J波、JTc、Tp-ec间期对心脏再同步化治疗除颤器患者术后触发治疗的预测价值

发布时间：2018-06-10 20:35

本文选题：慢性心力衰竭 + 心脏再同步化治疗　；参考：《安徽医科大学》2015年硕士论文

【摘要】：目的业已证实,心室复极异常在恶性室性心律失常发生发展的过程中发挥重要作用。J波、校正JT间期(JTc)、校正Tp-e间期(Tp-ec)分别代表心室复极早期状态、复极时限及跨壁离散的大小。本课题通过分析置入心脏再同步化治疗除颤器(Cardiac resynchronization therapy defibrillator, CRT-D)患者术前标准12导联心电图(electrocardiography, ECG)中J波、JTc、Tp-ec,初步探讨J波、JTcr和Tp-ec对术后触发治疗的预测价值及其相关性。同时,根据监测研究指标动态变化,初步评估C RT-D对心脏电机械活动的影响和对恶性心律失常的预测作用。方法连续选取收集CRT-D置入患者206例,入选病例需排除肝肾功能异常、电解质紊乱、急性脑血管意外、预激综合征、离子通道疾病、心律失常性右室心肌病及肥厚型心肌病。留取术前标准12导联ECG,读取最长校正JT间期导联中JTc、Tp-ec,记录J波阳性病例数。所有患者在安徽省立医院心内科电生理实验室完成术后定期随访,为期1年,完成1、3、6、9、12月心电图和心脏超声检查。根据收集随访资料的完整性及腔内电图证实抗心动过速起搏治疗(anti-tachycardia pacing therapy, ATP)、高能量除颤或低能量同步转律是由心室颤动或室性心动过速所致(即触发治疗),最终纳入本次研究患者总数192例,分为触发治疗组和非触发治疗组,比较两组一般基线情况,分析术前J波、JTc、Tp-ec与触发治疗事件的相关性,评估预测效果,并确定研究指标最佳界值。监测1年内JTc、Tp-ec的动态变化。所有纳入本研究的患者术前、术后均予以规范化药物治疗和术后常规随访。结果相关基线资料分析提示,年龄、心功能分级(NYHA分级)、高血压、糖尿病、房颤、基础心率、QRS波宽度等指标在触发治疗组和未触发治疗组间无统计学差异。触发治疗组J波阳性率大于未触发治疗组(P0.05)。JTc、Tp-ec在触发治疗组均有显著升高,与非触发治疗组相比有统计学差异(P0.05)。此外,两组在性别、左室舒张末期内径(Left ventricular end-diastolic dimension, LVEDD)、口服胺碘酮率指标上存在差异(P0.05)；左室射血分数(left ventricular ejection fraction, LVEF)、恶性心律失常病史两组基线亦有差异(P0.001)。根据触发治疗情况对JTc、Tp-ec绘制受试者工作曲线(receiver operating characteristic curve, ROC curve),结果显示当JTc≥358.50 ms, Tp-ec≥116.47 ms时,患者发生恶性心律失常的风险较大。同时,将上述可能的影响因素纳入多因素Logistic回归模型,分析后结果提示当JTC≥358.50 ms、Tp-ec≥116.47 ms时,患者术后接受CRT-D触发治疗的风险显著增加,与术后恶性心律失常的发生显著相关(()R=3.233,95%CI 1.411-7.406,P0. 05;OR=4.868,95%CI 2.174-11.042,P0.001),影响患者预后。CRT-D患者术后即刻的JTc、Tp-ec较术前显著增大(P0.05),但1年内随访结果提示,随时间的延长两者均有明显减小,其变化呈高峰后逐渐下降趋势。LVEF呈逐渐上升趋势,并从第3个月开始较术前有明显增大(P0.05)；同时,LVEDD呈逐渐下降趋势,并从第6个月开始较术前有明显缩小(P0.05)。可能提示CRT-D在改善心室重构的同时存在一定抗心律失常作用。而J波对术后触发治疗的预测价值不确定(P=0.065)。结论慢性心力衰竭患者术前JTc、Tp-ec的增大增加了CRT-D术后恶性心律失常发生风险,当JTc≥358.50ms、Tp-ec≥116.47 ms时,患者发生恶性心律失常的风险显著增大,并可能作为是否接受触发治疗的预测指标。CRT-D在改善心室重构的同时存在一定抗心律失常作用。
[Abstract]:Objective it has been proved that abnormal ventricular repolarization plays an important role in the development of malignant ventricular arrhythmia, the correction of the JT interval (JTc) and the correction of the Tp-e interval (Tp-ec) represent the early state of the ventricular repolarization, the repolarization time limit and the size of the transmural dispersion. This subject has been analyzed for the treatment of defibrillator (Cardiac) by cardiac resynchronization therapy (Cardiac). Resynchronization therapy defibrillator, CRT-D) J wave, JTc, Tp-ec in the standard 12 lead electrocardiogram (electrocardiography, ECG) before operation, and preliminarily discuss the predictive value and correlation of J wave, JTcr and Tp-ec for postoperative trigger therapy. Methods 206 cases of CRT-D were selected continuously. The patients were selected to exclude abnormal liver and kidney function, electrolyte disorder, acute cerebrovascular accident, preexcitation syndrome, ion channel disease, arrhythmogenic right ventricular cardiomyopathy and hypertrophic cardiomyopathy. The standard 12 lead joint before operation was taken to read the longest ECG. JTc, Tp-ec, and J wave positive cases were recorded in the JT interval lead. All patients were followed up for 1 years in the electrophysiological Laboratory of Department of Cardiology, Anhui Provincial Hospital for 1 years, complete 1,3,6,9,12 month electrocardiogram and echocardiography. The integrity of follow-up data and intracavity electrocardiogram (anti-tach) treatment (anti-tach) Ycardia pacing therapy, ATP), high energy defibrillation or low energy synchronous rotation was caused by ventricular fibrillation or ventricular tachycardia (trigger therapy). Finally, 192 patients were included in this study, divided into the trigger group and the non trigger treatment group, compared the general basis of the two groups, and analyzed the J wave, JTc, Tp-ec and the trigger treatment events before the operation. Correlation, evaluation of predictive effectiveness, and determination of the best boundary value of the study index. Monitoring the dynamic changes of JTc, Tp-ec within 1 years. All patients enrolled in this study were treated with standardized medication and postoperative routine follow-up. Results related baseline data analysis suggested age, cardiac function classification (NYHA classification), hypertension, diabetes, atrial fibrillation, and base. The basis heart rate, QRS wave width and other indexes were not statistically different between the trigger group and the untriggered treatment group. The positive rate of J wave in the trigger group was greater than that of the untriggered treatment group (P0.05).JTc, Tp-ec was significantly higher in the trigger treatment group, compared with the non trigger group (P0.05). In addition, the two groups were in the sex, left ventricular end diastolic diameter (the end diastolic diameter). Left ventricular end-diastolic dimension, LVEDD), there were differences in the oral amiodarone rate (P0.05), left ventricular ejection fraction (left ventricular ejection fraction, LVEF), and two groups of baseline differences in the history of malignant arrhythmia. Characteristic curve, ROC curve), the results show that when JTc is more than 358.50 MS, Tp-ec is more than 116.47 MS, the risk of malignant arrhythmia in patients is greater. At the same time, the possible factors are included in the multiple factor Logistic regression model. The results suggest that when JTC > 358.50 MS, Tp-ec > 116.47, the patients receive the trigger treatment after operation. The risk of treatment increased significantly and was significantly related to the occurrence of postoperative malignant arrhythmia (() R=3.233,95%CI 1.411-7.406, P0. 05, OR=4.868,95%CI 2.174-11.042, P0.001), which affected the immediate JTc in patients with.CRT-D after operation, and Tp-ec was significantly increased (P0.05) before operation (P0.05), but the follow-up results within 1 years showed a significant decrease with time. The trend of.LVEF was gradually rising after the peak of the peak, and increased obviously from third months (P0.05). At the same time, LVEDD decreased gradually and decreased significantly from sixth months before operation (P0.05). It may suggest that CRT-D has a certain antiarrhythmic effect while improving ventricular remodeling. And J wave. The predictive value of postoperative trigger therapy is uncertain (P=0.065). Conclusion the increase of JTc, Tp-ec increases the risk of malignant arrhythmia after CRT-D, and when JTc is more than 358.50ms, Tp-ec is more than 116.47 MS, the risk of malignant arrhythmia increases significantly, and may be used as a prediction for whether or not to accept trigger therapy. Target.CRT-D has some anti arrhythmic effects while improving ventricular remodeling.
【学位授予单位】：安徽医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R541.7

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