心脏再同步化治疗后左室逆重构与电活动变化关系探讨及间期优化研究

【作者】 梁义秀；

【导师】 宿燕岗；

【作者基本信息】 复旦大学 ， 内科学， 2010， 硕士

【摘要】 第一部分心脏再同步化治疗后左室逆重构与电重构及室性心律失常关系探讨目的探讨慢性心功能不全患者心脏再同步化治疗(CRT)术后左室逆重构与电重构及室性心律失常事件的关系。方法入选慢性心功能不全NYHA心功能Ⅲ-Ⅳ级、左室射血分数(LVEF)≤35%、心超提示心室收缩活动不同步而于我院行CRT(D)术的患者,随访术后即刻与术后6个月体表心电图与心脏超声,记录术后即刻和术后6个月QRS时限(QRSd)、LVEF、左室收缩末容积(LVESV)、左室舒张末容积(LVEDV);随访并记录脉冲发生器保存的术后6个月中室性心律失常次数,包括室性早搏(PVCs)与室性早搏连发(PVC runs)。根据术后6个月LVESV缩小比例是否≥15%分为有效组与无效组,分析所有患者和亚组内术前与术后QRSd的变化,对比组间QRSd变化和室性心律失常事件,并对左室逆重构程度与QRS时限变化和室性心律失常事件进行相关性分析。结果1.共入选43例患者,原发疾病均为特发性扩张型心肌病,以中至重度心衰为主,术前LVEF低下(32.98±6.45%),QRS时限延长(153.95±33.75ms),术后根据患者病情予心衰常规药物治疗。2.随访过程中未出现入选患者死亡。术前总体患者NYHA心功能Ⅲ级与Ⅳ级各有35例与8例,术后6个月NYHA心功能Ⅰ至Ⅳ级患者各有2、14、24与3例(P(0.01)。6分钟步行距离由术前280.33±105.67m延长至术后6个月时301.85±9 0.73m(P=0.03)。3.治疗有效组(△LVESV%≥15%)29例,治疗无效组(ΔLVESV%＜15%)14例,组间年龄、性别、病因、术前log(NT-proBNP)、术前EF、术前LVESV、术前QRSd、术后应用药物等均无差异。4.与CRT术前相比较,总体患者术后6个月LVEF有明显增加(32.98±6.45 vs 38.26±7.01%,P<0.01),LVESV与LVEDV减小(223.31±128.69 vs170.33±109.42ml,326.96±176.07 vs 266.30±162.37ml,P均<0.01),QRSd无明显变化(153.5±33.75 vs 149.77±25.87ms,P=0.498)。治疗有效组LVEF增加(32.28±6.10 vs 38.97±6.94%,P<0.01),LVESV、LVEDV均有减小(245.55±137.43 vs 166.30±116.43ml,355.94±186.29 vs 257.95±168.52ml,P均<0.01),QRSd缩短(158.28±30.13 vs 140.69±23.14,P<0.01)。治疗无效组的LVEF较术前未见改善(34.43±7.14 vs 36.79±7.17%,P=0.061),LVESV和LVEDV无明显变化(177.25±97.16 vs 178.68±96.82ml,P=0.872和266.91±140.17 vs 283.61±153.40ml,P=0.362),术后QRSd与术前相比无差异(145.00±39.95 vs 168.57±21.07ms,P=0.080)。治疗有效组与无效组的组间QRS变化有明显差异(-17.59±28.99 vs 23.57±46.51ms,P=0.017)。对总体患者术后LVESV变化比例与QRSd变化进行相关性分析显示呈正相关(r=0.523,P<0.01),在有效组与无效组两者均无相关性(r=0.304,P=0.109与r=0.287,P=0.320)。5.有效组与无效组术后6个月内室性心律失常事件次数存在显著差异,其中log(PVCs)为(1.66±0.73)次／天vs(2.67±0.56)次／天(P<0.01), log (PVC runs)为(0.73±0.85)次／天vs(2.01±0.51)次／天(P<0.01)。对术后心律失常事件次数与LVESV变化比例进行相关性分析,log(PVCs)和log(PVC runs)均与LVESV变化比例呈正相关(r=0.397和t=0.448,P均<0.01)。以log(PVCs)与log(PVC runs)为应变量,以年龄、性别、糖尿病史、术前NYHA心功能分级、术前log(NT-proBNP)、术前LVEF、术前QRSd、术后应用胺碘酮和术后6个月LVESV变化比例等因素为自变量进行多元逐步回归分析,结果显示只有LVESV变化比例是log(PVCs)的独立影响因素(β=2.360,P<0.01),而LVESV变化比例和性别是log (PVC runs)的独立影响因素(β=2.877,P<0.01和β=-0.735,P=0.034)。结论CRT有效表现为左室逆重构、电重构和室性心律失常事件减少,且左室逆重构程度与电重构及室性心律失常减少程度相关。左室逆重构程度与性别对CRT患者术后室性心律失常事件有一定的预测意义。第二部分心超指导与QuickOpt功能进行间期优化对CRT患者急性血流动力学影响的对比分析目的探讨在心超指导下和利用QuickOpt功能优化CRT患者感知房室延迟(SAV间期)、起搏房室延迟(PAV间期)和室间延迟(VV间期)对患者急性血流动力学的影响的一致性。方法共入选19例植入具有QuickOpt功能的CRT(D)的患者,利用体表心超通过调整起搏间期获得最大主动脉血流速度积分(aVTI)及其相应的SAV间期、PAV间期、VV间期；利用QuickOpt功能获得优化SAV、PAV、VV间期并测定相应aVTI,比较两种方法获得的优化AV、VV间期及其对应的aVTI的一致性。结果用心超法和IEGM法获得的最佳SAV, PAV, VV间期所对应的aVTI的一致相关系数(CCC)分别为95.95%,97.29%,92.45%,均有统计学意义(P<0.01)。心超法与IEGM法获得的优化SAV间期(131.67±22.30 ms vs 121.11±13.24 ms,P=0.117)、PAV间期(178.42±21.86 ms vs 171.05±12.87 ms,P=0.114)与VV间期均无显著差异(15.79±15.75 ms vs 16.32±20.20 ms.P=0.871).IEGM法进行间期优化花费时间比心超法大大减少(1.28±0.45分钟vs 43.60±11.07分钟,P<0.01)。结论利用QuickOpt功能对CRT患者进行术后间期优化,可以获得与心超优化一致的急性血流动力学影响效果,并且大大减少优化花费时间。更多还原

【Abstract】 Part One Relationship between reverse of left ventricle remodeling and electrical remodeling and ventricular arrhythmias after cardiac resynchronization therapyObjectives To investigate the relationship between reverse of left ventricle remodeling and electrical remodeling and ventricular arrhythmias after cardiac resynchronization therapy in chronic heart failure patients.Methods Patients with heart failure scheduled for implantation of a CRT device were studied. Selection criteria included moderate to severe heart failure(New York Heart Association classesⅢtoⅣ), left ventricular ejection fraction (LVEF)≤35%, and ventricular asynchrony detected by echocardiography. Echocardiographic and Electrocardiogramic data was recorded before, right after and 6 months after CRT implantation, including QRS duration, LVEF, left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume(LVEDV).Ventricular arrhythmia data was obtained through the pacemaker, including PVCs and PVC runs. Anatomical ’responders’ were defined as those with a reduction in LVESV of at least 15% by 6 months after implantation. Change of QRS duration in all patients and subgroup were analyzed, and relationship between anatomic remodeling and change of QRS duration and ventricular arrhythmias were assessed.Results 1. A total numbers of 43 patients were enrolled, including 29 as responders and 14 as nonresponders. There were no differences between the two groups in age, etiology, LVEF, QRS duration etc.2. All patients demonstrated an improvement in NYHA class (P<0.01) and 6 minute walk distance (P=0.03).3. All patients demonstrated an increased LVEF, a decreased LVESV and LVEDV, but without any change in QRS duration. Subgroup analysis revealed a similar change in LVEF, LVESV and LVEDV, but obvious decreased QRS duration in responders, while no change in LVEF, LVESV, LVEDV and QRS duration in non-responders. There is a significant difference between the change of QRS duration of the two groups. In all patients reduction of LVESV is positively correlated with change of QRSd(r=0.523, P<0.01).4. Anatomic responders suffered less PVCs and PVC runs than nonresponders (both P<0.01). Multiple regression analysis demonstrated responder status significantly predicts log(PVCs) (β=2.360, P<0.01), and both responder status and gender play a role in predicting log(PVC runs) (β=2.877, P<0.01 andβ=-0.735, P=0.034).Conclusions Effectiveness of CRT consists of reverse of anatomic remodeling, electrical remodeling and reduction of ventricular arrhythmias. Anatomic remodeling is in correlation with electrical remodeling and reduction of ventricular arrhythmias. Both remodeling of left ventricule and gender play a role in ventricular arrhythmias in patients after cardiac resynchronization therapy.Part Two A comparative study of acute hemodynamic effects of interval optimization for cardiac resynchronization therapy patients by echocardiography and QuickOpt functionObjective To investigate the concordance of acute hemodynamic effects of optimization of SAV delay, PAV delay and VV delay between echocardiography and QuickOpt function method.Methods A total number of 19 patients implanted with QuickOpt functioned CRT(D) were enrolled. Echocardiography was used to acquire aortic velocity time integral (aVTI) and optimized SAV, PAV, and VV delay. Also QuickOpt function was used to acquire the optimized SAV, PAV, and VV delay and further measurement of corresponding aVTI was made. Finally, concordance of obtained aVTI is calculated, and the intervals optimized by the two methods were compared.Results Concordance correlation coefficient (CCC) between the maximum aVTI values acquired by the standard method and those by the IEGM method were 95.95%,97.29%,92.45% respectively, by data analysis of the SAV, PAV and VV delays (P< 0.05). The optimal SAV, PAV and VV interval acquired by echocardiography method were not different from those by QuickOpt method (all P>0.05). Optimization of interval with QuickOpt method saves a lot of time compared with echocardiography method (1.28±0.45 minutes vs 43.60±11.07 minutes, P<0.01).Conclusion QuickOpt function is an alternative method for the optimization of AV, PV and VV delay settings in patients with CRT(D) which provides similar effect on acute hemodynamic analysis and saves a lot of time compared with standard echocardiography method.更多还原