双心房-右心室间隔上部三腔起搏对阵发性心房颤动伴心功能不全的长期治疗作用

Long-Term Beneficial Effects of Biatrial-Right Ventricular Upper Septal Pacing in Patients With Paroxysmal Atrial Fibrillation and Cardiac Dysfunction

目的:通过前瞻性对比研究,比较双心房-右心室间隔上部三腔起搏(BiA-RVUSP)与右心房-右心室间隔上部双腔起搏(RA-RVUSP)对药物难治性阵发性心房颤动(房颤)伴心功能不全患者的长期疗效。方法:将26例药物难治性阵发性房颤伴心功能不全患者,随机分为BiA-RVUSP组(A组)11例和RA-RVUSP组(B组)15例,另取同期基本情况相同的患者28例设常规药物治疗组(C组)。随访1年,全面比较起搏器A、B两组治疗前和治疗后,各起搏治疗组(A、B组)与药物治疗组间房颤事件的发生情况,心功能变化情况和评估患者的生活质量。结果:体表心电图P波时程A组治疗1年后较治疗前有显著缩短,而B组则有明显延长(P均<0.05)。超声心动图示A组起搏治疗1年后较治疗前左心房内径减少12.9%(P<0.05),舒张早期二尖瓣流速(E峰)和心房收缩期二尖瓣流速(A峰)均较治疗前有显著升高(P均<0.05);A组较B组治疗1年后左心房内径明显减小,A峰峰值明显升高(P均<0.05)。左心室射血分数A组和B组治疗1年后均较C组显著改善(P均<0.05)。A组治疗后的第1年内阵发性房颤发作频率较治疗前减少39.8%,较B组治疗前减少28.2%,有显著差异(P均<0.05);c组治疗后第1年房颤发作明显恶化,5/28例的患者转为永久性房颤。

Objective: To access the long-term effects of biatrial-right ventricular upper septal pacing compared with right atria-right ventricular upper septal pacing in patients with drug-refractory paroxysmal atrial fibrillation ( PAF) companied with cardiac dysfunction in a prospectively designed study. Methods: Twenty-six patients with drug-refractory PAF coupled with cardiac dysfunction were randomized into biatrial-right ventricular upper septal pacing group (group A,n = 11 ) and right atria-right ventricular upper septal pacing group (group B, n = 15). Twenty-eight patients at the same stage with drug-refractory PAF and similar underlying disorders were enrolled in the routine medical treatment group ( group C). The long-term effects of these treatments including pacings and medicine on the recurrence of PAF, cardiac performance and quality of life were evaluated before and one year follow-up after treatment. Results: Electrocardiogram recorders showed that, compared with the baselines, P wave duration was significantly shortened after pacing in group A but prolonged in group B (both,p <0. 05). Echocardiograms showed that the left atrial diameler( LAD) in group A was decreased by 12. 9% (p <0. 05) at 1 year after pacing compared with the baseline. At the same time both early diastolic mitral velocity(E) and that of atrial systole(A) increased significantly (both,p <0. 05). LAD was markedly shortened with increased A (both,p <0. 05) at 1 year after pacing in group A compared with those in group B. Equilibrium radionuclide angiocardiography showed that left ventricular ejection fractions in group A and B were significantly improved compared with those of group C during 1-year follow-up (both, p <0. 05). The frequency of recurrence of PAF in group A had a 39. 8% reduction(p <0. 05) within the first year after pacing versus before treatment and a 28. 2% reduction (p <0. 05) compared with that of group B during the first-year follow-up; Eighteen percent of patents in group C developed permanent atrial fibrillation. According to the questionnaires for Wakefield score, the improvements of quality-of-life in both pacing groups were markedly evident compared with group C during the period of 1 -year follow-up. The distance of 6-minute walking test at 1 -year after pacing was significantly longer in group A than that at baseline, and also that of groups B and C ( all, p < 0. 05 ). Conclusion: Long-term biatrial-right ventricular upper septal pacing may be an active and effective electrical approach for patients with drug-refractory PAF companied by cardiac dysfunction, with reduced episodes of PAF, and improved left ventricular global performance and quality of life.