DDD模式下右心室心尖部起搏与右心室流出道间隔部起搏的临床对比研究

目的 DDD模式下比较右心室心尖部（RVA）起搏与右心室流出道（RVOT）间隔部起搏对患者左心室重构及心功能的影响。方法回顾性分析2009年1月至2012年12月期间我院行永久起搏器（双腔DDD）植入治疗的患者219例,根据心室电极植入部位的不同分为A组（RVA起搏）、B组（RVOT起搏）,每组再根据患者术前左心室射血分数（LVEF）的不同分为两个亚组。调取患者12个月的随访资料,分析两组患者术后LVEF、左心房内径（LAD）、左心室舒张末期内径（LVEDD）及起搏治疗前后各项起搏参数、起搏QRS波群时限和术后并发症等。结果两组在手术成功率、术后并发症等方面的比较无显著差异。术后12个月,A组起搏阈值、电极阻抗较术中均有回落,LVEF较术前降低,LAD、LVEDD较术前增大,差异均有统计学意义（P〈0.05）;B组电极阻抗较术中有回落（P〈0.05）,起搏阈值、R波振幅与术中比较差异无统计学意义,LVEF、LAD、LVEDD与术前相比差异无统计学意义。B组的起搏QRS波群时限较A组显著缩短[（145.09±4.96）ms vs.（157.40±12.44）ms,P〈0.01]。对亚组进行分析发现：术前LVEF≥50%的患者,A、B两组仅LVEDD较术前有增大（P〈0.05）,LVEF和LAD与术前相比差异无统计学意义。术前LVEF〈50%的患者,A组患者的LVEF较术前降低,LAD、LVEDD较术前增大,差异均有统计学意义（P〈0.05）,而B组患者的LVEF、LAD、LVEDD与术前比较差异无统计学意义。结论运用主动固定电极行RVOT起搏在临床应用中是安全、可行的。经过12个月的起搏治疗,对术前心功能不全的患者,RVOT起搏能提供接近生理性的心室激动顺序,维持心室肌电-机械活动同步化,对患者心功能的损害小;对术前心功能正常的患者,虽然RVOT起搏提供了更为协调的心室收缩,但在保护患者左心室收缩功能及阻止左心室重构方面并未显示出优于RVA起搏的证据。

Comparison of effects on patients with cardiac function between RVA pacing and RVOT pacing with the same DDD pacemaker model

Objective To compare the effects of right ventricular outflow tract septum（RVOT） pacing and right ventricular apex（RVA） pacing on left ventricular remodeling and cardiac function. Methods Patients with SSS/AVB who were implanted with DDD pacemakers from January 2009 to December 2012 were enrolled. Depending on the ventricular electrode implanted part was divided into group A（RVA pacing） and group B（RVOT pacing）. Each group according to preoperative patients with left ventricular ejection fraction（LVEF） were divided into two subgroups. 12 months of follow-up data to be obtained, analysis of two groups of postoperative patients with LVEF, LAD, LVEDD and various post-operation parameters, paced QRS duration and postoperative complications. Results All 219 cases of surgeries were successful, the two group showed no significant difference in surgical success rate or postoperative complications. After 12 months of follow-up, Pacing threshold, electrode impedance of group A significantly decreased（P〈0.05）, R wave amplitude showed no significant changes; Electrode impedance of group B significantly decreased（P〈0.05）, but pacing threshold, R wave amplitude showed no significant changes. QRS duration in Group B significantly reduced than it in group A[（145.09±4.96）ms vs.（157.40±12.44）ms, P〈0.01]. Compared with preoperative, Group A reduced LVEF, increased LAD and LVEDD, the differences were statistically significant（P〈0.05）; LVEF, but in group B, significant changes not been found.Preoperative LVEF≥50% of the patients： LVEDD in both group increased compared with that before surgery（P〈0.05）, differences of LVEF and LAD had no statistical significance. Preoperative LVEF50% of the patients：Group A reduced LVEF, LAD, increased LVEDD, differences were statistically significant（P〈0.05）, Group B had no such significant differences. Conclusions RVOT pacing is safe and feasible in clinical application. For patients with cardiac insufficiency, RVOT pacing can make v