窄QRS波心衰病人心脏再同步化治疗疗效分析

Therapeutic Analysis on Cardiac Resynchronization Therapy in Heart Failure Patients with Narrow QRS Wave

目的分析窄QRS波心衰病人心脏再同步化治疗(CRT)的疗效。方法入选2010年9月—2015年9月就诊于内蒙古医科大学附属医院急诊内科的心衰病人作为病例组(n=57),分为两组,A组为心衰合并宽QRS波并植入CRT治疗组(n=46);B组为心衰并窄QRS波病人,实时三维超声心动图确定存在心脏运动不同步,植入CRT治疗组(n=11);选取45名同期于我院体检的正常人设为对照组(C组,n=45)。术前及术后3个月均行心电图、实时三维超声心动图及N末端脑钠肽原(NT-pro BNP)、高敏C反应蛋白(hs-CRP)、明尼苏达心力衰竭生活质量调查表评分(Minnesota score)、6 min步行试验(6MWT)检查,评估心功能,记录相关数据。结果术前各组间年龄、心率、体重指数,病例组组间用药情况、伴随疾病等比较,差异无统计学意义(P>0.05);病例组心功能、纽约心脏病协会(NYHA)分级、明尼苏达心力衰竭生活质量调查表评分、6MWT、左室射血分数(LVEF)、左室舒张末期容积(LVEDV)、左室收缩末期容积(LVESV)、血清NT-pro BNP以及hs-CRP水平,与C组比较均明显升高,差异均有统计学意义(P<0.05);A、B两组间比较,差异无统计学意义(P>0.05)。与术前比较,A组、B组术后3个月心功能NYHA分级、Minnesota score、6MWT、LVEF、LVEDV、LVESV、不同步指标、血清NT-proBNP、hs-CRP水平比较,差异有统计学意义(P<0.05或P<0.01),但两组术后3个月各指标比较差异无统计学意义(P>0.05)。结论实时三维超声心动图作为一种无创、安全可靠、可重复性强的检测手段,是评估心脏收缩同步化的可靠方法。NT-proBNP、hs-CRP等指标其血清水平随容量或压力负荷增加而升高,与左室重构、心功能不全的发生、发展和转归相关,因此,它们在一定程度上可以反映心衰的严重性及危险程度,并预测CRT术后疗效。使用心脏超声新技术结合NT-proBNP、hs-CRP为临床医生在CRT术前筛选合适病人,能够提高CRT疗效,并且使左室不同步的窄QRS波心衰病人,亦可通过CRT治疗获益。

Objective To observe the efficacy of cardiac resynchronization therapy（ CRT） in heart failure（ HF） patients with narrow QRS wave. Methods Fifty-seven patients with HF were selected from September 2010 to September 2015 and divided into group A（ QRS≥120ms,n = 46） and group B（ QRS 120 ms,n = 11） according to the QRS time. They were treated with CRT. Forty-five healthy individuals were as the controls（ group C）. The real-time three-dimensional echocardiography（ RT-3DE）,electrocardiogram（ ECG） were analyzed before and after 3 months of CRT. The levels of plasma N-terminal pro-brain natriuretic peptide（ NT-pro BNP）,high-sensitivity C-reactive protein（ hsCRP） were observed. The left ventricular ejection fraction（ LVEF）,left ventricular end-diastolicolume（ LVEDV）,end-systolic volume（ LVESV）,systolic synchronicity parameters,systolic synchronicity parameters,6 minutes walk test（ 6MWT） were evaluated. Results Before operation,all the indexes such as cardiac function NYHA classification,Minnesota scores,6MWT,and LVEF,LVEDV,LVESV,heart movement synchronization index,plasma NT- pro BNP and hs-CRP levels in group A and group B were significantly increased compared with group C（P〈0.05 or P〈0.01）. There was no difference between group A and group B（P〉0.05）. After 3 months of operation,there was difference in cardiac function NYHA classification,Minnesota scores,6 MWT,and LVEF,LVEDV,LVESV,heart movement synchronization index,plasma NT- pro BNP and hs-CRP levels in group A and group B compared with before operation（P〈0.05）. There was no significant difference in the indexes between group A and group B after 3 months of operation（P〉0.05）. Conclusion Real-time three-dimensional echocardiography as a noninvasive,safe and reliable,strong repeatability of the testing means,is a reliable method in evaluating cardiac systolic synchronization. The levels of plasma concentration of NT-pro BNP and hs-CRP rise,with the increase of volume or pressure load,and related to left ventricular remodeling and cardiac insufficiency of occurrence,development and the outcome,they can reflect the severity of heart failure and dangerous degree,and predict postoperative effect of CRT. Use of RT-3DE combined with the NT – pro BNP and hs-CRP can screening suitable patients for clinicians in CRT,can improve the CRT curative effect,and HF patients with narrow QRS wave and left ventricular asynchronous can also benefit by CRT.