右心室流出道间隔部起搏对心房颤动患者血流动力学和心功能的影响

鲜玉琼; 郑昌柱; 金 环; 陈 静; 王玉华; 徐迎辉; 居海宁

右心室流出道间隔部起搏对心房颤动患者血流动力学和心功能的影响

Effects of right ventricular outflow tract septum pacing on hemodynamics and cardiac function

摘要

摘要: 目的:比较右心室流出道间隔部（RVOTS）起搏和右心室心尖部（RVA）起搏对心房颤动（房颤）患者血流动力学、心功能及主要不良心血管事件的影响，评价RVOTS起搏的中远期疗效。方法：具备起搏器植入指征的慢性房颤患者68例，随机分配至RVOTS部起搏组(n=34)和RVA部起搏组(n=34)，均采用心室抑制型按需起搏模式（VVI），随访（27±10）个月。观察比较两组患者起搏时心电图QRS时限，血流动力学、心功能及主要不良心血管事件发生情况。结果： RVOTS组起搏心电图的QRS时限较RVA组显著缩短［(146±16) ms vs.(155±13) ms，P<0.05］。随访结束时，RVA组的左室射血分数（LVEF）较术前显著降低（0.58±0.10 vs. 0.64±0.12,P<0.05），左房内经（LAD）较术前显著扩大［（47±10） mm vs.(44±10) mm，P<0.05），在RVOTS组虽有类似的变化趋势［LVEF:0.59±0.08 vs. 0.63±0.11；LAD:(47±7) mm vs. (45±7) mm］，但均未达统计学差异，随访结束时两组间比较未达统计学差异；两组患者随访结束时血浆脑钠尿肽（BNP）水平均较术前显著增高［RVA组：（292±168） ng/L vs. (200±70) ng/L,P<0.01；RVOTS组：(225±88) ng/L vs.(192±69) ng/L,P<0.05］，RVA组增高更明显，且较同期RVOT组显著增高（P<0.05）；随访结束时，RVA组的平均NYHA心功能分级较术前显著增高(1.7±0.6 vs. 1.4±0.5,P<0.01) ； RVOTS组有类似的变化趋势（1.5±0.7 vs. 1.3±0.5）,但未达统计学差异，两组间实验后比较差异亦未达统计学意义。两组间因心衰住院率、脑梗死及因心血管死亡均无统计学差异。结论： RVOTS起搏的电和机械同步性比RVA起搏相对较好，其心功能损害及心脏重构也相对较轻，较RVA起搏接近生理。

Abstract: AIM:To compare the effects of right ventricular outflow tract septum (RVOTS) pacing and right ventricular apex (RVA) pacing on hemodynamics, cardiac function and major adverse cardiovascular events, and to evaluate the long-term efficacy of RVOTS pacing. METHODS: Sixty-eight patients with chronic atrial fibrillation and with indications of pacing were randomly assigned to RVOTS pacing group (n=34) and RVA pacing group (n=34), and on-demand suppressed ventricular pacing mode (VVI) was used. All the patients were followed up for a mean of (27±10) months. QRS duration of electrocardiogram (ECG) in pacing, hemodynamics, cardiac function and the occurrence of major adverse cardiovascular events were observed and compared. RESULTS: The QRS duration of ECG in pacing in RVOTS group was significantly narrower than that in RVA group (P<0.05). At the end of follow-up, the left ventricular ejection fraction (LVEF) was lower (0.58±0.10 vs. 0.64±0.12, P<0.05) and the left atrium diameter (LAD) was larger ［(47±10) mm vs. (44±10) mm, P<0.05］ than those of the preoperative in RVA group. A similar trend was observed in the RVOTS group but no statistical differences were seen ［LVEF: 0.59±0.08 vs. 0.63±0.11; LAD: (47±7) mm vs. (45±7) mm］. At the end of follow-up, no statistical differences were observed between groups. Plasma levels of brain natriuretic peptide (BNP) were significantly higher than those of preoperative in the two groups at the end of follow-up ［RVA group: (292±168)ng/L vs. (200±70)ng/L, P<0.01, RVOTS group: (225±88) ng/L vs. (192±69) ng/L, P<0.05］. The increase in RVA group was significantly higher than that in RVOTS group during the same period (P<0.05). At the end of follow-up, the mean NYHA classification of cardiac function was higher significantly than that of the preoperative in RVA group (1.7±0.60 vs. 1.4±0.5, P<0.01). A similar trend was observed in the RVOTS group (1.5±0.7 vs. 1.3±0.5), but there were no statistical differences. No statistical differences were observed at the end of follow-up and no statistical differences were observed in hospitalization rate for heart failure, cerebral infarction and cardiovascular death between groups. CONCLUSION: Compared with RVA pacing, RVOTS pacing keeps a better electrical and mechanical synchronization in ventricle, thus reducing the damage of cardiac function and cardiac remodeling. RVOTS pacing thus is more physiological than RVA pacing.

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