心脏再同步治疗术后患者死亡原因分析

Cause of death in patients with heat failure after cardiac resynchronization therapy

目的探讨心力衰竭患者心脏再同步治疗（CRT）术后的死亡原因及相关影响因素。方法对110例行CRT的心力衰竭患者[其中7例植入带有心脏再同步治疗除颤器（CRT—D）]进行长期随访，观察患者术后的转归情况，以及死亡患者的死亡原因、生存时间和相关影响因素。结果110例患者中有92例患者完成随访研究，随访1～132（48±28）个月，共死亡30例，死亡率为32．6％，5年生存率为66．9％±5．8％。24例为心脏性死亡，占总体死亡的80％，其中包括11例为心力衰竭恶化导致的死亡，13例为心脏性猝死（SCD），其余6例为非心脏性死亡。14例行CRT的持续性心房颤动（房颤）患者中有8例死亡；71例行CRT的窦性心律患者中死亡22例；前组的中位生存时间短于后组（50比87，P=0．013）；7例植人CRT—D的患者均无死亡；3组患者的死亡率差异有统计学意义（P=0．01）。合并慢性肾功能衰竭的CRT患者死亡率（66．7％）较无肾功能不良者（20．6％）高（相对危险度：3．24，95％CI1．88～5．59，P〈0．001）。结论CRT患者的主要死亡原因是心脏性死亡，其中包括心力衰竭恶化和SCD。CRT—D和CRT两组患者之间的死亡率差异有统计学意义，接受CRT的窦性心律患者较持续性房颤患者有显著的生存获益。合并慢性肾功能衰竭的CRT患者预后较差。对于合并持续性房颤的CRT患者同时给予房室结消融有可能进一步提高生存率。

Objective The aim of this study was to explore the cause of and the factors related to death in patients with heart failure （HF） after cardiac resynchronization therapy（CRT）. Methods One hundred and ten patients with congestive heart failure treated with CRT were enrolled in this study, including 7 patients underwent CRT＋an implantable defibrillator（CRT-D）. The postoperative outcome,cause of death, survival time, as well as the factors related to death were observed during the long follow-up. Results The mean follow-up period was 1 -132（48＋28）months, while 92 patients have completed the follow-up. Thirty patients died （32.6%）, and the 5-year survival rate was 66. 9% - 5.80/o. Twenty-four of them （80%） were cardiac causes （pump failure = 11 , sudden cardiac death = 13 ） , and 6 patients due to non-cardiac causes. Eight patients with persistent atrial fibrillation（n= 14） died,22 patients with sinus rhythm （n = 71 ） died, all patients with sinus rhythm who underwent CRT-D （ n = 7） were survival. There were significant differences （ P = 0. 01 ） in the mortality among the three groups. The mortality in patents with chronic renal failure （CRF） was higher than those without CRF （ HR ： 3.24,95% CI 1.88 - 5.59, P〈0. 001 ）. Conclusion Cardiac death, including heart pump failure and sudden cardiac death are the predominant causes of death in patients ＇after CRT. Patients with persistent atrial fibrillation or CRF have disadvantage in survival. CRT-D improve survival rate,and atrio-ventricular node ablation in patients with persistent atrial fihrillation may he a way to improve survival rate.