本文選題：心臟再同步治療 + 三維電激動標測��； 參考：《安徽醫(yī)科大學》2017年碩士論文

【摘要】：目的:針對慢性心力衰竭患者心臟再同步治療(cardiac resynchronize therapy,CRT)無反應這一臨床難題,應用三維電激動標測先進的技術(shù)手段評價心臟電不同步性,根據(jù)患者的個體差異及實際情況選擇經(jīng)不同途徑植入左室導線,經(jīng)前后自身對照,明確其對CRT療效的影響和機制,為進一步提高CRT療效提供新的思路。方法:選擇22例符合入選標準的CRT無反應患者:(1)CRT植入后6個月仍有心力衰竭發(fā)作,左心室收縮末期容積(LVESV)縮小15%且左心室射血分數(shù)(LVEF)提高5%;(2)仍存在心臟電不同步;(3)原起搏器導線距電激動最延遲部位的距離"g5cm;(4)患者至少進行6個月的臨床和超聲心動圖隨訪。排除標準:A.因心房顫動、頻發(fā)早搏等造成雙室起搏比例顯著下降的CRT患者;B.不穩(wěn)定性心絞痛或急性心肌梗死3個月內(nèi);C.冠脈旁路移植術(shù)3個月內(nèi);D.腦卒中3月內(nèi);E.腎功能不正�；颊�;F.惡性腫瘤晚期;G.不愿參加本研究或已參加其他研究;H.無法進行有效交流或溝通的患者[1、2]。均行三維電激動標測檢查,判斷左室電激動最延遲部位,術(shù)中行冠狀靜脈竇逆行造影,以了解冠狀靜脈竇分支血管情況,觀察激動最延遲部位附近有無合適血管,如有合適血管,選擇左心室電極放置位置與電激動最延遲最靠近部位,經(jīng)冠狀靜脈竇途徑植入左室導線;如附近無合適血管或血管畸形,則選擇經(jīng)房間隔穿刺途徑或室間隔穿刺途徑于激動最延遲部位植入左室心內(nèi)膜導線。結(jié)果:22例患者CRT左室導線植入后分別于1,3,6個月進行隨訪,術(shù)后1個月、3個月和6個月患者的左室收縮末期容積(LVESV)均較術(shù)前縮小(P0.05)、左室射血分數(shù)(LVEF)均較術(shù)前得到提高(P0.05)、二尖瓣返流程度(MR程度)均較術(shù)前減少(P0.05)和6分鐘步行距離(6min)均較術(shù)前增加(P0.05)。(1)LVESV術(shù)后1,3個月改善不如術(shù)后6個月明顯;(2)LVEF術(shù)后1個月的改善情況最明顯,3,6個月改善幅度趨于平穩(wěn);(3)QRS時限術(shù)后與術(shù)前比較明顯縮小,且具有統(tǒng)計學意義(P0.05);(4)MR程度術(shù)后6個月改善顯著;(5)6分鐘步行距離術(shù)后1,3,6個月改善幅度趨于平穩(wěn)。結(jié)論:在慢性心力衰竭CRT無反應的患者中,應用三維電激動標測技術(shù),評價左室電學失同步性,進而準確合理的選擇最佳途徑植入左室導線使其與電激動最延遲部位最靠近,能明顯提高患者的反應性。
[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.
【學位授予單位】：安徽醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R541.6

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