永久希氏束起搏在心力衰竭患者中的应用

Permanent His bundle pacing improving cardiac function in the patients with chronic systolic heart failure

目的 评估心力衰竭（心衰）患者中永久希氏束起搏的安全性及临床疗效.方法 选取2013年4月至2018年1月在武汉亚洲心脏病医院尝试希氏束起搏的心衰患者22例,回顾性分析其中14例成功永久希氏束起搏患者术前及术后随访期间的心功能（NYHA分级）、左心室舒张末期内径（LVEDD）、左心室射血分数（LVEF）、6 min步行距离（6MWD）、起搏心电图QRS时限,记录手术时间、手术方法、并发症、植入器械,对比分析术中及术后希氏束起搏阈值、感知、阻抗、希氏束起搏比例等参数.结果 永久希氏束起搏成功14例（63.6%）,其中选择性希氏束起搏（S-HBP）11例,非选择性希氏束起搏（NS-HBP）3例;永久性心房颤动（房颤）13例,窦性心律1例;植入装置：VVIR起搏器1例,DDDR起搏器1例,心脏再同步治疗起搏器（CRT-P）6例,心脏再同步治疗除颤器（CRT-D） 6例;同台完成房室结消融8例,总手术时间1.5～5.5（2.9±0.6） h,除1例血气胸外无其他并发症.患者随访（18.6±10.7）个月,希氏束起搏比例96.4%±3.3%.术前术后对比QRS时限[（164.9±31.3） ms对（126.7±15.0） ms,P=0.002]、LVEDD[（6.9±1.0） cm对（6.3±1.1） cm,P=0.009]、LVEF [（30.9±12.8）%对（40.1±13.3）%,P=0.012]、6MWD[（228±57） m对（414±45） m,P〈0.001]、心功能[（3.3±0.4）对（1.9±0.3）,P〈0.001]差异均有统计学意义.术中及术后随访期间起搏阈值[（2.2±1.6）V/0.4 ms对（2.3±1.8）V/0.4 ms,P=0.9]、感知[（3.8±2.3） mV对（3.2±1.6） mV,P=0.22]、阻抗[（530.7±74.4） Ω对（505.4±102.4） Ω,P=0.56],差异均无统计学意义.结论 永久希氏束起搏技术上安全可靠,虽难度较大,但对于心室起搏依赖、心室起搏恶化心功能、因房颤心衰行房室结消融以及部分CRT适应证的心衰患者,希氏束起搏能够显著改善心功能,值得更多的研究及临床实践进一步完善.

Objective To investigate the efficacy and safety of permanent His bundle pacing（HBP） in the patients with chronic heart failure（CHF）. Method We retrospectively collected data from 22 patients with CHF who underwent pacemaker implantation with permanent HBP in Wuhan Asia Heart Hospital from April 2013 to January 2018. The QRS duration,left ventricular end-diastolic diameter（LVEDD）,left ventricular ejection fraction（LVEF）,New York Heart Association functional class（NYHA class）,6-minute walk distance （6MWD） of post-procedure were compared to the pre-procedure. Results Fourteen patients（63.6%）were received successfully permanent HBP. Thirteen patients were diagnosed as permanent atrial fibrillation,one with normal sinus rhythm. Eleven were succeeded in selective HBP,3 were performed as nonselective HBP. The pacemaker generations included VVIR in 1 patient,DDDR in 1 patient,cardiac resynchronization therapy （CRT） pacemaker（CRT-P） in 6 patients,and CRT defibrillator（CRT-D）in 6 patients. Eight patients were given atrioventricular junction ablation in the same procedure. The time of total procedure was 1.5-5.5（2.9±0.6） hours. The average period of follow-up was（18.6±10.7）months. The patients＇ average HBP percentage was 96.4%±3.3%. The QRS duration of pre-procedure was（164.9±31.3） ms and was（126.7±15.0） ms of post-procedure（P=0.002）. There were significant improvements in LVEDD[（6.9±1.0） cm vs.（6.3±1.1） cm,P=0.009],LVEF[（30.9±12.8）% vs. （40.1±13.3）%,P=0.012],6MWD[（228±57） m vs.（414±45） m, P〈0.001]and NYHA class（3.3±0.4 vs. 1.9±0.3,P〈0.001）. The pacing thresholds[（2.2±1.6） V/0.4 ms vs. （2.3±1.8） V/0.4 ms,P=0.9],sensing[（3.8±2.3） mV vs. （3.2±1.6） mV,P=0.22],and impedance of HBP leads [（530.7±74.4） Ω vs. （505.4±102.4） Ω,P=0.56]were comparable during the procedure as well as during follow-ups. Conclusion Permanent HBP improved cardiac function significantly in heart failure patients with dependence of right ventricular pacing and a part of CRT patients.