不同起搏位点联合美托洛尔治疗缓室率房颤合并心力衰竭的临床效果对比

Different pacing sites combined with metoprolol on atrial fibrillation of slow ventricular rate complicated with heart failure

目的探讨右室流出道(RVOT)与右室心尖部(RVA)起搏联合美托洛尔对缓室率房颤合并心力衰竭患者的临床疗效。方法回顾性分析2011年10月~2017年9月我院收治的96例缓室率房颤合并心力衰竭患者的临床资料,患者均采取永久起搏器植入术联合术后口服美托洛尔治疗,根据心室电极植入部位分为RVOT组(n=57)与RVA组(n=39)。比较术前及术后1年时两组左心结构、左心功能、心电图参数、生活活动能力、明尼苏达心力衰竭生存问卷变化,并比较术中即刻及术后1年时两组起搏程控参数的差异。结果术后1年时,两组LVEDd、LVESd、LVEF、Tei指数、QRS波时限、P波离散度水平较术前均无明显变化(P>0.05),但RVOT组LVEDd、LVESd、Tei指数、QRS波时限、P波离散度水平均明显低于同期RVA组,LVEF水平均明显高于同期RVA组(均P<0.05)。术后1年时,两组6MWD水平较术前显著提升,且RVOT组明显高于RVA组(均P<0.05);两组MLHFQ较术前有显著下降,且RVOT组明显低于RVA组(均P<0.05)。术中即刻,RVOT组起搏阈值明显高于RVA组,而电极阻抗则明显低于RVA组(P<0.05)。术后1年时,两组起搏阈值、电极阻抗水平均较术中即刻有显著下降(P<0.05),但组间同期比较,差异无统计学意义(P>0.05)。结论RVOT起搏相较于RVA起搏,能为缓室率房颤合并心力衰竭患者提供更协调心室收缩节律,联合美托洛尔可有效避免左室重构,且该疗法安全性良好,对患者预后康复有利。

Objective To explore the clinical efficacy of right ventricular outflow tract(RVOT)or right ventricular apical(RVA)pacing combined with metoprolol on patients with atrial fibrillation of slow ventricular rate complicated with heart failure.Methods The clinical data of 96 patients with atrial fibrillation of slow ventricular rate complicated with heart failure were retrospectively analyzed.All patients were given permanent pacemaker implantation combined with postoperative oral administration of metoprolol,and they were divided into RVOT group(n=57)and RVA group(n=39)according to implantation site of ventricular electrode.The left ventricular structures[left ventricular end-diastolic diameter(LVEDd),left ventricular end-systolic diameter(LVESd)],left ventricular function[left ventricular ejection fraction(LVEF),myocardial performance(Tei)index],electrocardiogram(ECG)parameters(QRS wave duration,P wave dispersion)and life activity ability[6 min walking distance(6 MWD),Minnesota Living with Heart Failure Questionnaire(MLHFQ)]were compared between the two groups before operation and at 1 year after operation.The pacing program control parameters(pacing threshold,electrode impedance)were compared between the two groups immediately during operation and at 1 year after operation.Results At 1 year after operation,there were no significant changes in the LVEDd,LVESd,LVEF,Tei index,QRS wave duration and P wave dispersion in the two groups compared with those before operation(P>0.05),and the LVEDd,LVESd,Tei index,QRS wave duration and P wave dispersion in RVOT group were significantly lower than those in RVA group(P<0.01)while the LVEF level was significantly higher than that in RVA group(P<0.01).Immediately during operation,the pacing threshold in RVOT group was significantly higher than that in RVA group while the electrode impedance was significantly lower than that in RVA group(P<0.05).At 1 year after operation,the pacing threshold and electrode impedance in the two groups were significantly decreased compared with those before operation(P<0.01),but there were no significant differences between the two groups(P>0.05).Conclusion RVOT pacing can provide more coordinated ventricular contraction rhythm than RVA pacing in patients with atrial fibrillation of slow ventricular rate and heart failure.Combined with metoprolol,it can effectively prevent left ventricular remodeling,and the therapy has good safety and it is beneficial to the prognosis and rehabilitation of patients.