【作者】 王宇星；

【导师】 徐耕；

【作者基本信息】 浙江大学 ， 内科学（专业学位）， 2013， 博士

【摘要】 第一部分慢性心力衰竭患者心脏再同步治疗临床获益与左心室起搏位点的相关性研究目的：观察左心室起搏位点与慢性心力衰竭(chronic heart failure, CHF)患者心脏再同步治疗(cardiac resynchronization therapy, CRT)临床获益的相关性。分析左心室起搏位点是否会影响心力衰竭患者术后对CRT的反应性。左室最佳位点带来的临床获益是否会优于其它位点。方法：2006年1月至2012年12月在浙江大学医学院附属第二医院心内科住院并接受CRT-P/D治疗的204例患者纳入本临床研究,其中男性141例,女性63例,年龄64.8±11.9岁,随访17.8±14.9个月。按照左心室短轴、长轴以及是否为左室最佳位点三种不同的分组方法对患者的左心室电极起搏位点进行不同的分组：1、左前斜位即左室短轴切面分为前壁、侧壁(包括前侧区、侧区以及后侧区)、后壁三组。2、在右前斜位即左室长轴切面分为心尖段、心室中间段、基底段。3、按照是否为左室最佳起搏位点(LAO450的侧壁,RAO300的心室基底段和中间段的左心室起搏位点)分为最佳位点组与非最佳位点组。本研究的主要终点为患者心源性死亡或CRT三个月以后因心衰发作再入院,次要终点为患者CRT术后纽约心功能分级(NYHA class)以及左室射血分数(LVEF)、左室舒张末期内径(LVEDD)等心超指标的改善程度。采用Kaplan-Meier法计算随访期间的主要终点事件发生率并绘制时间-事件曲线,用对数秩和检验(log-rank test)进行数据比较分析。结果：心室短轴分组中各组患者术后在NYHA(P=0.754)、LVEF(P=0.966)、LVEDD(P=0.349)方面的改善程度无显著性差异。心室长轴分组中各组患者术后在NYHA (P=0.07)、LVEF (P=0.997)、LVEDD (P=0.688)方面的改善程度无显著性差异,但非心尖部(中间段及基底段)患者的NYHA分级改善趋势较心尖部患者更为明显(P=0.058)。最佳位点与非最佳位点的患者术后在NYHA (P=0.13)、LVEF (P=0.928)、LVEDD (P=0.123)方面的改善程度无显著差异。主要终点事件的相关分析结果表明：前壁、侧壁、后壁之间死亡或心衰再入院的发生情况无显著性差异(P=0.98)；最佳位点组与非最佳位点组无显著性差异(P=0.11)；心尖部患者CRT术后的死亡或心衰再入院率高于非心尖部(P=0.03)。结论：左心室电极位于左室的任何一节段都可以为患者在CRT术后带来临床获益。各分组中不同节段的左心室起搏位点术后临床获益程度无显著性差异。前壁、侧壁、后壁之间在生存分析方面无显著差异,最佳位点与非最佳位点在临床获益及生存分析方面均无显著性差异。心尖部的主要终点事件发生率高于非心尖部,手术中应避免将左室电极安置在心尖区域。第二部分双源螺旋CT冠状静脉成像在心脏再同步治疗中的应用目的：评价双源螺旋CT冠状静脉成像在心脏再同步治疗(CRT)中的临床价值。方法：35例择期行CRT的慢性心衰患者,男性25例,女性10例,平均年龄(65.2-12.1)岁。在CRT术前应用双源螺旋CT冠状静脉成像评估患者的冠状静脉窦及其分支的走行、开口位置、内径大小以及成角等解剖结构特点,并与术中冠状静脉逆行造影进行比对研究。结果：35例(100%)患者的冠状静脉窦(CS)、心大静脉(GCV)、心中静脉(MCV)均能通过MDCT清晰显影,26例(74.28%)患者显影清晰的左心室后静脉(PVLV)与左缘静脉(LMV)。CS平均长度为47.29±8.13mm,上下径12.50±4.97mm,前后径10.99±3.35mm。GCV开口内径为7.77±2.39mm。MCV开口内径为6.13±1.57mm,与右房侧夹角为65.11±16.690,到CS开口距离为12.01±6.04mm。PVLV开口内径为5.03±1.89mm,与CS右房侧夹角为117.73±34.380,到CS开口距离为34.15±13.42mm。LMV开口内径为4.9±1.64mm,与右房侧夹角为114.23±47.560,到CS开口距离为62.51±19.82mm.35例患者中28例(80%)选择LMV作为左室电极靶血管,6例(17.14%)选择PVLV静脉,1例为心大静脉前侧支。结论：双源螺旋CT能够准确清晰的显示冠状静脉系统解剖结构,可以指导CRT左室电极的置入。更多还原

【Abstract】 ObjectiveTo analyze the correlation between left ventricular pacing sites and the clinical outcome of CRT in patients with chronic heart failure. To determine whether the left ventricular pacing sites will affect the responsiveness of CRT and whether the optimal left ventricular lead positions will bring the best clinical effects.Methods204patients who received CRT-P/D in Department of Cardiology in Second Affiliated Hospital School of Medicine Zhejiang University (141male,63female,64.8±11.9years, follow-up of17.8±14.9months) were included in this clinical study. The left ventricular pacing sites of all cases were grouped in three different methods as the short axis, long axis of the left ventricular and whether the pacing site is optimal:1.In the left anterior oblique view or short-axis view of the left ventricle, it was divided into three groups as anterior, lateral (including anteriolateral, lateral and posteriolateral area) and posterior wall;2. In the right anterior oblique view or long-axis view of the left ventricle, it was divided into three groups as apical, middle and basal segment of the left ventricle;3. According to whether the pacing site is the optimal pacing site (refers to left ventricular pacing sites located in the lateral wall in the view of LAO450and basal or middle segments in the view of RAO300), it was divided into two groups as optimal site group and non-optimal site group. Analyze the clinical data collected before and after procedure. The primary endpoint was defined as cardiac death or heart failure hospitalization three months after CRT, the secondary endpoint was the improvement of NYHA class and LVEF、LVEDD、LVESD. Survival estimates were calculated by the Kaplan-Meier method and a log-rank test was used to compare survival between groups.ResultsGroups divided by ventricular short axis had no significant differences in improvement of NYHA (P=0.754), LVEF (P=0.966) and LVEDD (P=0.349). Groups divided by ventricular long-axis had no significant differences in NYHA (P=0.07), LVEF (P=0.997), LVEDD (P=0.688). The optimal site group had no significant improvement in NYHA (P=0.13), LVEF (P=0.928), LVEDD (P=0.123) compared to non-optimal site group. Correlation analysis of primary endpoint events showed that there was no significant difference in cardiac death and heart failure hospitalization among groups of anterior, lateral and posterior wall (P=0.98), the cardiac death and heart failure hospitalization after CRT in apical patients was higher than that in non-apical patients (P=0.03), there was no significant difference in mortality or readmission rate between the optimal site group and non-optimal site group (P=0.11).ConclusionsLeft ventricular pacing brings clinical benefits regardless of the pacing site. There is no significant difference of clinical benefits in groups with different pacing sites (anterior, lateral or posterior wall, apical or non-apical, optimal pacing site or non-optimal pacing site). However, left ventricular leads positioned in apical region are associated with an unfavorable outcome. It should be avoided to place the left ventricular lead in the apical region. PART TWO The application of multidetector computed tomography coronary venous angiography examination in patients with heart failure underwent cardiac resychronization therapyObjectiveThis study was designed to evaluate the value of multidetector computed tomography (MDCT) coronary venous angiography examination befor cardiac resychronization therapy (CRT).MethodsThe MDCT scans of35patients (25men, age65.2±12.1years) with a history of chronic heart failure were studied. The interindividual variability int terms of diameter, distance, angle of the maintributaries of the coronary venous system was analyzed. Retrograde coronary venography was performed during the procedure.ResultThe coronary sinus (CS), great cardiac vein (GCV), middle cardiac vein (MCV) were observed in all patients. Both the posterior vein of the left ventricular (PVLV) and the left marginal vein (LMV) were present in26(74.28%) patients. The mean length of CS was47.29±8.13mm, the diameter of the CS ostium was12.50±4.97mm and10.99±3.35mm respectively in supero-inferior and antero-posterior directions. the mean diameter of MCV/PVLV/LMV was6.13±1.57mm/5.03±1.89mm/4.9±1.64mm respectively, the angle between MCV/PVLV/LMV and CS form right atrum side was65.11±16.690/117.73±34.380/114.23±47.560respectively, the distance between MCV/PVLV/LMV and CS ostium was12.0±6.04mm/34.15±13.42mm/62.51±19.82mm. The LMV was chosen in28(80%) patients for left ventricular (LV) lead, and6(17.14) PVLV were chosen.ConclusionThe anantomy of the CS and its tributaries can be evaluated by MDCT. The pre-implantation knowledge of the venous anatomy may help to guide the LV lead placement.更多还原