心脏再同步化治疗顽固性心力衰竭合并心房颤动

Cardiac resynchronization therapy for patients with refractory congestive heart failure and atrial fibrillation

目的总结心脏再同步化治疗(CRT)合并心房颤动(房颤)的心力衰竭(心衰)的疗效,分析这类患者CRT反应的可能原因。方法 2003年3月至2007年3月接受CRT合并房颤的难治性心衰患者5例,4例为扩张型心肌病,1例为缺血性心肌病,NYHA心功能Ⅲ～Ⅳ级。4例经冠状窦途径成功置入左室电极,1例冠状窦途径失败后行右室双部位起搏(流出道间隔部和心尖部)。结果术后平均随访(12±13)个月,所有患者术后临床症状均有不同程度的改善,NYHA分级提高0+～2级;生活质量和活动耐力均有改善。平均双室起搏比例(90±9)%,其中第2、4、5例术后频发室性早搏,平均双室起搏比例偏低(77%～83%)。第2例加用胺碘酮后比例由83%升至95%,NYHA分级提高2级。5例患者先后于术后1～33个月死亡,直接死亡原因为室性心律失常者2例,心衰恶化者3例。结论 CRT同样可以使合并持续性房颤的难治性心衰患者受益,可以提高生活质量、活动耐力。保证完全的双室起搏是合并房颤的心衰患者对CRT反应的关键因素之一。合并房颤的难治性心衰患者可能更需要在严重心衰早期积极地选择CRT。部分合并房颤的难治性心衰患者,在行CRT同时应考虑植入除颤器。

Objective To evaluate the response and potential reasons of cardiac resynchronization therapy （CRT） in patients with refractory congestive heart failure （CHF） and atrial fibrillation （AF）.Methods Five cases of CHF complicated by AF from March 2003 to March 2007 were enrolled.Among them,there were four cases of dilated cardiomyopathy and one case of ischemic myopathy,with NYHA class Ⅲ-Ⅳ.Left ventricular leads were successfully implanted via coronary sinus in 4 patients.It failed in one case,and then,the case was subjected to pacing at two sites of right ventricle,including high septum aspect of right ventricle and apex.Results The average follow-up duration was 12±13 months.At the final follow-up visit,improvements in symptoms,quality of life and exercise tolerance in all patients were observed,and NYHA class increased by 0＋-2 grades.The average percentage of biventricular pacing （BiV-p） was （90±9）%.Case 2,4,and 5 suffered ventricular premature beat frequently,with lower percentage of BiV-p （77%-83%）.The percentage of BiV-p in case 2 increased from 83% to 95% after administration of amiodarone.All 5 patients died within 1-33 months after implantation,among which,3 died of deterioration of heart failure and 2 of ventricular arrhythmias.Conclusion CRT is effective in treating CHF patients complicated by AF.High percentage of BiV-p is one of the key factors influencing the response of CRT in this group of patients.For CHF patients with AF,CRT may need to be considered in the earlier stage of CHF.CRT-defibrillator treatment may be more suitable in some of these patients.