心脏再同步治疗术后QRS时限变化对长期疗效的影响

Impact of postoperative QRS duration change on cardiac resynchronization therapy

目的：通过分析植入心脏再同步治疗（ CRT）术后QRS时限（ QRSd）的变化,评估术后不同的QRSd对CRT长期预后的影响。方法2001年4月至2012年3月来自沈阳军区总医院及白求恩国际和平医院住院并植入CRT的心力衰竭患者164例,按术后QRSd变化分为3组：Ⅰ组：107例（ QRSd术前〉术后）,Ⅱ组：30例（ QRSd术前〈术后）,Ⅲ组：27例（ QRSd术前=术后）。观察术后3组病死率及心功能指标变化。结果随访48个月,3组患者的病死率及死因差异无统计学意义（ P〉0．05）。Ⅰ组和Ⅲ组术后心功能及左心室射血分数（LVEF）较Ⅱ组明显改善（P〈0．05-0．01）,且左心室舒张末期内径（ LVEDD）明显缩小（ P〈0．05-0．01）。Ⅱ组术后心功能及 LVEF也明显改善（ P〈0．05-0．01）,但LVEDD无明显缩小（P〉0．05）。术后QRSd较术前变宽或变窄与术前QRSd的基础值有关,术前QRSd〈140 ms是术后QRSd变宽的影响因素。结论术后QRSd变化对预后影响不同,QRSd变窄患者不但临床心功能恢复的较好,而且还可有明显的左心室逆重构,更奠定了长期心功能改善的基础。术后QRSd变化与术前QRSd有明显关系,术前QRSd〈140 ms时,术后QRSd变窄的几率小,因此,术前QRSd越宽,术后QRSd变窄的效果越好。

Objective To analyze the factors which affect the QRS duration （ QRSd） after cardiac re-synchronization therapy （ CRT） and evaluate the affection of postoperative different QRSd on CRT in patients with heart failure （HF）. Methods One hundred sixty-four patients with HF [130 men; mean age （58. 02± 10. 48）years,NYHA class Ⅲ in 84 patients and Ⅳ in 80 patients,left ventricular ejection fraction（LVEF）≤0. 35] for implantation of CRT device were studied between April 2001 and March 2012. The patients were di-vided into 3 groups according to postoperative QRSd change：GroupⅠ：107 cases,preoperative QRSd（164. 11± 72. 62）ms〉postoperative QRSd（125. 78±28. 99）ms,GroupⅡ：30 cases,preoperative QRSd（121. 97±17. 26） ms〈postoperative QRSd （156. 38±14. 75）ms,Group Ⅲ：27 cases preoperative QRSd （136. 96±19. 18）ms=postoperative QRSd （ 136. 96 ± 19. 18 ） ms. Patients were followed up for 6-48 months. Results During 48 months follow-up, there were 28 （ 26. 17%） deaths in GroupsⅠ, 7 （ 23. 33%） deaths in Group Ⅱ, and 5 （18. 52%）deaths in Group Ⅲ. Comparing with GroupⅡ,The NYHA class and LVEF were improved signifi-cantly and LVEDD were decreased significantly in GroupⅠand GroupⅢ（P〈0. 05 and P〈0. 01）. The NYHA class and LVEF were improved significantly, but LVEDD were not decreased significantly in GroupⅡ. Conclusion There was better outcome in postoperative QRSd narrowed or unchanged patients than that in QRSd widen patients. The QRSd changes after CRT were related with the durations of preoperative QRS. The preopera-tive QRSd〈140 ms was the main factor which made QRSd widen. Heart function parameters were improved sig-nificantly in patients （ QRSd〈140 ms） with left ventricular dyssynchrony,but no left ventricular reverse remod-eling was observed in those patients （ QRSd〈140 ms） .