三维电激动标测技术指导治疗CRT无反应的临床研究

发布时间：2018-06-06 23:00

本文选题：心脏再同步治疗 + 三维电激动标测　；参考：《安徽医科大学》2017年硕士论文

【摘要】：目的:针对慢性心力衰竭患者心脏再同步治疗(cardiac resynchronize therapy,CRT)无反应这一临床难题,应用三维电激动标测先进的技术手段评价心脏电不同步性,根据患者的个体差异及实际情况选择经不同途径植入左室导线,经前后自身对照,明确其对CRT疗效的影响和机制,为进一步提高CRT疗效提供新的思路。方法:选择22例符合入选标准的CRT无反应患者:(1)CRT植入后6个月仍有心力衰竭发作,左心室收缩末期容积(LVESV)缩小15%且左心室射血分数(LVEF)提高5%;(2)仍存在心脏电不同步;(3)原起搏器导线距电激动最延迟部位的距离"g5cm;(4)患者至少进行6个月的临床和超声心动图随访。排除标准:A.因心房颤动、频发早搏等造成双室起搏比例显著下降的CRT患者;B.不稳定性心绞痛或急性心肌梗死3个月内;C.冠脉旁路移植术3个月内;D.脑卒中3月内;E.肾功能不正常患者;F.恶性肿瘤晚期;G.不愿参加本研究或已参加其他研究;H.无法进行有效交流或沟通的患者[1、2]。均行三维电激动标测检查,判断左室电激动最延迟部位,术中行冠状静脉窦逆行造影,以了解冠状静脉窦分支血管情况,观察激动最延迟部位附近有无合适血管,如有合适血管,选择左心室电极放置位置与电激动最延迟最靠近部位,经冠状静脉窦途径植入左室导线;如附近无合适血管或血管畸形,则选择经房间隔穿刺途径或室间隔穿刺途径于激动最延迟部位植入左室心内膜导线。结果:22例患者CRT左室导线植入后分别于1,3,6个月进行随访,术后1个月、3个月和6个月患者的左室收缩末期容积(LVESV)均较术前缩小(P0.05)、左室射血分数(LVEF)均较术前得到提高(P0.05)、二尖瓣返流程度(MR程度)均较术前减少(P0.05)和6分钟步行距离(6min)均较术前增加(P0.05)。(1)LVESV术后1,3个月改善不如术后6个月明显;(2)LVEF术后1个月的改善情况最明显,3,6个月改善幅度趋于平稳;(3)QRS时限术后与术前比较明显缩小,且具有统计学意义(P0.05);(4)MR程度术后6个月改善显著;(5)6分钟步行距离术后1,3,6个月改善幅度趋于平稳。结论:在慢性心力衰竭CRT无反应的患者中,应用三维电激动标测技术,评价左室电学失同步性,进而准确合理的选择最佳途径植入左室导线使其与电激动最延迟部位最靠近,能明显提高患者的反应性。
[Abstract]:Objective: to study the nonresponse of cardiac resynchronization therapy in patients with chronic heart failure (CHF). According to the individual difference and actual situation of the patients, the left ventricular conductors were implanted in different ways, and the effect and mechanism on the efficacy of CRT were determined by self-control before and after, which provided a new way of thinking for further improving the curative effect of CRT. Methods: a total of 22 nonreactive CRT patients who met the inclusion criteria were selected. The patients still had heart failure 6 months after implantation. Left ventricular end-systolic volume (LVESVV) shrank by 15% and left ventricular ejection fraction (LVEF) increased by 5%. (3) the distance from the original pacemaker lead to the most delayed site of electrical stimulation (g5cm-1) was followed up for at least 6 months by clinical and echocardiography in patients with left ventricular ejection fraction (LVEF) and left ventricular ejection fraction (LVEF). Rule out: A. Patients with CRT who had decreased biventricular pacing due to atrial fibrillation and frequent premature beats. Unstable angina pectoris or acute myocardial infarction within 3 months. Coronary artery bypass grafting was performed within 3 months. E. Patients with abnormal renal function were treated with FG. Advanced malignant tumor G. Not willing to participate in this study or have participated in other studies. Patients who cannot communicate or communicate effectively [1 / 2]. Three-dimensional electrostimulation mapping was performed to determine the most delayed part of left ventricular electrical stimulation. Retrograde angiography of coronary sinus was performed during the operation to understand the branch of coronary sinus and to observe whether there were suitable vessels near the most delayed part. If there are suitable blood vessels, select the position of left ventricular electrode and the closest to the most delayed electrostimulation, and implant the left ventricular lead through the coronary sinus approach; if there is no suitable blood vessel or vascular malformation nearby, The transatrial septal approach or ventricular septal approach was selected to implant left ventricular endocardial conductors at the most delayed site. Results Twenty two patients with CRT were followed up for 3 months and 6 months after implantation of CRT. Left ventricular end-systolic volume (LVESVV), left ventricular ejection fraction (LVEF) and mitral regurgitation degree (Mr) were significantly decreased in 1 month, 3 months and 6 months after operation than those before operation (P 0.05) and 6 minutes. The improvement of LVESV in 3 months was less than that in 6 months after operation. The improvement was more obvious in 1 month than that in 6 months after LVEF. The improvement range of QRS at 6 months tended to be more stable than that before operation, and the time limit of QRS was significantly reduced after 6 months of operation. In addition, there was significant improvement in Mr degree of P0.05 and P0.05 at 6 months after operation. The distance from 6 minutes to 6 minutes after operation was 1: 3, and the range of improvement at 6 months tended to be stable. Conclusion: in patients with chronic heart failure (CHF), three-dimensional electrokinetic mapping was used to evaluate the electrosynchrony of left ventricle, and to select the best way to implant left ventricular conductors so as to be closest to the most delayed sites. It can obviously improve the patient's reactivity.
【学位授予单位】：安徽医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R541.6

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