Cardiac resynchronization therapy in patients with congenital heart disease and systemic right ventricle

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Non-contact mapping guided cardiac resynchronization therapy for a failing systemic right ventricle.

AIMS: Progressive systemic right ventricular (sRV) dysfunction, atrial and ventricular arrhythmias and sudden cardiac death are well-recognized late sequelae of atrial redirection surgery in which the right ventricle is left connected to the systemic circulation. Although cardiac resynchronization therapy (CRT) poses an attractive therapeutic option, little is known about indications, patient selection, and technical aspects of best lead placement. METHODS AND RESULTS: We undertook CRT in a 27-year-old female patient post-Mustard correction for d-transposition (d-TGA) with New York Heart Association (NYHA) grade III disability with QRS duration measuring 130 ms. There was also echocardiographic (TTE) evidence of severe sRV dysfunction. Non-contact mapping (NCM) was used to define sites of late activation within the sRV and the acute intra-arterial blood pressure (BP) response was assessed during implantation of a 4 french (F) lead onto the endocardial surface of the sRV. At 4 weeks post-implant sRV lateral wall motion had improved and the ejection fraction (EF) rose from 23 to 33%. The patient has been successfully anticoagulated and improved to NYHA II status after 6 months. CONCLUSION: The use of NCM proved safe and effective and provided a qualitative assessment of electrical viability of the sRV complimenting the measurement of mechanical function provided by TTE. The favourable clinical response in the above case justifies a prospective evaluation of this strategy.     

单中心心脏再同步治疗的长期病死率及原因分析

目的观察本中心心脏再同步治疗（CRT）的长期病死率,分析可能的相关因素。方法2001年3月至2010年4月135例患者行CRT治疗,男106例,平均年龄（59．95±11．14）岁。缺血性心肌病（ICM）44例,心功能Ⅲ～Ⅳ级（NYHA分级）,LVEF≤0．35。随访最长9年。结果全因死亡率为31．11％,其中心力衰竭占26．19％,猝死占38．1％。与存活患者比较,心力衰竭恶化死亡患者更年轻、CRT治疗前的临床指标差、肺动脉压高、左心室舒张末内径增大明显（P〈0．05）,而且PR间期明显延长（P〈0．05）,不理想的左心室电极导线位置（心中静脉和心大静脉）的比例增加（P〈0．01）。非心力衰竭死亡组CRT治疗后心功能的各项指标及活动耐量均改善,且随着时间延长改善更明显,而心力衰竭死亡组随着时间延长病情反复且加重。结论本中心CRT长期治疗的全因死亡率为31％,死亡原因中心脏性猝死发生率最高,心力衰竭恶化排第2位,经CRT后因心力衰竭和猝死导致的死亡率低于以前药物治疗（20％／4年和〉50％／5年）。对于心功能好转的患者预防猝死是重要的,心脏再同步治疗除颤器（CRT－D）应是首选治疗。     

心脏再同步治疗是慢性心力衰竭伴心脏收缩不同步患者治疗的希望所在

慢性心力衰竭是各种心脏病发展的严重阶段，是目前心脏病学尚未解决的难题之一。超过4000例患者的随机临床研究业已证实，心脏再同步治疗（CRT）不仅能改善心力衰竭患者运动耐量、生活质量，而且能逆转心肌重构，降低病死率。CRT正在成为慢性心力衰竭患者的常规治疗方法，但临床实践仍有许多值得探讨的问题。     

Prognostic value of NT-proBNP in patients with systemic morphological right ventricles: A single-centre experience

In systemic morphological right ventricles after atrial redirection surgery, NT-proBNP is correlated with NYHA-class, ventricular function and subaortic AV-valve regurgitation (TR). The impact of NT-proBNP on adverse clinical outcomes is, however, unknown.     

努力提高我国心脏再同步治疗的应用水平

心脏再同步治疗（CRT）已成为伴QRS波增宽的慢性心力衰竭患者的有效治疗方法。多中心临床研究证实,CRT不仅能改善慢性心力衰竭伴心脏收缩不同步患者的心功能,提高生活质量,而且可以降低死亡率,改善患者预后。2002年ACC／AHA／NASPE第一次将CRT治疗心力衰竭列入起搏适应证（Ⅱa类）。随着循证医学证据的不断积累,CRT治疗心力衰竭的地位不断提升。     

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.     

心脏再同步治疗发展的新时期

无疑,心脏再同步治疗（CRT）已成为当下心力衰竭非药物治疗的一线选择。一系列大规模临床试验以及我们亲身的临床实践都证实了CRT在改善心力衰竭患者症状,降低住院率和死亡率的卓越疗效。经过十几年的发展,CRT应用进入了一个全新时期,其远期发展可能关注于两个方面。一是在遵从现有指南的基础上,如何进一步提高CRT反应率,二是扩展CRT植入适应证,使潜在人群获益。     

心脏再同步治疗对慢性心力衰竭的临床疗效观察

目的观察心脏再同步治疗（CRT）对慢性心力衰竭的长期临床疗效。方法24例接受CRT的慢性心力衰竭患者,心功能Ⅲ～Ⅳ级（NYHA分级）,左心室射血分数（LVEF）≤0．35,左心室舒张末内径（LVEDD）／〉55mm,QRS时限≥120／TIS。植入前超声心动图及组织多普勒检查以评价心功能及心脏收缩不同步指标,并指导左心室电极导线的植入。植入后3、6个月及随后的每6个月进行随访,随访内容包括临床症状、心电图、LVEDD、LVEF及多普勒超声评价心脏收缩同步性指标。结果随访时间（12．0±4．6）个月,结果显示患者临床症状明显改善,QRS时限植入后较植入前缩短[（137．50±38．96）ms对（144．60±45．78）ms,P=0．67],但差异无统计学意义。植人后LVEDD较植入前明显缩小[（6．24±0．89）cm对（6．78±0．42）cm,P=0．03];LVEF则明显提高（0．36±0．09对0．31±0．03,P〈0．01）,左心房内径（LAD）也较术前明显缩小[（4．22±8．43）cm对（5．32±7．63）cm,P=0．01]。心脏收缩不同步指标与植入前相比也明显改善。结论对慢性心力衰竭的患者,CRT治疗可改善左心室功能,逆转左心室重构。     

心脏再同步化与常规治疗对心力衰竭患者心房颤动影响的比较

目的探讨心脏再同步化(CRT)与常规治疗对心力衰竭(简称心衰)患者心房颤动(简称房颤)的影响。方法选择行CRT、CRTD治疗的患者,作为CRT组。选择同期心衰行常规药物治疗的患者,作为对照组。比较两组患者治疗后,阵发性房颤、永久性房颤的发生率,以及房颤患者的预后差异。结果:①对照组房颤的发生率较CRT组高(阵发性房颤9/46 vs 5/47;永久性房颤24/46 vs 11/47,P均<0.05)。②常规药物治疗下房颤患者的死亡率高于窦性心律患者(P<0.05)。结论 CRT治疗后,房颤发生率较低,房颤并心衰患者的死亡率亦降低,CRT组心衰临床症状明显改善,心功能提高,运动耐量增加,生活质量提高。     

Indexed maximal left atrial volume predicts response to cardiac resynchronization therapy

Aims

Cardiac resynchronization therapy (CRT) has shown morbidity and mortality benefits in patients with advanced congestive heart failure (HF). Since about one-third of the patients did not appear to respond to CRT, it would seem reasonable to try to identify patients more accurately before implantation. Left atrial (LA) dimension has been proposed as a powerful outcome predictor in patients with heart disease. Accordingly, the aim of this study is to prospectively assess the predictive value of LA for selecting CRT responders.

Methods

Fifty two consecutive patients with refractory HF, sinus rhythm and left bundle branch block were enrolled in the study and planned for CRT implantation. Clinical and echocardiographic evaluations were performed before CRT implantation and after 6 months. Three LA volumes indexed to body surface area (iLAV) were computed to evaluate the LA complexity: maximal LAV (iLAVmax), LAV just before atrial systole (iLAVpre), and minimal LAV (iLAVpost). CRT responders were defined as those who presented a reduction of > 10% in LVESVi at 6-month follow-up.

Results

Responders (63%) and nonresponders (37%) had similar baseline clinical characteristics and pre-implantation LV volumes. However, baseline LA volumes were significantly associated with the extent of LV reverse remodeling: in particular, baseline iLAVmax was remarkably lower in responders than in nonresponders (50.2 ± 14.1 ml/m² vs 65.8 ± 15.7 ml/m², p = 0.001) resulting predictive for CRT response.

Conclusion

Patients with small iLAV result as better responders to CRT than larger one. iLAVmax is an independent predictor of LV reverse remodeling and allows to indentify the best candidates for CRT.     

The association between cardiac resynchronization therapy response and sexual activity in patients with heart failure

BackgroundSexual activity is an important indicator of quality of life and is significantly impaired in patients with heart failure (HF). Cardiac resynchronization therapy (CRT) has positive effects on cardiac dysfunction and endothelial dysfunction that lead to erectile dysfunction (ED). We aimed to evaluate whether CRT may improve sexual activity in patients with HF.MethodsIn total, 136 patients (mean age 61.8 ± 12.8 years) were evaluated for the study. All patients filled the Sexual Health Inventory for Men (SHIM) questionnaire for evaluation of their erectile functions before CRT device implantation. One hundred eighty days after CRT device implantation, the patients were re-evaluated with SHIM questionnaire.ResultsIn the whole study population, SHIM test scores were significantly increased after CRT (12.99 ± 3.22 vs. 18.03 ± 5.00; p<0.001). The patients were divided into two groups according to the CRT response. The increase in SHIM test scores was significantly more in the response (+) group than in the response (−) group [response (+) group: 6.94 ± 3.36; p<0.001 vs. response (−) group: 0.81 ± 1.77; p = 0.465]. A positive CRT response was found to be an independent predictor of SHIM score (p<0.001).ConclusionOur study showed that CRT had positive effects on ED of patients with HF.     

心衰患者起搏器升为CRT的疗效研究

目的评价合并心力衰竭的常规起搏器患者升级为CRT逆转左室重构的作用。方法入选起搏依赖、合并心力衰竭的常规起搏器患者,将其升级为CRT。观察手术前后患者QRS时限、左室舒张末期内径(LVEDD)、射血分数(LVEF)与肺动脉收缩压(SPAP)等心脏结构和功能的变化情况。结果常规起搏器升级为CRT后,QRS时限较前明显缩短,由术前的155.2±27.1ms缩短至130±15.0ms,p0.01。随访至术后6月,CRT有效率为68%(18/25例),LVEDD[(64.6±8.5)vs(57.56±9.5),p0.01]显著缩小,LVEF[(29.4±3.8)vs(32.5±4.1),p0.01]显著增加,SPAP[(46.6±12.8)vs(44.5±13.1),p0.01]也较前下降。结论对于起搏依赖、合并心力衰竭的常规起搏器患者,升级为CRT可显著改善心功能、逆转心肌重构。     

Long-term outcome in diabetic heart failure patients treated with cardiac resynchronization therapy

BACKGROUND: Diabetes mellitus is an independent risk factor for increased morbidity and mortality in heart failure (HF) patients. AIMS: To compare functional and structural improvement, as well as long-term outcome, between diabetic and non-diabetic HF patients treated with cardiac resynchronization therapy (CRT). METHODS: We compared response to CRT in 141 diabetic and 214 non-diabetic consecutive patients. Major events were; death from any cause, urgent heart transplantation and implantation of a left ventricular (LV) assist device. Frequencies of hospitalisation and defibrillator (CRT-D) discharges were also analyzed. RESULTS: CRT was able to significantly improve functional capacity, ventricular geometry and neurohumoral imbalance in both diabetic and non-diabetic patients over a median follow-up time of 34 months. Overall event-free survival was similar in diabetic and non-diabetic patients (HR 1.23, p=0.363), as was survival free from CRT-D interventions (HR 1.72; p=0.115) and hospitalisations (HR 1.12; p=0.500). On multivariable analysis, NYHA class IV (p=0.002), low LV ejection fraction (p=0.002), absence of beta-blocker therapy (p<0.001), impaired renal function (p=0.003), presence of an epicardial lead (p=0.025), but not diabetes (p=0.821) were associated with a poor outcome after CRT. CONCLUSIONS: Diabetic HF patients treated with CRT had a very favourable functional and survival outcome, which was comparable to non-diabetic patients.     

Deleterious effect of unintentional pacing from the middle cardiac vein in a patient with congenitally corrected transposition of the great arteries and ventricular septal defect. The beneficial effect of cardiac resynchronization therapy after heart surgery

This report presents a case of a 31-year-old male with congenitally corrected transposition of the great arteries, ventricular septal defect (VSD) and complete heart block who was admitted to our institution because of an exacerbation of heart failure after pacemaker implantation. The ECG and chest radiograph revealed that the ventricular lead was placed in the middle cardiac vein. After cardiosurgical procedure (VSD closure and atrioventricular valves replacement), the clinical symptoms of heart failure were still present. They diminished while the patient was on escape rhythm (40–70 bpm). Therefore, the previously implanted leads were removed and the transvenous, biventricular system was implanted, which resulted in a significant clinical improvement.     

心脏再同步治疗术后患者死亡原因分析

目的探讨心力衰竭患者心脏再同步治疗（CRT）术后的死亡原因及相关影响因素。方法对110例行CRT的心力衰竭患者[其中7例植入带有心脏再同步治疗除颤器（CRT—D）]进行长期随访,观察患者术后的转归情况,以及死亡患者的死亡原因、生存时间和相关影响因素。结果110例患者中有92例患者完成随访研究,随访1～132（48±28）个月,共死亡30例,死亡率为32．6％,5年生存率为66．9％±5．8％。24例为心脏性死亡,占总体死亡的80％,其中包括11例为心力衰竭恶化导致的死亡,13例为心脏性猝死（SCD）,其余6例为非心脏性死亡。14例行CRT的持续性心房颤动（房颤）患者中有8例死亡;71例行CRT的窦性心律患者中死亡22例;前组的中位生存时间短于后组（50比87,P=0．013）;7例植人CRT—D的患者均无死亡;3组患者的死亡率差异有统计学意义（P=0．01）。合并慢性肾功能衰竭的CRT患者死亡率（66．7％）较无肾功能不良者（20．6％）高（相对危险度：3．24,95％CI1．88～5．59,P〈0．001）。结论CRT患者的主要死亡原因是心脏性死亡,其中包括心力衰竭恶化和SCD。CRT—D和CRT两组患者之间的死亡率差异有统计学意义,接受CRT的窦性心律患者较持续性房颤患者有显著的生存获益。合并慢性肾功能衰竭的CRT患者预后较差。对于合并持续性房颤的CRT患者同时给予房室结消融有可能进一步提高生存率。     

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.