心力衰竭患者心脏再同步化治疗最新进展

心力衰竭指心脏结构或功能性原因导致心室充盈和/或射血功能受损而引起的一组综合征。心脏再同步化治疗(CRT)是心力衰竭中的一种器械治疗方式,旨在通过双心室起搏改善心室收缩的不同步,进而提高射血分数,改善心功能。自20世纪90年代开始CRT应用于临床,大量临床研究证实了其安全性及有效性,其适应证在不断扩大,但CRT与心脏再同步化治疗除颤器的选择在临床上一直存在疑问,且近几年希氏束-浦肯野系统起搏开始应用于CRT中,使这一领域出现新的憧憬。现就目前CRT的研究现状,其与心脏再同步化治疗除颤器和希氏束-浦肯野系统起搏的抉择进行综述,给临床工作提出一定的指导意义。     

应用心脏再同步除颤器治疗心力衰竭

本文讨论了植入性心律转复除颤器治疗作用及其副作用,在防治心源性猝死方面的主要临床系列研究的结果。也讨论了心脏再同步化治疗充血性心力衰竭的作用及其临床研究的结果和存在的问题。而具有除颤功能的心脏再同步除颤器已经开始进入临床治疗心力衰竭,但是仍然有许多未知领域需要研究予以澄清。     

心脏再同步化治疗慢性心力衰竭疗效观察

目的观察心脏再同步化治疗（CRT）慢性心力衰竭（CHF）的临床疗效。方法 20例CHF患者行CRT,术后随访（10.50±1.12）个月,观察心功能、QRS波时限、左室射血分数（LVEF）及相关心功能超声指标。结果 20例患者治疗后心功能均有明显改善,心功能NYHA分级由（3.30±0.48）级改善为（2.30±0.48）级,QRS波时限从（173.00±40.01）m s缩短至（145.00±15.81）ms,LVEF从（25±5）%提高至（33±7）%;以上观察指标治疗前后比较差异均有统计学意义（P〈0.05或〈0.01）。结论 CRT是治疗CHF的有效方法。     

心脏再同步化治疗慢性心力衰竭的临床疗效观察

目的 观察心脏再同步化治疗慢性心力衰竭的临床效果,探讨心脏再同步化治疗机制及目前存在问题.方法 选择43例药物治疗无效的严重心力衰竭患者进行三腔起搏器治疗,其中4例患者安装双心室同步房室顺序起搏自动复律除颤器,分别观察患者术前、术后3个月、术后6个月的QRS波时限、射血分数、左室舒张末期内径、左右室同步性差值、B型脑钠肽水平及6分钟步行距离的变化.结果 随访3～6个月,1例患者发生猝死,其余患者术后心功能的各项指标与术前相比均有明显改善(P＜0.05).结论 心脏再同步化治疗能显著改善药物治疗无效的慢性心力衰竭患者的心功能不全症状.     

心脏再同步化治疗能否降低进行性心力衰竭导致的死亡——四个代表性研究及其荟萃分析

充血性心力衰竭(简称心衰)是心内科治疗学上的难题,死亡率较高.     

心脏再同步化治疗慢性心力衰竭的疗效观察

目的观察心脏再同步化治疗(CRT)慢性心力衰竭(CHF)的临床疗效。方法26例CHF患者行CRT,全部患者均经冠状静脉窦置入左室导线1根至心脏静脉,术后随访13.8±10.4个月,观察心功能,患者活动度及夜间心率、QRS波时限,左室射血分数(LVEF)及相关心功能超声指标。结果24例治疗后心功能改善,2例猝死,有效率92.3%,心功能NYHA分级,从Ⅲ～Ⅳ级改善为Ⅱ～Ⅲ级,患者活动度从0.17±0.24小时/天增加至2.98±0.46小时/天,夜间心率由80.8±12.0次/分降低至61.3±2.5次/分,QRS波时限从158.60±31.86ms缩短至130.95±23.44ms,P<0.05。LVEF从0.21±0.05提高至0.35±0.05,P<0.05,其他相关超声指标较CRT之前明显改善(P均<0.05)。结论CRT是治疗CHF的有效方法。     

心脏再同步化治疗慢性心力衰竭的临床疗效

目的观察心脏再同步化治疗对慢性心力衰竭患者改善心功能和逆转左心室重构的作用。方法11例慢性心力衰竭患者接受心脏再同步化治疗,心功能NYHA分级Ⅲ～Ⅳ级,左室射血分数≤35%,伴QRS波时限≥130ms。随访1～36个月,观察和分析术前、术后相关参数的基准水平及参数基准水平的变量。结果心脏再同步化治疗后1～36个月,左心室射血分数、左心室短轴缩短率增加,左心室舒张末内径、二尖瓣返流、QRS波时限减少,NYHA分级提高到Ⅰ～Ⅱ级,6min步行距离明显增加。结论对于心功能NYHA分级Ⅲ级或Ⅳ级伴有室内传导阻滞的心力衰竭患者,心脏再同步化治疗能逆转左心室重构,改善心功能。     

心脏再同步化治疗慢性心力衰竭临床观察

目的观察心脏再同步化治疗(CRT)慢性心力衰竭(CHF)的疗效。方法 11例慢性心力衰竭患者行CRT,术后随访12个月,观察心功能、QRS时限、左室射血分数(LVEF)及相关心功能超声指标。结果 9例患者治疗后心功能均有明显改善,心功能NYHA分级从(3.5±0.4)级改善为(2.3±0.4)级,QRS时限从(157.0±21.4)ms缩短至(131.0±23.6)ms,LVEF从(26.7±5.2)%提高至(39.7±7.9)%;以上观察指标治疗前后比较差异均有统计学意义(P<0.05)。2例分别在植入起搏器后2个月及7个月死亡。结论 CRT通过改善心脏收缩同步性,提高左室射血分数,从而改善心功能,提高生活质量和运动能力。     

老年心力衰竭患者埋藏式心脏转复除颤器及心脏再同步化治疗的价值

埋藏式心脏转复除颤器(ICD)、心脏再同步化治疗(CRT)在老年心力衰竭(简称心衰)患者中应用越来越广。相关研究表明,CRT在逆转心室重构、改善老年心衰患者症状及预后、降低死亡率及再住院率方面的效果并不逊于年轻患者,年龄不应成为CRT植入的禁忌。老年患者植入ICD后受非心源性死亡因素的影响较大,长期获益较年轻患者差,因此对于高龄老年患者,需要综合评估其他共存的疾病及衰弱情况,是否植入ICD是医生和患者以及家属的共同决定。对于需要CRT治疗的老年心衰患者是选择CRT-D还是CRT-P,目前研究显示CRT-D可以提供短期生存优势,但较CRT-P的远期获益差,对于经济困难的患者CRT-P可能是很好的选择。     

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。     

Depression and severe heart failure: benefits of cardiac resynchronization therapy

Depression and Cardiac Resynchronization Therapy . Background: The relationship between depression and heart failure is neither coincidental nor trivial, since depression is a powerful predictor of re‐hospitalization and mortality. We prospectively studied the prevalence and impact of depression on the clinical outcomes of patients attending for cardiac resynchronization therapy (CRT). We specifically examined whether patients with depression have a different rate of response to CRT and whether CRT has an effect on depressive symptoms. Methods: Sixty‐eight recipients of CRT systems were included. The depressive status was evaluated before implant and after 6 months by a structured diagnostic interview measuring Diagnostic and Statistical Manual of Mental Disorders (DSM‐IV) criteria of major depression and by a self‐report questionnaire (Center for Epidemiological Studies Depression Scale, CES‐D). The CRT response was assessed at 6 months by a clinical composite score. Results: At inclusion, DSM‐IV criteria of major depression were identified in 41% of the population, while using the self‐report questionnaire 65% were observed to have mild to major depressive symptoms (CES‐D ≥ 16). Only 4 patients were taking antidepressants. At 6 months, 75% were considered responders to CRT. Response to CRT did not differ between those with and without depression at baseline. The rate of patients with depression at 6 months was significantly lower in responders to CRT compared with nonresponders. Conclusions: We found a high prevalence of depressive symptoms in patients receiving CRT systems. Patients with depression should not be excluded from CRT, because they demonstrate a similar rate of response than the persons without depression and the responders are less likely to be depressed at 6 months. (J Cardiovasc Electrophysiol, Vol. 23, pp. 631–636, June 2012)     

Predictors of appropriate defibrillator therapy among patients with an implantable defibrillator that delivers cardiac resynchronization therapy

INTRODUCTION: The purpose of this study was to determine predictors of appropriate implantable defibrillator (ICD) therapy among patients with heart failure who are treated with a cardiac resynchronization therapy-defibrillator (CRT-D). METHODS AND RESULTS: Patients enrolled in the Ventak CHF/Contak CD study were treated with a CRT-D device and were required to have NYHA class II-IV CHF, QRS duration > or = 120 msec, and a class I or II indication for an ICD. The study database was retrospectively analyzed during the 6-month postimplant period to identify predictors of appropriate ICD therapy. Five hundred and one of the 581 patients enrolled in the trial had successful device implantation and were included in this analysis. Patients were mostly male (83%), 66 +/- 11 years old, and had coronary artery disease (69%), a mean left ventricular ejection fraction (EF) = 0.22 +/- 0.07, and NYHA class II (33%), III (58%), or IV (9%) CHF symptoms. During 6 months of follow-up, 73 of 501 (14%) patients received an appropriate ICD therapy. Two independent predictors of appropriate therapy were identified: a history of a spontaneous, sustained ventricular arrhythmia (HR = 2.05; 95% CI = 1.31-3.20; P = 0.002) and NYHA class IV CHF (HR = 1.81; 95% CI = 1.10-2.96; P = 0.019). When patients with NYHA class II were excluded from analysis, a history of a sustained ventricular arrhythmia and the presence of NYHA class IV CHF symptoms remained as independent predictors of appropriate ICD therapy. CONCLUSIONS: In a select population of advanced heart failure patients receiving a CRT-D, NYHA class IV CHF was a powerful independent predictor of appropriate ICD therapy. Approximately one-quarter of the patients with NYHA class IV CHF who received a CRT-D device received an appropriate ICD therapy within 3 months after implant. Additional studies are needed to confirm an association between class IV CHF symptoms and an increased frequency of ICD shocks.     

Mortality of heart failure patients after cardiac resynchronization therapy: identification of predictors

Introduction: A direct comparison of survival benefits between cardiac resynchronization therapy‐pacemaker (CRT‐P) and defibrillator (CRT‐D) was not yet performed, leaving clinicians to question whether CRT‐P alone is enough to protect congestive heart failure (CHF) patients from sudden cardiac death and whether CRT‐D should be implanted to all CHF patients indicated for biventricular pacing. This study attempts to make this type of comparison in a large CHF population and seeks to identify predictors of death in patients with different comorbidities. Methods and Results: Study population consisted of 542 consecutive patients who were implanted with either CRT‐P (N = 147) or CRT‐D (N = 395) between 1999 and 2005. Patients' clinical and follow‐up data were entered in a prospective registry and retrieved for analysis. The primary endpoint of this study was all‐cause mortality during follow‐up. Total all‐cause mortality was significantly lower among patients with CRT‐D (18.5% vs. 38.8% of CRT‐P, χ²= 25.11, P < 0.001). Patients with one of three comorbidities—chronic renal failure (OR = 4.885, P = 0.005), diabetes mellitus (OR = 4.130, P = 0.003), and history of atrial fibrillation (OR = 1.473, P = 0.036)—appeared to have higher risk of death, while treatment with beta‐blocker (OR = 0.330, P = 0.002) or CRT‐D device (OR = 0.334, P = 0.003) seemed to be associated with lower mortality. Conclusions: Data from this nonrandomized study indicate that CRT‐D has additional survival benefits over CRT‐P. Given these findings, CRT‐D should be recommended to most CHF patients with indications for biventricular pacing. After CRT implant, chronic renal failure, diabetes mellitus, and history of atrial fibrillation are strong independent predictors of death.     

心脏再同步化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2008年1月至2009年8月行CRT的患者32例,其中12例植入再同步心脏转复除颤器(CRT-D)。32例中30例为窦性心律,2例为房颤心律。随访21.5±6.2个月,观察患者NYHA心功能分级、QRS波时限、左室射血分数(LVEF)、左室舒张末内径(LVEDD)、6分钟步行距离(6MWD)、因心功不全住院时间等。结果 32例植入CRT(D)患者中,有24例临床症状明显改善,心功分级降低,LVEF和6MWD增加,QRS波时限、LVEDD减少,因心功不全住院时间明显减少约24.5%(p<0.05)。8例患者心功能没有明显改善,但因心功不全住院时间减少约8.3%(p<0.05)。4例患者记录到室性心律失常事件(12.5%),2例室速经抗心动过速起搏(ATP)有效转复,2例患者因室颤而放电,均成功转复,CRT-D均能有效识别和转复。结论 CRT可明显改善CHF患者的心功能,提高生活质量,缓解临床症状,植入CRT-D可有效预防心源性猝死(SCD)。     

心脏再同步治疗慢性心力衰竭的临床疗效

目的观察心脏再同步治疗慢性心力衰竭的临床疗效。方法36例慢性心力衰竭合并室内传导阻滞的患者行双心室再同步起搏治疗。全部患者均经冠状静脉窦植入左心室导线至心脏静脉。治疗后随访12个月,观察心功能,6min步行距离,QRS波宽度,心室间运动延迟,左心室收缩、舒张末内径,左心室射血分数,二尖瓣反流面积。结果31例治疗后心功能改善,有效率86．1％（31／36）。心功能从Ⅲ～Ⅳ级（纽约心脏协会心功能分级）改善为Ⅱ～Ⅲ级;6min步行距离从（362±153）m提高至（528_＋165）m,差异有统计学意义（P〈0．01）;QRS波从（164．74±33．76）ms缩短至（129．45±42．27）ms,差异有统计学意义（P〈0．01）;心室间运动延迟时间从（65．19±21．50）ms缩短至（33．25±13．62）ms,差异有统计学意义（P〈0．01）;左心室舒张末内径从（66．52±10．23）mm缩小至（60．63±9．97）mm（P〈0．05）,左心室收缩末内径从（55．73±10．62）mm缩小至（47．45±11．35）mm,差异有统计学意义（P〈0．01）;左心室射血分数从30．35％±4．69％提高至42．27％±8．40％,差异有统计学意义（P〈0．01）;二尖瓣反流面积从（7．52±3．62）cm2减少至（4．33±2．07）cm2,差异有统计学意义（P〈0．01）。结论心脏再同步治疗是治疗慢性心力衰竭的有效方法,能使心脏活动再同步化,改善心功能。     

Right ventricular versus biventricular antitachycardia pacing in the termination of ventricular tachyarrhythmia in patients receiving cardiac resynchronization therapy: the ADVANCE CRT-D trial

BACKGROUND: The purpose of this investigation is to compare the efficacy of antitachycardia pacing (ATP) delivered via the right ventricular (RV) lead versus ATP delivered simultaneously via the right and left ventricular leads (biventricular [BiV]) in the termination of ventricular tachyarrhythmia (VT) in patients receiving cardiac resynchronization therapy (CRT) with ICD capabilities. METHODS AND RESULTS: The ADVANCE CRT is a prospective, multicenter, randomized, parallel trial evaluating RV versus BiV ATP in the termination of VT in CRT patients. The study will test the hypothesis that BiV ATP is superior to RV ATP in the termination of VT and fast VT. All patients with class I and IIa indications for an ICD implantation and CRT are included. The sample size has been estimated to 400 participants followed for 12 months to show a 10% benefit of BiV versus RV ATP. The efficacy of BiV ATP to terminate all VT presents the primary endpoint. The investigation is expected to be completed in 2007. CONCLUSIONS: The ADVANCE CRT trial is the first large randomized clinical investigation evaluating the efficacy of BiV ATP in patients under CRT and ICD therapy.     

心脏再同步治疗慢性心力衰竭患者的临床分析

目的评价心脏再同步治疗(cardiac resynchronization therapy,CRT)慢性心力衰竭的临床疗效。方法选择接受CRT的慢性心力衰竭患者29例,术后定期随访,观察患者心功能、LVEF、左心室舒张末内径(LVEDD),评价CRT的临床疗效,临床有效定义为心功能NYHA分级改善1级以上;超声心动图有效定义为左心室舒张末容积缩小>15%或LVEF绝对值增加>0.05%;否则定义为对CRT无反应。结果随访6～24(8.7±8.3)个月。与CRT前比较,术后21例LVEDD明显缩小,心功能分级明显减轻,LVEF明显增加,差异有统计学意义[(73.9±8.0)mm vs(68.7±10.2)mm,(3.1±0.1)级vs(2.0±0.1)级,(34±7)vs(42±6)%,P<0.05];临床对CRT的反应:有效21例,发生率为72.4%;对CRT无反应8例,发生率为27.6%,其中包括死亡2例。结论 CRT能改善慢性心力衰竭患者的左心室收缩功能,改善症状;对CRT的反应与入选患者是否真正存在心脏机械收缩不同步有关。     

Device therapy in heart failure patients with chronic kidney disease

Heart failure (HF) and chronic kidney disease (CKD) both carry significant risk for sudden cardiac death, hospitalization, and mortality; when combined, however, they markedly increase the risk of morbidity and mortality. Device therapies such as implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) are treatments proven to have significant benefit on clinical outcomes in select patients with HF. However, the majority of studies supporting the use of these devices have limited data on patients with CKD or end-stage renal disease. In this review, we discuss the intersection of HF and CKD as it relates to progressive HF and the risk of sudden death. Although these disorders are common and have a poor prognosis, the evidence available for guiding treatment decisions for the use of ICD and CRT devices in these patients is lacking. Given this lack of clear evidence, pragmatic clinical trials and comparative effectiveness studies are needed to help identify the appropriate use of ICD and CRT devices in this high-risk population of patients with HF and CKD.     

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。