左心室心尖部间隔起搏与基底部间隔起搏的临床疗效比较

Comparison of efficacy of left ventricular apical septal pacing versus basal septal pacing

目的比较行左束支起搏失败的病态窦房结综合征患者行左心室心尖部间隔起搏(LVASP)或左心室基底部间隔起搏(LVBSP)治疗的效果,为此类患者治疗方案的选择提供依据。方法2019年12月—2021年10月阜外华中心血管病医院诊治行左束支起搏失败的病态窦房结综合征伴基线QRS时程(QRSd)<120 ms患者40例,其中行LVASP者20例为LVASP组,行LVBSP者20例为LVBSP组。比较2组术后1周右心室间隔面电极植入点至三尖瓣隔瓣距离、电极植入室间隔深度、电极植入部位室间隔厚度;比较2组术中及术后1周、3个月、6个月时起搏参数(阈值、感知、阻抗)。术中起搏状态下行12导联心电图及腔内心电图,分别记录QRSd、V5导联左心室达峰时间(LVAT)。术前心脏自身工作状态下及术后1周、3个月、6个月时起搏状态下行12导联心电图记录QRSd,行超声心动图记录应变达峰时间离散度(PSD)。随访6个月,记录2组起搏器相关并发症发生情况、再发心力衰竭住院及生存情况。结果LVASP组右心室间隔面电极植入点至三尖瓣隔瓣距离[(37.68±8.48)mm]大于LVBSP组[(16.52±2.55)mm](t=10.676,P<0.001),电极植入室间隔深度、电极植入部位室间隔厚度与LVBSP组比较差异均无统计学意义(P>0.05)。LVASP组术中及术后1周、术后3个月、术后6个月时起搏阈值[(0.67±0.19)、(0.67±0.12)、(0.65±0.11)、(0.62±0.21)V/0.4 ms]、感知[(13.05±3.25)、(13.99±3.59)、(15.41±3.56)、(16.14±5.61)mV]、阻抗[(742.00±172.40)、(588.80±82.28)、(570.55±73.18)、(560.55±93.94)Ω]与LVBSP组[阈值(0.66±0.14)、(0.65±0.18)、(0.64±0.11)、(0.67±0.16)V/0.4 ms,感知(13.11±3.00)、(12.87±3.80)、(13.81±4.11)、(14.84±4.51)mV,阻抗(764.05±160.90)、(623.30±99.66)、(584.60±68.30)、(598.30±74.11)Ω]比较差异均无统计学意义(P>0.05);2组术后1周、术后3个月、术后6个月时起搏阈值与术中比较差异均无统计学意义(P>0.05);LVASP组术后3个月、术后6个月时起搏感知均高于术中(P<0.05),术后1周时与术中比较差异无统计学意义(P>0.05);LVBSP组术后1周、术后3个月、术后6个月时起搏感知与术中比较差异均无统计学意义(P>0.05);2组术后1周、术后3个月、术后6个月时起搏阻抗均低于术中(P<0.05),术后1周、术后3个月、术后6个月时比较差异均无统计学意义(P>0.05)。LVASP组术中LVAT[(56.20±12.31)ms]短于LVBSP组[(71.75±15.16)ms](t=3.561,P<0.001)。LVASP组术前QRSd[(95.20±14.29)ms]与LVBSP组[(95.60±14.38)ms]比较差异无统计学意义(P>0.05),术中及术后1周、术后3个月、术后6个月时QRSd[(136.95±17.80)、(138.65±18.59)、(137.25±16.81)、(136.60±17.11)ms]均长于LVBSP组[(115.95±16.31)、(114.95±16.37)、(116.35±14.89)、(116.50±13.41)ms](P<0.05);2组术中及术后1周、术后3个月、术后6个月时QRSd均长于术前(P<0.05)。LVASP组术前PSD[(53.35±7.55)ms]与LVBSP组[(53.95±8.97)ms]比较差异无统计学意义(P>0.05),术后1周、术后3个月、术后6个月时PSD[(62.05±11.72)、(63.95±10.45)、(63.45±13.00)ms]均小于LVBSP组[(71.15±12.27)、(71.35±11.18)、(71.55±10.81)ms](P<0.05);2组术后1周、术后3个月、术后6个月时PSD均大于术前(P<0.05)。随访6个月,2组均未发生起搏器相关并发症及再发心力衰竭住院、死亡。结论行左束支起搏失败的病态窦房结综合征患者行LVASP和LVBSP治疗时短期内起搏参数相对稳定,无不良事件发生,而LVASP的心脏机械同步性优于LVBSP,可作为此类患者的备选治疗方案。

Objective To compare the therapeutic efficacy of left ventricular apical septal pacing(LVASP)versus left ventricular basal septal pacing(LVBSP)in patients with sick sinus syndrome who failed left bundle branch pacing,and to provide a basis for the selection of treatment plans.Methods From December 2019 to October 2021,40 patients with sick sinus syndrome and baseline QRS duration(QRSd)<120 ms who failed left bundle branch pacing were treated in Fuwai Central China Cardiovascular Hospital,and were divided into LVASP group(n=20)and LVBSP group(n=20).The distance between the right ventricular septal electrode implantation site and the tricuspid septal valve,the electrode implantation depth in interventricular septum,and the thickness of interventricular septum at the electrode implantation site were compared between two groups 1 week after pacing.The pacing parameters(threshold,perception,impedance)were compared between two groups during pacing and 1 week,3 months and 6 months after pacing.The QRSd and left ventricular activation time(LVAT)in lead V5 were recorded by 12-lead electrocardiogram(ECG)and intracavitary electrocardiography during pacing.The QRSd was recorded by 12-lead ECG before pacing and in pacing state 1 week,3 months and 6 months after pacing,and peak strain dispersion(PSD)was recorded by echocardiography.A follow-up survey was done for 6 months to record the occurrence of pacemaker related complications,readmission due to recurrent heart failure,and survival in two groups.Results The distance from the right ventricular septal electrode implantation site to the tricuspid septal valve was longer in LVASP group[(37.68±8.48)mm]than that in LVBSP group[(16.52±2.55)mm](t=10.676,P<0.001),and there were no significant differences in the electrode implantation depth in interventricular septum and the thickness of the ventricular septum at the electrode implantation site between two groups(P>0.05).There were no significant differences in the pacing thresholds[(0.67±0.19),(0.67±0.12),(0.65±0.11),(0.62±0.21)V/0.4 ms],perception values[(13.05±3.25),(13.99±3.59),(15.41±3.56),(16.14±5.61)mV]and impedance values[(742.00±172.40),(588.80±82.28),(570.55±73.18),(560.55±93.94)Ω]in LVASP group compared with those in LVBSP group[pacing thresholds:(0.66±0.14),(0.65±0.18),(0.64±0.11),(0.67±0.16)V/0.4 ms;perception values:(13.11±3.00),(12.87±3.80),(13.81±4.11),(14.84±4.51)mV;impedance values:(764.05±160.90),(623.30±99.66),(584.60±68.30),(598.30±74.11)Ω]during pacing,and 1 week,3 months and 6 months after pacing(P>0.05).There were no significant differences in the pacing thresholds 1 week,3 months and 6 months after pacing compared with those during pacing in two groups(P>0.05).The perception value was higher 3 and 6 months after pacing than that during pacing in LVASP group(P<0.05),and showed no significant difference 1 week after pacing compared with that during pacing(P>0.05).In LVBSP group,the perception value showed no significant difference 1 week,3 months and 6 months after pacing compared with that during pacing(P>0.05).The impedance values were lower 1 week,3 months and 6 months after pacing than those during pacing in two groups(P<0.05),and showed no significant differences 1 week,3 months and 6 months after pacing(P>0.05).The LVAT was shorter in LVASP group[(56.20±12.31)ms]than that in LVBSP group[(71.75±15.16)ms](t=3.561,P<0.001).There was no significant difference in the QRSd between LVASP group[(95.20±14.29)ms]and LVBSP group[(95.60±14.38)ms]before pacing(P>0.05).The QRSd values were longer in LVASP group[(136.95±17.80),(138.65±18.59),(137.25±16.81),(136.60±17.11)ms]than those in LVBSP group[(115.95±16.31),(114.95±16.37),(116.35±14.89),(116.50±13.41)ms]during pacing and 1 week,3 months and 6 months after pacing(P<0.05),which were longer than those before pacing in two groups(P<0.05).There was no significant difference in the PSD between LVASP group[(53.35±7.55)ms]and LVBSP group[(53.95±8.97)ms]before pacing(P>0.05).The PSD values were smaller in LVASP group[(62.05±11.72),(63.95±10.45),(63.45±13.00)ms]than those in LVBSP group[(71.15±12.27),(71.35±11.18),(71.55±10.81)ms]1 week,3 months and 6 months after pacing(P<0.05),which were larger than those before pacing in two groups(P<0.05).The 6-month follow-up showed no pacemaker related complications,readmission due to recurrent heart failure or death.Conclusions The pacing parameters are stable with no adverse events in the short term after LVASP and LVBSP in patients with sick sinus syndrome who have failed the left bundle branch pacing.The heart mechanical synchrony of LVASP is better than that of LVBSP,and can be regarded as an alternative treatment.