希氏-浦肯野系统起搏在置入人工心脏瓣膜患者中的应用

His-Purkinje system pacing in patients with prosthetic cardiac valves

目的探讨希氏-浦肯野系统起搏(HPSP)在置入人工心脏瓣膜患者中应用的可行性与安全性及其对患者心功能的影响。方法入选2014年9月至2021年6月在南京医科大学第一附属医院心血管内科尝试行HPSP且术前存在人工心脏瓣膜的患者,收集患者的年龄、性别、起搏器植入适应证、置换的人工心脏瓣膜类型、手术并发症、临床随访资料、起搏参数(阈值、R波振幅和阻抗)、QRS时限(QRSd)和左心室达峰时间(LVAT),以及左心室收缩末期内径(LVESD)、左心室舒张末期内径(LVEDD)、左心室射血分数(LVEF)等超声心动图数据。结果共纳入32例尝试行HPSP且术前已置入人工心脏瓣膜的患者,其中8例尝试希氏束起搏(HBP),7例成功,24例尝试左束支起搏(LBBP),均成功,总成功率96.88%(31/32)。HBP组的起搏阈值明显高于LBBP组[(1.22±0.78)V对(0.47±0.13)V,P=0.04],感知显著低于LBBP组[(6.63±4.97)mV对(13.09±7.12)mV,P=0.03],差异均具有统计学意义。随访(16.21±10.61)个月,两组患者的起搏参数保持稳定。宽QRS波组患者(QRSd≥120 ms)行HPSP后QRSd较术前明显缩短[(152.59±19.79)ms对(132.34±12.78)ms,P=0.004],窄QRS波组患者(QRSd<120 ms)行HPSP后QRSd较术前明显延长[(94.43±7.38)ms对(122.53±10.86)ms,P<0.001];两组患者的LVAT差异无统计学意义[(78.63±9.20)ms对(75.13±13.80)ms,P=0.41]。HPSP后患者的心功能及心脏大小未见明显变化。结论人工心脏瓣膜置换术后发生缓慢性心律失常的患者行HPSP成功率高,是可行的,且HPSP可以维持心脏的电同步性,从而保护这类特殊患者的心功能。

Objective To investigate the feasibility and safety of His-Purkinje system pacing(HPSP)in patients with prosthetic cardiac valves and its effect on cardiac function.Methods Patients with pre-operative prosthetic cardiac valves who tried HPSP in Department of Cardiology,The First Affiliated Hospital of Nanjing Medical University from September 2014 to June 2021 were enrolled.General information including age,gender,indications of pacemaker implantation,types of prosthetic cardiac valves and clinical follow-up data of all patients were collected.Programmed parameters,such as pacing threshold,R wave amplitude and pacing impedance were analyzed regularly.Electrocadiographic characteristics like QRS duration(QRSd)and left ventricular activation time(LVAT)as well as echocardiographic data like left ventricular end-systolic diameter(LVESD),left ventricular end-diastolic diameter(LVEDD)and left ventricular ejection fraction(LVEF)were also collected.Results A total of 32 patients with prosthetic cardiac valves who tried HPSP were included in this study.Among them,8 patients tried His-Purkinje system pacing(HBP),7 succeeded,and 24 patients tried left bundle branch pacing(LBBP),all succeeded,with a total success rate of 96.88%(31/32).The pacing threshold of the HBP group was significantly higher than that of the LBBP group[(1.22±0.78)V vs.(0.47±0.13)V,P=0.04],and the sensing was significantly lower than that of the LBBP group[(6.63±4.97)mV vs.(13.09±7.12)mV,P=0.03].Within(16.21±10.61)months follow-up,the pacing parameters remained stable in both groups.QRSd of patients in the wide QRS group(QRSd≥120 ms)after HPSP was significantly shorter than that before operation[(152.59±19.79)ms vs.(132.34±12.78)ms,P=0.004],which was significantly longer after HPSP in the narrow QRS group(QRSd<120 ms)[(94.43±7.38)ms vs.(122.53±10.86)ms,P<0.001].And LVAT of the two groups was not statistically different[(78.63±9.20)ms vs.(75.13±13.80)ms,P=0.41].There was no significant change in cardiac function and heart size after HPSP.Conclusion HPSP is feasible in patients with bradyarrhythmia after prosthetic cardiac valves implantation,and HPSP can maintain the electrical synchronicity of the heart,thus protecting the cardiac function of the patients.