单纯左心室起搏实现心脏再同步化治疗的临床观察

The clinical observation of left univentricular pacing in cardiac resynchronization therapy

目的 通过对单纯左心室起搏与双心室起搏的临床疗效比较,探讨单纯左心室起搏作为慢性心力衰竭患者心脏再同步化治疗(CRT)的可行性.方法 选择符合中国心力衰竭诊断和治疗指南2014的CRT适应证患者52例,男性32例,女20例,平均年龄(60.7±13.3)岁,患者成功植入CRT后随机分为两组,单纯左心室起搏组(LVP组,26例)采用右心房左心室起搏模式,标准双心室起搏组(BVP组,26例)采用右心房双心室起搏模式,术后12周进行随访并程控,观察患者术前及术后12周6 min步行距离(6MWD)、N末端B型利钠肽前体(NT-proBNP)、纽约心功能(NYHA)分级及心脏超声指标的变化.结果 组内比较显示,两组患者术后12周NYHA分级、NT-proBNP、舒张末期左心室内径(LVEDD)、左心室间隔部与侧壁基底段收缩期达峰时间差(TPSD)、二尖瓣反流面积(MRA)、主肺动脉射血前时间差(IVMD)较术前均有所降低(P均<0.05),6MWD、左心室射血分数(LVEF)较术前均有所升高(P均<0.05);组间比较显示,LVP组术前术后LVEF、MRA、IVMD、TPSD的差值优于BVP组[(△9.2±5.5)%比(△5.6±3.7)%,P=0.021;(△-1.7±0.6)cm2比(△-0.8±+0.3)cm2,P=0.038;(△-15.3±8.5) ms比(△-10.2±8.1)ms,P=0.033;(△-19.2±4.5)ms比(△-9.6±3.7)ms,P=0.035];而NYHA分级、6MWD、NT-proBNP、LVEDD未见明显差别[△-1.44±0.30比△-1.39±0.34,P=0.062;(△188±41)m比(△190±35)m,P=0.051;(△-3011±803)pg/ml比(△-2889±745)pg/ml,P=0.066;(△-7.2±4.5)mm比(△-8.6±3.7)mm,P=0.064];LVP组有8例发生不良事件,BVP组有7例发生不良事件,两组患者不良事件的发生率无统计学差异(P>0.05).结论 单纯左心室起搏通过程控优化能够实现心室收缩同步最大化,可以明显改善心功能指标;单纯左心室起搏成为慢性心力衰竭CRT治疗的一种策略选择有一定的可行性.

Objective To compare clinical outcomes between left univentricular pacing(LVP)and biventricular pacing(BVP)and to investigate the feasibility of LVP in cardiac resynchronization therapy(CRT).Methods 52 patients with chronic heart failure(CHF)who were eligible for CRT indications were enrolled in our study,after implanted CRT-P/D successfully patients were divided into LVP group(n=26)programmed left univentricular pacing and BVP group(n=26)programmed biventricular pacing for 12 weeks.Adverse events(arrhythmia events,aggravated symptom of heart failure,sudden cardiac death,et al),New York Heart Association(NYHA)class,6 minutes walking distance(6MWD),NT-proBNP,left ventricular end-diastolic diameter(LVEDD),the difference between time to peak from basal segment of later wall to septum in left ventricular(TPSD),left ventricular ejection fraction(LVEF),MRA,and interventricular mechanical delay(IVMD)were observed and compared.Results Compared with preoperation,NYHA classification,NT-proBNP,LVEDD,TPSD,MRA and IVMD were reduced significantly,moreover,6MWD and LVEF were improved markedly in 12 weeks after operation.The improvement of LVEF,MRA,IVMD and TPSD in LVP was more outstanding than them in BVP[(△9.2±5.5)%vs(△5.6±3.7)%,P=0.021;(△-1.7±0.6)cm2 vs(△-0.8±0.3)cm2,P=0.038;(△-15.3±8.5)ms vs(△-10.2±8.1)ms,P=0.033;(△-19.2±4.5)ms vs(△-9.6±3.7)ms,P=0.035],the difference of NYHA Classification,6MWD,NT-proBNP,LVEDD between in two groups was not discovered[△-1.44±0.30 vs△-1.39±0.34,P=0.062;(△188±41)m vs(△190±35)m,P=0.051;(△-3 011±803)pg/ml vs(△-2 889±745)pg/ml,P=0.066;(△-7.2±4.5)mm vs(△-8.6±3.7)mm,P=0.064];8 adverse events in LVP and 7 in BVP occured,the rate of adverse events in two groups were not statistical difference(P>0.05).Conclusion Left univentricular pacing with programming suitable parameters can achieve maximized resynchronization during ventricular systolic;Left univentricular pacing is feasible in CRT patients with intrinsic conductive.