右室心尖部起搏对心脏功能正常患者左室收缩同步性及功能的影响

目的应用超声心动图组织多普勒技术评价右室心尖部起搏对左室收缩同步性及心脏功能的影响,探讨起搏诱发的心室不同步收缩对于心脏功能的影响机制。方法65例置入双腔起搏器的病窦综合征患者分别在心室节律全部为起搏节律或室上性节律状态下行常规及组织多普勒超声心动图检查,测量左室收缩功能及收缩同步性指标。结果右室完全起搏模式下左室收缩功能下降(射血分数:0.58±0.07 vs 0.61±0.01,P<0.001),左室6节段收缩期平均速度下降(4.0±1.5cm/s vs 4.7±1.6cm/s,P<0.001),心室收缩同步性下降(12节段达峰时间标准差:37.5±12.5ms vs 23.7±10.2ms,P<0.001),心室同步性恶化程度与收缩功能恶化中度相关(r=0.37,P<0.05)。结论右室心尖部起搏可致左室收缩不同步及左室功能降低。     

右室心尖部起搏QRS波时限对心功能的影响

目的通过观察起搏QRS波时限来预测长期右室心尖部起搏对心脏功能的影响及与心力衰竭的关系。方法对87例因病态窦房结综合征或三度房室阻滞而安装起搏器的病人进行起搏QRS波时限测量、血浆脑钠肽(BNP)的测定、心脏多普勒超声检查并进行长期动态随访,以术后即刻起搏QRS波190ms作为一个分割值把病人分为两组,观察右室心尖部起搏QRS波时限的延长与心力衰竭之间的关系。结果平均随访43±14月,15例(17.2%)出现明显心衰(NYHAⅢ～Ⅳ级)。术后6个月,心衰组的起搏QRS波时限明显延长,血清BNP值增高(p<0.01)。术后6个月,相比与起搏QRS<190ms组,起搏QRS≥190ms组的BNP明显增高(p<0.01)。整个随访期间,起搏QRS≥190ms组心衰发生率要明显增高(p<0.01)。结论右室心尖部起搏QRS波时限的延长与心脏功能的受损和心力衰竭发生密切相关,可以作为心脏功能损害的预测指标。     

右室高位室间隔与右室心尖部起搏对心功能影响的比较

56例Ⅲ度房室传导阻滞和病窦综合征病人根据起搏部位分为:右室心尖部起搏组(RVA组),右室高位室间隔起搏组(RHVS组)。起搏后3个月左室射血分数、每搏输出量明显高于RVA组,B型脑利钠肽、QRS波时限明显低于RVA起搏。结论:HRVS起搏对心功能的影响优于RVA组,可能是一个较为理想的起搏部位。     

右室心尖部起搏前后心功能水平的对比研究

42例行单纯右室起搏 ,根据术前患者的心功能水平按纽约心脏病学会 (NYHA)心功能分为≤ 2级和≥ 3级两组。结果 :2 1例心功能≤ 2级患者术前射血分数 (EF)与术后 6个月比较无显著性差异(P >0 .0 5 ) ,而 2 1例心功能≥ 3级患者则有显著性差异 (P <0 .0 1)。两组组间比较术前QRS波时限比较无显著性差异 (P =0 .2 3 6) ,而术后 6个月比较则有显著性差异 (P <0 .0 5 )。结论 :单纯右室起搏治疗对患者心功能呈负性影响 ,心功能≥ 3级的患者不宜选择右室心尖部起搏。     

起搏负荷超声心动图评价右室高位室间隔起搏和右室心尖部起搏对心脏功能的影响

目的评价右室高位室间隔(HRVS)起搏和右室心尖部(RVA)起搏对心脏结构和功能的影响。方法71例病窦综合征、完全性房室传导阻滞患者根据心室起搏电极植入部位的不同,随机分为HRVS起搏组(36例)和RVA起搏组(35例)。分别于术前、术后3个月和术后12个月通过超声心动图和起搏负荷超声心动图检查对患者左室收缩和舒张末期容积(LVESV和LVEDV)、左右室射血前时间差值(LRVPEI)、室间隔与左室后壁收缩延迟时间(SPWMD)、左室射血分数(LVEF)等相关指标进行观察随访。结果术后3个月、12个月时,两组各项起搏参数均无差别。术后3个月时,HRVS起搏组的LRVPEI和SPWMD均明显小于RVA起搏组(P<0.05),两组间其他指标在基础状态超声下无显著差别,在起搏负荷超声下HRVS起搏组的LVEF明显高于RVA起搏组(P<0.05)。术后12个月时,HRVS起搏组的LRVPEI、SPWMD和LVESV三项指标均显著小于RVA起搏组(P<0.05),LVEF明显高于RVA起搏组(P<0.01);LVEDV小于RVA起搏组,但无统计学意义。结论HRVS起搏对心脏结构和功能的不良影响明显低于RVA起搏。     

长期右心室心尖部起搏患者起搏QRS时限与左心结构和功能的关系

近来研究显示在慢性心力衰竭患者中，QRS时限和左心室射血分数（LVEF）之间存在负相关，QRS时限延长是心脏性猝死的独立危险因子。而目前国内外对长期心脏起搏者起搏QRS（pQRS）时限与心功能关系的研究甚少。通过常规心电图测得长期右心室心尖部起搏患者的pQRS时限，探讨其与左心结构、左心室收缩功能及心室间不同步的关系。[第一段]     

右室心尖部起搏对左室电机械活动的影响

目的运用超声心动图和组织多普勒检查,分析右室心尖部起搏对左室电机械活动的影响;探讨能够预测右室心尖部起搏后左室内机械活动不同步性的因素。方法选取因病窦综合征置入双腔永久起搏器的患者28例,术后7天分别测量患者在自身心律、VVI起搏两种状态下的超声心动图和组织多普勒心功能指数(Tei指数)、左室内不同步指数(Ts-SD)等参数并分析左室内机械活动不同步的影响因素。结果64.2%的患者在右室起搏期间,表现为左室机械活动的不同步;Ts-SD显著增加(40.10±18.50 ms vs 29.96±18.87 ms,P=0.034);右室起搏后Tei指数明显增加(0.49±0.23 vs 0.38±0.21,P(0.01);自身心律状态下的Ts-SD指数是右室起搏时出现左室收缩不同步现象的独立预测因素(OR=1.079,P=0.029)。结论右室心尖部起搏导致左右心室之间及左室内收缩不同步,对患者心脏整体功能带来不利的影响。     

右室流出道与右室心尖部起搏对心脏收缩功能和左室重构的影响

目的评价右室流出道(RVOT)和右室心尖部(RVA)起搏对心脏收缩同步性、收缩功能和左室重构的影响。方法82例高度或III度房室传导阻滞患者随机分为RVOT起搏组(A组,n=43)和RVA起搏组(B组,n=39),以术前左室12节段达峰时间标准差(Ts-SD)是否>32.6ms对两组患者进行亚组分组,Ts-SD>32.6ms者为A1亚组与B1亚组,Ts-SD≤32.6ms为A2亚组与B2亚组。于术前及术后6个月分别进行超声心动图检查,测量舒张末左室容积(LVEDV)、收缩末左室容积(LVESV)、左室射血分数(LVEF),并采集组织多普勒图像(TDI)进行脱机分析,测量主动脉瓣射血前时间(APET)、肺动脉瓣射血前时间(PPET)、左室12节段收缩达峰时间(Ts),计算室间电机械延迟(IVMD)和Ts-SD。结果术后6个月,两组的IVMD均较术前增加;两组Ts-SD与术前比无差异。亚组分析表明术前同步性好的A2、B2亚组术后Ts-SD升高;术前同步性差的A1亚组术后Ts-SD降低。术后6个月两组LVEDV、LVESV及LVEF与术前比较均无差异,组间比较亦无差异。结论RVOT和RVA起搏短期内对左室收缩功能及左室重构均无影响,术前收缩不同步者可从RVOT起搏中获益。     

右室间隔部起搏的部位选择与X线影像特点——简单方法确定起搏后QRS波尽可能窄的部位

目的探讨右室间隔部不同部位起搏后QRS波时限与形态,并分析起搏后QRS波较窄处电极的X线影像特点与定位方法;方法将本院近期行右室间隔面起搏50例患者心室电极植入部位在X线后前位结合脊柱影分为高、中(距心影下缘1.5～2个椎体影)、低三部分,右前斜位(RAO)时将心影纵向均分为4区,并分析左前斜位(LAO)下电极的指向,不同部位起搏术中测试参数,起搏后QRS波形态,电轴,时限,术中、术后并发症以及随访中起搏器工作情况;结果所有电极LAO投照时均指向脊柱侧,RAO投照时电极头端位于心影3区(46支)或4区(4支),后前位下中位间隔组起搏后QRS波时限明显窄于高位和低位组(138±21 ms vs 162±20 ms,159±35 ms),电轴也较其他两组更接近于正常(40±35度)(P<0.05),3组术中测试参数与随访结果无差异。结论在间隔面距心影下缘1.5～2个椎体影高度处且RAO时头端位于3区者起搏后QRS波时限较窄,电轴较正常,植入简便安全。     

QRS波时限延长与心功能不全

QRS波时限延长在心力衰竭(简称心衰)患者中较常见。自然状态下,QRS波时限延长与心功能不全密切相关,往往QRS波时限越长纽约心脏病协会心功能分级越高,左室射血分数越低,起搏状态下亦是如此;QRS波时限延长在终末期心衰患者心脏再同步化治疗中具有重要的作用;QRS波时限进行性延长与心功能不全也密切相关。     

Native QRS complex duration predicts paced QRS width in patients with normal left ventricular function and right ventricular pacing for atrioventricular block

Introduction

Prolonged paced QRS duration is a predictor of development of heart failure during chronic right ventricular pacing. One determinant of paced QRS width might be His-Purkinje system dysfunction, manifested in wide native (escape or conducted beat) QRS complexes in patients with atrioventricular (AV) block.

Methods

Fifty patients with normal left ventricular function who are undergoing implantation of a pacemaker for AV block were enrolled. The duration of the QRS complex was measured on the surface electrocardiogram during escape rhythm in 28 patients with total AV block and during conducted beats in 22 patients with second-degree, fixed ratio (2:1 or 3:1) AV block, as well as during ventricular paced rhythm after pacemaker implantation in all patients.

Results

A close, positive correlation was found between native and paced QRS duration in the second-degree AV block group (R = 0.74, P < .001). This association was also significant but less pronounced in the total AV block group (R = 0.46, P = .014).

Conclusion

Native QRS width, especially in case of fixed ratio (2:1 or 3:1) second-degree AV block, is a predictor of paced QRS duration in patients with AV block and normal left ventricular function. Wide QRS complex before implantation may carry a higher risk of developing heart failure with right ventricular pacing.     

Prolongation of QRS duration and axis deviation in the right bundle branch block are not markers for left ventricular systolic dysfunction

BACKGROUND:

Right bundle branch block (RBBB) is not commonly associated with structural heart disease and left ventricular (LV) systolic dysfunction. The purpose of the present study was to determine whether the QRS duration and degree of right axis deviation (RAD) or left axis deviation (LAD) in patients with RBBB predicted a subset of patients with significant LV systolic dysfunction.

METHODS:

In the present prospective study, 75 of 200 consecutive patients with RBBB had their ejection fraction (EF) evaluated by echocardiography. The relationship among QRS duration, axis and EF was derived.

RESULTS:

There were no significant differences in sex and EF among the patients with a normal axis, RAD or LAD. The EFs of patients with a normal axis (n=27), RAD (n=15) and LAD (n=33) were 52±15%, 49±14% and 46±17%, respectively (P=0.35). The mean EF (46±16%) of patients with a QRS duration of 150 ms or greater (n=53) was not significantly different from the mean EF (49±18%) of patients with a QRS duration of less than 150 ms (n=22) (P=0.54). For patients with a QRS of 120 ms or greater and less than 150 ms (n=22), QRS of 150 ms or greater and 180 ms or less (n=48), and QRS of greater than 180 ms (n=5), the mean EFs were 49±18%, 47±16% and 44±7%, respectively (P=0.78). There was no significant correlation between QRS duration and EF in all patients (r=0.03, P=0.83), EF and RAD (r=0.38, P=0.16) or EF and LAD (r=0.26, P=0.14).

CONCLUSIONS:

In patients with RBBB, the QRS duration and axis do not have a significant relationship with EF. Furthermore, prolongation of the QRS duration (150 ms or greater) in the presence of RBBB is not a marker of significant LV systolic dysfunction.     

Assessment of heart failure and left ventricular systolic dysfunction after cardiac pacing in patients with preserved left ventricular systolic function

BACKGROUND: There is an accumulating data suggesting the deleterious effects of right ventricular pacing on left ventricular performance. Such pacing mimics left bundle branch block resulting in a prolonged QRS duration and causes ventricular asynchrony. AIMS: The purpose of this study is to assess heart failure and left ventricular systolic function after cardiac pacemaker implantation in patients with atrioventricular block and preserved systolic left ventricular function. Secondly, we sought to search for predictive factors of developing left ventricular dysfunction after pacing. METHODS: In this prospective study, we included patients who had been implanted for at least six months. They underwent medical history and examination, 12 leads electrocardiogram and echocardiography before pacemaker implantation and when attending to routine pacemaker follow up. RESULTS: Forty-three patients (22 men and 21 women, age 71+/-12 years) were included in this study. Twenty-nine patients had DDD pacing and 14 VVI pacing. The ventricular lead was implanted in the apex in all patients. After a median follow up of 18+/-11 months, 11 patients (25%) developed signs of congestive heart failure. NYHA was higher after implantation (1.64+/-0.7 versus 2.27+/-0.8, p>0.00001). Left ventricular ejection fraction decreased significantly during follow up (60+/-6% versus 51+/-13%, p=0.0002). Eleven (25%) patients developed left ventricular dysfunction. We compared patients who had left ventricular ejection fraction (LV EF) less or equal to 40% (group A) and patients having LV EF greater than 40% (group B) after implantation. Patients in group A had a paced QRS width significantly larger than group B (181+/-32 ms versus 151+/-26 ms, p=0.002), a significantly prolonged intra left ventricular electromechanical delay (115+/-59 ms versus 45+/-35 ms, p<0.0001) and interventricular delay (44+/-29 ms versus 27+/-18 ms, p=0.02). Age, sex, diabetes hypertension, pacing mode and percentage of ventricular pacing were similar in both groups. A paced QRS width of 180 ms had the best sensitivity and specificity for detecting left ventricular dysfunction: sensitivity=54% and specificity=93%, p=0.01, area under the curve=0.75. CONCLUSION: Patients with atrioventricular block and preserved left ventricular systolic function at baseline decrease significantly left ventricular ejection fraction after pacing. Induced ventricular asynchronism plays a major role in the deterioration of left ventricular function. Prolonged paced QRS width is a good predictor of left ventricular dysfunction after pacing. Larger prospective studies are needed to confirm these data.     

应用左心室舒张末容积校正的QRS持续时间对心脏同步化治疗的预测作用

目的 探究左心室舒张末容积校正的QRS持续时间(QRSd/LVEDV)对心脏同步化治疗的预测作用.方法 2010年1月至2019年1月于解放军总医院选择接受心脏同步化治疗(CRT)的慢性心力衰竭患者79例,在手术前1个月内和术后1年分别进行了心电图和超声心动图检查QRSd和左心室舒张末容积(LVEDV),对上述资料进行...     

心电图碎裂QRS波与急性心肌梗死患者室性心律失常及左心室收缩功能的相关性

目的探讨急性心肌梗死(AMI)患者碎裂QRS波(fQRS)与室性心律失常、心率变异性(HRV)、左心室收缩功能的相关性。方法随机选择我院2011年1月至2012年10月确诊为AMI的住院患者120例。男性99例,女性21例,28⁸2岁,平均(60±13)岁。根据12导心电图QRS波形态分为3组:A组:fQRS组、B组:病理性Q波组、C组:fQRS合并病理性Q波组。采用动态心电图分析室性心律失常、HRV各项时域参数指标;心脏彩超检测左心室舒张末期内径(LVDD)及左心室射血分数(LVEF),并进行3组间比较分析。结果①AMI患者室性心律失常指标室性期前收缩LOWN分级Ⅲ级、ⅣA级、ⅣB级比较,A组(34.2%、36.8%、26.3%)、C组(33.3%、28.3%、16.7%)发生率均高于B组(9.1%、4.5%、0),差异有统计学意义(均为P<0.05)。②AMI患者A组、C组心率变异性的各项时域参数指标(SDNN、SDANN index、rMSSD、pNN50、三角指标)较B组均明显降低,差异均有统计学意义(均为P<0.01)③AMI患者的LVDD A组(51.71±8.44)、C组(50.32±7.35)的显著高于B组(45.14±6.44),LVEF A组(46.92±6.96)、C组(49.00±7.80)低于B组(53.23±7.95),差异均有统计学意义(均为P<0.05)。结论 AMI患者fQRS波的出现可能与①室性心律失常,尤其是恶性室性心律失常事件及HVR明显降低有关;②患者左心室收缩功能明显下降有关。     

Relationship between QRS duration, left ventricular volumes and prevalence of nonviability in patients with coronary artery disease and severe left ventricular dysfunction

BACKGROUND: Patients with coronary artery disease (CAD), a QRS duration >or=120 ms and left ventricular ejection fraction (LVEF) or=120 ms was present in 91 patients (69%). Although there were no differences in LVEF, patients with longer QRS durations had significant larger end-diastolic and end-systolic volumes (p<0.01). Substantial nonviable tissue in the inferior or lateral wall was present in 29% of patients with a QRS duration >or=120 ms versus 7% of those with a QRS duration <120 ms (p<0.01). CONCLUSIONS: An increased QRS duration is associated with more advanced remodeling in patients with CAD and poor LV function. Almost one third of these patients with a prolonged QRS duration have no viable tissue in the inferolateral wall, an area that is usually stimulated with CRT.     

右心室不同部位起搏对心脏收缩同步性及心功能的影响

目的比较右心室流出道（right ventricular outflow tract,RVOT）起搏与右心窀心尖部（riht ventficular apex,RVA）起搏对心脏收缩同步性指标及收缩功能的影响。方法2004年1月至2005年1月在我院植入VVL／VVIR,DDD／DDDR起搏器的患者,随机接受RVA起搏和RVOT起搏。植入前检查12导联体表心电罔及超声心动图,记录QRS时限、左心室舒张末内径（LVEDD）、左心房内径（LAD）、左心事射血分数（LVEF）。植入后记录心室起搏状态下的QRS时限。随访时间为2年,随访内容包括LVEDD、LAD、LVEF,同时应用脉冲组织多普勒技术测定心室问激动延迟（IVMD）以及左心室内收缩同步性指标（Ts-SD）。结果共随访30例患者,其中RVA起搏17例,RVOT起搏13例,两组患者间年龄、性别及心血管疾病等基本情况筹异无统计学意义。植入前两组患者问QRS时限、LVEDD、LAD及LVEF差异无统计学意义,植入后RVOT起搏状态下QRS时限较RVA起搏明显缩短[（140．15±11．36）ms对（160．76±23．68）ms,P=0．033],植入后两组间IVMD[（25．7±9．1）mS对（36．7±10．0）ms,P=0．076]比较差异无统计学意义,两组问Ts—SD（13．34ms对42．96ms,P=0．001）比较差异有统计学意义;植入后随访两年,两组患者间LAD差异无统计学意义[（43±6）ms对（42±9）ms,P=0．759],同RVA组相比,RVOT组LVEDD缩小[（5．10±0．76）mm对（5．28±0．40）mm,P=0．048],LVEF明显增加（0．56±0．04对0．52±0．02,P=0．001）。结论同右心窄流出道起搏相比,右心室心尖部起搏对患者心功能呈负性影响,且加重左心室内不同步收缩。