希氏-浦肯野系统起搏在心房颤动伴缓慢心律失常中应用价值研究

Study on the application value of his-purkinje system pacing in atrial fibrillation with bradyarrhythmia

目的探讨希氏-浦肯野系统起搏(HPSP)在心房颤动伴缓慢心律失常中的应用价值。方法选取北部战区总医院自2016年3月至2020年12月收治的因心房颤动伴缓慢心律失常而行HPSP的123例患者为研究对象。将有临床症状的持续性心房颤动伴缓慢心室率,即动态心电图检查24 h心室率<80000次的94例患者纳入A组,进一步将A组患者分入RR间期匀齐组(A1组,n=40)和RR间期不匀齐组(A2组,n=54)2个亚组;将有临床症状的持续性心房颤动伴长间期,即动态心电图检查24 h心室率>80000次且伴有5 s以上长间期的29例患者纳入B组。由术者选择希氏束起搏(HBP)或左束支起搏(LBBP);如HPSP不成功,则采用传统方法起搏。比较A组(A1组+A2组)和B组的一般资料,记录HPSP参数,分析HBP、LBBP的手术情况和并发症发生情况。结果123例患者中,男性85例(69.1%);平均年龄(69.9±10.5)岁;扩张型心肌病18例,缺血性心肌病4例;22例(17.9%,22/123)同时伴有心力衰竭(左室射血分数<0.50),平均左室射血分数为(0.39±0.08);17例(13.8%,17/123)伴束支传导阻滞,平均QRS波时限为(166±13)ms,其中,12例为左束支传导阻滞,5例为右束支传导阻滞。A1组、A2组平均心率、总心搏低于B组,发现心房颤动时间长于B组,差异有统计学意义(P<0.05)。92例患者首先尝试HBP,术中平均X射线曝光时间为(9.1±5.9)min,成功率为91.3%(84/92)。HBP术中和术后次日阈值分别为(1.3±0.5)V/1.0 ms和(1.2±0.4)V/1.0 ms,差异无统计学意义(P>0.05);术中和术后次日R波振幅分别为(3.5±2.2)mv和(4.0±2.4)mv,差异无统计学意义(P>0.05);术后次日阻抗为(556.1±107.4)Ω,低于术中的(634.5±103.4)Ω,差异有统计学意义(P<0.05)。31例患者首先尝试LBBP,术中平均X射线曝光时间为(9.5±4.6)min,成功率为90.3%(28/31)。LBBP术中和术后次日阈值分别为(1.1±0.4)V/1.0 ms和(1.2±0.3)V/1.0 ms,差异无统计学意义(P>0.05);术中和术后次日R波振幅分别为(11.0±3.6)mv和(11.7±3.1)mv,差异无统计学意义(P>0.05);术后次日阻抗为(647.3±101.7)Ω,低于术中的(745.3±118.6)Ω,差异有统计学意义(P<0.05)。所有患者均未发生气胸、心包填塞、电极移位、穿孔等并发症。结论将HBP或LBBP作为首选治疗心房颤动伴缓慢心律失常可行,手术成功率和安全性均较高。

Objective To evaluate the value of his-purkinje system pacing(HPSP)in atrial fibrillation with bradyarrhythmia.Methods A total of 123 patients treated with HPSP for atrial fibrillation with bradyarrhythmia in General Hospital of Northern Theater Command from March 2016 to December 2020 were selected as the research subjects.A total of 94 patients with clinical symptoms of persistent atrial fibrillation accompanied by slow ventricular rate(24 hours ventricular rate<80000 times by dynamic electrocardiogram)were enrolled into group A,and further divided into two subgroups:uniform RR interval group(A1 group,n=40)and uneven RR interval group(A2 group,n=54).A total of 29 patients with persistent atrial fibrillation with clinical symptoms and long interval(ventricular rate>80000 at 24 hours by dynamic electrocardiogram and long interval over 5 seconds)were included in group B.The surgeon chosed his-bundle pacing(HBP)or left bundle branch pacing(LBBP).If HPSP was not successful,traditional pacing methods were used.The general data of group A(A1 group+A2 group)and group B were compared,HPSP parameters were recorded,HBP and LBBP operation and complications were analyzed.Results Among 123 patients,85(69.1%)were male,average age was(69.9±10.5)years,dilated cardiomyopathy in 18 cases and ischemic cardiomyopathy in 4 cases.There were 22 patients(17.9%,22/123)with heart failure(left ventricular ejection fraction<0.50),and the mean left ventricular ejection fraction was(0.39±0.08).There were 17 patients(13.8%,17/123)with bundle branch block,with a mean QRS duration of(166±13)ms,of which 12 patients had left bundle branch block and 5 patients had right bundle branch block.The average heart rate and total heart rate of A1 group and A2 group were lower than that of group B,and the duration of atrial fibrillation was longer than that of group B,with statistical significance(P<0.05).Ninety-four patients first tried HBP,with an average intraoperative X-ray exposure time of(9.1±5.9)minutes and a success rate of 91.3%(84/92).The threshold values of HBP during and on the second day after surgery were(1.3±0.5)V/1.0 ms and(1.2±0.4)V/1.0 ms,respectively,and there were no significant differences(P>0.05).The amplitude of R-wave was(3.5±2.2)mV and(4.0±2.4)mV,respectively,and there were no significant differences(P>0.05).The impedance on the second day after surgery was(556.1±107.4)Ω,which was lower than(634.5±103.4)Ωduring surgery,and the difference was statistically significant(P<0.05).LBBP was first tried in 31 patients,with an average intraoperative X-ray exposure time of(9.5±4.6)minutes and a success rate of 90.3%(28/31).The thresholds values of LBBP during and on the second day after surgery were(1.1±0.4)V/1.0 ms and(1.2±0.3)V/1.0 ms,respectively,and there were no significant differences(P>0.05).The amplitude of R-wave was(11.0±3.6)mV and(11.7±3.1)mV,respectively,and there were no significant differences(P>0.05).The impedance on the second day after surgery was(647.3±101.7)Ω,which was lower than(745.3±118.6)Ωduring surgery,and the difference was statistically significant(P<0.05).None of the patients had pneumothorax,cardiac tamponade,electrode displacement,perforation and other complications.Conclusion It is feasible to use HBP or LBBP as the first choice for the treatment of atrial fibrillation with bradyarrhythmia,with high surgical success rate and safety.