心脏再同步治疗除颤器术后室性心律失常的预测因素

Predictors of ventricular arrhythmias after cardiac resynchronization therapy defibrillator

目的心脏再同步治疗除颤器(CRT-D)术后的室性心律失常(ventricular arrhythmias,VA)风险及预测因素与普通心律转复除颤器不同,本研究拟探索CRT-D术后VA的预测因素.方法连续入选自2007年9月至2015年6月复旦大学附属中山医院心内科植入CRT-D的患者,收集术前临床、心电图与超声心动图等基线资料,收集术后首次发生导致CRT-D适当治疗的VA事件的时间,采用单因素与Cox多因素回归分析寻找发生VA事件的预测因素.结果共入选255例患者,中位随访时间31.3个月,有127例患者发生VA事件.单因素回归分析显示可以CRT-D术后VA事件的预测因素包括心脏性猝死(SCD)二级预防(P=0.03)、心房颤动(P=0.01)、心功能(NYHA分级)(P=0.04)、肌钙蛋白(P=0.02)、N末端一脑钠肽前体(NT-proBNP,P<0.01)、左心房内径(P<0.01)与肺动脉压力(P<0.01).Cox多因素回归分析显示CRT-D术后发生VA事件的独立预测因素为SCD二级预防[风险比(HR)=3.14,P=0.002]、心功能(HR=1.85,P=0.04)、估算的肾小球滤过率(HR=0.98,P=0.004)、肺动脉压(HR=1.02,P=0.02)、左心室射血分数(HR=0.95,P=0.03).结论 SCD二级预防、心功能、肾小球滤过率降低、肺动脉压力升高和左心室射血分数降低,是高CRT-D术后发生VA事件的独立预测因素;整合这些预测因素,可能有助于优化CRT-D患者的筛选.

Objective To investigate the predictors ofventricular arrhythmias (VA) after cardiac resynchronization therapy-defibrillator (CRT-D) implantation.Methods Patients receiving CRT-D between September 2007 and June 2015 were consecutively included.Baseline characteristics were retrospectively collected regarding clinical,electrocardiographic and echocardiographic information,and VA events recorded during follow-up.Univariate and multivariate regression analysis were used to identify predictors of VA after CRT implantation.Results A total of 255 patients were included.After a median follow-up duration of 31.3 months,VA events occurred in 127 patients.Univariate regression analysis showed that indication for secondary prevention of sudden cardiac death (SCD)(P=0.03),atrial fibrillation (P=0.01),New York Heart Association (NYHA) cardiac function class (P=0.04),cardiac troponin (P=0.02),NT-proBNP (P<0.01),left atrial diameter (P<0.01),and pulmonary pressure (P<0.01) were predictive of VAs.Multivariate regression analysis demonstrated that indication for secondary prevention of SCD [hazard ration (HR)=3.14,P=0.002],NYHA class (HR=1.85,P=0.04),estimated glomerular filtration rate (HR=0.98,P=0.004),pulmonary pressure (HR=1.02,P=0.02) and left ventricular ejection fraction (HR=0.95,P=-0.03) were independent predictors of VA after CRT-D implantation.Conclusion Indication for secondary prevention of SCD,higher NYHA class,reduced estimated glomerular filtration rate,higher pulmonary pressure and impaired left ventricular ejection fractionwere identified as independent predictors of VAs after CRT-D implantation,and these parameters could be further integrated to optimize appropriate selection of CRT-D candidates.