心力衰竭患者植入心脏再同步化治疗除颤器后恰当放电情况以及序贯管理

发布时间：2018-03-18 15:09

本文选题：心力衰竭　切入点：心脏再同步化治疗　出处：《中国循环杂志》2017年06期 　论文类型：期刊论文

【摘要】：目的:了解不同病因心力衰竭患者接受心脏再同步化治疗除颤器(CRT-D)治疗后室性心律失常的发生情况以及CRT-D诊断和治疗情况,分析CRT-D治疗后室性心律失常发生的独立预测因素,明确CRT-D放电对死亡率的影响,探讨CRT-D恰当放电的管理措施及效果。方法:对2009-01至2015-04期间我科成功植入CRT-D的42例患者进行随访,缺血性心肌病组12例,其中埋藏式心脏复律除颤器(ICD)一级预防8例,ICD二级预防4例;非缺血性心肌病组30例,其中ICD一级预防19例,ICD二级预防11例。对恰当放电的患者采用药物调整、器械参数调整、血运重建及射频消融的序贯治疗。结果:缺血性心肌病组平均随访(38.1±24.0)个月,7例患者术后发生室性心律失常,5例患者CRT-D恰当放电。非缺血性心肌病组平均随访(27.5±17.8)个月,11例患者术后发生室性心律失常,10例患者CRT-D恰当放电。两组差异无统计学意义(P0.05);缺血性心肌病组患者的数阵抗心动过速起搏(ATP)治疗室性心律失常的成功率高于非缺血性心肌病组(69%vs 55%,P0.05)。COX模型多因素回归分析显示ICD二级预防是术后室性心律失常发生的独立影响因子(P=0.001)。随访期间,CRT-D放电患者的死亡率明显高于CRT-D无放电患者(43%vs 0%,P0.05)。经药物调整、器械参数调整、血运重建及射频消融的四步序贯治疗,缺血性心肌病组中80%的恰当放电患者未再放电。经药物调整、器械参数调整及射频消融的三步序贯治疗,非缺血性心肌病组中90%的恰当放电患者未再放电、10%的患者放电减少。结论:ICD二级预防是术后室性心律失常发生的独立影响因子;植入CRT-D的患者,如果出现放电事件,死亡风险会增加;药物调整、器械参数调整以及血运重建、射频消融的序贯治疗对减少CRT-D恰当放电相当重要。
[Abstract]:Objective: to investigate the incidence of ventricular arrhythmias and the diagnosis and treatment of CRT-D in patients with heart failure after cardiac resynchronization therapy (CRT-D), and to analyze the independent predictors of ventricular arrhythmias after CRT-D treatment. To determine the effect of CRT-D discharge on mortality, and to explore the management measures and effects of proper discharge of CRT-D. Methods: 42 patients with successful CRT-D implantation in our department from 2009-01 to 2015-04 were followed up, 12 cases in ischemic cardiomyopathy group, 12 cases in ischemic cardiomyopathy group, 12 cases in ischemic cardiomyopathy group. There were 8 cases of primary prevention of ICD with implantable cardioverter defibrillator, 4 cases of secondary prevention of ICD, 30 cases of non-ischemic cardiomyopathy group, including 19 cases of primary prevention of ICD, 11 cases of secondary prophylaxis of ICD. The patients with proper discharge were treated with drug adjustment and instrument parameter adjustment. Sequential treatment of revascularization and radiofrequency ablation. Results: the average follow-up of 7 patients with ischemic cardiomyopathy was 38.1 卤24.0 months. 5 patients with ventricular arrhythmias developed ventricular arrhythmias after operation. The average follow-up of non-ischemic cardiomyopathy group was 27.5 卤17.8. 11 patients with ventricular arrhythmias developed ventricular arrhythmias and 10 patients with ventricular arrhythmias developed proper discharge of CRT-D after operation. There was no significant difference between the two groups (P 0.05). The success rate of treating ventricular arrhythmias in ischemic cardiomyopathy patients was higher than that in patients with ischemic cardiomyopathy. Multivariate regression analysis showed that secondary prevention of ICD was an independent influence factor of ventricular arrhythmias after operation in patients with non-ischemic cardiomyopathy. The mortality rate of patients with CRT-D discharge was significantly higher than that of patients without CRT-D discharges (P 0.05). Device parameter adjustment, revascularization and radiofrequency ablation were performed in four steps. 80% patients with proper discharge in ischemic cardiomyopathy group were not redischarged. Three step sequential therapy was performed with drug adjustment, device parameter adjustment and radiofrequency ablation. In the non-ischemic cardiomyopathy group, 90% of the patients with proper discharge did not discharge 10% of the patients. Conclusion the secondary prevention of CRT-D is an independent factor in the occurrence of ventricular arrhythmias after operation, and in the patients implanted with CRT-D, if a discharge event occurs, Risk of death increases; drug regulation, device parameter adjustment, and revascularization, and sequential radiofrequency ablation are important to reduce the proper discharge of CRT-D.
【作者单位】：大连医科大学附属第一医院心血管病医院心力衰竭与结构性心脏病科;
【分类号】：R541.6

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