心脏再同步治疗后射血分数改善的心力衰竭患者室性心律失常事件的评估

Evaluation of ventricular arrhythmic events in heart failure with improved ejection fraction patients after cardiac resynchronization therapy

目的分析非缺血性心肌病心力衰竭(心衰)患者经心脏再同步治疗(CRT)后达到射血分数改善的心衰(HFimpEF)标准的患者中室性心律失常事件(VAE)的发生情况,探讨在此类人群中植入心律转复除颤器(ICD)作为心脏性猝死(SCD)一级预防的价值。方法回顾性分析南京医科大学第一附属医院心血管内科2013年1月至2022年4月植入心脏再同步治疗起搏器(CRT-P)或心脏再同步治疗除颤器(CRT-D)的非缺血性心肌病心衰患者173例,其中18例患者因符合SCD二级预防被排除,最终纳入155例患者,中位年龄66.7岁,年龄范围18~85岁,男108例(108/155,69.7%),中位随访时间27个月(12~55个月)。根据基线及末次随访时的左心室射血分数(LVEF)分为LVEF未改善的射血分数降低的心衰(HFrEF)组(末次随访LVEF≤40%或ΔLVEF<10%)及LVEF改善的HFimpEF组(末次随访LVEF>40%,且ΔLVEF≥10%),其中HFimpEF组根据末次随访LVEF是否≥50%分为LVEF完全改善组(末次随访LVEF≥50%)和LVEF部分改善组(末次随访,40%<LVEF<50%),分别比较其基线特征及术后VAE的发生情况,VAE定义为持续性室性心动过速、心室颤动需抗心动过速起搏和/或恰当放电治疗或药物复律治疗。结果研究共纳入155例患者,其中HFimpEF组95例,HFrEF组60例;两组患者VAE的发生率分别为5.3%和21.7%,差异有统计学意义(P=0.002)。HFimpEF组中64例患者LVEF部分改善,其中4例(4/64,6.3%)记录到VAE;31例LVEF完全改善患者中仅1例(1/31,3.2%)记录到VAE,两组发生率差异无统计学意义(6.3%对3.2%,P=0.897)。多因素Logistic回归分析提示完全性左束支传导阻滞、女性、不符合SCD 1.5级预防适应证、不合并慢性阻塞性肺疾病是非缺血性心肌病患者CRT后达到HFimpEF的独立预测因素。随访时未达到HFimpEF标准及CRT植入前的心衰病程是VAE发生的独立预测因素。结论非缺血性心肌病患者CRT后HFimpEF者,其VAE的发生率明显低于HFrEF者。LVEF部分改善组与LVEF完全改善组的VAE发生率差异无统计学意义。

Objective To analyze the occurrence of ventricular arrhythmic events(VAE)in patients with non-ischemic cardiomyopathy heart failure who met the heart failure with improved ejection fraction(HFimpEF)criteria after cardiac resynchronization therapy(CRT),and to evaluate the value of implantable cardioverter defibrillator(ICD)for primary prevention of sudden cardiac death(SCD)in this population.Methods Retrospective analysis of 173 patients with non-ischemic cardiomyopathy heart failure who underwent cardiac resynchronization therapy pacemaker(CRT-P)or cardiac resynchronization therapy defibrillator(CRT-D)implantation from January 2013 to April 2022 at the Department of Cardiology,The First Affiliated Hospital with Nanjing Medical University,of which 18 patients were excluded because they were eligible for SCD grade 2 prophylaxis,and finally included 155 patients with a mean age of 66.7 years,age ranging from 18 to 85 years,108 males(108/155,69.7%),and a median follow-up time of 27 months(12-55 months).The people were divided into the heart failure with reduced ejection fraction(HFrEF)group with no improvement in left ventricular ejection fraction(LVEF)(LVEF≤40%orΔLVEF<10%at the last follow-up)and HFimpEF group with improved LVEF(LVEF>40%at last follow-up andΔLVEF≥10%),in which the HFimpEF group was divided into LVEF completely improved group(LVEF≥50%at last follow-up)and LVEF partially improved group(40%<LVEF<50%at last follow-up)according to whether LVEF≥50%at last follow-up.The baseline characteristics and the occurrence of VAE were compared.VAE was defined as sustained ventricular tachycardia(VT),ventricular fibrillation(VF)requiring anti-tachycardia pacing(ATP)and/or appropriate discharge therapy.Results Among them,95 were HFimpEF and 60 were HFrEF.The incidences of VAE were 5.3%and 21.7%in the two groups,respectively,with statisical differences(P=0.002).sixty-four patients in the HFimpEF group had partial improvement in LVEF,of which 4(4/64,6.3%)recorded VAE.Only 1 of 31 patients(1/31,3.2%)with complete improvement in LVEF was recorded VAE,and the incidence was not statistically different between the two groups(6.3%vs.3.2%,P=0.897).Multifactorial Logistic regression analysis suggested that complete left bundle branch block,female,not meeting SCD class 1.5 prophylaxis indications,and not having chronic obstructive pulmonary disease(COPD)were independent predictors of achieving HFimpEF after CRT in patients with non-ischemic cardiomyopathy.Failure to meet HFimpEF criteria at follow-up and the course of heart failure before CRT implantation were independent predictors of ventricular arrhythmias.Conclusion The incidence of VAE was significantly lower in non-ischemic cardiomyopathy patients with HFimpEF after CRT treatment than in those with HFrEF.There was no statistically significant difference in the incidence of ventricular arrhythmias between the groups with partial improvement and full improvement in LVEF.