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

【摘要】：本研究共分兩階段進(jìn)行。第一階段:目的多項(xiàng)研究證實(shí),右室心尖部起搏可引起類(lèi)似左束支傳導(dǎo)阻滯的傳導(dǎo)異常,激動(dòng)起源于右室,經(jīng)室間隔通過(guò)心肌細(xì)胞傳至左室,使得左室基底部后壁或側(cè)后壁最遲激動(dòng),可引起室間隔的矛盾運(yùn)動(dòng),心室間及左室內(nèi)部的運(yùn)動(dòng)不同步。長(zhǎng)期、高比率的右室起搏可嚴(yán)重?fù)p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(chǔ)已存在心功能不全的患者中更為明顯。而目前關(guān)于右室其他起搏點(diǎn),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(shù)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(shí)踐中開(kāi)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(guò)觀察合并左心室收縮功能不全的三度房室傳導(dǎo)阻滯(atrioventricular block,AVB)患者植入CRT裝置后左室射血分?jǐn)?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(jí)等心臟功能及結(jié)構(gòu)超聲指標(biāo)的變化,探討CRT對(duì)此類(lèi)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(huì)(New York Heart Association,NYHA)心功能分級(jí)I-III級(jí);并排除曾接受心臟電器械裝置植入(無(wú)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(shù)史,存在具修復(fù)指征的瓣膜病,預(yù)期壽命小于1年的患者。術(shù)前收集患者年齡、性別、基礎(chǔ)疾病、QRS時(shí)限、形態(tài)及超聲指標(biāo)等基線資料。對(duì)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(shù)前、術(shù)后6個(gè)月和12個(gè)月多次連續(xù)行超聲心動(dòng)圖檢查,以LVEF、LVESV作為主要觀察指標(biāo),結(jié)合LVEDV、LVEDD、LVESD、MR等多項(xiàng)指標(biāo),分析CRT術(shù)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(shù)后LVEF逐漸上升,術(shù)后6個(gè)月LVEF與術(shù)前相比增加(4.92±5.24)%(P0.05),術(shù)后12個(gè)月LVEF進(jìn)一步增加(5.02±6.52)%(P0.05);LVESV則較術(shù)前逐漸降低,術(shù)后6個(gè)月LVESV下降(25.02±17.95)ml(P0.05),12個(gè)月時(shí)LVESV進(jìn)一步下降(24.79±22.49)ml(P0.05);其他指標(biāo)亦有相似改善,術(shù)后6個(gè)月與術(shù)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(jí)下降0.49±0.76(P0.05),上述指標(biāo)在術(shù)后12個(gè)月進(jìn)一步降低,與術(shù)后6月對(duì)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(jí)下降0.22±0.55級(jí)(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(dǎo)阻滯(atrioventricular block,AVB)患者應(yīng)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(yù)測(cè)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(shù)前臨床資料及術(shù)后隨訪資料,術(shù)后12個(gè)月左室收縮末期容積(left ventricular end-systolic volume,LVESV)較術(shù)前下降≥15%或左室射血分?jǐn)?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(wú)逆轉(zhuǎn)組,比較兩組患者的臨床資料,并采用二分類(lèi)Logisitic回歸模型分析CRT逆轉(zhuǎn)左室重構(gòu)的預(yù)測(cè)因素。結(jié)果共入選患者65例,平均年齡(62±14)歲,隨訪12個(gè)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(shí)限120ms(27/12,P=0.001)、心室間激動(dòng)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(diǎn)距離左室16節(jié)段最小容積點(diǎn)時(shí)間間隔的標(biāo)準(zhǔn)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(wú)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(shí)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(dú)立預(yù)測(cè)因素。結(jié)論對(duì)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(duì)于這類(lèi)人群,女性、QRS時(shí)限120ms及Tmsv16-SD(%R-R)≥8.3%或可作為CRT逆轉(zhuǎn)左室重構(gòu)的預(yù)測(cè)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(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R541.7
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本文編號(hào)：2079581