心脏再同步治疗的随访及疗效观察

目的探讨心脏再同步化起搏治疗（CRT）的长期疗效以及随访相关技术细节。方法15例慢性心力衰竭患者,男性13例,女性2例,平均年龄72．25岁,其中扩张性心肌病8例、缺血性心肌病5例、高血压性心脏病2例。按常规方法置入CRT后对起搏系统参数进行优化,观察长期疗效。结果随访12个月,经过双心室起搏辅以优化的起搏参数及药物治疗,左心室射血分数从29％提高至42％,差异有统计学意义（P〈0．01）;左心室舒张末内径从65．8mm缩小至59．6mm,差异有统计学意义（P〈0．01）;QRS波从144ms缩短至124ms,差异有统计学意义（P〈O．01）;心衰临床症状减轻,心功能改善,运动耐量增加,生活质量提高,心脏重塑进程延缓,因而心衰住院事件减少。结论CRT能够使心衰患者临床症状减轻,心功能改善,生活质量提高,心脏重塑进程延缓。随访优化起搏参数和药物治疗对提高疗效是十分重要的。     

心脏再同步化治疗慢性心力衰竭伴持续性心房颤动的疗效观察

目的评价心脏再同步化治疗(CRT)慢性心力衰竭(心衰)合并持续性心房颤动(房颤)患者的临床疗效。方法选择慢性心衰患者23例,其中13例窦性心律患者及4例房颤患者(房颤CRT患者)接受双心室起搏治疗,另6例房颤患者(药物治疗患者)继续服用抗心衰药物治疗。术后3个月进行随访,观察患者的心功能分级(NYHA),6 min步行距离,超声心动图测定各房室腔内径大小、LVEF、二尖瓣反流以及速度向量成像超声评价同步性参数的变化。结果 17例患者三腔起搏器置入术均取得成功。术后3个月随访,房颤CRT患者心功能分级[(3.00±0.00)级vs(2.25±0.50)级]、左心房内径[(52.75±3.50)mm vs (45.25±3.50)mm,P<0.05]、LVEF[(36.25±4.79)% vs (42.00±5.16)%]及二尖瓣反流(3.25±0.50 vs 1.50±0.58,P<0.01)较术前均有明显改善,速度向量成像超声结果显示,室内不同步较术前有明显改善。与药物治疗患者比较,房颤CRT患者LVEF、左心房内径、二尖瓣反流明显改善。结论对于慢性心衰合并持续性房颤患者,在有效控制心室率的基础上行CRT明显优于药物保守治疗,与窦性心律患者一样可以改善心功能。     

心脏再同步化治疗改善慢性心力衰竭患者运动能力的长期观察

16例晚期心力衰竭患者 ,置入双心室三腔起搏器 ,行心脏再同步化治疗 (CRT)。术前、术后及随访中观察 6min步行距离。患者均成功置入起搏器。 6min步行距离 ,术前 3 73± 13 0m ,术后升至 43 6± 119m ,随访 694± 3 96天 ,为 3 92± 10 5m。心脏再同步化治疗可以改善慢性心力衰竭患者的运动耐量。     

心脏再同步化治疗慢性心力衰竭伴持续性心房颤动的疗效

目的评价心脏再同步化治疗(CRT)慢性心力衰竭(简称心衰)合并持续性心房颤动(简称房颤)患者的临床疗效。方法选择慢性心衰患者53例,其中42例窦性心律患者及11例房颤患者接受双心室起搏治疗,术后3个月进行随访,观察患者的心功能分级,6 min步行距离,超声心动图测定各房室腔内径大小、左室射血分数(LVEF)、二尖瓣返流以及速度向量成像超声评价同步性参数的变化。结果 53例三腔起搏器置入术均取得成功。与术前相比,术后3个月房颤CRT患者心功能分级(2.30±0.47级vs 3.0±0.02级)、左房内径(44.9±3.8 mm vs52.2±4.2 mm,P<0.05),LVEF(0.43±0.02 vs 0.32±0.03)及二尖瓣返流(1.5±0.2 vs 3.18±1.75,P<0.01)均有明显改善,速度向量成像超声结果显示,室内不同步较术前有明显改善。窦性心律患者术后各项心功能及不同步指标较术前亦有明显改善,与房颤CRT患者比较差异无显著性。结论对于慢性心衰合并持续性房颤患者,CRT与窦性心律一样可以改善心功能。     

CRT治疗慢性心衰的临床观察

目的观察心脏再同步化治疗(CRT)慢性心力衰竭(CHF)患者的临床疗效。方法选择2006年5月～2009年4月植入CRT起搏器的患者8例,其中7例为窦性心律;1例为房颤。优化AV间期及/或VV间期等参数,随访10.1±8.9个月,观察患者心功能改善情况、QRS波时限改变和左室射血分数(LVEF)、左室舒张末内径(LVEDD)、二尖瓣返流及左/右心室不同步等心脏超声参数的变化。结果所有8例患者植入CRT起搏器后,心功能分级与LVEF提高,临床症状明显减轻,6分钟步行距离增加,QRS波时限、LVEDD及MR减少,左/右心室不同步明显改善,心衰平均住院时间减少约33%(p0.05);1例患者CRT植入后13个月发生VT/VF猝死。结论CRT可明显改善CHF患者的心功能,缓解临床症状并提高生活质量;对可能发生VT/VF的高危CHF患者,置入CRT(D)可预防心源性猝死。     

顽固性心力衰竭心脏再同步化治疗远期疗效研究

目的评价心脏再同步化治疗(CRT)对顽固性心力衰竭的长期疗效及生存预后的影响。方法18例顽固心力衰竭患者入选为CRT组,另选与之各项临床特征相比均无显著性差异的18例为对照组。所有患者均有CRT的适应证。CRT组施行右心房双心室或单纯双心室起搏并动态随访、优化起搏参数,同时两组患者皆给予正规的抗心力衰竭药物治疗。结果CRT组患者平均随访1～48(24.7±12.4)月,对照组平均随访1～38(20.9±10.5)月。CRT组辅以常规药物治疗,因心力衰竭住院事件减少,因心力衰竭死亡率下降,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,所有指标变化与对照组差异均有显著性意义。结论与单纯药物治疗相比,CRT结合药物治疗更可使某些顽固性心力衰竭患者在以上多方面受益。合理用药、动态随访和个体化参数优化是保证起搏系统稳定发挥CRT功能和患者充分受益的关键。     

心脏再同步化治疗顽固性心力衰竭合并心房颤动

目的总结心脏再同步化治疗(CRT)合并心房颤动(房颤)的心力衰竭(心衰)的疗效,分析这类患者CRT反应的可能原因。方法 2003年3月至2007年3月接受CRT合并房颤的难治性心衰患者5例,4例为扩张型心肌病,1例为缺血性心肌病,NYHA心功能Ⅲ～Ⅳ级。4例经冠状窦途径成功置入左室电极,1例冠状窦途径失败后行右室双部位起搏(流出道间隔部和心尖部)。结果术后平均随访(12±13)个月,所有患者术后临床症状均有不同程度的改善,NYHA分级提高0+～2级;生活质量和活动耐力均有改善。平均双室起搏比例(90±9)%,其中第2、4、5例术后频发室性早搏,平均双室起搏比例偏低(77%～83%)。第2例加用胺碘酮后比例由83%升至95%,NYHA分级提高2级。5例患者先后于术后1～33个月死亡,直接死亡原因为室性心律失常者2例,心衰恶化者3例。结论 CRT同样可以使合并持续性房颤的难治性心衰患者受益,可以提高生活质量、活动耐力。保证完全的双室起搏是合并房颤的心衰患者对CRT反应的关键因素之一。合并房颤的难治性心衰患者可能更需要在严重心衰早期积极地选择CRT。部分合并房颤的难治性心衰患者,在行CRT同时应考虑植入除颤器。     

双心室起搏兼顾房室结优先使QRS波进一步变窄的研究

目的：探索在接受抗心衰起搏治疗的患者中,通过双室起搏兼顾房室结优先,力求QRS波进一步变窄的可能性和方法学。方法：选取2008年5月～2012年12月入选昆明医科大学一附院心内科收住入院,确诊为慢性充血性心力衰竭、有CRT-P/D适应证并成功植入抗心衰三腔起搏器的患者60例(男47例、女13例、平均年龄63.87±9.29岁)。术后随访期内,所有患者均分别给予双室起搏兼顾房室结优先和传统双室起搏两种CRT工作模式。比较兼顾模式和传统模式在心电图QRS波宽度上的差异。结果：60例患者的CRT系统在静息状态下,均可借助程控仪和12导体表心电图监测,实现传统和兼顾两种CRT工作模式(成功率100%)。且两种CRT工作模式的QRS波平均宽度均分别小于CRT术前(115.78±19.30ms和137.03±19.76ms与155.72±28.78ms,P均<0.01)。静息状态下,兼顾模式的QRS波平均宽畸程度低于传统模式,QRS波平均时限短于传统模式(115.78±19.30ms与137.03±19.76ms,P<0.01)。兼顾模式的QRS波平均宽度较传统模式减少15.5%。结论：传统CRT工作模式强调100%双室起搏夺获,弃用自身房室传导,造成QRS波偏宽畸,可能是部分患者对CRT无应答的原因之一。     

探讨心脏再同步治疗慢性心力衰竭的疗效

目的探讨心脏再同步治疗慢性心力衰竭的疗效。方法选择我院2011年2月~2014年1月收治的20例采用心脏再同步治疗的慢性心力衰竭患者,行心脏再同步起搏治疗(CRT),治疗后观察心功能。结果 20例患者均成功置入起搏器,心功能明显改善,治疗后6 min步行距离高于治疗前,心电图QRS波宽、心室间运动延迟、左心室收缩末内径(LVDS)、左心室舒张末内径(LVEDD)、左心室射血分数(LVEF)、二尖瓣反流面积均低于治疗前,差异均有统计学意义(P0.05)。随访中死亡2例,死亡时间术后10~12个月。结论 CRT治疗慢性心力衰竭疗效确切,可以减轻患者的临床症状,改善心脏功能,提高其生活质量。     

起搏参数调整对老年起搏器植入患者生活质量的研究

目的 探讨起搏参数调整对老年起搏器植入患者生活质量的影响。方法80例接受永久起搏治疗的患者,男41例,女39例,年龄70.5±11.5(65～86)岁。随访期间采用常规心电图、动态心电图、超声心动图、6分钟步行测距、生活质量评分等指标,观察起搏系统干预前后的疗效、心功能分级和生活质量变化。结果 随访期内实施起搏系统干预共168次,其中调整AVD27例,调整起搏频率19例,调整感知性能14例,改变起搏模式8例,起搏故障探查术6例,VVI改DDD8例,3例起搏器介导性心动过速被纠治。优化起搏系统前后,“起搏患者生活质量测评”分值提高,差异有显著性(P<0.05)。结论 优化起搏系统可确保起搏治疗高效、安全,显著提高患者生活质量;起搏系统优化应坚持提高随访效率、个体化原则。     

冠状动脉介入治疗联合心脏再同步化治疗缺血性心肌病顽固性心力衰竭

目的　观察经皮冠状动脉介入治疗 (PCI)联合心脏再同步化治疗 (CRT)缺血性心肌病顽固性心力衰竭的疗效和安全性。方法　 7例均经冠状动脉造影证实为缺血性心肌病 ,NYHA分级Ⅳ级 ;其中 6例伴有心室内传导阻滞且QRS时限≥ 130ms,1例三度房室传导阻滞 ,1例持续性快速心房颤动 ,2例曾发作心室颤动 ,左室舒张末期内径≥ 5 5mm ,左室射血分数≤ 0 4 0。 5例PCI术后 6个月复查冠状动脉造影均无再狭窄 ,其后行CRT ;2例先行CRT 2周后行PCI。结果　PCI和CRT手术均成功 ,5例为右房加双室三腔起搏 ,1例快速心房颤动者行CRT同时行房室结射频消融术 ,1例行心脏三腔起搏除颤器置入术。 1例术后 4个月死于再次急性心肌梗死 ,其余 6例存活者随访 5～4 1(2 3 2± 13 8)个月 ,5例先行PCI及 2例先行CRT者联合介入治疗后心功能进一步明显改善 ,NYHA提高 2级 ,6min步行距离明显增加 ,超声二尖瓣反流和心电图QRS时限明显减少。 2例无室壁瘤者左室舒张末期内径及左室射血分数明显改善 ,5例轻度改善或无明显变化。结论　PCI及CRT联合治疗缺血性心肌病顽固性心力衰竭可改善心功能 ,提高生活质量并改善其预后 ,并具有较高的安全性。     

Progression of heart failure in right univentricular pacing compared to biventricular pacing

BACKGROUND: Cardiac resynchronization therapy (CRT) improves hemodynamics and symptoms of heart failure by reducing ventricular dyssynchronity. Conversely, recent studies have demonstrated that right univentricular pacing in patients with an ejection fraction below 40% aggravates heart failure. In this retrospective study, we compared progression of disease in patients with mild to moderate heart failure that were treated with a right univentricular pacing device and patients with congestive heart failure that were treated with a biventricular system. METHODS: 107 patients were included. 59 received a right ventricular pacing device and 48 a biventricular system. Patients were assessed after 1 and 6 months by NYHA class, echocardiographic parameters (EF, LVEDD) and hospitalization for heart failure. RESULTS: Hospitalization for heart failure after implantation of the devices was more frequent in patients that received a conventional pacemaker with a single lead in the right ventricle than in patients that were treated with a CRT system (12% vs. 6%, p<0.05), although heart failure was more advanced in the CRT group at baseline. Ejection fraction in the right ventricular pacing group further decreased from 43%+/-4 at baseline to 38%+/-4 after 6 months (p<0.05). Left ventricular enddiastolic diameter (LVEDD) was 51+/-7 mm and 58+/-6 mm (p<0.05) at 6 months. In the CRT group, EF was 23%+/-4 at baseline and 31%+/-7 after 6 months (p<0.05.). LVEDD improved from 56+/-4 mm before implantation to 52+/-7 mm and 6 months (p<0.05). CONCLUSION: Progression of heart failure symptoms in the right univentricular pacing group was more pronounced compared to the CRT group, despite the fact that patients assigned to the CRT group had more severe symptoms of heart failure at baseline. Biventricular pacing relieved symptoms of heart failure, whereas right univentricular pacing with subsequent conduction delay of the left ventricle further deteriorated pre-existing heart failure. Therefore, patients with an indication for pacemaker therapy because of bradycardia and co-existing mild to moderate heart failure might benefit from early implantation of a CRT system.     

双心室起搏的临床疗效观察

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 1 0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电极导线于左室侧静脉、心大或心中静脉 ,行双心室同步起搏 (其中 2例为四腔起搏 )。通过临床观察、超声心动图测定及 6分钟平地行走评定对心功能的影响。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电极导线行双心室起搏 ,产生较窄 QRS波 ,临床心功能从 ～ 级提高至 ～ 级 ( NYHA) ,同时使二尖瓣返流减少 ,射血分数提高 ,左室舒张末期内径缩小 ,6分钟平地行走距离比术前明显提高。结论　双心室起搏对难治性心力衰竭可能有辅助治疗作用。     

双心室起搏治疗充血性心力衰竭

探讨双心室起搏技术治疗慢性充血性心力衰竭的临床疗效。 11例充血性心力衰竭患者 ,男 9例、女 2例 ,年龄 5 4± 7岁。心功能 (NYHA)Ⅲ～Ⅳ级 ,均伴有心室内传导阻滞。全部患者置入三腔双心室起搏器 ,左心室电极置于冠状静脉侧支及后侧分支内。结果 :手术全部成功。所有患者于置入后症状改善 ,体表心电图QRS时限由 15 9.8± 4 .4 2ms缩至 130 .5± 3.6 9ms ,P <0 .0 1。随访 6～ 18个月 ,超声心动图显示左室射血分数由 0 .2 5± 0 .0 5增至 0 .38± 0 .0 5 ,P <0 .0 1、舒张期充盈改善、二尖瓣返流减少。结论 :双心室起搏可以改善药物控制困难的伴室内传导阻滞的心衰患者的临床症状 ,改善心功能 ,提高生活质量。     

心脏再同步治疗缺血性与非缺血性心肌病的临床应用

目的报道142例心脏再同步治疗缺血性与非缺血性心肌病临床应用。方法 142例心肌病慢性心力衰竭患者心功能Ⅲ-Ⅳ级(NYHA分级),男性91例,女性51例,平均年龄59．8岁,左心室内径平均72．32mm,平均左心室射血分数(LVEF)为0．29。患者均伴有室内阻滞,平均QRS波时限为(146．7±21．4)ms。142例患者中,扩张性心肌病98例,缺血性心肌病44例。分别观察双心室起搏前后LVEF变化。结果双心室同步起搏后,患者心功能得到明确改善,142例患者平均LVEF从术前的0．29±0．08增加至0．36±0．07,LVEF值平均提高0．07(P<0．05)。左心室充盈时间延长,二尖瓣反流量减少。扩张性心肌病患者平均LVEF从术前的0．28提高到术后的0．37。缺血性心肌病患者平均LVEF从术前的0．30提高到术后的0．36。均有显著改善。结论无论扩张性心肌病患者还是缺血性心肌病患者心脏再同步治疗后心功能均有显著提高。     

Effectiveness of resynchronization therapy in patients with end-stage heart failure

Biventricular pacing has been introduced to treat patients with end-stage heart failure, and short-term results of this technique are promising. Because data on longer follow-up are limited to 3-month follow-up, the sustained effect of biventricular pacing is unclear and long-term survival is unknown. Forty patients with end-stage heart failure in New York Heart Association (NYHA) functional class III or IV with left ventricular (LV) ejection fraction (EF) <35%, QRS duration >120 ms, and left bundle branch block morphology received a biventricular pacemaker. At baseline, and at 3 and 6 months after implantation, the following parameters were evaluated: NYHA class, Minnesota quality-of-life score, QRS duration on surface electrocardiogram, 6-minute walking distance, and LVEF. Long-term follow-up was obtained for up to 2 years. All clinical parameters improved significantly at 3 months and remained unchanged at 6-month follow-up. LVEF increased from 24 +/- 9% to 34 +/- 11%. Before implantation, patients were hospitalized (for congestive heart failure) an average of 3.9 +/- 5.3 days/year compared with 0.5 +/- 1.5 days/year after implantation. Long-term follow-up showed a survival of 87.5% at 2 years. Thus, biventricular pacing resulted in improvement of symptoms and quality of life, accompanied by improvement in 6-minute walking distance and LVEF. These effects were observed at 3 months after implantation and were maintained at 6-month follow-up. Moreover, 2-year survival was excellent.     

Comparison of benefits from cardiac resynchronization therapy in patients with ischemic cardiomyopathy versus idiopathic dilated cardiomyopathy

Cardiac resynchronization therapy (CRT) is a recently introduced therapeutic option for patients with severe heart failure and intraventricular conduction disturbances. However, it is estimated that 20% to 30% of patients may not respond to CRT. Patients with ischemic cardiomyopathy (IC) may respond less favorably to CRT compared with patients with idiopathic dilated cardiomyopathy (IDC). Accordingly, the beneficial effects of CRT were evaluated in 2 subsets of patients (IC and IDC). Seventy-four patients with end-stage heart failure, New York Heart Association (NYHA) class III or IV, left ventricular (LV) ejection fraction <35%, QRS >120ms, and left bundle branch block received a biventricular pacemaker. At baseline and 6 months after implantation these parameters were evaluated: NYHA class, Minnesota quality-of-life score, QRS duration, and 6-minute walking distance. LV ejection fraction and severity of mitral regurgitation were assessed before and 6 months after CRT using 2-dimensional echocardiography. Long-term follow-up and hospitalization rates were obtained up to 2 years. Of the 74 patients, 46% (n = 34) had IC and 54% (n = 40) IDC. At 6 months follow-up all clinical parameters, QRS duration, LV ejection fraction, and mitral regurgitation improved significantly in both groups. Long-term (2-year) follow-up showed a survival rate of 87.5% for patients with IDC and 88.3% for patients with IC. The percentages of responders to CRT (defined as an improvement in NYHA class >or=1 grade) were comparable in both groups (65% vs 71%). Therefore, the underlying etiology of heart failure (IC vs IDC) was not related to the response to CRT.     

心脏再同步化治疗晚期扩张型心肌病13例的效果

目的: 观察心脏再同步化治疗（CRT）晚期充血性心力衰竭的临床疗效。方法: 晚期扩张型心肌病患者13例接受CRT,NYHA心功能分级为Ⅲ～Ⅳ级,左室射血分数（LVEF）为（27.4±9.7）%,左室舒张末期内径（LVEDD）为(72.8±9.6)mm,QRS时限为( 137.8＋30.4)ms。术后观察QRS时限的变化,随访左室电极起博阈值、心功能分级、LVEF及LVEDD。结果: 术后QRS时限减少为（123.8±17.1）ms。所有患者随访3～38月,左室电极慢性阈值为（1.1±0.6）V/0.4 ms。与术前相比,NYHA心功能分级从(3.4±0.5)降低为(1.5±0.9); LVEF从(27.4±9.7)%上升至(43.5±18.5)%(P<0.05);LVEDD从(72.8±9.6)mm缩小为(65.5±11.6)mm（P<0.05）。结论: CRT可改善心功能,提高LVEF,并可逆转左心室重构。     

Effect of cardiac resynchronization therapy on the incidence of ventricular arrhythmias in patients with an implantable cardioverter-defibrillator.

BACKGROUND: Cardiac resynchronization therapy (CRT) reduces mortality in selected patients with heart failure. However, this result may not be entirely related to the beneficial hemodynamic effects of CRT. OBJECTIVES: The purpose of this study was to assess retrospectively the effect of CRT on the incidence of appropriate therapy in patients with an implantable cardioverter-defibrillator (ICD). METHODS: Sixty-five patients (48 men and 17 women; mean age 58 +/- 13 years) with an ICD (31 biventricular, 34 dual-chamber) were included in the study. Clinical, ECG, and ICD stored data and electrograms were collected. RESULTS: Biventricular and dual-chamber ICDs were implanted in 31 and 34 patients, respectively, who had either ischemic (n = 36) or dilated cardiomyopathy (n = 29). Thirty-two (49%) patients received > or =1 appropriate ICD therapy during follow-up of 11 +/- 8 months. Thirty-five percent and 62% of patients with biventricular (n = 11) and dual-chamber ICDs (n = 21), respectively, received appropriate ICD therapy during the follow-up period (odds ratio = 0.340, P = .048). Stratifying the patients according to underlying heart disease and ejection fraction resulted in an adjusted odds ratio = 0.239 (P = .029). Comparing the rate of > or =1 appropriate ICD therapy between the two groups by Kaplan-Meier analysis and the log rank test resulted in P = .027. CONCLUSION: In this retrospective analysis, biventricular pacing was associated with a decreased incidence of sustained ventricular arrhythmias requiring ICD therapy. The antiarrhythmic effect of biventricular pacing could contribute to the reduction in mortality reported in recent large-scale clinical trials on CRT. However, further prospective studies are warranted to clarify this issue.