初期开展心脏再同步化治疗慢性心力衰竭的效果及技术难点

The effects and technical difficulties during a learning curve of cardiac resynchronization therapy in patients with chronic heart failure

目的总结分析初期开展心脏再同步化治疗(CRT)慢性心力衰竭(简称心衰)的效果及技术问题。方法对20例植入CRT/CRTD的患者观察术前、术后6个月的心功能指标,描述左室电极的植入过程,随访患者预后。结果术后6个月有关心功能指标均明显改善(P均<0.01),随访32.9±21.9个月,死亡4例,其中1例猝死,3例非心脏原因死亡。左室导线进入冠状窦失败改为右室双位点起搏2例(2/20,10%),左室导线难以固定于靶静脉改为经心中静脉与靶静脉吻合支1例(1/20,5%),冠状静脉阶段性狭窄1例(1/20,5%),术后导线脱位3例(3/20,15%)均成功复位。术前冠状动脉造影/冠状静脉显影9例(9/20,45%),术中测试左室电极刺激膈肌跳动经调整电极位置均可避免。结论 CRT治疗心衰有效;术前冠状动脉/冠状静脉造影对指导和易化左室导线植入有益。右室双位点起搏改善心衰不明显,适当调整电极可避免膈肌刺激。

Objective To investigate the effects and technical difficulties of initial stage cardiac resynchronization ther- apy （CRT） implantation in patients with chronic heart failure （CHF）. Method The cardiac function indexes between before and 6 months after CRT implantation were compared in 20 patients. The procedures of left ventricular leads were configured and the prognosis were followed up. Results All cardiac function indexes in 6 months after CRT were amelio- rated siguificantly （P 〈0.01 ）. At follow-up of 32.9 ± 21.9 months, 4 cases died of a sudden death and 3 cases died of non-cardiac causes. The double ventricular pacing were changed to double-site pacing of right ventricle because the left ventricular leads were aborted to enter into coronary sinus in 2 cases （ 2/20,10% ）. The left ventricular lead were fixed into an anastomotic branch from middle cardiac vein which is anastomosesd with the target coronary vein via middle cardiac vein instead of the target vein itself because that fixation of the left ventricular lead into the target vein was failed（ 1 case, 1/20, 5% ）. A successful implantation was achieved in a patient with segmental stenostic coronary vein. Dislocations of the left ventricular leads after implantation happened in 3 patients （3/20,15 % ） and all were reset successfully. Coronary artery/ vein system angiography before CRT implantation procedures were carried out in 9 patients （9/20,45%）. Diaphragm stim- ulation were all avoided by regulating the lead positions. Conclusion It is effective for CRT in patients with CHF. A coronary artery/vein system angiography before CRT procedure is benefit. Double-site pacing of right ventricle does not im- prove the cardiac functions markedly. Diaphragm stimulation could he avoided by appropriate regulation of left ventricular lead positions.