高右心室起搏比例心力衰竭患者起搏器升级后长期疗效观察

Long term effects of upgrading to cardiac resynchronization therapy in heart failure patients after high percentage right ventricular pacing

目的探讨高心室起搏比例心力衰竭患者起搏器升级为心脏再同步治疗(CRT)后的长期临床疗效。方法选取心室高比例起搏后发生心力衰竭的普通起搏器患者,升级为CRT治疗后,长期观察患者的纽约心脏病学会(NYHA)心功能分级、左心室射血分数(LVEF)、左心室舒张末期内径(LVEDD)、左心房内径(LAD)的变化。观察起搏器升级后12个月CRT的应答率。应答率的标准为LVEF绝对数改善5%以上。长期观察病死率及临床心脏事件,最长随访观察85个月。结果 9例高比例心室起搏的心力衰竭患者升级为CRT后,平均随访(37.33±27.81)个月,术后QRS时限明显缩短[(146.67±30.00)ms比(171.33±25.98)ms,P<0.05],术后12个月NYHA改善[(1.89±0.93)级比(3.44±0.53)级,P<0.05],78%(7/9)患者CRT有应答,其中33%(3/9)患者升级1年后为超应答(LVEF≥50%),平均LVEF明显升高[(0.42±0.11)比(0.32±0.05),P<0.05],LVEDD明显减小[(61.22±11.41)mm比(70.33±9.39)mm,P<0.05],LAD明显减小[(40.22±6.51)mm比(43.44±4.67)mm,(P<0.05)]。长期随访过程中,1例(11.1%)患者术后23个月死于心力衰竭,1例(11.1%)患者术后34个月新发室速,经抗心动过速起搏终止。结论长期随访观察的结果显示,高心室起搏比例的心力衰竭患者升级为CRT后,CRT应答率高,患者心功能较前明显改善,心脏结构逆重塑。

Objective To evaluate the long term effects of cardiac resynchronization therapy（ CRT） in patients with chronically right ventricle paced heart failure. Methods A retrospective study was performed on the patients with high proportion of ordinary pacing upgraded to CRT after heart failure,the NYHA heart function classification,left ventricular ejection fraction（ LVEF）,left ventricular end diastolic diameter（ LVEDD） and left atrial diameter（ LAD） changes were observed. The CRT response rate and super response rate were determined 12 months later. The standard of response rate wamore than 5% for LVEF absolute logarithm. Long-term observation of mortality and clinical cardiac events,and the longest follow-up observation was 85 months. Results Nine cases of patients with heart failure and high percentage of ventricular pacing underwent CRT operation,the average follow-up was（ 37. 33 ± 27. 81） months.The mean QRS duration was significantly reduced[（ 146. 67 ± 30） ms versus（ 171. 33 ± 25. 98） ms,P〈0. 05]. NYHA heart function improved after 1 year[（ 1. 89 ± 0. 93） versus（ 3. 44 ± 0. 53）,P〈0. 05]. There were 78%（ 7/9） patients had response to CRT,33%（ 3/9） patients had super-response to CRT（ EF≥50%） after 1 year. The average LVEF increased significantly[（ 0. 42 ± 0. 11） versus（ 0. 32 ± 0. 05）,P〈0. 05],LVEDD reduced significantly[（ 61. 22 ± 11. 41） mm versus（ 70. 33 ± 9. 39） mm,P〈0. 05],LAD reduced significantly[（ 40. 22 ± 6. 51） mm versus（ 43. 44 ± 4. 67） mm,（ P〈0. 05） ]. During long-term follow up,1 case（ 11. 1%） died of heart failure after 23 months,1 case（ 11. 1%） developed new ventricular tachycardia and terminated by anti tachycardia pacing in 34 months after the operation. Conclusion Long term follow-up demonstrated that high response of CRT upgrading in the patiens with chronic right ventricular pacing,cardiac function is significantly improved and cardiac reconstruction is reversed remodeling.