心脏再同步治疗起搏参数优化对血流动力学的影响及随访

Optimal atrioventricular and interventricular delay in patients with congestive heart failure post cardiac resynchronization therapy：hemodynamics and short-term follow-up

目的应用超声心动图观察心脏再同步治疗（CRT）后不同时期AV、VV间期优化对心力衰竭血流动力学的影响，探讨AV、VV间期优化在增强CRT临床疗效中的作用。方法扩张性心肌病心力衰竭患者32例接受CRT治疗，并于植入术后7d，3、6个月在超声心动图指导下进行AV、VV间期优化，观察优化后不同时间起搏参数、血流动力学指标。结果32例入选患者均一次成功植入三腔起搏器，术后1、3、6个月随访起搏阈值、感知、阻抗的改变差异无统计学意义（P〉0．05）。CRT植入术后7d，87％（28／32）、90％（29／32）患者分别需要AV、VV间期优化，植入术后6个月仍有18％（6／32）、16％（5／32）患者分别再次需要AV、VV间期优化。植入术后7d、3个月优化起搏与术后未优化相比，舒张期充盈时间（DFT）延长、Tei指数下降（P〈0．05）。植入术后6个月优化起搏与植入术后即刻相比DFT延长、主动脉瓣前向血流速度时间积分（V11）增加、Tei指数下降、E／Em比值下降、左心室射血分数（LVEF）明显增加（P〈0．05）。结论CRT植入术后AV、VV间期优化改善心力衰竭患者的血流动力学，可以带来良好的临床疗效。

Objective To assess the hemodynamic effects of cardiac resynchronization therapy（CRT） with atrio-ventricular （AV） ,interventricular （VV） delay optimization by eehoeardiogram and evaluate the improvement of clinical therapy in patients with AV ,VV delay optimization in CRT. Methods Thirty-two dilated eardiomyopathy patients with severe heart failure were treated with CRT. All patients were regularly performed AV ,VV delay optimization on 7^th day,3^nd month and 6^th month after CRT. During the follow-up, hemodynamics by echocardiogram and pacing parameters were studied. Results All patients were implanted pacemaker successfully. No significant changes were observed in threshhold, sense and impedence on the 1^th month, the 3^th month and the 6^th month optimization（ P 〉 0. 05 ）. Twenty-eight cases were optimized AV delay （87%） and 29 cases were optimized VV delay （90%） on the 7^th day after CRT. Meanwhile,AV delay was reoptimized in 6 cases （ 18% ） and VV delay was reoptimized in 5 cases （ 16% ） on the 6^th month after CRT. Diastolic filling time （DFF） increased significantly and Tel index decreased significantly （P 〈 0. 05 respectively）compared with pre-optimization. DFT, aortic velocity time integral （VTI） , Tel, E/Era and LVEF were significantly ameliorated （P 〈 0. 05 ） on the 6^th month after AV ,VV delay optimization. Conclusion AV ,VV delay optimization after CRT can improve the hemodynamies and clinical effects in patients with refractory heart failure.