心脏再同步化治疗中经胸心外膜起搏导线的植入技术

目的探讨经胸心外膜左心室导线植入在慢性充血性心力衰竭心脏再同步化治疗中的意义。方法对1例经静脉植入左心室导线因冠状静脉窦开口畸形而放弃的患者行经胸植入左心室心外膜导线植入。结果右心房、右心室心内膜起搏导线植入及两根心外膜起搏导线缝合均顺利,术后未出现严重并发症。术后2周后临床症状逐渐改善,NYHA心功能分级从术前Ⅲ、Ⅳ级提高至Ⅱ级,LVEDD从72mm减至66mm,优化程控起搏器后超声心动图描记术检查室间隔基底部与左心室侧壁间失同步性改善,第3天心外膜起搏导线阈值从术中的2.0V降为0.5V且稳定。已随访12周临床症状、心功能改善,组织多普勒显像示左心室内恢复同步化。结论心脏再同步化治疗经胸心外膜左心室导线植入是安全、可行的,特别是对经静脉途径失败的患者,是可选择的方法之一;术中左心室导线的定位及术后的综合处理十分重要。     

心脏再同步化治疗充血性心力衰竭的临床分析

目的:观察心脏再同步化治疗(CRT)脉冲起搏器对充血性心力衰竭患者的临床疗效。方法:选择10例心功能NYHAⅢ～Ⅳ级、起搏前心电图QRS平均时限≥140ms患者,植入CRT起搏器。应用超声心动图测定CRT起搏器植入前和术后1年后左心功能变化。结果:植入CRT起搏器后,NYHA分级、6min步行距离明显改善,左心室射血分数和舒张充盈增加,心电图QRS时限缩短。结论:心脏再同步化治疗充血性心力衰竭疗效明显。     

左室双部位心室三位点起搏心脏再同步化治疗

目的介绍左室双电极行心室三部位起搏心脏再同步化治疗射血分数(EF)值降低心力衰竭的的经验和临床疗效。方法 2012年8月至2014年7月共有3例心房颤动伴完全性左束支传导阻滞的女性患者,因EF值降低心力衰竭植入左室双电极行心室三部位起搏心脏再同步化治疗。局麻下采用微创介入方法,在钢丝导引下送一根左室电极至心大静脉或侧静脉;另送一根左室电极至侧静脉或后静脉;再送心室电极入右室心尖部,分别连接脉冲发生器的心房、左室和右室孔。结果 3例患者均手术成功,术中起搏参数满意,无并发症发生。随访2,12,24个月,1例患者出现导线移位和起搏阈值增高,患者心功能恶化。其他2例患者心功能明显改善,超声提示心脏缩小,左室EF升高,起搏器参数理想。结论对于EF降低心力衰竭伴永久性心房颤动、有心脏再同步治疗指征的患者,经皮左室双电极行心室三部位起搏心脏再同步化治疗是安全、疗效较好的方法。     

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.     

心脏同步化治疗慢性心力衰竭疗效及临床经验总结

目的总结心脏同步化起搏治疗慢性心力衰竭的疗效及临床经验。方法回顾性分析接受再同步化治疗的26例慢性心力衰竭伴心室内传导延迟患者的临床资料,着重分析再同步化治疗的方法和疗效。结果患者均接受心脏再同步化治疗,年龄（57.0±11.6）岁,男22例（84.6%,22/26）,其中再同步化转复除颤器16例（62%,16/26）,非缺血性心肌病22例（85%,22/26）,9例（35%,9/26）有慢性房性心律失常,2例需外科植入左心室心外膜电极。心脏再同步化治疗后QRS波时限由（161±29）ms缩短为（137±15）ms,差异有统计学意义（P≤0.01）;患者心功能均有明显改善,心功能分级比治疗前降低,差异有统计学意义[（1.9±0.9）级vs.（3.2±0.6）级,P≤0.01];射血分数比治疗前提高,差异有统计学意义（34.0%±13.3%vs.24.9%±6.8%,P≤0.01）。6分钟步行距离、血清脑钠肽浓度以及左心室舒张或收缩末内径均有显著改善（P≤0.05）。术后随访（2.5±1.7）年,7例（27%,7/26）死亡,其中2例心源性猝死。结论心脏同步化起搏治疗显著改善慢性心力衰竭患者心功能,逆转心肌重构,减低病死率。     

左心室心内膜起搏

传统的心脏再同步化治疗(CRT)通过心外膜起搏左心室,在优化的室间间期下,与右心室心内膜导线共同实现双心室起搏,逐步改善慢性心力衰竭(心衰)患者的心脏同步性和心功能,降低心衰住院率和全因死亡率。但左心室心外膜起搏受冠状静脉解剖的影响,导线相关并发症相对较多,影响了CRT疗效。左心室心内膜起搏可以避免血管条件的限制,实现更佳的再同步、减少导线相关并发症,因而成为现阶段的研究热点。     

小儿植入心外膜永久起搏器术后22例随访分析

目的探讨小儿植入心外膜永久起搏器的治疗效果、并发症及心功能状况。方法对22例儿童植入心外膜永久起搏器。其中男10例,女12例,手术年龄8.5个月(3 d~11岁),体质量6.35(2.7~43.6)kg。因先天性心脏病术后Ⅲ°房室传导阻滞而植入起搏器18例,先天性完全性房室传导阻滞2例,阿斯综合征和病态窦房结综合征各1例。随访3个月~5年3个月,收集患者检查结果及心室夺获阈值、电极阻抗等电生理学信息。结果除1例植入双腔起搏器外,其余均植入单腔起搏器。与心动过缓有关的临床症状消失,患儿发育良好,起搏和感知功能良好。有2例(9.1%)患儿死亡(原因不明),3例(13.6%)出现电池提前耗竭而重新植入起搏器,未出现电极断裂、移位及囊袋感染等并发症。末次复查超声心动图左心室射血分数为66%±6%,有1例(4.8%)患者出现心功能不全,左心室射血分数为51%,没有因心力衰竭入院的患者。将末次复查心室夺获阈值、电极阻抗、灵敏度与植入起搏器即刻进行比较,未发现显著变化。结论心外膜起搏近、中期治疗效果令人满意。本组出现因安装单腔起搏器导致心功能不全的患者,需进一步优化起搏器选择策略。     

双心室同步起搏治疗充血性心力衰竭的临床应用

目的　观察三腔双心室起搏治疗充血性心力衰竭效果。方法　患者男性 2例 ,女性 1例 ,平均年龄 5 7岁 ,为充血性心功能衰竭伴左束支阻滞 ,植入三 (四 )腔双心室起搏器。左心室起搏通过冠状静脉窦植入 2 187或 2 188电极导线 ,置于心后静脉起搏左心室 ,左右心室电极导线通过 Y形转接器与双腔起搏器连接。结果　双心室起搏并辅以合适的 AV延迟后 ,患者心力衰竭症状明显改善 ,N YHA分级从 ～ 级改善至 级 ,二尖瓣返流明显减少。结论　初步临床应用提示 ,双心室同步起搏治疗充血性心力衰竭是可行而有效的     

无导线心脏起搏

<正> 自1958年人工心脏起搏器问世后,其各种功能都发生了瞩目的发展,然而掣肘起搏器应用的并发症却仍然较多,其中经静脉植入式电极导线带来的问题是其主要原因,资料表明:起搏器植入10年内约21%的电极导线发生了故障,这给一定比例的患者增加了痛苦,甚至危及了生命。即使在追求心室再同步化治疗的时代,经静脉置人式电极的局限性不可避免,如:受冠状静脉窦先天发育的影响,左心室起搏电极不能进入冠状窦或不易到达理想的起搏部位;为此,人们一直在探寻无电极导线起搏技术。     

经室间隔穿刺植入心脏再同步化治疗左心室心内膜导线的经验

目的:对于经冠状窦途径植入心脏再同步化治疗(CRT)左心室心外膜导线失败的患者,探讨采用经室间隔穿刺的方法植入左心室心内膜导线的安全性和疗效。方法:2例患者因冠状窦畸形经冠状窦途径植入CRT左心室心外膜导线失败,采用经室间隔穿刺的方法植入左心室心内膜导线,随访电极参数及CRT疗效。结果:2例患者均成功采用经室间隔穿刺的方法植入CRT左心室心内膜导线,随访期间电极参数稳定,未见明显不良事件,患者心功能得到改善。结论:针对经冠状窦途径植入CRT左心室心外膜导线失败的患者,采用经室间隔穿刺的方法植入左心室心内膜导线获得成功,但因例数少,该方法的安全性及有效性仍值得进一步研究。     

心内膜电极心肌内埋置心脏再同步化治疗扩张型心肌病心力衰竭

目的探讨经胸心内膜电极心肌内埋置技术进行扩张型心肌病心力衰竭(简称心衰)的同步化治疗(CRT)效果。方法对1例置入冠状静脉窦电极困难导致心包压塞的扩张心肌病患者行经胸心内膜电极心肌内埋置技术进行电极置入,进行三腔起搏同步化治疗心衰。结果组织多普勒显示患者的房室、左室内存在明显收缩不同步,但在放置静脉窦电极时心脏穿孔出血。由于急诊条件无法使用心外膜电极,在开胸止血后右房、右室、左室均行心内膜电极心肌内埋置,未出现严重并发症。术后临床症状逐渐改善,NYHA心功能分级从术前Ⅲ-Ⅳ级提高至Ⅱ级,左室舒张末径从88mm减至68mm,优化程控起搏器后超声心动图描记原来收缩最延迟的左室侧壁和后壁中间段均有明显的达峰时间大幅缩短,分别缩短252ms和204ms。左室内最大收缩延迟由415ms缩短为163ms,左室收缩不同步指数由193ms缩短为65ms。随访3个月后电极的起搏阈值没有明显变化。结论经胸心内膜电极心肌内埋置技术进行扩张型心肌病心衰的CRT是安全、可行的,特别是静脉窦电极放置失败而无法选用心外膜电极时是可选择的方法。     

心脏再同步治疗在窄QRS波慢性心力衰竭患者的疗效观察

目的:观察窄QRS波慢性心力衰竭(CHF)患者的双心室再同步治疗的临床疗效。方法:筛选16例窄QRS波CHF患者行双心室再同步治疗,所有病例均经冠状静脉窦植入左心室导线至心脏静脉,术后平均随访1～43个月,平均13个月,观察心功能、左心室射血分数、二尖瓣反流面积、左心室舒张末和收缩末内径等的变化。结果:16例患者治疗后心功能明显改善,有效率75%,心功能从Ⅲ～Ⅳ级(NYHA分级)改善为Ⅱ～Ⅲ级,左心室射血分数从(0.31±0.11)%提高至(0.38±0.10)%,P0.05,每搏输出量从(74±8)ml提高至(96±4)ml,P0.05,二尖瓣反流面积从(8±4)cm2减少至(6±3)cm2,P0.05,左心室舒张末内径、收缩末内径虽有缩小趋势但没有显著差异[(69±7)mmvs.(68±9)mm;(59±10)mmvs.(56±11)mm]。结论:双心室再同步治疗对某些窄QRS波CHF患者同样有效。     

Coronary sinus stenting for the stabilization of left ventricular lead during resynchronization therapy.

We report on two patients treated with cardiac resynchronization therapy, in whom early (intra-operatively, 64-year-old man) and late (4 months post-operatively, 57-year-old woman) instability of the left ventricular (LV) lead occurred. In order to stabilize the electrodes, stents were deployed in both patients within the coronary sinus, into the space between the lead and the wall of the vein effectively pinning the lead to the wall. During 3 and 5 months of follow-up, the electrodes remained stable and allowed for successful resynchronization in both cases. Stenting within the coronary sinus seems to be a safe method for LV lead stabilization, which can substantially increase the success rate of resynchronization therapy. This new approach, although promising, has to prove its safety and should not be practised routinely until long-term follow-up data are available.     

Isolation of the phrenic nerve to suppress diaphragmatic contraction induced by cardiac resynchronization

Left phrenic nerve stimulation is a well-known complication of cardiac resynchronization therapy (CRT). We report a case where electronic or anatomical repositioning of the left ventricular (LV) electrode (within the coronary sinus tributaries) was not feasible/effective. Surgical graft interpositioning was performed to successfully isolate the phrenic nerve from the previously implanted coronary sinus epicardial LV lead.     

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。     

心脏再同步化治疗心力衰竭伴传导阻滞患者的近期随访

目的 观察心脏再同步化治疗（CRT）心力衰竭伴传导阻滞患者心功能改善情况.方法 连续入选在我科住院的终末期心力衰竭患者45例,按照QRS时限、形态分为完全性左束支传导阻滞组、完全性右束支传导阻滞组和非特异性室内传导阻滞组,分别评估、测量三组患者术前及术后6个月的NYHA分级、左室舒张末内径（LVED）、左室射血分数（LVEF）及血浆B型利钠肽（BNP）浓度.结果 完全性左束支传导阻滞组和非特异性室内传导阻滞组患者术后NYHA分级改善[（2.8±0.3）级比（3.6±0.2）级,（2.9±0.3）级比（3.5±0.4）级,P＜0.05],LVED缩小[（67.2±7.5）mm比（74.2±6.5）mm,（66.4±9.9）mm比（75.8±9.1）mm,P＜0.05],LVEF增大[（33.6±7.7）％比（26.6±7.2）％,（44.4±5.1）％比（28.6±5.7）％,P＜0.05],血浆BNP浓度下降[（3988.4±628.3）pg/ml比（8542.6±1384.9）pg/ml,（3573.2±749.5）pg/ml比（6666.2±1110.5）pg/ml,P＜0.05];完全性右束支传导阻滞组NYHA分级没有改善[（3.3±0.2）级比（3.4±0.3）级,P＞0.05],LVED无变化[（61.2±5.0）mm比（62.4±4.3）mm,P＞0.05],LVEF没有增大[（35.2±12.3）％比（33.4±11.8）％,P＞0.05],血浆BNP浓度无明显变化[（6844.7±774.8）pg/ml比（7558.6±1327.4）pg/ml,P＞0.05].结论 心脏再同步化治疗能够改善完全性左束支传导阻滞及非特异性室内传导阻滞患者的心脏功能,不能改善完全性右束支传导阻滞患者的心脏功能.     

Baseline characteristics of patients randomized in The Resynchronization Reverses Remodeling In Systolic Left Ventricular Dysfunction (REVERSE) study

The Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction (REVERSE) study is a randomized controlled trial currently assessing the safety and efficacy of cardiac resynchronization therapy in patients with asymptomatic left ventricular (LV) dysfunction with previous symptoms of mild heart failure. This paper describes the baseline characteristics of randomized patients; 610 patients with New York Heart Association (NYHA) class II (82.3%) heart failure or asymptomatic (NYHA class I) LV dysfunction with previous symptoms (17.7%) were randomized in 73 centers. The mean age was 62.5+/-11.0 years, the mean LV ejection fraction was 26.7%+/-7.0%, and the mean LV end-diastolic diameter was 66.9+/-8.9 mm. A total of 97% of patients were taking angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and 95.1% were taking beta-blockers, which were at the target dose in 35.1% of patients. Compared with previous randomized cardiac resynchronization therapy trials, REVERSE patients are on better pharmacologic treatment, are younger, and have a narrower QRS width despite similar LV dysfunction.     

Role of multislice computed tomography for preprocedural evaluation before revision of a chronically implanted transvenous left ventricular lead

The purpose of this study was to determine the feasibility of multislice computed tomography (MSCT) to assess the coronary sinus (CS) and its tributaries in patients who are undergoing cardiac resynchronization therapy and need a left ventricular (LV) lead revision. Preprocedural imaging modality, which may enable delineation of the cardiac venous anatomy in patients who need LV lead replacement, has not yet been evaluated. Ten patients with heart failure with previously implanted cardiac resynchronization therapy devices, who presented with worsening heart failure, were studied with MSCT and tissue Doppler imaging echocardiography before LV lead replacement. MSCT was performed to evaluate patency of the CS and coronary veins, and tissue Doppler imaging echocardiography assessed the region and the magnitude of mechanical dyssynchrony. An excellent concordance in the vein diameter, location, and status between MSCT and angiography was found. Apart from the need to perform a venoplasty in 1 patient and an unsuccessful lead explantation in another patient, all other anatomic issues were correctly predicted by MSCT. CS or vein occlusion were present in 4 patients, and in 3 of them surgical LV lead replacement was performed. Identification of a patent venous system enabling successful transvenous lead implantation was possible in 2 patients. Direct visualization of the proximity of the target vein to the phrenic nerve and the diaphragm guided lead selection and position in 4 patients. In conclusion, MSCT may be used to delineate the coronary venous anatomy in patients in whom LV lead replacement is needed to help strategize whether a transvenous or transthoracic approach may be preferred for LV lead revision.     

Myocardial gene expression in heart failure patients treated with cardiac resynchronization therapy responders versus nonresponders.

OBJECTIVES: We studied whether functional improvement after cardiac resynchronization therapy (CRT) is associated with reversal of the heart failure (HF) gene program. BACKGROUND: Cardiac resynchronization therapy improves exercise tolerance and survival in patients with advanced congestive HF and dyssynchrony. METHODS: Twenty-four patients referred for CRT underwent left ventricular (LV) endomyocardial biopsies immediately before CRT implantation (baseline). In addition, 17 of them underwent LV endomyocardial biopsy procurement 4 months later (follow-up). In 6 control patients with normal LV function, LV biopsies were obtained at the time of coronary artery bypass grafting. The LV messenger ribonucleic acid (mRNA) levels of contractile and calcium regulatory genes were measured by quantitative real time polymerase chain reaction and normalized for glyceraldehyde 3-phosphate dehydrogenase (GAPDH). The HF patients showing an improvement in New York Heart Association (NYHA) functional class by >1 score and a relative increase in LV ejection fraction > or =25% at 4 months after CRT were considered as responders. RESULTS: The HF patients were characterized by lower LV mRNA levels of alpha-myosin heavy chain (alpha-MHC), beta-myosin heavy chain (beta-MHC), sarcoplasmic reticulum calcium ATPase 2alpha (SERCA), phospholamban (PLN), and higher brain natriuretic peptide (BNP) mRNA levels as compared with control subjects. Responders to CRT (n = 11) showed an increase in LVEF (p < 0.001), a decrease in left ventricular end-diastolic diameter (p = 0.003), and NYHA functional class (p = 0.002), and a reduction in N-terminal proBNP levels (p = 0.032) as compared with baseline. This was associated with an increase in mRNA levels of alpha-MHC (p = 0.035), SERCA (p = 0.032), a decrease in BNP mRNA levels (p = 0.002), and an increase in the ratio of alpha-/beta-MHC (p = 0.018) and SERCA/PLN (p = 0.012). No significant changes in molecular profile were observed in nonresponders. CONCLUSIONS: In HF patients with electromechanical cardiac dyssynchrony, functional improvement related to CRT is associated with favorable changes in established molecular markers of HF, including genes that regulate contractile function and pathologic hypertrophy.