右心室起搏导线位置对心脏再同步治疗效果的影响

Effects of right ventricular lead location on outcome of cardiac resynchronization therapy

目的 评价右心室起搏导线位置对心脏再同步治疗（CRT）效果的影响.方法 71例顽固性心力衰竭患者接受CRT手术,53例左心室导线植入侧壁或侧后壁,18例植入前壁或下壁（非侧后壁）；48例右心室导线植入心尖部,23例植入流出道间隔部.术前记录受试者心功能（NYHA分级）、QRS时限（QRSd）、左心室射血分数（LVEF）、左心室舒张末期内径（LVEDD）及左心室收缩末期内径（LVESD）；术后6个月对上述参数进行随访,比较不同右心室起搏部位对CRT临床疗效的影响.结果 术后6个月,右心室心尖部起搏组LVEF高于流出道间隔部起搏组[（0.44±0.07）对（0.40±0.07）,P=0.048],余心功能、QRSd、LVEDD、LVESD等各项指标均差异无统计学意义（P＞0.05）.根据左心室起搏部位进一步分为侧壁或侧后壁与非侧后壁两组,就侧壁或侧后壁组,右心室心尖部起搏较间隔部起搏可更好地提高心输出量LVEF[（0.45±0.07）对（0.40±0.08）,P=0.027],改善心功能[（2.59±0.59）对（3.00±0.68）,P=0.038],对于非侧后壁组,比较右心室心尖部与流出道间隔部起搏,各项指标均差异无统计学意义（P＞0.05）.结论 若无视左心室起搏部位,右心室心尖部起搏略优于流出道间隔部起搏；而对于左心室侧壁和/或侧后壁起搏者,应尽量将右心室导线置于心尖部,以获得较好疗效.

Objective Toevaluate the effect of right ventricular（RV） lead location on clinical response to cardiac resynchronization therapy（CRT）.Methods A total of 71 patients with refractory heart failure received CRT,among whom 53 subjects had a laterally or posterolaterally positioned left ventricular（LV） lead;another 18 subjects had the LV lead inferiorly or anteriorly（non-posterolaterally） positioned.As for the RV lead,48 cases placed at apex（RVA） while the other 23 placed at outflow tract septum （RVOT septum）.Before and 6 months after implantation,NYHA functional class,QRS duration （QRSd） of electrocardiogram and echocardiographic parameters including LV ejection fraction （LVEF）,LV end-diastolic diameter （LVEDD） and LV endsystolic diameter（LVESD）were recorded in all the subjects.A comparison was made according to different RV pacing sites.Results At 6-month follow-up,RVA pacing had only a slightly higher LVEF than that RVOT pacing[（0.44±0.07） vs（0.40±0.07） P=0.048].Except for that,no other differences could be seen between these two groups（P〉0.05）.When we separately assessed the significance of RV pacing site in different LVstimulation sites,the RVA pacing was associated with higher LVEF [（0.45 ± 0.07） vs （0.40 ± 0.08）,P =0.027] and better NYHA class improvement[（2.59±0.59） vs （3.00±0.68）,p =0.038] compared with RVOT septum site when the LV stimulation site was lateral or posterolateral vein.However,there were no significant differences in terms of clinical improvement,QRSd and echocardiography with a non-posterolaterally positioned LV lead （P〉0.05）.Conclusion RVA pacing was only a bit superior to RVOT pacing following CRT,irrespective of LV pacing site.If the LV lead was located at lateral or posterolateral vein,we recommend an RVA pacing site in order to get a better response.