影响心力衰竭伴永久性心房颤动再同步治疗的相关因素分析

Causes of non-response to cardiac resynchronization therapy in heart failure patients with permanentatrial fibrillation

目的评估心力衰竭伴永久性心房颤动心脏再同步治疗（CRT）的长期疗效，分析影响疗效的相关因素。方法33例心力衰竭伴永久性心房颤动接受CRT治疗的患者，其中单纯双心室起搏26例，双心室起搏＋房室结消融7例，随访6-48个月，观察CRT术前及术后各时间点的心功能指标。结果按术后6个月左心室射血分数（LVEF）是否增加15％分为CRT应答组和无应答组，应答组24例，无应答组9例。在4年的随访中，死亡6例，两组各3例。术前基础状况比较，CRT无应答组LVEF高于CRT应答组（37％比32％，P〈0．01）。经多因素logistic回归分析提示，心力衰竭病程、肺动脉压及48个月双心室起搏比例均是永久性心房颤动伴心力衰竭患者CRT无应答的独立危险因素，无应答组心力衰竭的病史更长（6年比4年，P〈0．05）、肺动脉压力明显增高[53比32mmHg（1 mm Hg=0．133kPa），P〈0．05]，双心室起搏比率少（76％比92％，P〈0．01）。结论心力衰竭伴永久性心房颤动接受CRT治疗长期观察亦有较好的疗效，无应答比例与窦律相当。影响CRT疗效的因素主要有心力衰竭的病程、肺动脉压力增高及双心室起搏比例，房室结消融是增加双心室起搏比率的有效方法，但大部分患者用p受体阻滞剂能达到满意的双心室起搏比率，若药物不能控制心率或不能耐受者，建议行房室结消融术。

Objective To evaluate the long-term effects and analyze causes of non-response to cardiac resynchronization therapy （CRT） in heart failure （HF） patients with permanent atrial fibrillation （AF）. Methods Thirty-three patients with HF and AF [29 men, mean age （61 ＋ 10） years, NYHA class m or IV, left ventricular ejection fraction （LVEF） ≤ 35%, QRS≥ 120 ms in 31 cases] underwent bi- ventrlcular pacing （ n = 26 ） or bi-ventricular pacing and atrioventricular node ablation （ AVN-ablation, n = 7 ） were included in this study. Non-response was defined： the increase of left ventricular ejection fraction （LVEF） was less than 15%. Patients were followed-up for 4 years. Results Six patients died during follow up. Non-responder to CRT was observed in 6 out of 27 survived patients （22.22%）. Six out of 7 patients underwent AVN-ablation were in responder group and 1 in non-responder group. Comparing with responder group, the baseline LVEF was significantly higher （37% vs. 32% , P = 0. 003 ）, and the history of HF was significantly longer （ 6. 3 years vs. 4. 1 years, P = 0. 039 ） , pulmonary artery pressure was significantly higher （53 vs. 32 mm Hg, P = 0. 027 ）, bi-ventricular pacing percentage （ BIVP% ） was significantly lower （75.86% vs. 91.73% , P = 0. 007 ） in non-responder group. Conclusions Higher LVEF, longer HF history, higher pulmonary artery pressure and lower BIVP% are factors linked with non-responses to CRT in this patient cohort. CRT plus AVN-ablation is associated with high response rate to CRT in this patient cohos.