆重构关系探讨

目的 探讨慢性心力衰竭患者心脏再同步治疗（CRT）后心室电重构和室性心律失常与左心室逆重构的关系.方法 入选因心力衰竭于我院行CRT的患者,随访术后即刻与术后6个月体表心电图与超声心动图,记录术后6个月期间窒性心律失常发作次数.根据术后6个月左心室收缩末容积缩小比例（ ΔLVESV）≥15％与否分为有效组与无效组,对比组间QRS时限变化（ΔQRSd）和室性心律失常事件,对左心室逆重构程度与ΔQRSd和室性心律失常事件进行相关性分析,寻找CRT治疗后室性心律失常的预测因素.结果 共入选43例患者,有效组29例,无效组14例,组间基线资料与术后应用药物等差异无统计学意义.全部患者CRT后6个月QRSd无变化（P=0.50）,有效组QRSd明显缩短（P＜0.01）,无效组无变化（P=0.08）.组间ΔQRSd差异有统计学意义（P=0.02）.全部患者CRT后ΔLVESV与△QRSd呈正相关（r=0.523,P＜0.01）.CRT 6个月内室性早搏（PVCs）与室性早搏连发（PVCruns）次数分析显示,log（PVCs）与log（PVC runs）在组间差异有统计学意义（P＜0.01）,log （PVCs）和log.（PVC runs）均与ΔLVESV呈正相关（P＜0.01）.多元回归分析显示,ΔLVESV是log （PVCs）的独立预测因素（β=2.36,P＜0.01）,ΔLVESV和男性是log（ PVC runs）的独立预测因素（β=2.88,P＜0.01;β=-0.74,P=0.03）.结论 CRT后左心室逆重构与电重构及室性心律失常发生减少相关.左心室逆重构程度及性别对CRT患者术后室性心律失常事件有预测意义.     

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。     

合并符合新诊断标准的左束支阻滞的慢性心力衰竭患者应用心脏再同步化治疗的疗效分析

目的:分析慢性心力衰竭患者合并符合新诊断标准的左束支阻滞(LBBB)(真性LBBB)能否从心脏再同步化治疗(CRT)中更能获益。方法:研究入选2005-06至2013-05接受CRT的19例患者,依据术前体表心电图QRS波的形态,符合新诊断标准即为真性LBBB组(n=13),符合传统诊断标准即为假性LBBB组(n=6);比较所有入选患者CRT术前与术后左心室射血分数(LVEF)、左心室舒张末内径(LVEDD)、QRS波时限(QRSd)及心室间机械延迟时间(IVMD);同时比较两组患者术后LVEF、LVEDD、QRSd、IVMD、16节段达最小收缩末容积时间标准差(Tmsv16-SD)及16节段达最小收缩末容积时间的最大差值(Tmsv16-Dif)有无差异。结果:两组患者在CRT术后的LVEF、LVEDD、IVMD及QRSd均较术前有明显的改善;而且与假性LBBB组比,真性LBBB组的LVEDD[(5.95±0.72)mm vs(7.13±0.78)mm,P0.01]、IVMD[(22.45±8.00)ms vs(27.63±13.09)ms,P0.01]及QRSd[(140.38±5.80)ms vs(153.68±14.38)ms,P0.01]改善更明显;术后两组患者的Tmsv16-SD、Tmsv16-Dif及LVEF的差异均无统计学意义。结论:合并真性LBBB和假性LBBB的心力衰竭患者均能从CRT中获益,合并真性LBBB的心力衰竭患者获益更明显。     

伴右束支传导阻滞的心力衰竭患者行心脏再同步化治疗疗效欠佳的相关因素分析

目的分析伴右束支传导阻滞(RBBB)者心脏再同步化治疗(CRT)疗效欠佳的可能影响因素。方法 209例接受CRT的患者,根据其术前QRS波形态分为左束支传导阻滞(LBBB)与RBBB组,比较两组基线临床特征和CRT术后6个月临床心功能、QRS波时限(QRSd)、左室射血分数(LVEF)等心脏超声指标的差异。剔除缺血性心肌病、重度肺动脉高压和QRSd150 ms的病例后,再次比较两组间CRT疗效差异。结果与LBBB组比较,RBBB组缺血性心肌病占比较高(26.0%vs 11.3%),肺动脉收缩压亦高[(50.14±17.10)mmHg vs(44.27±15.16)mmHg],QRSd则较窄[(152.36±26.84)ms vs(162.92±29.67)ms](P0.05)。CRT术后6个月,LBBB组临床心功能改善、LVEF的提高均显著优于RBBB组(P0.05)。而将缺血性心肌病、重度肺动脉高压和QRSd150ms的病例剔除后,CRT术后两组间各项指标均无差异。结论缺血性心肌病、重度肺动脉高压、相对较窄的QRS波可能是RBBB者CRT疗效欠佳的原因。     

左束支起搏置入失败原因分析

目的：回顾分析我院开展的左束支起搏病例，评估左束支起搏的可行性和安全性，分析失败病例的原因。方法：收集2018年9月至2022年3月，在我院心内科诊治的行左束支区域起搏88例患者的临床资料，分析术前临床资料、术中情况、随访情况，分析失败原因。结果：88例患者男性62例，女性26例，平均年龄（72±12）岁，79例成功完成左束支起搏手术（90%）。术前窄QRS者，术后QRSd无明显变化[（97±8）vs.(98±8)ms,P> 0.05]; QRSd介于120～150ms之间和QRSd> 150ms者，术后QRS明显缩短[（133±9）vs.(107±11)ms,(165±13)vs.(100±7)ms,P <0.01]，且随访起搏器参数和QRSd稳定。9例失败，9患者均存在特殊或复杂的临床情况，8例更改手术方案完成手术。失败病例手术时间明显延长，术前心房颤动、心力衰竭、慢性阻塞性肺疾病、传统CRT无应答、心外科手术史多（P <0.01）,LVEF更低（P<0.01）,LAD、LVEDD、RAD、RVD值更大（P <0.01）。房室扩大致手术失败比例最...     

慢性心力衰竭患者QRS时间延长的临床意义

目的评价慢性心力衰竭患者心电图QRS时间延长的临床意义。方法将入选的620例慢性心力衰竭患者按QRS时间分为≥120ms组（n=120）和〈120ms组（n=500）,比较两组患者QRS时间与左心室射血分数（LVEF）、左心室短轴缩短分数（LVFS）、NYHA心功能分级、左心房左心室大小、二尖瓣反流、左心室壁厚度和住院死亡率。结果①≥120ms组QRS时间（143±21）ms,〈120ms组为（89±12）ms;②〈120ms组LVEF及LVFS分别为（47．02±16．13）％、（22.85±10．34）％,均较≥120ms组（37．00±13.91）％和（15．65±8．83）％大（P〈0．01）;⑨两组患者NYHA心功能分级差异无统计学意义（P〉0．05）;④≥120ms组左心房内径、左心室舒张末期内径较〈120ms组大（P〈005或001）;⑧≥120ms组二尖瓣反流率（82．1％）较〈120ms组（67．5％）高;⑧两组患者左心室壁厚度和住院死亡率差异均无统计学意义（P〉0.05）。结论心电图QRS时间可作为判断慢性心力衰竭患者病情的一项指标。     

Usefulness of QRS duration to predict response to cardiac resynchronization therapy in patients with end-stage heart failure

Despite current selection criteria, 20% to 30% of patients treated with cardiac resynchronization therapy (CRT) do not benefit. It has been suggested that QRS duration may not be the optimal criterion to select patients for CRT. The objective of this study was to systematically evaluate the predictive value of QRS duration for response to CRT in a large group of consecutive patients. A total of 242 patients with heart failure scheduled for implantation of a CRT device were studied. Selection criteria for CRT included moderate to severe heart failure (New York Heart Association classes III to IV), left ventricular ejection fraction (LVEF)120 ms. Before CRT implantation, QRS duration and clinical status were assessed, and 2-dimensional echocardiography (LV volumes and LVEF) was performed. Clinical status and changes in LVEF and LV volumes were reassessed at 6-month follow-up. After 6 months of CRT, 68% of patients were classified as clinical responders (improvement of >or=1 grade in New York Heart Association class) and 60% as echocardiographic responders (decrease>10% in LV end-systolic volume). At baseline, no significant differences were observed in QRS duration between clinical responders and nonresponders and between echocardiographic responders and nonresponders. No significant relation was demonstrated between baseline QRS duration and improvement in clinical and echocardiographic variables at 6-month follow-up. In conclusion, baseline QRS duration is not predictive for clinical and echocardiographic responses to CRT at 6-month follow-up. Better predictors for CRT response are needed.     

Intrathoracic impedance changes reflect reverse left ventricular remodeling in response to cardiac resynchronization therapy in chronic heart failure patients

Intrathoracic impedance monitoring has been reported to be useful for prediction of worsening chronic heart failure (CHF). However, it has not revealed the relation between changes in intrathoracic impedance and improvement of cardiac function in CHF patients with cardiac resynchronization therapy (CRT) implantation. Therefore, we investigated whether intrathoracic impedance change reflects reverse left ventricular (LV) remodeling in response to CRT in patients with CHF. The study subjects consisted of 29 CHF patients (23 males, mean age 64 ± 12 years) with CRT-defibrillator (CRT-D) implantation. The patients were divided into two groups based on whether the Opti-vol Fluid Index^? reached over 60 ohms (group A, n = 7) or not (group B, n = 22) within 6 months of observation after CRT-D implantation. Levels of plasma B-type natriuretic peptide (BNP) were measured, and LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), and LV ejection fraction (LVEF) were evaluated before and 6 months after CRT-D implantation. In group B, BNP (556 ± 88 pg/mL versus 330 ± 70 pg/mL, P < 0.05), LVEDV (177 ± 18 mL versus 149 ± 14 mL, P < 0.01), and LVESV (128 ± 14 mL versus 100 ± 12 mL, P < 0.01) were significantly decreased 6 months after CRT-D implantation. LVEF (28 ± 2% versus 35 ± 2%, P < 0.01) was significantly increased after CRT-D implantation. On the other hand, no significant changes were detected in any parameters in group A. These data showed intrathoracic impedance changes reflected reverse LV remodeling in response to CRT in patients with CHF. Therefore, the monitoring of changes in intrathoracic impedance is useful for predicting CRT responders in patients with CHF.     

Reverse Electrical Remodeling by Cardiac Resynchronization Therapy: Prevalence and Clinical Impact

Intrinsic QRS Narrowing with CRT . Background: Cardiac resynchronization therapy (CRT) improves left ventricular ejection fraction (LVEF) in patients with congestive heart failure, LV systolic dysfunction, and a wide QRS complex. Previous reports suggest that CRT may also induce electrical remodeling but the impact on clinical outcome remains unknown. Objective: We sought to determine (1) if chronic CRT induces a relevant shortening of the intrinsic QRS (iQRS), (2) whether changes in the native conduction system correlate with clinical or echocardiographic response to CRT, and (3) to identify predictors of iQRS width shortening. Methods: We prospectively included 85 consecutive patients with left bundle‐branch block who received a CRT device in 3 French centers. NYHA class, iQRS duration, LVEF, and left ventricular volumes were assessed before and 1 year after CRT implantation. Clinical and echocardiographic CRT responders were defined respectively as NYHA class improvement >1 class without heart failure hospitalization and an increase of LVEF by ≥10% and/or a decrease in LVESV by ≥15%. Electrocardiographic responders were defined as a decrease in iQRS duration by ≥20 ms. Results: Baseline and 1‐year follow‐up mean iQRS durations were, respectively, 168.0 ± 19.7 ms and 149.6 ± 31.6 ms (P < 0.0001). Electrocardiographic response, observed in 43/85 patients (51%), was associated with a greater rate of clinical (P = 0.035) and echocardiographic (P = 0.023) response. Younger age, male gender, and longer baseline QRS width were independent predictors of electrocardiographic response. Conclusion: CRT decreases iQRS duration. A reduction of at least 20 ms in iQRS duration is associated with better clinical and echocardiographic response. (J Cardiovasc Electrophysiol, Vol. 23, pp. 1219–1227, November 2012)     

电生理标测冠状静脉窦分支最延迟电激动处植入左室导线行心脏再同步化治疗

目的探讨电生理标测冠状静脉窦(CS)分支最延迟电激动处植入左室导线行心脏再同步治疗(CRT)。方法 10例中重度心力衰竭患者,均满足NYHA心功能Ⅲ～Ⅳ级,左室射血分数(LVEF)<0.35且QRS波时限≥120 ms。CRT术中在可植入左室导线的CS分支内进行电生理标测,将标测的最延迟心室电激动处作为左室导线的植入部位,观察该方法的可行性及临床疗效。结果 10例中,扩张型心肌病7例,缺血性心脏病3例;7例为窦性心律,3例为心房颤动;9例ECG表现为左束支传导阻滞,1例为室内传导阻滞。对10例的28个可作为左室导线植入部位的CS分支进行了电生理标测,10例均成功将左室导线植入在标测的最延迟电激动处,该处局部电位较体表ECG的QRS波起始延迟116±28 ms。术后即刻QRS波时限为121±17 ms,比术前153±30 ms明显缩短,P<0.01。8例CRT术后随访时间超过3个月,均有CRT应答(8/8,100%),其中3例超应答(3/8,37.5%),另外1例缺血性心肌病患者CRT术后2个月死于急性前壁心肌梗死;8例CRT应答患者NYHA心功能分级、6 min步行距离、LVEF值、左室收缩末容积、二尖瓣返流速度均较术前明显改善(1.6±0.5级vs 3.3±0.5级;405±92 m vs 307±82m;0.42±0.06 vs 0.30±0.04;121±38 ml vs 153±44 ml;3.9±1.2 m/s vs 4.5±1.5 m/s,P均<0.01)。结论电生理标测指引CS分支最延迟电激动处植入左室导线的CRT方法可行且短期疗效明显。     

The resynchronization therapy in narrow QRS study (RethinQ study): Methods and protocol design

Background Numerous trials have demonstrated the effectiveness of cardiac resynchronization therapy (CRT) as an adjunct to medical therapy for the relief of heart failure (HF) symptoms in patients with a wide QRS duration (QRSd). Current guidelines recommend CRT in patients with an EF <35%, medically refractory NYHA Class III–IV HF and QRSd ≥120 ms. Previous studies have demonstrated QRSd as a marker of electrical dyssynchrony fails to predict response to CRT. In addition, studies have demonstrated significant differences in QRSd post CRT between responders and non-responders. Moreover, smaller non-controlled studies demonstrated that HF patients with a narrow QRSd may benefit from CRT. A growing body of evidence suggests that echocardiographic criteria may be a better method to evaluate mechanical dyssynchrony (MD) which may predict those that will benefit from CRT, particularly those with a narrow QRSd. The Resynchronization Therapy In Narrow QRS (RethinQ) study will evaluate mechanical dyssynchrony using echocardiography (both M mode and TDI) as an eligibility requirement for CRT. Methods The RethinQ study is a prospective, multi-center, randomized, double blind controlled clinical study. The objective of the RethinQ study is to evaluate the effectiveness of CRT in patients with approved ICD indication, advanced HF (NYHA Classification III), narrow QRSd (<130 ms) and evidence of MD measured by echocardiography. Conclusion We hypothesize that patients with narrow QRS <130 ms, advanced HF, and MD as measured by echocardiography will benefit from CRT. An erratum to this article can be found at     

Has Mechanical Dyssynchrony Still a Role in Predicting Cardiac Resynchronization Therapy Response?

Current guidelines for cardiac resynchronization therapy (CRT) include electrical but not mechanical dyssynchrony assessment. Our study aims to investigate the effects of isolated or combined mechanical and electrical dyssynchrony, according, respectively, to a standard deviation of tissue Doppler imaging (TDI) derived time to systolic peak ≥32.6 ms and to a QRS duration ≥120 ms, in predicting CRT reverse remodeling. Method: One hundred ninety‐two CRT patients were studied. All patients underwent a complete standard and TDI echocardiography examination before and 6 months after CRT. According to baseline evaluation patients were divided into Group 1, patients with isolated electrical dyssynchrony (QRS ≥ 120 ms, TS‐SD < 32.6), Group 2, patients with isolated mechanical dyssynchrony (QRS < 120 ms, TS‐SD ≥ 32.6) and Group 3, patients with combined electrical and mechanical dyssynchrony (QRS ≥ 120 ms, TS‐SD ≥ 32.6). Patients were considered CRT responders according to ≥15 left ventricular end‐systolic volume (LVESV) reduction at follow‐up (FU). Result: At FU, 86 (45%) patients were responders. The highest CRT response rate was observed in Group 3 (62/119, 52%, P < 0.001 vs. Group 1). No significant differences in response rate were observed between Group 1 (13/47, 27%) and Group 2 (11/26, 42%). In Group1, CRT did not induce any significant change in LV end‐diastolic volume (LVEDV), LVESV, LV ejection fraction (LVEF), myocardial performance index (MPI), while in Group 2, LVEF (P < 0.001) and MPI (P < 0.05) were improved. In Group 3, LVEDV, LVESV, LVEF, MPI were significantly improved (P < 0.0001 for all). Conclusion: Our data demonstrate that the highest CRT response rate can be achieved by combining traditional QRS criterion and a currently used echocardiographic dyssynchrony parameter. (Echocardiography, 2010;27:831‐838)     

右心室起搏导线位置对心脏再同步治疗效果的影响

目的 评价右心室起搏导线位置对心脏再同步治疗（CRT）效果的影响.方法 71例顽固性心力衰竭患者接受CRT手术,53例左心室导线植入侧壁或侧后壁,18例植入前壁或下壁（非侧后壁）;48例右心室导线植入心尖部,23例植入流出道间隔部.术前记录受试者心功能（NYHA分级）、QRS时限（QRSd）、左心室射血分数（LVEF）、左心室舒张末期内径（LVEDD）及左心室收缩末期内径（LVESD）;术后6个月对上述参数进行随访,比较不同右心室起搏部位对CRT临床疗效的影响.结果 术后6个月,右心室心尖部起搏组LVEF高于流出道间隔部起搏组[（0.44±0.07）对（0.40±0.07）,P=0.048],余心功能、QRSd、LVEDD、LVESD等各项指标均差异无统计学意义（P＞0.05）.根据左心室起搏部位进一步分为侧壁或侧后壁与非侧后壁两组,就侧壁或侧后壁组,右心室心尖部起搏较间隔部起搏可更好地提高心输出量LVEF[（0.45±0.07）对（0.40±0.08）,P=0.027],改善心功能[（2.59±0.59）对（3.00±0.68）,P=0.038],对于非侧后壁组,比较右心室心尖部与流出道间隔部起搏,各项指标均差异无统计学意义（P＞0.05）.结论 若无视左心室起搏部位,右心室心尖部起搏略优于流出道间隔部起搏;而对于左心室侧壁和/或侧后壁起搏者,应尽量将右心室导线置于心尖部,以获得较好疗效.