缓慢型心律失常合并右束支阻滞的起搏器置入患者房室间期设置的优化研究

Optimized atrioventricular delay in pacemaker implanted patients with right bundle branch block and bradyarrhythmia

目的探讨缓慢型心律失常合并右束支阻滞(CRBBB)的双腔起搏器置入患者的优化程控模式。方法筛选符合心脏永久起搏适应证且合并CRBBB并置入双腔起搏器的患者。设置起搏频率60次/分,记录不同房室延迟(AVD)下的十二导联心电图,测量PR间期或AP-R间期、自身QRS波时限以及不同AVD设置下起搏QRS波时限,获取最窄的起搏QRS波时限及对应的最佳AVD,计算最佳AVD与PR间期或AP-R间期的差值。结果共入选28例患者,其中男性占71.4%,平均(65.5±11.6)岁。病窦综合征合并CRBBB 12例,CRBBB合并间歇Ⅱ度或Ⅲ度房室传导阻滞16例。心室电极3例放置于右室心尖部,25例放置于间隔部。自身QRS波时限135～169ms,平均(152±9)ms。设置感知房室延迟(SAVD)较PR间期缩短(43±6)ms或起搏房室延迟(PAVD)较AP-R间期短(21±4)ms时获得最窄的起搏QRS波,时限为93～120ms,平均(104±10)ms,较自身QRS波时限缩短30～71ms,平均(49±14)ms。优化后CRBBB图形"消失",QRS形态接近正常。结论对于缓慢型心律失常合并CRBBB的患者,右室起搏结合优化AVD既保留了正常的左室激动顺序同时纠正了原来滞后的右室激动,可获得接近正常的QRS波群。

Objective To investigate the optimal programmed mode of patients implanted dual-chamber pacemak- er with right bundle branch block （CRBBB） and bradyarrhythmia. Methods Patients were enrolled who had the indications of permanent pacemaker implantation as well as CRBBB and underwent dual-chamber pacemaker implan- tation. 12-lead electrocardiogram were recorded at different atrioventricular delay （AVD） and measure the corre- sponding QRS duration. The optimal AVD was the one with the narrowest QRS duration. Results A total of 28 patients were enrolled, of whom 71.4% were male, with an average age of （65.5~11.6） years. Sick sinus syndrome with CRBBB in 12 cases, CRBBB with intermittent Ii or III degree atrioventricular block in 16 cases. In 3 cases ven- tricular electrodes were placed in the right ventricular apex while in the other 25 cases the electrodes were placed in the right ventricular septum. Baseline of QRS duration was 135--169 ins.The average QRS duration was （152 ~ 9） ms. When the sensing AVD（SAVD） was （43 ~ 6） ms shorter than the PR interval or pacing AVD（PAVD） was （21 ±4） ms shorter than the AP-R interval, the narrowest QRS duration was obtained, about 93--120 ms with an av- erage of （104± 10）ms which was shorter than the baseline QRS duration of 30--71 ms, an average of （49 __ 14） ms. After optimally set up, the right bundle branch block disappeared and the QRS morphology was close to nor- mal. Conclusion In patients with bradyarrhythmia and CRBBB, right ventricular pacing combined with optimized AVD not only retains the normal left ventrieular activation sequence, but also corrects the original lag of right ven- tricular activation and thus leading to a nearly normal QRS complex.