双心室起搏在严重心力衰竭病人中的应用

Usefulness of biventricular pacing in severe heart failure patients

目的 探讨双心室心脏起搏在技术上的可行性及其在严重心力衰竭中的应用价值。方法 4例原发性扩张型心肌病 ,心功能III或IV级 ,合并左束支传导阻滞 ,QRS时间≥ 12 0ms。经锁骨下静脉将左心室外膜起搏电极置于心脏后侧支静脉 ,按常规方法安置右心房和右心室电极。起搏器程控为DDD工作方式 ,AV间期设置为 10 0ms。在 12个月随访中 ,观察临床、心电图、运动试验 (6min步行距离 )和超声心动图指标的变化以评价疗效。结果 (1) 4例均成功安置双心室心脏起搏器 ,术后心力衰竭症状明显缓解 ,并于手术后 9～ 2 0d出院。出院前停用所有静脉用药 ,包括利尿剂、强心剂和扩血管药 ;(2 )随访 :4例心功能均改善一级 ,6min步行距离增加 76～ 2 84m。超声心动图显示 :左心室和左心房前后径分别减小 3～ 7mm和 2～ 7mm ,左心室射血分数增加 4%～ 7%。结论 对严重心力衰竭合并左束支传导阻滞的病人 ,以心房为基础的双心室起搏能改善心功能、缓解症状。

Objective To assess the technical feasibility and clinical effects of biventricular pacing in severe congestive heart failure patients. Methods Four male patients were diagnosed as primary dilated cardiomyopathy. All patients were NYHA class III/IV with left bundle branch block. The QRS width was ≥120 ms. A special permanent pacing lead was put into posterolateral cardiac vein through subclavian vein as an epicardial pacing lead of left ventricle. The right atrial and ventricular pacing leads were implanted in routine way. The pacemaker was programmed as DDD mode and AV interval was set to 100ms. Clinical, ECG, exercise testing and echocardiographic parameters were evaluated over a 12 month follow up period. Results (1) Implantation of biventricular pacing system was successful in 4 patients. All patients were discharged from the hospital between 9 20 days after implantation and all the intravenous medication, such as diuretics, digitalis, vasodilators were withdrawn because of significant improvement of symptoms;(2) At the follow up,the functional class was improved by one grade in 4 patients and 6 minute hall walk distance increased by 76 284 m; echocardiographic parameters showed that the diameters of left ventricle and atrium decreased by 3 7 mm and 2 7 mm, left ventricular ejection fraction increased by 4% 7%, the degree of mitral regurgritation decreased. Conclusion Atrial based biventricular pacing seems to be of clinical value in severe heart failure patients with left bundle branch block.