本文選題：心臟再同步治療 + 三度房室傳導阻滯��； 參考：《安徽醫(yī)科大學》2017年碩士論文

【摘要】：本研究共分兩階段進行。第一階段:目的多項研究證實,右室心尖部起搏可引起類似左束支傳導阻滯的傳導異常,激動起源于右室,經(jīng)室間隔通過心肌細胞傳至左室,使得左室基底部后壁或側(cè)后壁最遲激動,可引起室間隔的矛盾運動,心室間及左室內(nèi)部的運動不同步。長期、高比率的右室起搏可嚴重損害心功能,甚至使患者發(fā)展為心力衰竭,這一現(xiàn)象在基礎已存在心功能不全的患者中更為明顯。而目前關于右室其他起搏點,如間隔部、流出道部的研究未發(fā)現(xiàn)有優(yōu)于右室心尖部起搏的證據(jù),希氏束起搏因技術難度高,且不適用于希氏束以下部位阻滯的患者,尚難以在臨床實踐中開展。心臟再同步治療(cardiac resynchronization threapy,CRT)可糾正右室起搏引起的不同步現(xiàn)象,或可避免右室起搏的不利影響。本研究通過觀察合并左心室收縮功能不全的三度房室傳導阻滯(atrioventricular block,AVB)患者植入CRT裝置后左室射血分數(shù)(LVEF)、左室收縮末期容積(LVESV)、左室舒張末期容積(LVEDV)、左室舒張末期內(nèi)徑(LVEDD)、左室收縮末期內(nèi)徑(LVESD)、二尖瓣返流(MR)分級等心臟功能及結(jié)構(gòu)超聲指標的變化,探討CRT對此類患者心功能及心臟重構(gòu)的影響。方法選取2009年1月至2014年10月在安徽省立醫(yī)院植入CRT的三度AVB患者,要求LVEDD≥55mm,LVEF≤50%,紐約心臟病協(xié)會(New York Heart Association,NYHA)心功能分級I-III級;并排除曾接受心臟電器械裝置植入(無論后期保留或移除),不穩(wěn)定性心絞痛,急性心肌梗死,入選前3月內(nèi)內(nèi)有冠脈搭橋或介入手術史,存在具修復指征的瓣膜病,預期壽命小于1年的患者。術前收集患者年齡、性別、基礎疾病、QRS時限、形態(tài)及超聲指標等基線資料。對于存在心功能不全癥狀體征的患者完善最佳藥物治療,使心功能穩(wěn)定。植入CRT裝置后分別于術前、術后6個月和12個月多次連續(xù)行超聲心動圖檢查,以LVEF、LVESV作為主要觀察指標,結(jié)合LVEDV、LVEDD、LVESD、MR等多項指標,分析CRT術后患者心功能及心室重構(gòu)變化情況。結(jié)果共入選49例患者,術后LVEF逐漸上升,術后6個月LVEF與術前相比增加(4.92±5.24)%(P0.05),術后12個月LVEF進一步增加(5.02±6.52)%(P0.05);LVESV則較術前逐漸降低,術后6個月LVESV下降(25.02±17.95)ml(P0.05),12個月時LVESV進一步下降(24.79±22.49)ml(P0.05);其他指標亦有相似改善,術后6個月與術前相比,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分級下降0.49±0.76(P0.05),上述指標在術后12個月進一步降低,與術后6月對比,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分級下降0.22±0.55級(P0.05)。第二階段:目的分析合并左心室收縮功能不全的三度房室傳導阻滯(atrioventricular block,AVB)患者應用心臟再同步治療(cardiac resynchronization threapy,CRT)后發(fā)生心室重構(gòu)逆轉(zhuǎn)的預測因素。方法選取2009年1月至2015年5月在安徽省立醫(yī)院植入CRT的三度AVB患者,收集術前臨床資料及術后隨訪資料,術后12個月左室收縮末期容積(left ventricular end-systolic volume,LVESV)較術前下降≥15%或左室射血分數(shù)(left ventricular ejection fraction,LVEF)增加≥5%定義為心室重構(gòu)逆轉(zhuǎn),將患者分為逆轉(zhuǎn)組和無逆轉(zhuǎn)組,比較兩組患者的臨床資料,并采用二分類Logisitic回歸模型分析CRT逆轉(zhuǎn)左室重構(gòu)的預測因素。結(jié)果共入選患者65例,平均年齡(62±14)歲,隨訪12個月,發(fā)生心室重構(gòu)逆轉(zhuǎn)的患者為36例(55.4%),逆轉(zhuǎn)組女性(25/11,P=0.011)、基線QRS時限120ms(27/12,P=0.001)、心室間激動延遲(interventricular mechanical delay,IVMD)≥40ms(30/18,P=0.027)、心率校正后的心電圖Q波起始點距離左室16節(jié)段最小容積點時間間隔的標準差(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)的比例高于無逆轉(zhuǎn)組,二元Logisitic回歸分析顯示,女性(OR=6.228,95%CI 1.561~24.842,P=0.01)、QRS時限120ms(OR=7.778,95%CI 1.996~30.769,P=0.003)與Tmsv16-SD(%R-R)≥8.3%(OR=8.134,95%CI 2.064~32.057,P=0.003)是心室重構(gòu)發(fā)生逆轉(zhuǎn)的獨立預測因素。結(jié)論對于合并左室收縮功能不全的三度AVB患者,CRT是一種有益的起搏模式及治療方法,可使患者LVEF明顯增加,LVESV顯著下降,并具有持續(xù)性。CRT可改善患者心功能,逆轉(zhuǎn)心室重構(gòu)。此外對于這類人群,女性、QRS時限120ms及Tmsv16-SD(%R-R)≥8.3%或可作為CRT逆轉(zhuǎn)左室重構(gòu)的預測因素。
[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.
【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】：R541.7
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本文編號：2079581