右室间隔部不同部位起搏时心电图形态特点及心室收缩同步性临床研究

发布时间：2018-04-10 05:14

本文选题：右心室间隔部起搏　切入点：起搏　出处：《南京大学》2015年硕士论文

【摘要】：目的：通过对比分析右室间隔不同部位起搏时的QRS波形态、QRS波间期及心室收缩同步性等指标的差异,总结具体间隔部何处起搏时效果更优,进而指导右室导线植入部位的选择。方法：入选2014年6月至2015年3月期间在鼓楼医院心内科因房室传导阻滞需植入永久起搏器的患者。术前收集其临床基本情况及心电图资料,术中记录起搏参数,术后所有患者在心室完全起搏的情况下行标准12导联心电图及心脏彩超检查,测量记录起搏心电图QRS间期(PQRSd),Ⅰ、Ⅲ导联QRS波主波方向,胸导联发生移行的导联,以及心室间(IVMD)和心室内收缩同步性指标(SPWMD、 Tmsv16-SD、SDI,其中Tmsv16-SD和SDI由三维心脏彩超获得)。并使用心脏彩超对右室间隔部起搏导线精确定位,依据定位结果,分组分析各组间起搏参数、起搏心电图形态特点、QRS间期、心室收缩同步性等指标的差异。结果：共入选患者30例,其中25例患者完成资料收集,依据心脏彩超定位结果,将25例患者分为流入道间隔组与流出道间隔组,并依据定位结果将流入道间隔组进一步分为间隔近心尖部组与间隔中下部组。研究发现：1、流入道间隔起搏与流出道间隔起搏时均可获得稳定的起搏参数,且起搏阈值、感知、阻抗等参数间并无明显差异；2、流入道间隔部起搏组与流出道间隔起搏组相比,前者PQRSd稍宽,差异无统计学意义(150.3±14.Oms VS 147.8±8.7ms;P=0.614);PQRSd于流入道间隔中下部起搏时最窄,且相比间隔近心尖部起搏时差异具有统计学意义(141.67±9.5ms VS 156.75±13.7ms;P=0.040);3、流入道间隔部起搏组与流出道间隔起搏组相比,心电图Ⅲ导联主波方向及移行导联存在差异(P值分别为0.037及0.012),且Ⅲ导联主波正向对流出道间隔部起搏有预测价值(AUC=0.776,P=0.02)；而间隔近心尖部起搏时,Ⅲ导联QRS波主波多为负向或等电位线,胸导联多在V6或之后出现移行,Ⅲ导联主波方向及移行导联对右室导线位于间隔近心尖部有预测价值(AUC分别为0.849及0.908,P值均小于0.05)。4、心室机械收缩同步性方面,IVMD、SPWMD、Tmsv16-SD、SDI等指标相比,流入道间隔部起搏组优于流出道间隔部起搏组,且SPWMD、Tmsv16-SD、SDI等指标差异存在显著性,尤以SPWMD差异最明显(P=0.007),且上述指标在流入道间隔中下部起搏时最小。5、PQRSd与左右心室间的同步性存在相关性,而与心室内收缩同步性无明显相关。结论：1、在植入右室间隔部导线时,Ⅲ导联主波方向及移行导联对右室导线位于间隔近心尖部有预测价值,而由于间隔近心尖部起搏时,PQRd较宽,长期该部位起搏可能对心功能造成有害影响,故在行右室间隔部起搏时,除应满足W线影像标准外,Ⅲ导联主波方向及胸导联移行部位也是重要的参考标准。2、在急性期内,相比流出道间隔部起搏,流入道间隔部起搏时室间及室内均可获得较好的同步性,且以左室内机械收缩同步性优越性最明显,故流入道间隔部是更优的起搏位置选择。3、流入道间隔中下部起搏时,PQRSd最窄,并且该部位起搏时心室收缩同步性亦优于流入道间隔近心尖部起搏及流出道起搏时,故流入道间隔中下部是理想的心室间隔起搏位点。
[Abstract]:Objective: QRS wave morphology through the comparative analysis of different right ventricular pacing sites interval, and other indicators of the shrinkage difference synchronization of the QRS wave interval and ventricular septum, summarize the specific where pacing is better, and to guide the selection of the location of the right ventricular lead implantation. Methods: selected from June 2014 to March 2015 during the Gulou Hospital Department of Cardiology for atrioventricular block need permanent pacemaker implantation in patients before the surgery. The clinical situation and ECG data, pacing parameters were recorded after operation, all patients performed a standardized complete ventricular pacing in 12 lead ECG and echocardiography examination, measuring and recording the pacing ECG QRS interval (PQRSd), 1, QRS wave in lead III the main wave direction, leads the transitional lead, and inter ventricular systolic synchrony (IVMD) and ventricular index (SPWMD, Tmsv16-SD, SDI, Tmsv16-SD and SDI by 3D heart color Super). And the use of echocardiography for precise positioning of the right ventricular septal pacing leads, based on the positioning results, grouping analysis of pacing parameters between groups, pacing ECG morphological characteristics, QRS interval, ventricular systolic synchrony index difference. Results: there were 30 patients, 25 patients completed the data collection, according to cardiac ultrasound localization results, 25 patients were divided into inlet septal group and septum group, and based on the positioning results will flow into the septum were further divided into the lower interval near the apex group and the interval. The study found: 1, inlet septal pacing and outflow tract septal pacing can obtain stable pacing parameters the pacing threshold and impedance parameters, perception, there were no significant differences between the 2 groups; septum pacing, inflow and outflow tract septal pacing group compared to the former PQRSd slightly wider, the difference was not statistically significant (150.3 + 14.Oms VS 14 7.8 + 8.7ms; P=0.614; PQRSd) in the lower inlet septal pacing in the narrow, and compared with statistical significance between near apex pacing difference (141.67 + 9.5ms VS 156.75 + 13.7ms; P=0.040; 3), inflow tract septal pacing group and septum pacing group compared to the ECG wave in lead III the direction and the transitional lead difference (P = 0.037 and 0.012), and the main wave in lead III positive outflow septal pacing has predictive value (AUC=0.776, P=0.02); and the interval near apex pacing, QRS wave in lead III main wave is negative to the line or, more chest lead in V6 or after the migration of lead III main wave direction and migration leads to right ventricular lead in interval near the apex has predictive value (AUC = 0.849 and 0.908, P values were less than 0.05.4), ventricular systolic synchrony, IVMD, SPWMD, Tmsv16-SD, SDI compared with other indicators, inflow tract Septal pacing group is better than the outflow tract septal pacing group, and SPWMD, Tmsv16-SD, SDI and other indicators have significant differences, especially in SPWMD, the most obvious difference (P=0.007), and the index in the lower inlet septal pacing in the minimum.5, the synchronization of the PQRSd and between the left and right ventricular in correlation with ventricular in synchrony was found. Conclusion: 1, implanted in the right ventricular septum lead, lead III main wave direction and migration leads to right ventricular lead in interval near the apex have predictive value, but because of the distance between apex pacing, PQRd wide, the long-term pacing may cause harmful effects it is good to cardiac function, right ventricular septal pacing, should satisfy the W line image standard,.2 standard reference lead III main wave direction and the precordial transitional zone is also important, in the acute period, compared with RVOT pacing, inflow tract septum up Pre room and indoor can achieve good synchronization, and the mechanical advantage of left ventricular systolic synchronization is the most obvious, so the inflow tract septum pacing is better choice of the location of.3, into the lower tract pacing interval, PQRSd the most narrow, and the ventricular pacing when the systolic synchrony is also superior to the distance between apical pacing and outflow from stroke, so the inflow of lower tract interval ventricular septal pacing site is ideal.

【学位授予单位】：南京大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R541.7

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