心脏再同步化治疗单中心病历分析及再同步化治疗应答预测因子研究

发布时间：2018-06-19 10:15

本文选题：心力衰竭 + 心脏再同步化治疗　；参考：《中国人民解放军医学院》2015年博士论文

【摘要】：背景与目的充血性心力衰竭(心衰)是影响我国国民健康、增加卫生支出的重大公共卫生问题。心脏再同步化治疗(Cardiac Resynchronization Therapy, CRT)可改心衰患者的临床症状及预后,是伴有收缩不同步心衰患者的一线治疗措施。然而,CRT术后无反应者高达30%左右。减少CRT术后无反应,预测CRT疗效一直是CRT治疗的重点。本课题拟回顾性分析我院接受CRT治疗患者的临床资料及随访情况,揭示CRT治疗的现状：采用速度向量成像(Velocity Vector Imaging,VVI)技术对心衰患者心脏的同步性进行评估,并进一步随访观察CRT术后患者的疗效,探讨VVI技术在预测CRT效果中的作用：回顾性分析我院长期随访的92例CRT患者,观察CRT患者心电图的变化与CRT术后应答之间的关系。通过以上研究,希望对我们的临床工作带来一定的借鉴。方法第一部分回顾性分析2001年6月至2014年6月在我院住院,药物治疗不理想,并成功接受CRT-P/D植入或升级为CRT-P/D治疗的心衰患者基线资料及长期随访资料。根据左室功能和逆重构指标,将CRT应答分为无反应、有反应和超反应组。分析CRT不同反应组患者临床指标及器械治疗参数的差异,接受CRT治疗后心衰症状及预后改善情况。第二部分选择接受CRT治疗的心衰患者48例,采用WI技术评价患者CRT术前心脏收缩同步性,分析左室长轴十二节段收缩速度达峰时间(Time topeak of systolic velocity, Ts)的最大-最小差值(Ts max-min)、十二节段速度达峰时间的标准差(Standard deviation of the time to peak of systolic velocity, Ts-SD)。CRT术后6个月左室收缩末容积(Left Ventricular End-Systolic Volume, LVESV)较术前减少≥15%定义为有反应。探讨VVI技术在预测CRT应答中的作用。第三部分回顾性分析我院长期随访的92例CRT患者的心电图,及其长期随访资料。分析CRT术后不同反应组QRS时限及电轴的变化。CRT术后,患者心电图电轴变化主要为三个方向：→前,→右,以及冠状面顺钟向旋转。以每个方向的电轴变化积1分,CRT术后,电轴变化≥2分定义为电轴明显变化。CRT术后6个月LVESV较术前减少≥15%定义为有反应。分析CRT患者心电图在预测CRT应答中的作用。结果第一部分CRT术后患者长期随访92例(82%),CRT无反应、有反应及超反应的患者例数分别为28例(30.9%),64例(69.1%),27例(29.4%)。三组患者在年龄、性别、抗心衰及抗心律失常药物治疗上,均无明显差异。无反应组的房颤患者比例为57.1%,明显高于有反应组及超反应组(24.3%和18.5%,P=0.004)。有反应组及超反应组,CRT术后的客观指标左室射血分数(Left Ventricular Ejection Fraction, LVEF),左室舒张末内径(Left Ventricular End Diastolic Diameter, LVEDD),6分钟步行距离(6-Minute Walking Distance, 6MWD), LVESV及主观指标(NYHA分级)均较术前改善(P0.01),术后QRS时限明显缩短(158.0±33.2 ms比146.8 ± 28.7 ms,161.9 ± 33.3 ms匕142.9± 28.9 ms, P0.01);而无反应组患者,CRT术后客观指标(LVEF, LVEDD, 6MWD)无改善(P0.05),术后QRS时限较术前增宽(138.9±26.2 ms比157.2± 33.3ms, P0.01), LVESV增大(153.1 ±43.9 ml 比 165.1 ±49.6 ml, P0.01),而NYHA分级有一定程度的提高(P0.01)。在改善心衰预后上,CRT-D优于CRT-P。第二部分CRT术后有反应患者为30例(62.5%)。将患者CRT术前心肌长轴方向的Ts max-min、Ts-SD绘制ROC曲线,长轴的Ts-SD的ROC曲线面积为0.82 ± 0.07, Ts-SD≥40.5时,其灵敏度为79.2%,特异度为71.2%。Ts max-min的ROC曲线面积为0.76±0.07,Ts max-min≥124.O日寸,其灵敏度为70.8%,特异度为77.8%。第三部分CRT术后有反应患者为64例(69.6%)。CRT术后有反应组的女性18例(28.1%),左束支阻滞比例显著高于无反应组(89.1%比71.4%,P0.05),QRS波时限较无反应组宽(158.1±31.2 ms比138.9±26.2 ms,P0.05)；无反应组的房颤患者比例明显高于有反应组(57.1%比21.9%,P0.01)。多元回归分析显示,QRS时限≥140ms、房颤及CRT术后电轴明显变化[OR,5.12,(1.67,15.51)]是CRT有反应的预测因素。QRS时限≥140ms患者CRT术后有反应的机率是QRS时限140ms的4.97倍。电轴变化积分增加1分,CRT术后有反应的可能性增加5.1倍。结论第一部分(1)CRT-P/D可改善心衰患者的症状及预后；在改善预后上,CRT-D优于CRT-P:(2)接受CRT治疗的患者,抗心衰药物治疗的依从性较好：(3)房颤是导致误放电、起搏比例偏低的重要因素,可能是降低术后应答的重要原因。第二部分 (1)CRT可改善患者的心功能,改善患者的预后：(2)采用VVI技术对心衰患者CRT治疗前心脏长轴的同步性进行评估,长期随访结果显示,Ts-SD对预测CRT应答有一定的辅助作用。第三部分 (1)患者CRT术前QRS时限≥140ms,术后电轴明显变化,均为CRT有反应的预测因子：(2)房颤是CRT无反应的预测因子：作为可调整的因素,房颤应当受到高度重视。
[Abstract]:Background and objective congestive heart failure (heart failure) is a major public health problem affecting national health and increasing health expenditure. The clinical symptoms and prognosis of heart failure patients with cardiac resynchronization therapy (Cardiac Resynchronization Therapy, CRT) are the first-line treatment for patients with systolic dyssynchrony of heart failure. However, after CRT The non responders were as high as 30%. Reducing the no response after CRT and predicting the effect of CRT were always the focus of CRT treatment. This subject is to review the clinical data and follow-up of patients receiving CRT treatment in our hospital, and to reveal the status of CRT therapy: the synchronization of the heart failure of heart failure by the speed vector imaging (Velocity Vector Imaging, VVI). The effect of CRT after CRT was followed up, and the effect of VVI technique in predicting the effect of CRT was discussed. A retrospective analysis of the long-term follow-up of CRT patients in our hospital and the relationship between the changes of electrocardiogram and the response after CRT were observed. Through the above study, we hope to bring a certain loan to our clinical work. Method 1. Part one retrospective analysis of the baseline data and long-term follow-up data of heart failure patients who were hospitalized in our hospital from June 2001 to June 2014 and were successfully treated with CRT-P/D implantation or upgraded to CRT-P/D for heart failure. According to the left ventricular function and inverse remodeling index, the CRT should be divided into non reactive, reactive and superreactive groups. C RT in different reaction groups, the difference in clinical parameters and equipment treatment parameters, the symptoms of heart failure after CRT treatment and the improvement of prognosis. The second part selected 48 cases of heart failure patients receiving CRT treatment, and WI technique was used to evaluate the systolic synchronism of the heart before CRT, and the peak time of the systolic velocity of the twelve segment of the left ventricular long axis (Time Topeak of) was analyzed. The maximum minimum difference (Ts max-min) of systolic velocity, Ts, and the standard deviation of the twelve segment velocity to peak time (Standard deviation of the time to peak), 6 months after the operation, the volume of the left ventricular end contraction is defined as a reaction. The role of technology in predicting CRT response. The third part reviewed the electrocardiogram of 92 patients with CRT in our long-term follow-up and the long-term follow-up data. After the analysis of the QRS time limit and the change of the electrical axis of the different reaction groups after CRT, the electrocardiogram axis changes were mainly three directions: before, to the right, and the clockwise rotation of the coronal plane. Change. The change of the electric axis in each direction was 1 points, after CRT, the change of the electric axis was more than 2 points, which was defined as the obvious change of the axis of the electric axis. The effect of the electrocardiogram in the first part of the first part CRT was 92 cases (82%), and the results of the first part of the CRT patient were followed up in the prediction of the CRT response. The results of the first part of the first part CRT were 92 cases (82%), no reaction, reaction and excess of CRT. The number of patients with reaction was 28 (30.9%), 64 (69.1%) and 27 (29.4%). The three group had no significant difference in age, sex, anti heart failure and antiarrhythmic treatment. The proportion of patients with atrial fibrillation in the non reaction group was 57.1%, obviously higher than that in the reaction group and the superreaction group (24.3% and 18.5%, P=0.004). The reaction group and the superreaction group, the CRT operation, were significantly higher than those in the reaction group and the superreaction group. The left ventricular ejection fraction (Left Ventricular Ejection Fraction, LVEF), the left ventricular end diastolic diameter (Left Ventricular End Diastolic Diameter, LVEDD), the 6 minute walking distance (6-Minute), and the subjective index were significantly shorter than those before the operation (158 + 33.). The 2 ms ratio was 146.8 + 28.7 MS, 161.9 + 33.3 MS dagger 142.9 + 28.9 MS, P0.01), and the objective index (LVEF, LVEDD, 6MWD) after CRT was not improved (P0.05), and the QRS time after operation was wider than before operation (138.9 + 26.2 MS ratio 157.2). The improvement of degree (P0.01). In improving the prognosis of heart failure, CRT-D was superior to CRT-P. second part CRT after CRT operation, and the patients with reaction were 30 (62.5%). The ROC curve was plotted by Ts-SD in the long axis of myocardium before CRT, the ROC curve area of the long axis Ts-SD was 0.82 + 0.07, and the sensitivity was 79.2% when Ts-SD was more than 40.5. The area of ROC curve was 0.76 + 0.07, Ts max-min > 124.O day inch, the sensitivity was 70.8%, the specificity was 77.8%. third part CRT, 64 cases (69.6%) after.CRT operation, 18 cases (28.1%), the left bundle branch block was significantly higher than that in the non reaction group (89.1% than 71.4%, P0.05), and the QRS wave time was wider than that in the non reactive group (158.1 + 31.). The ratio of 2 ms to 138.9 + 26.2 MS, P0.05), the proportion of patients with atrial fibrillation in the non reaction group was significantly higher than that in the reaction group (57.1% ratio 21.9%, P0.01). The multivariate regression analysis showed that the QRS time limit was more than 140ms, the atrial fibrillation and the electrical axis of the CRT after CRT were obviously changed [OR, 5.12, (1.67,15.51). The time limit of 140ms was 4.97 times. The integral of the electric axis was increased by 1 points and the possibility of reacting after CRT increased by 5.1 times. Conclusion the first part (1) CRT-P/D can improve the symptoms and prognosis of the patients with heart failure; in the improvement of prognosis, CRT-D is superior to CRT-P: (2) of the patients receiving CRT treatment, and the compliance of anti heart failure drugs is better: (3) atrial fibrillation leads to mistaken discharge, The important factor of low pacing ratio may be an important reason for reducing the postoperative response. The second part (1) CRT can improve the patient's cardiac function and improve the patient's prognosis: (2) the VVI technique is used to evaluate the synchronism of the long axis of the heart before CRT treatment in heart failure patients. The long-term follow-up results show that Ts-SD has a certain auxiliary role in predicting the CRT response. The third part (1) of the third (1) patients prior to CRT had a QRS time limit of more than 140ms, and the postoperative electrical axis was obviously changed. (2) atrial fibrillation was a predictor of CRT no response: as an adjustable factor, atrial fibrillation should be highly valued.
【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R541.6

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