左右心室电极间距离指导心脏再同步化治疗临床效果和安全性

The clinical effect and safety of cardiac resynchronization therapy guided by the interlead distance between left and right ventricular electrodes

目的探究左右心室电极间距离(DD)指导心脏再同步化治疗(CRT)的有效性和安全性。方法选取2018年5月至2020年1月在南昌大学第一附属医院经最佳药物治疗并接受DD指导CRT的心力衰竭(心衰)患者34例作为观察组,既往研究中接受常规CRT心衰患者75例作为对照组。术后CRT影像资料获取:二维影像上用游标卡尺测量正位时心脏横径(L),分别在正位、左前斜位、右前斜位时测得DD并取最大值,计算DD/L;记录左前斜40°、右前斜30°投影下左心室和右心室电极植入位置。参照《心血管系统疗效评价指标》和meta分析疗效评价标准,CRT临床效果分为显效应答、有效应答和无应答。分析两组患者随访期因心衰再入院次数、全因病死例数。结果观察组患者CRT应答总有效率略高于对照组(94.1%对89.3%,P=0.721),CRT显效应答率显著高于对照组(29.4%对9.3%,P=0.007)。观察组、对照组患者随访期因心衰再入院次数分别为2次、13次,全因病死例数分别为0例、5例。观察组DD、DD/L与对照组相比显著提高(P<0.001)。观察组左心室电极位于基底部位比例高于对照组(70.0%对18.0%,P<0.05),位于前外侧壁比例也高于对照组(46.7%对19.7%,P=0.007)。右心室心尖部起搏右心室时,左心室电极位于前外侧壁和基底部可获得较高的DD、DD/L;右心室室间隔中部起搏右心室时,左心室电极位于后外侧壁与较高的DD相关。结论DD指导CRT安全性高,可提高CRT总体应答率。

Objective To investigate the clinical efficacy and safety of cardiac resynchronization therapy(CRT)guided by the interlead distance between left and right ventricular electrodes(DD).Methods A total of 34 patients with heart failure,who were admitted to the First Affiliated Hospital of Nanchang University of China to receive optimal medication together with DD-guided CRT,were enrolled in this study as study group,while other 75 patients with heart failure,who received routine CRT,which had already been reported in previous study,were used as control group.After treatment,CRT imaging materials were collected.On twodimensional images the transverse diameter of heart(L)at anteroposterior(A-P)position,and the maximum DD values at A-P position,left anterior oblique(LAO)position and right anterior oblique(RAO)position were accurately measured by using vernier caliper,and the DD-to-L(DD/L)ratios were calculated.The projection sites of left and right ventricular electrodes at 40°LAO and 30°RAO positions were recorded.According to《Evaluation Index of Curative Effect of Cardiovascular System》and the evaluation criteria for curative efficacy based on meta analysis,the clinical effects of CRT were classified into significant response,effective response and no response.The number of readmission patient due to heart failure and the number of death due to all reasons during the follow-up period were compared between the two groups.Results In the study group,the total effective rate of response to CRT was 94.1%,which was slightly higher than 89.3%in the control group(P=0.721),and the significant response rate to CRT was 29.4%,which was strikingly higher than 9.3%in the control group(P=0.007).During the follow-up period,the numbers of readmission patient due to heart failure in the study group and in the control group were 2 and 3 respectively,and the numbers of death due to all reasons in the study group and in the control group were 0 and 5 respectively.The DD values and DD/L ratios in the study group were remarkably higher than those in the control group(P<0.001).The proportion of patients,in whom the left ventricular electrode was located at basal part of heart,in the study group was 70.0%,which was obviously higher than 18.0%in the control group(P<0.05);and the proportion of patients,in whom the left ventricular electrode was located at anterior lateral wall of heart,in the study group was 46.7%,which was significantly higher than 19.7%in the control group(P=0.007).Pacing right ventricle from right ventricular apex could obtain higher DD values and DD/L ratios when the left ventricular electrode was located at the anterior lateral wall or basal part of heart;and pacing right ventricle from the middle part of interventricular septum could obtain higher DD values,which were well correlated with the posterior lateral wall location of the left ventricular electrode.Conclusion The DD-guided CRT carries high safety,and this technique can improve the overall response rate to CRT.