CRT-P/D治疗射血分数降低的心力衰竭患者超反应发生的相关因素分析

Analysis on factors related to super-response events in heart failure patients with reduced ejection fraction by CRT-P/D therapy

目的探讨心脏再同步化治疗(cardiac resynchronization therapy with pacemaker function/defibrillation function,CRT-P/D)在射血分数降低的心力衰竭患者中发生超反应的预测因素及不良事件的影响因素。方法回顾分析我科2015年1月至2017年1月收治的59例因心力衰竭采用CRT-P/D治疗并随访12个月以上的患者,采集一般临床资料、心电图、心脏超声、不良事件发生等临床数据。以术后12个月左室射血分数(left ventricular ejection fraction,LVEF)升高幅度分3组:超反应组(幅度≥15%,14例),中度反应组(5%≤幅度<15%,23例),轻度/无反应组(幅度<5%,22例)。采用方差分析及多因素Logistic回归分析筛选CRT-P/D治疗发生超反应的独立预测因素。采用Kaplan-Meier法进行预后分析,COX回归模型明确影响预后的危险因素。结果超反应组术前心房颤动比例、右房内径(right atrial diameter,RA)明显低于中度反应组及轻度/无反应组(P<0.05),双心室起搏比例明显高于中度反应组及轻度/无反应组(P<0.01)。多因素Logistic回归结果显示病程<1.5年(OR=17.54,95%CI=1.41~216.96,P=0.02)、RA<35 mm(OR=23.70,95%CI=1.60~349.32,P=0.02)、双心室起搏比例>96%(OR=36.35,95%CI=12.17~609.03,P=0.01)是术后发生超反应的独立预测因素。预后分析显示无事件(心衰再住院、恶性心律失常、全因死亡)生存率超反应组高于中度反应组及轻度/无反应组(Log Rank:P<0.01),多因素Cox回归分析显示对于复合不良事件的发生,心房颤动是影响预后的独立因素(P<0.05,HR=2.35,95%CI=1.067~5.19)。结论对于CRT-P/D治疗射血分数降低的心力衰竭患者,病程<1.5年、RA<35 mm,双心室起搏比率>96%是发生超反应的重要预测因素,心房颤动是影响术后不良事件发生的独立因素。

Objective To analyze the influencing factors for the occurrence of super-response and adverse events in heart failure patients with reduced ejection fraction by cardiac resynchronization therapy with pacemaker/defibrillation （CRT-P/D） therapy. Methods A retrospective analysis was performed on 59 heart failure patients undergoing CRT-P/D therapy in our department from January 2015 to January 2017. All the patients were followed up for more than 12 months. Their general information, electrocardiogram, echocardiogram, and adverse events were collected and analyzed. According to the elevation of left ventricular ejection fraction （LVEF） at 12 months postoperatively, these patients were divided into superresponse group （range ≥15%, n=14）, moderate-response group （5%～15%, n=23）, and mild/nonresponse group （〈5%, n=22）. ANOVA and multivariate logistic regression analysis were used to screen independent factors for super-response events due to CRT-P/D therapy. Kaplan-Meier analysis was adopted for prognostic analysis, and COX regression model was used to further identify the risk factors for prognosis. Results For the super-response group, the proportion of atrial fibrillation and the diameter of right atrial （RA） was significantly lower and smaller （P〈0.05）, while the proportion of biventricular pacing was obviously higher than those in the moderate- and mild/non-responde groups （P〈0.01）. Multivariate logistic regression results showed that the disease course 〈1.5 years （OR=17.54, 95%CI： 1.41~216.96, P=0.02）, RA〈35 mm （OR=23.70, 95%CI： 1.60~349.32, P=0.02）, proportion of biventricular pacing 〉96% （OR=36.35, 95%CI： 12.17~609.03, P=0.01） were independent prognostic factors for occurrence of super-response events after surgery. Prognostic analysis showed that there were more patients obtaining event-free survival （heart failure hospitalization, malignant arrhythmia, or all-cause death） in the super-response group than the moderate and mild/non-response groups （Log Rank P〈0.01）. Multivariate Cox regression analysis indicated that atrial fibrillation was an independent factor for prognosis （P〈0.05, HR=2.35, 95%CI： 1.067~5.190）. Conclusion For the heart failure patients with reduced ejection fraction and undergoing CRT-P/D therapy, disease course 〈1.5 years, RA 〈35 mm, and biventricular pacing proportion 〉96% are important predictive factors for occurrence of super-response events. Atrial fibrillation is an independent factor for postoperative adverse events.