通过左心室心外膜导线行心脏再同步治疗六例分析

Analysis of Cardiac Resynchronization Therapy via Left Ventricular Epicardial Lead Insertion in 6 Patients

目的：回顾性分析对于经冠状静脉窦放置左心室导线失败的心力衰竭（心衰）患者，通过左心室心外膜导线行心脏再同步治疗（CRT）的安全性和疗效。方法：选取2010—11至2013—01因慢性心衰住院行CRT，经心内科手术不成功而通过内、外科杂交行CRT的患者6例。对所有病例进行临床情况分析，包括病因、术前心功能状况、心电图和超声心电图结果、手术记录及术后情况；出院后定期随访，第1次随访为3-6个月，以后每半年随访1次，观察患者心功能、心电图以及超声心动图变化。结果：6例患者经静脉行CRT失败后，1周内择期杂交行CRT／CRT联合植入式心脏复律除颤器（CRT-D），手术成功，左山室导线阈值（1．0±0.3）V／0．4ms，无术中并发症；手术后平均住院10．5天，无严重并发症及死亡。随访3～18个月（平均10．5个月），其中4例患者心功能分级改善至少I级，且超声心动图显示左心室射血分数（LVEF）值增加至少5％，其中2例伴左心室舒张末内径缩小。6例患者均存活，1例因心衰恶化在CRT植入后6个月行心脏移植术。结论：因解剖因素异常而导致经静脉行CRT失败时，经胸小切口放置左心室心外膜导线是一种安全有效的替代方法；且通过杂交行CRT可以改善心衰患者的预后。

Objective： To analyze the safety and efficacy of cardiac resynchronization therapy （CRT） via left ventricular （LV） epicardial lead implantation in chronic heart failure （CHF） patients who failed to coronary sinus lead insertion method. Method： We retrospectively studied 6 CHF patients who failed to coronary sinus lead insertion and received CRT implantation by hydride approach of epicardial LV minithoracotomy in our hospital from 2010-11 to 2013-01. We analyzed the pathogenesis, cardiac condition before, during and after the operation, examined ECG and echocardiography. The patients were first followed-up at 3-6 months, and then every 6 months to observe the relevant changes. Results： All 6 patients received elective minithoracotomy for LV lead implantation within 1 week of the failed procedure, the pacing threshold was （1.0±0.3） V/0.4ms, the average in-hospital time was 10.5 days, there were no complication and death. During 3-18 （10.5） months follow-up period, 4 patients＇ cardiac function improved for at least I degree, echocardiography showed that LVEF increased for at least 5% and 2 of them had decreased left ventricular end diastolic diameter. All patients survived, 1 received heart transplantation at 6 months after CRT implantation due to CHF worsening. Conclusion： CRT implantation by hydride approach of epicardial LV minithoracotomy is a safe and feasible alternation in patients who failed to coronary sinus lead insertion method, it may improve the cardiac function in CHF patients.