不同起搏部位的心室电机械同步性分析

Evaluation of cardiac electrical and mechanical synchrony in different pacing sites

目的:本研究旨在评价心脏不同起搏部位对心室电及机械同步性的影响。方法:选择2019年1月—2019年10月于天津市胸科医院因房室传导阻滞或心房颤动(房颤)伴缓慢心室率行永久起搏器安置术、左室射血分数(LVEF)>40%的患者53例。根据心室电极植入位置分为希浦系统起搏24例,其中包括希氏束起搏(HBP)组14例,左束支起搏(LBBP)组10例;右室间隔起搏(RVSP)组15例;深部室间隔起搏(DVSP)组14例。测量术后QRS宽度及左室激动达峰时间(LVAT)。术后1年起搏器程控评价心室电极参数并行心脏彩超检查及临床不良事件随访。应用二维斑点追踪技术测量并计算胸骨旁短轴水平左室18节段收缩期径向应变达峰时间平均值(Trs-AVG)、标准差(Trs-SD)及最大差(Trs-Dif),评价左室收缩同步性情况。结果:患者术后QRS时限、LVAT、Trs-AVG、Trs-SD、Trs-Dif相比,HBP与LBBP起搏组无明显差异;DSVP组较希浦系统起搏组上述时限均延长并出现统计学差异。DVSP组较RVSP组患者上述时限均显著缩短,两组术后QRS时限:(120.7±7.4)ms∶(152.1±7.4)ms,LVAT:(80.6±6.6)ms∶(108.1±3.4)ms,Trs-AVG:(366.5±32.3)ms∶(422.3±43.9)ms,Trs-SD:(43.5±8.4)ms∶(67.6±9.7)ms,Trs-Dif:(146.6±35.3)ms∶(257.6±47.2)ms,P<0.01。起搏术后QRS宽度与Trs-SD强相关(r=0.895)。与LBBP、DVSP、RVSP组相比,HBP组导线起搏阈值高(2.4±0.9 V/0.4 ms),R波振幅低(4.6±1.1)mV,P<0.01。RVSP组患者术后LVEF较其余3组相比略减低(P=0.023),4组患者术后左室舒张末期内径未见统计学差异。结论:希浦系统起搏及DVSP的左室电及机械收缩同步性均优于RVSP。

Objective:To evaluate the effects of different pacing sites on the electromechanical synchronization of the ventricle.Methods:The 53 patients after permanent pacing who with left ventricular ejection fraction(LVEF)>40%and anticipated pacemaker-dependent were enrolled from January 2019 to October 2019 in Tianjin Chest Hospital in the study.According to the location of electrode implanted,patients were divided into His-Purkinjie system pacing group(24 cases)including 14 patients in His bundle pacing(HBP)and 10 patients in left bundle branch pacing(LBBP);right ventricular septal pacing group(RVSP,15 cases)and deep ventricular septal pacing group(DVSP,14 cases).The QRS duration and left ventricular activation time(LVAT)after pacing were measured.The lead parameters,echocardiography and clinical events were recorded following 1 year.The time to peak radial strain of left ventricle(LV)18 segments were derived from the parasternal short-axis views by two-dimensional speckle tracking imaging(2 D-STI),then calculated the standard deviations(Trs-SD),the maximal temporal difference(Trs-Dif),and the average value(Trs-AVG)of LV 18 segments to evaluate the LV synchrony.Results:Compared with His-Purkinjie system pacing group,the QRS duration,LVAT,Trs-AVG,Trs-SD and Trs-Dif were longer in patients from DSVP group(P<0.05).However,compared with RVSP group,above parameters were obviously shorter in DVSP group(DVSP vs RVSP,QRS duration:120.7±7.4 ms vs 152.1±7.4 ms;LVAT:80.6±6.6 ms vs 108.1±3.4 ms;Trs-AVG:366.5±32.3 ms vs 422.3±43.9 ms;Trs-SD:43.5±8.4 ms vs 67.6±9.7 ms;Trs-Dif:146.6±35.3 ms vs 257.6±47.2 ms;P=0.000).The QRS duration after pacing was positively correlated with Trs-SD.Higher threshold value(2.4±0.9 V/0.4 ms)and lower amplitude of R wave(4.6±1.1 mV)of ventricular electrode were recorded in patients of HBP(P<0.01).The LVEF of patients in RVSP group for 1 year later were lower than others(P=0.023),and no statistical difference of LVEDD after pacing was observed in the four groups.Conclusion:Both His-Purkinjie system pacing and DVSP were superior to RVSP in electromechanical synchronization of LV.DVSP might be an alternative of physiological pacing form.