發(fā)布時間：2018-06-19 10:15

  本文選題：心力衰竭 + 心臟再同步化治療��； 參考：《中國人民解放軍醫(yī)學(xué)院》2015年博士論文

【摘要】：背景與目的充血性心力衰竭(心衰)是影響我國國民健康、增加衛(wèi)生支出的重大公共衛(wèi)生問題。心臟再同步化治療(Cardiac Resynchronization Therapy, CRT)可改心衰患者的臨床癥狀及預(yù)后,是伴有收縮不同步心衰患者的一線治療措施。然而,CRT術(shù)后無反應(yīng)者高達30%左右。減少CRT術(shù)后無反應(yīng),預(yù)測CRT療效一直是CRT治療的重點。本課題擬回顧性分析我院接受CRT治療患者的臨床資料及隨訪情況,揭示CRT治療的現(xiàn)狀：采用速度向量成像(Velocity Vector Imaging,VVI)技術(shù)對心衰患者心臟的同步性進行評估,并進一步隨訪觀察CRT術(shù)后患者的療效,探討VVI技術(shù)在預(yù)測CRT效果中的作用：回顧性分析我院長期隨訪的92例CRT患者,觀察CRT患者心電圖的變化與CRT術(shù)后應(yīng)答之間的關(guān)系。通過以上研究,希望對我們的臨床工作帶來一定的借鑒。方法第一部分回顧性分析2001年6月至2014年6月在我院住院,藥物治療不理想,并成功接受CRT-P/D植入或升級為CRT-P/D治療的心衰患者基線資料及長期隨訪資料。根據(jù)左室功能和逆重構(gòu)指標(biāo),將CRT應(yīng)答分為無反應(yīng)、有反應(yīng)和超反應(yīng)組。分析CRT不同反應(yīng)組患者臨床指標(biāo)及器械治療參數(shù)的差異,接受CRT治療后心衰癥狀及預(yù)后改善情況。第二部分選擇接受CRT治療的心衰患者48例,采用WI技術(shù)評價患者CRT術(shù)前心臟收縮同步性,分析左室長軸十二節(jié)段收縮速度達峰時間(Time topeak of systolic velocity, Ts)的最大-最小差值(Ts max-min)、十二節(jié)段速度達峰時間的標(biāo)準(zhǔn)差(Standard deviation of the time to peak of systolic velocity, Ts-SD)。CRT術(shù)后6個月左室收縮末容積(Left Ventricular End-Systolic Volume, LVESV)較術(shù)前減少≥15%定義為有反應(yīng)。探討VVI技術(shù)在預(yù)測CRT應(yīng)答中的作用。第三部分回顧性分析我院長期隨訪的92例CRT患者的心電圖,及其長期隨訪資料。分析CRT術(shù)后不同反應(yīng)組QRS時限及電軸的變化。CRT術(shù)后,患者心電圖電軸變化主要為三個方向：→前,→右,以及冠狀面順鐘向旋轉(zhuǎn)。以每個方向的電軸變化積1分,CRT術(shù)后,電軸變化≥2分定義為電軸明顯變化。CRT術(shù)后6個月LVESV較術(shù)前減少≥15%定義為有反應(yīng)。分析CRT患者心電圖在預(yù)測CRT應(yīng)答中的作用。結(jié)果第一部分CRT術(shù)后患者長期隨訪92例(82%),CRT無反應(yīng)、有反應(yīng)及超反應(yīng)的患者例數(shù)分別為28例(30.9%),64例(69.1%),27例(29.4%)。三組患者在年齡、性別、抗心衰及抗心律失常藥物治療上,均無明顯差異。無反應(yīng)組的房顫患者比例為57.1%,明顯高于有反應(yīng)組及超反應(yīng)組(24.3%和18.5%,P=0.004)。有反應(yīng)組及超反應(yīng)組,CRT術(shù)后的客觀指標(biāo)左室射血分?jǐn)?shù)(Left Ventricular Ejection Fraction, LVEF),左室舒張末內(nèi)徑(Left Ventricular End Diastolic Diameter, LVEDD),6分鐘步行距離(6-Minute Walking Distance, 6MWD), LVESV及主觀指標(biāo)(NYHA分級)均較術(shù)前改善(P0.01),術(shù)后QRS時限明顯縮短(158.0±33.2 ms比146.8 ± 28.7 ms,161.9 ± 33.3 ms匕142.9± 28.9 ms, P0.01);而無反應(yīng)組患者,CRT術(shù)后客觀指標(biāo)(LVEF, LVEDD, 6MWD)無改善(P0.05),術(shù)后QRS時限較術(shù)前增寬(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分級有一定程度的提高(P0.01)。在改善心衰預(yù)后上,CRT-D優(yōu)于CRT-P。第二部分CRT術(shù)后有反應(yīng)患者為30例(62.5%)。將患者CRT術(shù)前心肌長軸方向的Ts max-min、Ts-SD繪制ROC曲線,長軸的Ts-SD的ROC曲線面積為0.82 ± 0.07, Ts-SD≥40.5時,其靈敏度為79.2%,特異度為71.2%。Ts max-min的ROC曲線面積為0.76±0.07,Ts max-min≥124.O日寸,其靈敏度為70.8%,特異度為77.8%。第三部分CRT術(shù)后有反應(yīng)患者為64例(69.6%)。CRT術(shù)后有反應(yīng)組的女性18例(28.1%),左束支阻滯比例顯著高于無反應(yīng)組(89.1%比71.4%,P0.05),QRS波時限較無反應(yīng)組寬(158.1±31.2 ms比138.9±26.2 ms,P0.05)；無反應(yīng)組的房顫患者比例明顯高于有反應(yīng)組(57.1%比21.9%,P0.01)。多元回歸分析顯示,QRS時限≥140ms、房顫及CRT術(shù)后電軸明顯變化[OR,5.12,(1.67,15.51)]是CRT有反應(yīng)的預(yù)測因素。QRS時限≥140ms患者CRT術(shù)后有反應(yīng)的機率是QRS時限140ms的4.97倍。電軸變化積分增加1分,CRT術(shù)后有反應(yīng)的可能性增加5.1倍。結(jié)論第一部分(1)CRT-P/D可改善心衰患者的癥狀及預(yù)后；在改善預(yù)后上,CRT-D優(yōu)于CRT-P:(2)接受CRT治療的患者,抗心衰藥物治療的依從性較好：(3)房顫是導(dǎo)致誤放電、起搏比例偏低的重要因素,可能是降低術(shù)后應(yīng)答的重要原因。第二部分 (1)CRT可改善患者的心功能,改善患者的預(yù)后：(2)采用VVI技術(shù)對心衰患者CRT治療前心臟長軸的同步性進行評估,長期隨訪結(jié)果顯示,Ts-SD對預(yù)測CRT應(yīng)答有一定的輔助作用。第三部分 (1)患者CRT術(shù)前QRS時限≥140ms,術(shù)后電軸明顯變化,均為CRT有反應(yīng)的預(yù)測因子：(2)房顫是CRT無反應(yīng)的預(yù)測因子：作為可調(diào)整的因素,房顫應(yīng)當(dāng)受到高度重視。
[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.
【學(xué)位授予單位】：中國人民解放軍醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R541.6

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