双心室再同步化起搏患者焦虑抑郁情绪测评及心理干预研究

目的:探讨双心室同步化起搏(Biventricular pacing,CRT)患者手术前后焦虑抑郁情绪以及心理干预对其的影响。方法:30例行双心室同步化起搏患者术前及术后一天均进行焦虑抑郁情绪测评[医院焦虑抑郁情绪量表(HAD,包括焦虑(A)和抑郁(D)部分)和Beck抑郁量表(BDI量表)],并将患者随机分为心理干预组和非心理干预组各15例,一周后再次评定焦虑抑郁情绪,比较两组统计学差异。结果:所有双心室同步起搏患者术后一天焦虑抑郁情绪对术前[HAD(A):(6.82±3.96)vs(9.95±4.76);HAD(D):(5.53±3.37)vs(9.12±6.04);BDI:(7.41±5.01)vs(12.76±8.04)]明显改善(均P<0.05)。术后一周非心理干预组焦虑抑郁差值与心理干预组比较有显著统计学意义,且心理干预组术后焦虑抑郁情绪较术前比较亦有明显改善[HAD(A):(4.59±3.54)vs(9.95±4.76);HAD(D):(4.59±2.83)vs(9.12±6.04);BDI:(5.41±3.92)vs(12.76±8.04)],P<0.05,差别有显著统计学意义。结论:双心室同步化起搏能改善心肌病患者焦虑抑郁情绪,术后早期心理干预治疗能更加显著改善患者焦虑和抑郁情绪,为该类患者术后提高生活质量,减轻医疗负担,具有显著临床意义。     

心脏静脉球囊扩张及双心室同步起搏

临床资料.患者男性，54岁，因反复发作胸闷气短4年加重1个月入院，既往高血压病史30余年，未行系统降压治疗。入院后查心电图QRS波130ms，超声心动图示左心室舒张末期内径(LVEDD)75mm，左心室射血分数(LVEF)0．35。诊断为高血压性心脏病，心功能Ⅲ级(NYHA分级)。入院后给予药物治疗心力衰竭，在病情相对稳定的情况下，接受三腔双心室起搏治疗。     

心脏再同步治疗:双心室起搏还是希氏-浦肯野系统起搏?

希氏-浦肯野系统(希浦系统)起搏是近年出现的除传统双心室同步起搏外同样能达到心脏再同步治疗(CRT)的新方法。本文阐述了2种方法达到CRT的途径、机制、临床证据及各自的利弊,并对现阶段CRT方式的选择提出了建议。     

心脏再同步化起搏治疗随访

目的探讨心脏再同步化起搏治疗(CRT)随访的相关技术细节。方法22例难治性充血性心力衰竭(简称心衰)患者(男14例、女8例),年龄59.5±7.8(47~74)岁,其中扩张型心肌病16例、高血压性心脏病6例。按常规方法置入双室起搏器后,按一定程序对起搏系统及患者的临床综合反应随访观察,根据患者反应及时对起搏系统参数进行优化。结果随访22±13.01(1~48)个月,双室起搏辅以优化的起搏参数及药物治疗。心衰临床症状改善,心功能提高,运动耐量增加,生活质量提高,心脏重塑进程延缓,因心衰住院事件减少。结论CRT必须从置入起搏器的即刻开始进行动态随访、优化起搏参数。     

双心室起搏心电图的额面心电轴分析

目的 分析行心脏再同步治疗（CRT）的患者在不同起搏模式下的心电图QRS波电轴的分布特点,以及与左心室导线位置、左心室逆重构的关系.比较12导联同步心电图机自动分析与手动测量的心电轴的差异.方法 入选2012年11月到2013年6月在上海复旦大学附属中山医院行CRT植入的41例患者,分别记录患者术后3个月在单纯左心室起搏,左心室提前60ms、40ms、20ms、0ms,右心室提前20ms、40ms,单纯右心室起搏的12导联同步心电图共326份,记录12导联同步心电图机自动分析得出的心电轴,同时手动测量I和aVF导联QRS波的净振幅,代入公式：心电轴=57.3＆#215;ATAN（aVF/I）,计算相应的心电轴.比较术前、术后6个月超声心动图结果[左心室收缩未期内径（LVESD）],明确有无左心室逆重构发生.左心室逆重构定义为术后6个月LVESD减小≥15％.根据手术中左前斜位、后前位X线透视片明确左心室导线位置.结果 ①随着右心室起搏成分的减少,左心室成分的增加,QRS波额面电轴逐渐由左偏转为右偏（r,=0.412,P＜0.001）,不同的VV间期之间,QRS波额面电轴的分布不全相同（Pearson x2=68.7,P＜0.001）;②左心室导线植入部位与心电轴分布之间无明显的相关性（rs=0.08,P=0.149）;③在双心室同步起搏模式下,不同QRS波电轴分布范围,左心室逆重构的发生率差异无统计学意义（P=0.115）;④12导联同步心电图机自动分析与手动测量的QRS波额面电轴一致性程度一般（ICC=0.563,95％ CI：0.483～ 0.635,F=3.58,P＜0.001）.结论 VV间期的改变可使QRS波电轴产生迁移,起搏成分从右心室主导转移为左心室主导时,QRS波额面电轴出现顺时针偏移的现象.QRS波心电轴与左心室导线位置相关性差,仅根据心电轴难以判断左心室导线的位置.单一时间点双心室同步起搏QRS波电轴对于左心室逆重构无预测价值.12导联同步心电图机自动分析出的QRS波额面电?     

CRT 起搏心电图的分析与诊断

心脏再同步化治疗（cardiac resynchronization therapy,CRT）已经成为慢性心力衰竭伴心室不同步的Ⅰ类适应证,临床上 CRT 起搏心电图大量增加。在 CRT 起搏心电图分析和诊断中,必须掌握以下特点：①左右心室单独起搏的心电图特点;②窦性心律下,房室顺序和心室顺序起搏的心电图特点;③异位心律下 CRT 起搏心电图的特点;④ CRT 起搏器的特殊功能。     

一例心室起搏管理患者的心电图分析

1例因房室传导阻滞(AVB)植入具有心室起搏管理(MVP)功能起搏器患者的心电图,当房室传导功能正常时,以AAIR模式工作。出现间歇或短暂AVB,提供心室备用起搏。出现持续性AVB,转换为DDDR模式工作。具有MVP功能的起搏器可降低累计心室起搏百分比。     

心室起搏管理减少心室起搏比例的临床随访

目的探讨心室起搏管理(Managed Ventricular Pacing,MVP)对永久起搏器植入患者累计心室起搏比例(cumulative ventricular pacing proportion,Cum VP%)的影响。方法 (1)42例患者植入具有MVP功能的起搏器后,分别在常规DDDR和MVP两种工作状态下进行随访研究。其中先以常规DDDR状态工作1个月后,再以MVP状态工作1个月、6个月和12个月,分别计算累计心房起搏百分比(Cumulative atrial pacing proportion,Cum AP%)和Cum VP%;(2)计算在两种不同工作状态下Cum VP%小于40%的人数比例;(3)了解相关不良事件发生情况。结果 (1)传统DDDR模式工作1个月后,42例患者Cum VP%为(95.12±26.32)%。MVP模式工作下第1、6和12个月Cum VP%分别为:(19.63±44.80)%;(17.11±39.63)%;(15.62±46.80)%,(P0.05);(2)常规DDDR工作状态下Cum VP%小于40%的人数为0;而MVP模式下随访期间分别为(95.21±7.81)%;(96.73±3.20)%;(97.70±2.80)%(P0.05);(3)随访期间无相关不良事件发生。结论与传统DDDR模式相比,MVP模式可显著减少Cum VP%。     

心室起搏管理的原理与心电图图例分析

心室起搏管理是以心房为基础的双腔起搏模式,抛弃了传统双腔起搏模式固有存在的心房和心室事件的一一对应关系,是最小化心室起搏策略的一种新功能,可表现出一些独特的心电图现象。     

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。     

Permanent His-bundle pacing as an alternative to biventricular pacing for cardiac resynchronization therapy: A multicenter experience

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心房起搏后双结功能的远期电生理随访

目的　了解心房按需起搏器（ＡＡＩ）植入术后窦房结和房室传导功能的远期转归。方法　对２２ 例植入ＡＡＩ起搏器患者用食管心房起搏检测术后远期双结功能电生理参数，并与术前比较分析（ｔ检验）。随访时间３０～１０２ 个月。结果　窦房结功能：ＳＡＣＴ、ＳＮＲＴ、ＣＳＮＲＴ参数与术前比较（Ｐ＞ ０．２５）差异无显著性。房室传导功能：心电图未发现显性房室传导障碍，术前房室传导功能障碍者未见明显加重，检测房室传导文氏阻滞点无隐性阻滞，与术前比较（Ｐ＞ ０．２５），差异无显著性。房室传导２∶１ 阻滞点，与术前比较（Ｐ＞ ０．２５）差异无显著性。结论　病态窦房结综合征患者植入ＡＡＩ起搏器后，窦房结功能和房室传导功能未见有意义的减退，也未出现起搏器依赖性     

Optimizing sequential biventricular pacing using radionuclide ventriculography

BACKGROUND: Biventricular pacemakers are usually programmed with the default setting of synchronous biventricular pacing, although the ventricles may be paced sequentially. Whether this parameter is important for optimizing resynchronization therapy is not clear. OBJECTIVES: The purpose of this study was to investigate whether sequential pacing acutely improves left ventricular ejection fraction (LVEF) and dyssynchrony and to assess the feasibility of nuclear ventriculography for device optimization. METHODS: Twenty-seven patients implanted with a biventricular pacemaker or implantable cardioverter-defibrillator for heart failure were studied. LVEF was measured using planar radionuclide ventriculography during simultaneous biventricular pacing and during sequential pacing at four different interventricular intervals ranging from LV-40 (preexciting the left ventricle by 40 ms) to LV+40 (preexciting the right ventricle). Interventricular and intraventricular dyssynchrony were analyzed by phase analysis at each setting. RESULTS: There was great heterogeneity in individual response to VV interval programming. Twenty-four of 27 patients (89%) had significant changes (both favorable and unfavorable) in LVEF at different interventricular delays, with variations of up to 10% in absolute terms. Simultaneous biventricular pacing yielded maximal LVEF in 9 of 27 patients (33%), with a relative increase in LVEF of 18 +/- 14% by optimized sequential pacing in the remaining patients. Interventricular dyssynchrony varied significantly, with least dyssynchrony at the LV-20 setting (P = .024). There were no significant differences in intraventricular dyssynchrony at the different settings. CONCLUSION: Programming VV intervals has considerable impact on LVEF. However, there is a great degree of variation between patients in response to these settings, requiring individual assessment for device optimization.     

Clinical outcomes of conduction system pacing compared to biventricular pacing in patients requiring cardiac resynchronization therapy

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Predictors of super-response to cardiac resynchronization therapy: the significance of heart failure medication, pre-implant left ventricular geometry and high percentage of biventricular pacing

Background Super-responders (SRs) are defined as patients who show crucial cardiac function improvement after cardiac resynchronization therapy (CRT). The purpose of this study is to identify and validate predictors of SRs after CRT. Methods This study enrolled 201 patients who underwent CRT during the period from 2010 to 2014. Clinical and echocardiographic evaluations were conducted before CRT and 6 months after. Patients with a decrease in New York Heart Association (NYHA) functional class ≥ 1, a decrease in left ventricular end-systolic volume (LVESV) ≥ 15%, and a final left ventricular ejection fraction (LVEF) ≥ 45% were classified as SRs. Results 29% of the 201 patients who underwent CRT were identified as SRs. At baseline, SRs had significantly smaller left atrial diameter (LAD), LVESV, left ventricular end-diastolic volume (LVEDV) and higher LVEF than the non-super-responders (non-SRs). The percentage of patients using angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARB) was higher in SRs than non-SRs. Most SRs had Biventricular (BiV) pacing percentage greater than 98% six months after CRT. In the multivariate logistic regression analysis, the independent predictors of SRs were lower LVEDV [odd ratios (OR): 0.93; confidence intervals (CI): 0.90–0.97], use of ACEI/ARB (OR: 0.33; CI: 0.13–0.82) and BiV pacing percentage greater than 98% (OR: 0.29; CI: 0.16–0.87).Conclusion Patients with a better compliance of ACEI/ARB and a less ecstatic ventricular geometry before CRT tends to have a greater probability of becoming SRs. Higher percentage of BiV pacing is essential for becoming SRs.     

Regression of dilated-hypokinetic hypertrophic cardiomyopathy by biventricular cardiac pacing.

The evolution of hypertrophic cardiomyopathy (HCM) towards dilatation and hypokinesis is an increasingly recognized complication with a high incidence of adverse outcomes, including sudden cardiac death, requiring defibrillator implantation and cardiac transplantation. It is generally regarded as the irreversible 'burnt-out' end-stage manifestation of HCM. We report one of the first cases of profound regression of the dilated-hypokinetic state by the application of biventricular pacing and cardiac resynchronization therapy (CRT). Reviewing the literature on the role of pacing in HCM and the energetic rationale for CRT in HCM prompts us to suggest that further systematic studies are needed urgently to assess the role of CRT in HCM variants.     

双心室起搏的初步临床经验

目的 探讨缺血性或扩张型心肌病合并充血性心力衰竭行永久性双心室起搏治疗的临床效果。方法 对５例缺血性或扩张型心肌病合并难治性心力衰竭和左束支阻滞患者常规植入右心室起搏导线的同时植入冠状静脉窦导线于心大静脉或心中静脉,分别行右心室心尖部起搏及双心室起搏,应用Ｓｗａｎ－Ｇａｎｚ导管或超声心动图测定不同起搏地心功能的影响。结果 在充血性心力衰竭合并左束支阻滞患者植入冠状静脉窦导经至心大静脉或心中静脉行以     

Acute and chronic haemodynamic effects of biventricular pacing and of switching to different pacing modalities in heart failure patients

BACKGROUND: In patients with severe heart failure, sinus rhythm and wide QRS complex biventricular (BiV) pacing leads to clinical and haemodynamic improvement, but the immediate reversibility of these changes is not known. METHODS: We assessed the acute and medium-term (3-month) haemodynamic effects of BiV pacing and of switching to other pacing modalities in 21 patients with severe heart failure, sinus rhythm and QRS>or=130 ms. Haemodynamic studies were performed: 1) at the time of implantation of a BiV pacing device, during AAI pacing, atrial synchronous right ventricular (RV) pacing, atrial synchronous left ventricular (LV) pacing and atrial synchronous BiV pacing (all at 100 bpm); 2) after 3 months of continuous BiV pacing--with evaluations being made by switching to RV and the other pacing modalities. RESULTS: At both the acute and medium-term evaluations, BiV pacing provided the greatest improvement in cardiac index. Switching from BiV to RV pacing led to a more marked decrease in the cardiac index at 3 months. No strict correlation was evident between acute and medium-term effects of BiV pacing on cardiac index. CONCLUSION: Cardiac resynchronization by BiV pacing provides acute/medium-term improvements in cardiac index. Sudden, medium-term failure of LV stimulation can lead to an even more pronounced haemodynamic derangement than that inducible by RV pacing at baseline. Acute haemodynamic evaluations do not seem to provide a powerful way for identifying medium-term responders.     

Comparison of different approaches for optimization of atrioventricular and interventricular delay in biventricular pacing

Aims: It has been shown that optimizing atrioventricular (AV) andinterventricular (VV) delay improves cardiac performance inpatients with biventricular pacemakers. However, there is nostandard method for optimization available yet. The aim of thisstudy was to compare echocardiographic parameters—displacementimaging, A wave duration, and aortic velocity time integral(VTI)—and acoustic cardiography derived electromechanicalactivation time (EMAT) using different approaches of AV andVV delay optimization. We tested whether the initial optimizationof the AV interval followed by VV optimization at that optimalAV interval or initial optimization of the VV interval followedby AV optimization at the determined optimal VV interval wasaccurate and consistent, and how this compared to testing everyconceivable combination of AV and VV intervals available. Methods and results: A group of 20 patients with biventricular pacemakers was included.Displacement imaging, A wave duration, and aortic VTI were determinedat different combinations of AV (100, 150, 200, 250 ms) andVV (RV40, 0, LV40 ms) intervals. If AV duration was determinedfirst, displacement imaging identified the best setting in 8/20,aortic VTI in 10/20, A duration in 13/20, and EMAT in 18/20patients. With VV duration determined first, the best settingwas more difficult to identify regardless of the method used.There was a poor agreement in optimal AV and VV delays of thedifferent methods, and there was no single patient in whom allfour methods yielded the same delay combination. Conclusion: It is advisable to measure a full grid of AV and VV delays toidentify optimal settings rather than optimizing one of thetwo delays first. Different techniques for delay optimizationresulted in different optimal delay combinations.