心脏再同步治疗中逆行冠状静脉造影及左室电极植入61例临床分析

Clinical analysis of retrograde coronary venography and left ventricular lead implantation in cardiac resynchronization therapy

目的分析心脏再同步治疗术中冠状静脉逆行造影(RCV)及左室电极植入的方法和安全性。方法2001年4月至2006年12月我院收治的61例心力衰竭患者,男52例,女9例,平均年龄59.4±11.7(30～81)岁。其中扩张型心脏病35例,缺血性心肌病19例,高血压心脏病7例。入选标准:心功能(NYHA)Ⅲ～Ⅳ级,左心室舒张末径≥55mm,左心室射血分数<0.40。根据RCV静脉解剖特点,个体化选择起搏静脉径路和左室电极,以获得理想的左心室起搏部位。结果61例共63次RCV,左室电极静脉部位分别是心侧28例、心后侧18例、心中9例、心中与心侧交通支4例、心大2例。术中发生冠状静脉夹层2例和心肌穿孔1例,其中1例3年间共3次造影,前2次分别因静脉狭窄和夹层而未植入左室电极,第3次改用较软的冠状窦电极导管引导长鞘和较细的OTW电极而成功植入;另2例发生轻微夹层、穿孔和少量心包积液但血液动力学稳定未影响左室电极植入。3例心侧静脉狭窄,1例狭窄50%,仍通过4189左室电极;1例近中段狭窄80%,电极不能通过而应用球囊扩张数次后,送入4193左室电极;另1例静脉较细且近中段狭窄50%,电极未能植入,3年后植入较细的OTW1056T电极。结论冠状静脉变异较大,左室电极以经侧静脉和后侧静脉植入为主,部分可经心中静脉进入理想的起搏部位。术中细致规范地操作、及时更换合适器械可使并发症发生率降至最低。

Objective To analyze the feasibility and safety of retrograde coronary venography （RCV） and left ventricular lead implantation in cardiac resynchronization therapy （CRT）. Methods Sixty one patients （52 men and 9 women, mean age 59.4 ± 11.7 years） with NYHA classⅢ-Ⅳ received CRT from April 2001 to December 2006. The etiologies of heart failure were idiopathic dilated cardiomyopathy in 35 patients, ischemic heart disease in 19 patients and hypertension cardiomyopathy in 7 patients. The inclusion criteria were ventricular end-diastolic dimension 〉 55 mm and LVEF 〈： 0. 40. The choice for veinous approach and left ventricular lead were individualized according to different venous anatomy in order to obtain ideal pacing position. Results RCV was completed 63 times in 61 patients. Left ventricular leads were located in lateral vein in 28 patients, posterior lateral vein in 18 patients, middle cardiac vein in 9 patients, communicating branch of lateral vein and middle cardiac vein in 4 patients and anterior interventricular vein in 2 patients. Coronary artery dissection and myocardial perforation took place in 2 patients and pericardial tamponade in 1 patient during the operation. One patient had experienced 2 failed attempts of CRT due to vein stenosis and dissection. CRT was completed successfully in the third attempt without dissection and pericardial tamponade because of the application of soft coronary sinus lead and thin OTW lead. Small dissection and myocardial perforation and pericardial effusion took place in other 2 patients which had not affected the procedures because of stable hemodynamics. Different degree of vein stenosis was found in 3 patients. The left ventricular lead passed through successfully in the patient with 50% vein stenosis without dilatation and also in another patient with 80% stenosis after dilatation with PTCA balloon. A thin OTW 1056T lead was needed in the third patient having vein stenosis of 50% in the proximal end. Conclusion Since there is great variation in the anatomy of coronary veins, the optimal location for left ventricular lead implantation can be archieved in the lateral and the posterior lateral vein or sometimes in the middle cardiac vein. Porper operation and choice of devices can minimize the occurance of complications.