心脏再同步治疗对合并收缩功能不全的三度房室传导阻滞患者左心室重构的影响

发布时间：2018-06-28 22:20

  本文选题：心脏再同步治疗 + 三度房室传导阻滞　； 参考：《安徽医科大学》2017年硕士论文

【摘要】：本研究共分两阶段进行。第一阶段:目的多项研究证实,右室心尖部起搏可引起类似左束支传导阻滞的传导异常,激动起源于右室,经室间隔通过心肌细胞传至左室,使得左室基底部后壁或侧后壁最迟激动,可引起室间隔的矛盾运动,心室间及左室内部的运动不同步。长期、高比率的右室起搏可严重损害心功能,甚至使患者发展为心力衰竭,这一现象在基础已存在心功能不全的患者中更为明显。而目前关于右室其他起搏点,如间隔部、流出道部的研究未发现有优于右室心尖部起搏的证据,希氏束起搏因技术难度高,且不适用于希氏束以下部位阻滞的患者,尚难以在临床实践中开展。心脏再同步治疗(cardiac resynchronization threapy,CRT)可纠正右室起搏引起的不同步现象,或可避免右室起搏的不利影响。本研究通过观察合并左心室收缩功能不全的三度房室传导阻滞(atrioventricular block,AVB)患者植入CRT装置后左室射血分数(LVEF)、左室收缩末期容积(LVESV)、左室舒张末期容积(LVEDV)、左室舒张末期内径(LVEDD)、左室收缩末期内径(LVESD)、二尖瓣返流(MR)分级等心脏功能及结构超声指标的变化,探讨CRT对此类患者心功能及心脏重构的影响。方法选取2009年1月至2014年10月在安徽省立医院植入CRT的三度AVB患者,要求LVEDD≥55mm,LVEF≤50%,纽约心脏病协会(New York Heart Association,NYHA)心功能分级I-III级;并排除曾接受心脏电器械装置植入(无论后期保留或移除),不稳定性心绞痛,急性心肌梗死,入选前3月内内有冠脉搭桥或介入手术史,存在具修复指征的瓣膜病,预期寿命小于1年的患者。术前收集患者年龄、性别、基础疾病、QRS时限、形态及超声指标等基线资料。对于存在心功能不全症状体征的患者完善最佳药物治疗,使心功能稳定。植入CRT装置后分别于术前、术后6个月和12个月多次连续行超声心动图检查,以LVEF、LVESV作为主要观察指标,结合LVEDV、LVEDD、LVESD、MR等多项指标,分析CRT术后患者心功能及心室重构变化情况。结果共入选49例患者,术后LVEF逐渐上升,术后6个月LVEF与术前相比增加(4.92±5.24)%(P0.05),术后12个月LVEF进一步增加(5.02±6.52)%(P0.05);LVESV则较术前逐渐降低,术后6个月LVESV下降(25.02±17.95)ml(P0.05),12个月时LVESV进一步下降(24.79±22.49)ml(P0.05);其他指标亦有相似改善,术后6个月与术前相比,LVEDV下降(25.61±24.24)ml(P0.05),LVEDD下降(3.22±2.91)mm(P0.05),LVESD下降(4.43±2.86)mm(P0.05),MR分级下降0.49±0.76(P0.05),上述指标在术后12个月进一步降低,与术后6月对比,LVEDV下降(28.18±22.36)ml(P0.05),LVEDD下降(4.17±3.14)mm(P0.05),LVESD下降(4.92±4.40)mm(P0.01),MR分级下降0.22±0.55级(P0.05)。第二阶段:目的分析合并左心室收缩功能不全的三度房室传导阻滞(atrioventricular block,AVB)患者应用心脏再同步治疗(cardiac resynchronization threapy,CRT)后发生心室重构逆转的预测因素。方法选取2009年1月至2015年5月在安徽省立医院植入CRT的三度AVB患者,收集术前临床资料及术后随访资料,术后12个月左室收缩末期容积(left ventricular end-systolic volume,LVESV)较术前下降≥15%或左室射血分数(left ventricular ejection fraction,LVEF)增加≥5%定义为心室重构逆转,将患者分为逆转组和无逆转组,比较两组患者的临床资料,并采用二分类Logisitic回归模型分析CRT逆转左室重构的预测因素。结果共入选患者65例,平均年龄(62±14)岁,随访12个月,发生心室重构逆转的患者为36例(55.4%),逆转组女性(25/11,P=0.011)、基线QRS时限120ms(27/12,P=0.001)、心室间激动延迟(interventricular mechanical delay,IVMD)≥40ms(30/18,P=0.027)、心率校正后的心电图Q波起始点距离左室16节段最小容积点时间间隔的标准差(the standard deviation of time-to-minimum systolic volume of the 16 left ventricular segments expressed in percentage of R-R duration,Tmsv16-SD(%R-R))≥8.3%(28/10,P=0.001)的比例高于无逆转组,二元Logisitic回归分析显示,女性(OR=6.228,95%CI 1.561~24.842,P=0.01)、QRS时限120ms(OR=7.778,95%CI 1.996~30.769,P=0.003)与Tmsv16-SD(%R-R)≥8.3%(OR=8.134,95%CI 2.064~32.057,P=0.003)是心室重构发生逆转的独立预测因素。结论对于合并左室收缩功能不全的三度AVB患者,CRT是一种有益的起搏模式及治疗方法,可使患者LVEF明显增加,LVESV显著下降,并具有持续性。CRT可改善患者心功能,逆转心室重构。此外对于这类人群,女性、QRS时限120ms及Tmsv16-SD(%R-R)≥8.3%或可作为CRT逆转左室重构的预测因素。
[Abstract]:This study is divided into two stages. First stage: several studies have confirmed that the right ventricular apical pacing can cause abnormal conduction of the left bundle branch block, which originates from the right ventricle and passes through the ventricular septum through the cardiac myocytes to the left ventricle, causing the posterior or lateral wall of the left ventricle to be most excited, which can cause the contradictory movement of the ventricular septum and ventricles. In the long term, a high ratio of right ventricular pacing can seriously damage the heart function and even make the patient develop heart failure. This phenomenon is more obvious in the patients with the existence of cardiac insufficiency in the base. At present, the study on other right ventricular pacing points, such as the interval, and the outflow tract, is not better than the right ventricular heart. The evidence of apex pacing is that the patients with high technical difficulty and not applicable to the block below the hash bundle are difficult to be carried out in clinical practice. Cardiac resynchronization threapy (CRT) can correct the asynchrony caused by right ventricular pacing, or avoid the adverse effects of right ventricular pacing. Left ventricular ejection fraction (LVEF), left ventricular end systolic volume (LVESV), left ventricular end diastolic volume (LVEDV), left ventricular end diastolic diameter (LVEDD), left ventricular end diastolic diameter (LVEDD), left ventricular end systolic diameter (LVESD) and mitral regurgitation (MR) of the left ventricular end diastolic volume (LVEDV), and left ventricular end diastolic diameter (LVEDD) were observed by observing the three degree atrioventricular block (AVB) patients with left ventricular systolic dysfunction. The effects of CRT on cardiac function and cardiac remodeling in such patients were investigated. Methods three degrees AVB patients implanted with CRT in Anhui Provincial Hospital from January 2009 to October 2014 were selected, and LVEDD was more than 55mm, LVEF < 50%, and New York heart disease association (New York Heart Association, NYHA) classification I-III Level; and exclude cardiac electrical equipment implantation (regardless of later retention or removal), unstable angina, acute myocardial infarction, the history of coronary artery bypass or interventional surgery in March, the existence of prosthesis valve disease, patients with a life expectancy less than 1 years. Baseline data such as state and ultrasound index. For patients with symptoms and signs of cardiac insufficiency, the best drug treatment was perfected to make the heart function stable. The CRT device was followed up to 6 months and 12 months after the operation. LVEF, LVESV as the main observation index, combined with LVEDV, LVEDD, LVESD, MR and many other fingers. The changes of cardiac function and ventricular remodeling after CRT were analyzed. Results 49 patients were selected, and the LVEF increased gradually after operation. 6 months after operation, LVEF increased (4.92 + 5.24)% (P0.05), LVEF further increased (5.02 + 6.52)% (P0.05) 12 months after operation; LVESV decreased gradually and LVESV decreased (25.02 + 17.95) ml (P0.) 6 months after operation (P0.) ml (P0.). 05), the LVESV decreased further (24.79 + 22.49) ml (P0.05) at 12 months, and the other indexes had similar improvement. Compared with the preoperative, the LVEDV decreased (25.61 + 24.24) ml (P0.05), LVEDD decreased (3.22 + 2.91) mm (P0.05), LVESD decreased (4.43 + 2.86) mm (P0.05), and the grade dropped 0.49 + 0.76, and the above index decreased further in the postoperative month after the operation. Compared with June, LVEDV decreased (28.18 + 22.36) ml (P0.05), LVEDD decreased (4.17 + 3.14) mm (P0.05), LVESD decreased (4.92 + 4.40) mm (P0.01), MR grade decreased 0.22 + 0.55 grade (P0.05). Second stage: three degrees atrioventricular block (atrioventricular) with left ventricular systolic dysfunction was treated with cardiac resynchronization treatment Predictive factors for ventricular remodeling reversal after cardiac resynchronization threapy (CRT). Methods three degrees AVB patients implanted with CRT in Anhui Provincial Hospital from January 2009 to May 2015 were selected to collect preoperative clinical data and postoperative follow-up data. 12 months after operation, left ventricular end systolic volume (left ventricular end-systolic volume, LVESV) More than 15% or 5% of left ventricular ejection fraction (left ventricular ejection fraction, LVEF) was defined as ventricular remodeling reversal, and the patients were divided into reverse and non reversal groups. The clinical data of the two groups were compared and the predictive factors of CRT reversal of left ventricular remodeling were analyzed by the two classification Logisitic regression model. The results were selected for the patients. 65 cases, the average age (62 + 14) years, followed up for 12 months, 36 cases (55.4%), reverse group women (25/11, P=0.011), baseline QRS time 120ms (27/12, P=0.001), ventricular interventricular agitation delay (interventricular mechanical delay, IVMD) > 40ms (30/18,), heart rate corrected starting point of ECG distance from left ventricular 16 The standard deviation (the standard deviation of time-to-minimum systolic volume of the 16 of the left ventricular segments) is higher than the non inverse rotation group, and the two yuan regression analysis shows that the female CI 1.561~24.842, P=0.01), QRS time limit 120ms (OR=7.778,95%CI 1.996~30.769, P=0.003) and Tmsv16-SD (%R-R) > 8.3% (OR=8.134,95%CI 2.064~32.057) are independent predictors for reversal of ventricular remodeling. Conclusion it is a useful pacing model and treatment for patients with three degrees of left ventricular systolic dysfunction. LVEF significantly increased, LVESV decreased significantly, and persistent.CRT could improve cardiac function and reverse ventricular remodeling. In addition, for these people, women, QRS time limit 120ms and Tmsv16-SD (%R-R) more than 8.3% or as a predictor of CRT reversal of left 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】：2017
【分类号】：R541.7
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本文编号：2079581