定期超声心动图引导下AV及VV间期优化在心脏再同步治疗中的长期疗效观察

Effect of periodic pacemaker optimization in long-term cardiac resynchronization therapy

目的 探讨定期超声心动图引导下优化AV及VV间期在长期心脏再同步治疗（CRT）中的临床价值.方法 回顾分析2002年6月至2012年10月新疆医科大学第一附属医院心脏中心成功植入CRT或心脏再同步治疗除颤器（CRT-D）的慢性心力衰竭患者108例.根据AV及W间期优化频率分为定期系统优化组（n=35）及非定期系统优化组（n=73）.经过长期随访比较2组患者长期疗效.非致命心血管事件或因心力衰竭进展死亡为主要终点事件,左心房内径（LAD）、左心室舒张末期内径（LVEDD）、左心室收缩末期内径（LVESD）、左心室射血分数（LVEF）作为次要终点事件.结果 2组患者基线特征、随访时间（P=0.122）及应答率（P=0.524）差异无统计学意义.定期系统优化组非致命性心血管事件或因心力衰竭进展死亡较未定期优化组发生率更低（P=0.035）.多因素Cox分析中,未定期系统优化显著提高患者非致命性心血管事件或因心力衰竭进展死亡发生风险（风险比3.192,95％ CI l.536 ～5.176,P=0.012）.定期系统优化显著提高患者心功能（NYHA分级,P＜0.001）,生存质量评分（P=0.001）及6min步行试验（6-MWT,P=0.002）.此外定期系统优化组LAD较未定期优化组显著缩小（P=0.009）,LVEF（P=0.039）显著提高.结论 定期超声心动图引导下AV及VV间期优化能够提高CRT长期疗效.

Objective To investigate the clinical value of the periodic echocardiographic（echo）-guide pacemaker optimization of atrioventricular （AV）and interventricular（VV） delays in long-term cardiac resynchronization therapy（CRT）.Methods Recipients of CRT devices （n =108） with paired echocardiographic and clinical assessment at baseline and end of this analysis were divided into two groups according to periodic pacemaker optimization （Group1）and non-periodic pacemaker optimization（Group2）.The long-term effect of CRT in subgroups was compared at the end of presented study.The primary endpoint was nonfatal heart failure（HF）event or HF-related death.The secondary endpoint included left ventricular end-diasolic diamension （LVEDD）,left ventricular end-systolic diamension（LVESD）,left atrial diamension （LAD）,and left ventricular ejection fraction （LVEF）.Results There was no significant difference in the baseline characteristics,follow-up period and responder＆#39; s rate between subgroups The patients with periodic pacemaker optimization had a lower combined rate of nonfatal HF event or HF-related death[22.9% （in Group1）vs.43.8% （in Group2）,P=0.035].Multivariate analysis showed that non-periodic pacemaker optimization was associated with increased risk of nonfatal HF event or HF-related death（hazard ratio 3.192 ;95% confidence interval 1.536 ～ 5.176,P =0.012）.NYHA class （P〈0.001）,6-minute walking distance（P =0.002）,quality-of-life score（P =0.001） were significantly improved in patients with periodic pacemaker optimization.Moreover,the mean reduction of LAD（18.29% vs.9.85%,P=0.009） and mean improvement of LVEF（13.17% vs.7.70%,P=0.039）was directly related to periodic pacemaker optimization at the end of study （median：28 months; inter-quartile range：18 to 38 months）.Couclusion Periodic echo-guide pacemaker optimization of AV delays and VV delays lead to long-term improvement in CRT.