长期右室起搏对充血性心力衰竭的心功能和预后的影响

Effect of long- term right ventricular pacing on cardiac function and prognosis in patients with chronic heart failure

目的常规右心室心脏起搏治疗慢性心力衰竭患者应用于临床已有多年。本研究主要观察右心室房室延迟优化起搏术后1个月和6个月心功能变化,并对其预后进行随访6-60个月。方法40例慢性心力衰竭患者,心功能Ⅱ~Ⅳ级,左室射血分数<35%,二尖瓣返流,12例患者伴有Ⅰ度房室传导阻滞,平均QRS(162±12)ms,平均PR间期(210±50)ms。安装右心房-右心室起搏器后进行房室延迟优化,采用彩色多普勒超声心动图观察二尖瓣返流、心功能变化,并在1个月和6个月进行复查,进行随访6-60个月。结果右心室起搏后1个月和6个月,QRS时间无明显变化,左室内径、左房内径和短轴缩短率无明显变化。对左室游离壁长轴运动幅度(从0.95cm±0.37cm到0.80cm±0.45cm)和室间隔长轴运动幅度(从0.43cm±0.28cm到0.48cm±0.28cm)影响无统计学意义。也不影响左室射血速度和搏出距离。7例(17.5%)患者二尖瓣返流完全消失,其余33例(82.5%)患者二尖瓣返流时间缩短从(486±101)ms到(408±90)ms(P<0.05),Tei指数降低从1.13±0.60到0.89±0.40(P<0.05)。延长左心总舒张充盈时间从(17±2.6)sec/min到(24.5±5.1)sec/min,增加Z比例从(57±17)%到(74±10)%(P<0.05)。随访期间死亡8例,心脏移植1例,安装左心辅助装置1例。结论优化房室延迟后的右心室起搏减少了慢性心力衰竭二尖瓣返流,改善了1个月和6个月左室收缩力和舒张充盈时间以及心脏作功指数。但远期死亡率较高。及时将右室起搏更新为双心室起搏是一个合理的选择。

Objective In patients with complete atrioventricular block, dual chamber pacing (DDD) maintains atrioventricular (AV) sequence. However, in patients with abnormal systolic function, the effect of long term DDD pacing on duration of QRS, mitral regurgitation and left ventricular function remains unclear. The aim of this study was to investigate effect of optimal AV delay right ven. tricular pacing on cardiac function at 1 month and 6 months, and follow up the prognosis for 6-60 months. Methods 40 chronic heart failure patients with dilated cardiomyopathy and conduction delay, cardiac functional grading Ⅱ~Ⅳ, left ventricular ejection fraction (LVEF)< 35%, QRS duration mean (162±12) ms and PR interval mean (210±50) ms. All who were implanted DDD pacemaker, were studied by M-mode and Doppler echocardiogram during VDD mode at optimised AV delay. Left ventricular and left atrium sizes as well as mitral regurgitation were assessed by echocardiography. Results After pacing, QRS duration did not have significant changes. Left ventricular dimension and left atrial dimension did not significantly change. Left free wall long axis excursions were similar (from 0.95 cm±0.37cm to 0.80 cm±0.45 cm). Septal wall long axis motion did not have significant changes (from 0.43 cm±0.28 cm to 0.48 cm± 0.28 cm). Left ventricular ejection time and stroke distance were Similar. 17.5%(7/40) patients MR disappear. 82.5%(33/40) patients,duration of mitral regurgitation reduced from (486±101) ms to (408±90) ms. Tei index decreased from 1.13±0.60 to 0.89±0.40 (P<0.05), total LV filling time increased from (17±2.6) sec/min to (24.5±5.1) sec/min, Z ratio were increased from (57±17)% to (74 ± 10)%(P<0.05). Follow up 6-60 months, 8 patients died, one for heart transplantation,1 for left ventricular assistant de? vice. Conclusion In patients with dilated cardiomyopathy and LBBB underwent right ventricular pacing with optimal AV delay reduced MR, increased left ventricular contractility and left ventricular diastolic filling time as well as left ventricular performance index.