心脏再同步治疗60例并发症分析

The assessment of complications of 60 patients with a CRT or CRT-D implanted

目的分析心脏再同步治疗(CRT)术中、术后并发症发生规律及防范对策。方法1999年7月至2006年1月,60例慢性心力衰竭患者[男性39例,女性21例,平均年龄(59.8±9.1)岁]接受CRT或CRT-D植入手术,其中52例双心室起搏。在最短1个月、最长66个月、平均22个月的随访期内追踪患者临床表现、死因以及各种并发症发生情况,同时给予相应的治疗干预。结果随访期内17例死亡(28.3%)的原因分别为心脏性猝死7例(11.7%,含1例手术失败)、心力衰竭恶化8例(13.3%,含1例手术失败)、中风1例(1.7%)、车祸1例(1.7%)。31例次并发症(51.7%)中7例左心室导线植入失败(11.7%)、2例冠状静脉窦夹层或穿孔(3.3%)、4例膈肌刺激(6.7%)、1例心律失常风暴(1.7%)、5例术中急性左心衰竭(8.3%)、4例导线脱位(6.7%)、3例阈值升高(5%)、3例交叉感知(5%)、2例囊袋积血(3.3%)。改行右心室流出道+右心室尖双部位起搏的6例患者,QRS波变窄程度和心力衰竭改善程度均不如双心室起搏显著,且3例死于心力衰竭恶化。5例CRT-D患者无心脏性猝死。结论严格把握适应证、提高左心室导线植入成功率、优化起搏系统的硬件和软件等,可确保患者在获益于CRT治疗的同时最大限度降低并发症风险。

Objective This study was conducted to assess complications related to cardiac resynchronization therapy （CRT） and their solution. Implantation of left ventricular lead is a complicated procedure with potential of complications. This study is an analysis of complications of biventricular pacing in patients with chronic heart failure. Methods CRT or CRT-D implantation was performed in 60 patients （ males in 39 and females in 21, mean age of 59 years old） with advanced chronic heart failure and intraventricular conduction delay. All adverse events and clinical outcome were evaluated during a mean follow-up period of 22 months after the implantation procedure in all patients. Different type of left ventricular lead was inserted to one of cardiac veins,especially posterior or lateroposterior cardiac vein, to pace left ventricle. Results The CRT procedue success rate was 96. 7%. Causes of 17 died patients included cardiac sudden death （7 cases, 11.7% ）, worsening CHF （8 cases,13.3% ） ,stroke （ 1 case, 1.7% ） and traffic accident （1 case, 1.7% ）. All 31 complica- tions （51.7%） consisted of unsuccessful left ventricular lead implant （7 cases, 11.7% ）, coronary sinus dissection （2 cases, 3. 3% ）, phrenic stimulation （4 cases, 6. 7% ）, ventricular arrhythsmia storm （ 1 cases, 1.7% ） ,acute left heart failure （5 cases,8.3% ） ,lead displacement （4 cases,6. 7% ） ,elevated pacing thresh- olds （3 cases,5% ） ,sense disfunction （3 cases,5% ） ,pacer bag hematoma （2 cases,3.3% ） ,52 BiV pacing patients had more improvement in the QRS duration and clinical outcome than 6 RVA ＋ RVOT pacing patients. None of CRT-D patients died from cardiac sudden death. Conclusions Patients with CHF could benefit from CRT or CRT-D, however, complication risk related to CRT should be reduced by all means.