双腔起搏器治疗扩张型心肌病缓慢性心律失常并心力衰竭

目的　观察双腔起搏治疗扩张型心肌病 (DCM)缓慢性心律失常合并心力衰竭的临床效果。方法　 2 5例DCM缓慢性心律失常合并心力衰竭患者 ,植入双腔起搏器。起搏频率调至 6 0～ 70次 / min,A - V间期在窦房结功能异常者调至 170～ 2 0 0 m s、房室传导阻滞或合并窦房结功能异常者调至 12 0～ 15 0 ms。并继续给予药物治疗心力衰竭 ,对伴频发室性早搏、短阵室性心动过速、阵发性心房颤动患者给予抗心律失常药物治疗 ,随访观察 0 .5～ 8年。结果　 2 4例临床症状明显改善 ,1例改善不明显。1例窦性心动过缓伴阵发性心房颤动患者和 2例窦性心动过缓伴有室性早搏、短阵室性心动过速的患者术后未用抗心律失常药物治疗 ,心房颤动、短阵室性心动过速消失 ,频发室性早搏显著减少。心功能平均改善达 1.5级 (P<0 .0 5 ) ,6 m in步行距离由平均 30 9m增加至 4 17m (P<0 .0 5 )。心排血量 (CO)在初期明显增加 (P<0 .0 0 1) ,左心室射血分数 (L VEF)改善 (P<0 .0 1) ,心胸比率、左心室舒张末径(L VEDD)、左心室收缩末径 (L VESD)变化无显著性差异 (P>0 .0 5 ) ,3月、6月后心胸比率、L VEDD、L VESD逐渐减小 (P<0 .0 5 ) ,CO、L VEF仍得以改善 ,尤其是在 3月时 L VEF改善显著 (P<0 .0 0 1)。结论　双腔起搏器是治疗缓慢性?     

多普勒超声心动图评价DDD双腔起搏器房室间期血流动力学作用

双腔起搏器所选定的房室间期 (ＡＶＰ)仅仅确定了右房室之间的电激动顺序 ,并未解决房室之间特别是左房室间机械性运动的相互关系。对其最佳ＡＶＰ研究目前尚有争论。因此 ,本研究使用多普勒超声心动图在一组心功能正常患者中研究不同ＡＶＰ时血流动力学改变及发生机制。一、资料与方法1 对象 :按置ＤＤＤ起搏器患者 12例 ,男 8例 ,女 4例 ,平均年龄 (4 9± 15 )岁 ,均经Ｘ线胸片和超声心动图等系统检查而确定心脏舒缩功能正常。起搏器按置时间为 (13± 7)个月。2 方法 :平卧下调控起搏形式为起搏心房和心室 ,心率80次 /ｍｉｎ ,ＡＶＰ被分…     

扩张型心肌病心力衰竭的血液动力学改变

应用Swan-Ganz导管、核素、超声心动图观察21例扩张型心肌病患者的血液动力学改变,结果表明除心肌收缩功能降低外,同时表现左室舒张充盈受损,左室EF均<30％,7例患者CI<2.2L/m~2/min,左室短轴缩短率(ΔD％)平均为7.4％,左室周径向心缩短率(MVCF)平均为0.31circ/s,13例患者PCWP>18mmHg(平均为29.19mmHg);CI与PCWP、HR、左室舒张横径均呈负相关性,心脏大小在一定程度上反映CI的变化。     

双腔心脏起搏器A—V间期的研究进展

双腔心脏起搏器的Ａ－Ｖ间期与心率，左室舒张和收缩功能有密切联系。选择适当的Ａ－Ｖ间期可获得较好的血流动力学效应以及减少起搏器介入性心动过速的发生。     

三腔起搏器治疗扩张型心肌病的临床应用(附二例报告)

目的观察三腔双心室起搏治疗扩张型心肌病的临床效果,探讨三腔双心室起搏的治疗机制及目前存在的问题.方法患者两例均为男性,平均年龄57.5岁.诊断扩张型心肌病,完全性左束支传导阻滞,心功能Ⅲ～Ⅳ级(NYHA).两位患者均进行双心室起搏,左心室起搏通过冠状静脉窦植入2188导线,于其血管分支内进行左心室起搏.左、右心室的导线通过Y型转换器与双腔起搏器连接.术前、术后一周及术后6个月应用十二导联心电图、超声心动图及活动耐量(6分钟步行距离)进行评价,观察双心室起搏的临床效果.结果双心室起搏后,患者心功能得到明显改善,左室射血分数从0.23提高至0.48,左室充盈时间延长,心功能改善至Ⅱ级.结论临床效果观察提示,双心室起搏能明显改善扩张型心肌病患者的心功能.     

双腔起搏器中房室间期的程控及临床应用

双心腔起搏对血流动力学的影响主要表现在两个方面：它可保持房室的顺序收缩或房室同步,但仅有房室同步尚不能提供最佳的血流动力学效应,还必须有一个最佳的房室延迟（ＡＶ ｄｅｌａｙ）或称为房室间期（ＡＶ ｉｎｔｅｒｖａｌ）,即在心室收缩之前有最佳的时间进行心房收缩,因此双腔起搏的ＡＶ间期的长短与起搏的血流动力学效应关系密切。最佳的ＡＶ间期对心室充盈,减少房室瓣返流,保持正常的心房压力及防止不良的循环及神经体液反射都是很重要的。不恰当的ＡＶ间期所带来的血流动力学负面作用甚至大于一般的心室起搏。起搏器中的不同…     

双腔起搏器治疗扩张型心肌病13例报告

目的：探讨双腔起搏器治疗对扩张型心肌病伴心力衰竭的疗效。方法：13例扩张童心肌病患者，明显的心功能不全，经药物治疗效果不佳，植入双腔起搏器，以DDD起搏方式治疗，AV间期调至100ms。结果：术后患者心力衰竭症状明显好转，心脏缩小，左室射血分数(EF)、心排出量(CO)、心排血指数(CI)明显增加，随访2～37个月，1例死于脑栓塞，2例猝死，1例因发生心房颤动、改为VVI方式起搏后心力衰竭死亡，其余9例心功能不全得到较为理想的控制。结论：提示双腔起搏器治疗对改善扩张型心肌病患者心功能有明显效果。     

EF值对双腔或多腔起搏器治疗扩张型心肌病的疗效评价

为探讨双腔或多腔起搏器治疗扩张型心肌病的疗效 ,我院自 1 999年 3月起对 5例植入以双腔或多腔方式起搏器的扩张型心肌病患者 ,借助心脏超声心动图测量不同房室间期的 EF值来调整最适房室间期 ,以达双腔或多腔起搏器治疗扩张型心肌病的最佳疗效。现报道如下 :1　资料与方法1 .1　一般资料 :5例患者均为男性 ,年龄 47～ 74岁 ,平均年龄 6 4± 1 1岁。常规心电图均为窦性心律。冠状动脉造影阴性。经病史、体检、心脏 X片、超声心动图示 ,各心腔明显增大 ,左心室舒张末内径为 72± 3 mm,心肌搏动普遍减弱 ,室壁和室间隔均不增厚、在排除其他…     

双腔起搏器治疗缺血性心肌病心力衰竭四例

原发性心肌病心力衰竭用起搏器治疗，近年来取得了一定的疗效，兹报告对缺血性心肌病引起的心力衰竭用又腔起捧器治疗的初步经验，以探讨双腔起搏治疗缺血性心肌病心力衰竭的可行性。4例患者，男性3例，女性1例，年龄65～74(69±5.7)岁，均经冠状动脉造影、超声心动图检查确诊为缺血性心肌病(扩张型)，心功能Ⅲ～Ⅳ级，其中3倒合并二度以上房室阻滞．1例并发病态窦房结综合征，各房室腔均明显扩大，均经药     

国产卡托普利注射液对扩张型心肌病的急性血流动力学效应

目的观察国产卡托普利注射液对扩张型心肌病（DCM）的急性血流动力学影响。方法选住院确诊DCM患者6例，采用自身对照的方法，于静脉给予卡托普利后30min及2hr，经Swan－Ganz导管测定平均肺动脉压（MPAP）、肺毛细血管楔嵌压（PCWP）、心输出量（CO）和心脏指数（CI）。结果卡托普利静脉注射可使MPAP及PCWP下降，而CO及CI增加，且用药后2hr较30min更为明显。结论国产卡托普利注射液对DCM患者具有良好的急性血流动力学效果。     

Haemodynamic benefit of a rate-adapted A-V delay in dual chamber pacing

In dual chamber pacing, an improvement of exercise capacityis expected when the atrial refractory period is shortened,because the 2/1 point is increased. This objective can be achievedby greatly reducing atrio-ventricular delay (AVD) on exercise.Are such variations (up to 100–120 ms) detrimental froma haemodynamic standpoint? This study was performed to analysethis particular aspect of DDD pacing. Three DDD pacing modes,differing by their AVDs (fixed 200 ms AVD, fixed 150 ms AVD,and rate-adapted AVD) were tested in random order, with a haemodynamicprotocol including ten patients with chronic atrio-ventricular(A-V) block. For the rate-adapted AVD pacing mode, AVD was reducedby 20 ms every 10beats min^–1 increment (from 220 ms at90 beats min^–1 to 100 ms at 150 beats min^–1). Pacingrate was increased from 90 to 150 beats min^–1 by incrementsof 10 beats min^–1 every 5 min. Cardiac performance was significantly improved with the rate-adaptedAVD above the two fixed AVDs, despite a large A VD variation.When A VD was rate adapted, cardiac index, stroke volume indexand left ventricular systolic work index were generally higherand pulmonary capillary wedge pressure, pulmonary arterial pressureand systemic vascular resistances were generally lower, especiallyat 120, 130 and 140 beats min^–1. Comparing the two fixedAVDs, 200 AVD improved cardiac function more at lower heartrates, whereas 150 AVD improved cardiac function more at higherheart rates. Despite its limitations, this study demonstratesthat the potential benefits of reducing AVD with increasingheart rates should be twofold in dual chamber pacing:

1. haemodynamic,optimizing cardiac performance on exercise forall heart rates,especially in cases of organic heart disease;
2. electrophysiologic,permitting a sufficiently rapid maximaltracking rate in caseswith long post-ventricular atrial refractoryperiods, allowinga satisfactory level of exercise.

     

Pacing for patients with congestive heart failure and dilated cardiomyopathy

Considerable evidence has now accumulated that permanent pacing may provide symptomatic benefit for at least some patients with CHF. Recently, the most promising results with left ventricular or biventricular pacing have been obtained. The data for improvement in survival with pacing is less compelling. The mortality of CHF associated with systolic dysfunction of the left ventricle remains high and arrhythmic deaths are frequent. Clinical trials such as the Sudden Cardiac Death Heart Failure Trial (SCD-HeFT) are currently underway to investigate the role of the implantable defibrillator in patients with heart failure. The development and general availability of ICDs with biventricular pacing capability may play an increasingly important role in the overall therapeutic plan for this group of patients to allow for optimization of functional status with pacing and protection from sudden cardiac death with defibrillation.     

Dual chamber pacing in the treatment of congestive heart failure

The present work reviews current literature and the authors' experience of dual chamber pacing in the treatment of patients with congestive heart failure (CHF). In these patients, the atrial contribution to ventricular filling may be less than optimal, especially in the presence of first degree atrioventricular block or mitral insufficiency, both of which are common in the elderly subject with CHF. Dual chamber pacing with short atrioventricular delays has proved effective in enhancing ventricular filling and, in selected cases, cardiac output, with improvement in clinical and instrumental parameters of heart failure. However, for an appropriate atrioventricular synchronization of the left chambers during pacing, the interatrial conduction time must be considered, to avoid atrial contraction against a closed mitral valve. Thus, dual chamber pacing may be a treatment option for CHF that fails to respond to medical therapy.     

Dual chamber pacing with optimal AV delay in congestive heart failure: a randomized study.

AIM: A prospective randomized trial was set up to evaluate contractile parameters and quality of life in patients with congestive heart failure. METHODS AND RESULTS: We describe the results from 38 patients in sinus rhythm and with chronic heart failure due to congestive cardiomyopathy, prospectively randomized to optimal medical therapy (Group 1, 19 patients) or optimal medical therapy plus dual chamber pacemaker programmed to optimal AV delay (Group 2, 19 patients). At a 6 month follow-up, 7/19 patients in Group 1 had died compared with 5/19 patients in Group 2. During follow-up, there were few significant changes in evaluated parameters except for mitral regurgitation time, which was prolonged in Group 1 and shortened in Group 2. The systolic left ventricular diameter shortened significantly only in Group 2. An energy and activity questionnaire showed that the effect of DDD pacing in the latter patient population was beneficial. CONCLUSIONS: From these results we may conclude that at the 6 month follow-up DDD pacing with echo-optimized AV interval programming can improve quality of life without affecting survival.     

卡维地洛治疗扩张型心肌病心力衰竭疗效观察

目的　评价第三代 β受体阻滞剂卡维地洛治疗扩张型心肌病 (DCM)心力衰竭的临床疗效。方法　 6 2例 DCM心力衰竭患者在接受常规治疗 (洋地黄、利尿剂、血管紧张素转换酶抑制剂 )病情稳定后 ,随机分为卡维地洛组和美多心安组。均从小剂量 (卡维地洛组 ,2 .5 m g bid;美多心安组 ,6 .2 5 m g bid)缓慢递增。检测治疗前后 DCM患者左心室功能和结构的变化以及血液中内皮素 - 1(ET- 1)、心钠素 (ANP)和血管紧张素 (Ang )的改变。结果　治疗 6个月后 ,两组心脏功能分级均明显改善 ,左心室射血分数 (L VEF)、短轴缩短率 (FS)、左心室射血前期与射血时间比(PEP/ L VET)、舒张早期峰值血流速度 (PFVE)、舒张早期峰值血流速度与舒张晚期峰值血流速度比 (PFVE/ PF-VA)均明显增加 ,卡维地洛组较美多心安组 L VEF增加更为明显。两组左心房内径 (L AD)、左心室收缩末期内径(L VSD)、左心室舒张末期内径 (L VDD)明显减小 ,卡维地洛组 L VSD减小较美多心安组更明显。治疗后血浆中ET- 1、ANP和 Ang 均明显降低。结论　卡维地洛和美多心安都能够改善 DCM心力衰竭患者左心室收缩和舒张功能 ,逆转左心室重构 ,卡维地洛较美多心安疗效更佳。     

曲美他嗪对扩张型心肌病心力衰竭患者心功能的疗效观察

目的 观察曲美他嗪(TMZ)对扩张型心肌病(DCM)患者心力衰竭的临床疗效.方法 46例DCM伴中重度心力衰竭患者随机分为TMZ治疗组(TMZ组)和常规治疗组(对照组).对照组予常规抗心力衰竭治疗,TMZ组在常规治疗的基础上加用TMZ 20 mg,3次/d,观察治疗前和治疗20周后患者心功能分级、左室射血分数(LVEF)、左室收缩末期内径(LVEDs)、左室舒张末期内径(LVEDd)的变化.结果 治疗20周后,TMZ组心功能分级的显效率和总有效率均显著优于对照组(P＜0.05),超声心动图LVEF明显提高(P＜0.01),LVEDs和LVEDd显著缩小(P＜0.05,P＜0.01).结论 曲美他嗪可以改善DCM患者的心功能,可以作为辅助治疗.     

Ventricular dyssynchrony in dilated cardiomyopathy: the role of biventricular pacing in the treatment of congestive heart failure

Despite advances in pharmacologic therapy, the prognosis of patients with advanced congestive heart failure (CHF) remains poor. Many of these patients have cardiac conduction abnormalities, such as left bundle-branch block or interventricular conduction delays, that can lead to ventricular dyssynchrony (abnormal ventricular activation that results in decreased ventricular filling and abnormal ventricular wall motion). Biventricular pacing is an alternative, nonpharmacologic therapy under active investigation for the treatment of CHF. Resynchronization devices with transvenous leads in the right atrium, right ventricle, and left ventricle (via the coronary sinus) have been implanted in patients to provide atrial triggered biventricular pacing. The use of such devices has been associated with improvement in ejection fraction, dP/dt, stroke work, and functional class. The proposed mechanisms involved in improving ventricular function with biventricular pacing include improved septal contribution to ventricular ejection, increased diastolic filling times, and reduced mitral regurgitation. This article reviews the pathophysiology of ventricular dyssynchrony and examine insights from clinical trials that are evaluating cardiac resynchronization therapy for CHF.     

Amrinone therapy for congestive heart failure in outpatients with idiopathic dilated cardiomyopathy

Amrinone, 100 mg orally every 8 hours, was administered to 13 patients with moderate-to-severe congestive heart failure (CHF) for 1 month on an outpatient basis to determine the beneficial and undesirable effects of this new cardioactive agent in this clinical setting. These subjects received conventional CHF medications during the course of study. Ten patients who received conventional CHF medications alone served as a control group. Changes in functional classification were not significantly different between the 2 treatment groups. Amrinone augmented exercise capacity 37% above baseline compared with a 12% improvement for the control group. Noninvasive indexes of resting left ventricular function (echocardiography and systolic time intervals) did not change significantly for either group, nor was there a significant change in the exercise ejection fraction. All patients treated with amrinone had ≥ 1 symptom-related or laboratory-detected adverse effect. An increase in the frequency of ventricular ectopic beats was noted at rest in 4 and with exercise in 6 patients (salvos of nonsustained ventricular tachycardia in 2). Six subjects treated with amrinone had gastrointestinal symptoms and 8 developed a viral-like illness. Other adverse effects noted in the amrinone-treated group included near-syncope, headaches, marked anxiety, chest pain, palpitations, maculopapular rash, hypokalemia, and elevation of serum transaminase levels. The control patients had significantly fewer adverse effects.Although individual patients with CHF may benefit from long-term amrinone therapy, the low benefitto-risk-adverse effect ratio does not warrant widespread application of this drug in the outpatient management of CHF and requires caution when prescribing.