心脏再同步化治疗适应证的变迁

Development of cardiac resynchronization therapy indications

心脏再同步化治疗（CRT）慢性心力衰竭已走过20个春秋，其疗效已得到充分的肯定。随着系列临床研究结果的揭晓，其适应证也不断发生改变。从1998年最早的Ⅱb（C）类适应证，逐步发展到I（A）类适应证；从纽约心脏病协会（NYHA）心功能Ⅲ或Ⅳ级拓展到I～Ⅱ级；从窦性心律患者发展到心房颤动患者。对起搏依赖的心力衰竭患者其适应证变化也很大，从Ⅱb类适应证进展到I（B）适应证，并且对左心室射血分数（LVEF）降低没有严格限制，其目的是为了防止大量右心室起搏给心力衰竭患者带来的危害，使患者达到最大获益。然而在QRs时限及形态的掌握上更加严格。目前认为，对QRS时限≥150ms及完全性左束支传导阻滞（LBBB）患者，CRT治疗的获益最大，已经否定了对窄QRS时限（〈120ms）的疗效。我们相信随着循证医学证据的积累，CRT治疗的目标人群会更加明确和具体，CRT应答率会进一步提高。

The clinical benefits of cardiac resynchronization therapy （CRT） for chronic heart failure （HF） has been convinced for 20 years. Indications for CRT have been continuously modified with a series of published clinical trials, including classes of recommendation from Ⅱb to Ⅰ and level of evidence from C to A since 1998, NYHA heart function class from Ⅲ/Ⅳ to Ⅰ /Ⅱ and addition of patients atrial fibrillation. Especially for the pacemaker-dependent patients with HF, indication has been improved from classⅡb to class Ⅰ （B） no strict limitation of LVEF with the aim of preventing the right ventricular pacing shortage and maximal benefit, however, QRS duration and morphology are strictly controlled. Currently, patients with complete LBBB morphology and a QRS duration ≥ 150 ms were considered to receive the maximum benefit, and a QRS duration 〈 120 ms has been denied to get benefit. It is believed that indications for CRT will be clear and specific with more and more evidences from evidence-based medicine, and the non-responder to CRT will be further reduced.