微创胸腔镜心外膜电极技术和冠状静脉窦电极技术进行心脏再同步治疗的比较研究

目的 探讨微创胸腔镜心外膜电极导线技术和冠状静脉窦电极导线技术完成心脏再同步治疗(CRT)的效果.方法 回顾性总结北京安贞医院2007年4月至2009年6月的28例进行CRT治疗的心肌病心力衰竭的病例资料.治疗前所有患者均经心电图和超声心动图明确诊断心力衰竭伴心脏不同步.所有患者右心房和右心室电极导线均在X线引导下植入,左心室电极导线植入中,10例采用微创胸腔镜心外膜电极导线技术(组1),其中有3例因为冠状静脉窦电极无法植入而转入外科.18例采用冠状静脉窦电极导线技术(组2).组1患者在术中经食管超声心动图监测下测试左心室侧壁不同位置,寻找同步效果最理想的位置,并使用无损伤缝线固定左心室心外膜电极.围术期和随访5～24个月监测心脏结构、功能和同步效果.结果 所有患者术中电极导线放置顺利.组1患者术后顺利拔除气管插管,除1例发生肺炎外无明显并发症.2组患者术后均临床症状改善顺利出院.随访结果显示:组1左心室最大收缩延迟时间由术前(390.7±42.1)ms缩短为(135.7±37.2)ms,左心室不同步指数(Ts-SD)由术前的(143.7±30.1)ms降为(50.3±22.3)ms,心室间机械延迟(IVMD)由术前(57.7±24.9)ms降为(27.0±10.8)ms.左心室射血分数(LVEF)由术前0.320±0.007升到0.400±0.006,左心室舒张末内径(LVEDD)由术前(71.3±12.8)mm降低为(62.3±6.5)mm.组2结果显示:左心室最大收缩延迟时间由术前(396.7±36.1)ms缩短为(293.7±119.2)ms,Ts-SD由术前的(147.7±22.1)ms降为(96.3±34.3)ms,IVMD由术前(59.7±35.9)ms降为(27.0±25.8)ms.LVEF由术前0.281±0.077升到0.330±0.076,LVEDD由术前(71.3±9.8)mm降为(67.3±9.5)mm.其中组1在改善左心室最大收缩延迟时间和Ts-SD方面优于组2,差异有统计学意义(P＜0.05).结论 两种同步治疗技术均可以获得较好的心力衰竭治疗效果,其中微创胸腔镜心外膜电极技术完成心力衰竭CRT治疗对于非严重心功能不良者安全可行,而且由于心外膜电极导线在左心室侧后壁位置的良好选择性,使其可以更好地纠正左心室内部的不同步运动.

Comparison of minimally invasive surgical implantation of left ventricular epicardial electrode with coronary sinus endocardial electrode for cardiac resynchronization therapy in patients with cardiomyopathy heart failure

Objective To compare the minimally invasive surgical implantation of left ventricular epicardial electrode technique and coronary vein sinus endocardial electrode technique for cardiac resynchronization therapy(CRT) in cardiomyopathy heart failure. Methods During April 2007 to May 2009 total 28 patients were diagnosed as advanced heart failure with cardiac dysynchronization through ECG and Tissue Doppler Echos. Ten received surgical epicardial electrode implantation ( group 1 ) and 18 received coronary sinus electrode implantation ( group 2). For the group 1 patients, the electrodes were placed in right atrial and ventricle guided by X ray under the general anesthesia. The right atrial and ventricle electrodes were connected with the three chamber pacemaker. The Tissue Doppler Echo TEE technique was used to search suitable left ventricle place for the ideal CRT therapy. Then the epicardial electrode was fixed at the ideal place. The resynchronization features were examined after surgery during the follow of 5 ～ 24 months. Results The endocardial and epicardial electrodes were implanted successfully without any serious complication in group 1 patients. All patients were discharged without any adverse cardiac episodes. For the group 1 patients during the 5 ～ 24 months follow-up the left ventricle maximize delay time decreased from ( 390. 7 ± 42.1) ms to ( 135.7 ± 37.2 ) ms, the left dysynchronization index (Ts-SD) decreased from ( 143.7 ±30. 1 ) ms to (50. 3 ±22. 3) ms,the inter-ventricle mechanical delay time (IVMD) decreased from (57.7 ±24. 9) ms to (27.0 ± 10. 8) ms,left ventricle end-dilation diameters (LVEDD) increased from (71.3 ± 12. 8) mm to (62. 3 ±6. 5) mm and the left ventricle ejection fraction (LVEF) increased from 0. 320 ±0. 007 to 0. 400 ±0. 006. For the group 2 patients during the follow up period the left ventricle maximize delay time decreased from (396. 7 ± 36. 1 ) ms to (293.7 ± 119. 2)ms,Ts-SD decreased from ( 147.7 ± 22. 1 ) ms to (96. 3 ± 34.3) ms,IVMD decreased from ( 59.7 ± 35.9 ) ms to (27.0±25.8) ms,LVEDD increased from (71.3 ±9.8) mm to (67.3 ±9.5) mm and LVEF increased from 0. 281 ±0. 077 to 0. 330 ±0. 076. The left ventricle resynchronization results were better in the group 1 cases. Conclusion Cardiac resynchronization results were good in both groups and the surgical epicardial therapy could improve the left ventricle resynchronization.