心衰合并房顫患者CRT治療

1、心衰合并房顫患者CRT治療,房顫與心衰的關(guān)系,心衰促使房顫的發(fā)生, 心衰導(dǎo)致心房的結(jié)構(gòu)和電生理發(fā)生重構(gòu)。這些重構(gòu)包括心房擴(kuò)大、心房不應(yīng)期的縮短,心房傳導(dǎo)的減慢,心房復(fù)極各向異性的程度加重。這些改變促使并維持房顫的發(fā)生。 實(shí)驗(yàn)研究發(fā)現(xiàn),心衰能夠?qū)е露喾N離子通道電生理特性發(fā)生改變,如L2型Ca2 +電流,短暫性鉀電流( Ito )及緩慢延遲整流性鉀電流( IKs )密度降低,而短暫內(nèi)向Na + /Ca2 +交換電流增加,這些變化導(dǎo)致房顫的發(fā)生率和持續(xù)時(shí)間均明顯增加。 房顫促使心衰的發(fā)生房顫時(shí),心室率控制不佳、不規(guī)則心室起搏、心房收縮功能消失,均能降低心室收縮功能并加重心衰,Am J Cardio.

2、2003;91(6A):2D-8D,XUGENG 2009-12-12,房顫心衰互為影響,心衰 房顫 心房電生理的異常 心房結(jié)構(gòu)改變 容量和壓力負(fù)荷 房顫 心衰 AV失同步 心室率控制欠佳 心率變異,一般人群中房顫的發(fā)生率為0.4% 心血管病患者的房顫的發(fā)生率為4% 心衰患者中的房顫的發(fā)生率為10-50% Maisel WH,Stevenson LW Atrial fibrillation in heart failure:epidemiolody,pathopyhsiology and rationale for therapy. Am J Cardio.2003;91(6A):2D-8D,

3、心衰患者房顫的發(fā)病率,房顫發(fā)病率隨心功能的降低增加,XUGENG 2009-12-12,房顫心衰常常同時(shí)存在,CRT植入者中，永久性房顫約占20,Christophe Leclercq and Phipippe Mabo, Cardiac resynchronization therapy and atrial fibrillation. Do we have a final answer. European Heart Journal 2008 29, 1597-1599,心衰合并房顫患者CRT治療,CRT能否減少心衰患者房顫的發(fā)生？ CRT對心衰合并房顫患者是否可行有效？ 對永久性房顫患者

4、如何使用CRT治療,心衰合并房顫的患者，我們有幾個(gè)問題需要思考,CRT隨機(jī)對照試驗(yàn)累計(jì)病例數(shù),CRT隨機(jī)對照試驗(yàn)累計(jì)病例數(shù)約6000例，房顫病人只占5,CRT 能否減少心衰患者房顫的發(fā)生,法國Kis等進(jìn)行的臨床研究顯示,心臟再同步治療(CRT)后6個(gè)月,晚期心衰的房顫患者臨床獲益顯著,左房和左室重構(gòu)也顯著改善。但是,多達(dá)93%的患者并未轉(zhuǎn)復(fù)為竇性心律。 該研究納入74例晚期心衰的房顫患者,患者平均年齡為68歲,其中男性67例,患者均接受CRT。在CRT前和CRT后6個(gè)月分別對患者進(jìn)行紐約心臟學(xué)會(huì)(NYHA)心功能分級、生活質(zhì)量評分及6分鐘步行距離等臨床指標(biāo)的評估,還進(jìn)行超聲檢查,以確定患者的左

5、室射血分?jǐn)?shù)(LVEF)、左室直徑和左房直徑,Cardiac resynchronisation therapy in chronic atrial fibrillation: impact on left atrial size and reversal to sinus rhythm,Heart 2006;92:490494. doi: 10.1136/hrt.2005.064816,結(jié)果顯示,在CRT后6個(gè)月,患者的NYHA心功能分級、生活質(zhì)量評分、6分鐘步行距離及LVEF均顯著改善。另外,左房和左室舒張末和收縮末直徑在CRT后6個(gè)月也均顯著改善(P0.01)。 在進(jìn)行CRT時(shí),90%的持

6、續(xù)房顫患者(18/20例)轉(zhuǎn)復(fù)為竇性心律。但在隨訪期間,72%(13/18例)又轉(zhuǎn)為房顫,且均未自行轉(zhuǎn)為竇性心律。 因此,只有7%(5/74例)患者轉(zhuǎn)為竇性心律,CRT可使晚期心衰房顫患者臨床獲益 但僅7%的患者轉(zhuǎn)復(fù)為竇性心律,CRT對心衰合并房顫患者是否可行有效,MUltisite Stimulation In Cardiolopathies trial（MUSTIC,METHODS Of 131 patients included, 42/67 in sinus rhythm (SR) and 33/64 in atrial fibrillation (AF)were followed u

7、p longitudinally at 9 and 12 months by 6-min walked distance, peak oxygenuptake (peak VO2), quality of life by the Minnesota score, NYHA class, echocardiography,and left ventricular ejection fraction by radionuclide technique. RESULTS At 12 months, all SR and 88% of AF patients were programmed to Bi

8、V pacing. Comparedwith baseline, the 6-min walked distance increased by 20% (SR) (p 0.0001) and 17% (AF)(p 0.004); the peak VO2 by 11% (SR) and 9% (AF); quality of life improved by 36% (SR)(p 0.0001) and 32% (AF) (p 0.002); NYHA class improved by 25% (SR) (p 0.0001)and 27% (AF) (p 0.0001). The eject

9、ion fraction improved by 5% (SR) and 4% (AF). Mitralregurgitation decreased by 45% (SR) and 50% (AF). Conclusions. We found a significant sustained benefit in exercise tolerance quality of life from BiV over a 12-month follow-up period. A reduction in mitral regurgitation and an improvement in eject

10、ion fraction were also observed. Hospitalizations for HF were fewer during BiV pacing. Whether these favorable results translate into an improved survival remains to be established,J Am Coll Cardiol 2002;40:111 8) 2002 by the American College of Cardiology Foundation,房顫合并心衰CRT治療 竇律、房顫組對比,Received 24

11、 June 2007; revised 1 February 2008; accepted 10 March 2008; online publish-ahead-of-print 4 April 2008,MulticentreLongitudinalObservationalStudy (MILOS) 2006,竇律、房顫組對比,723例，561例竇律/162例房顫，平均隨訪25月。BV 88% 結(jié)果 SR VS AF 兩組均改善6分鐘步行距離、LVEF；改善NYHA分級,XUGENG 2009-12-12,Comparison of Usefulness of Cardiac Resyn

12、chronization Therapy in Patients With Atrial Fibrillation and Heart Failure Versus Patients With Sinus Rhythm and Heart Failure. Am J Cardiol 2007;99:12521257,2007年Delnoy等對96例竇律和 167例房顫CRT比較研究，觀察 12個(gè)月 兩組生存率和住院率相似,房顫合并心衰CRT治療 竇律、房顫組對比,房顫病人是否和病竇病人同樣受益,2008年Upadhyay等在 JACC發(fā)表了一項(xiàng)薈萃分析 2487篇報(bào)道 5個(gè)臨床研究報(bào)告，116

13、4例病人資料。 結(jié)論是同竇性心律患者一樣，房顫CRT治療也同樣能明顯改善射血分?jǐn)?shù)和NYHA分級,房顫心衰CRT薈萃分析,研究基線表,房顫病人是否和病竇病人同樣收益,全因死亡率比較：房顫組微高，與竇律組比較無統(tǒng)計(jì)學(xué)差異,All-cause mortality. A total of 85 deaths were reported across the included studies at 1 year (41 among AF patients and 44 in sinus rhythm patients). Although there was increased mortality in

14、 patients with AF, the calculation of risk did not reach statistical significance (risk ratio: 1.57,95% CI: 0.87 to 2.81, p 0.13) (Fig. 2). There was no significant heterogeneity between studies (I2 47.5%). Among 4 studies that reported cause of death, approximately 79% (weighted average) were from

15、cardiovascular causes, including stroke (1820,22,房顫病人是否和病竇病人同樣收益,左室射血分?jǐn)?shù)比較：房顫組與竇律組均改善，房顫組更明顯,Ejection fraction. The LVEF improved significantly across all studies for both patients in sinus rhythm and patients in AF. Average LVEF increased from 25.3% to 35.2% in patients with AF and from 24.6% to 33.

16、8% for those in sinus rhythm. Although patients in AF had slightly higher LVEF at baseline, they also showed a slightly greater change in LVEF (0.39% greater change in LVEF vs. those in sinus rhythm, 95% CI: 0.22 to 0.55, p 0.0001) (Fig. 3).There was a significant degree of heterogeneity for this ou

17、tcome (I2 97.1%). Notably, the method of calculatingLVEF was not reported in standard fashion and could notbe compared between studies,NYHA心功能分級比較：房顫組與竇律組均改善約1級，竇律組更明顯,Change in NYHA functional class. Four studies reported data on NYHA functional class (1820,22). At baseline, patients in AF had slig

18、htly more severe NYHA functional class heart failure than those in sinus rhythm (3.0 vs. 2.9,p 0.03). Overall, both groups improved by approximately 1 functional class, although patients in AF showed slightly less improvement on average (0.84 average change, 95%CI: 0.96 to 0.73 for AF patients; 0.90

19、, 95% CI: 1.0 to 0.8 for sinus rhythm patients; weighted mean difference of change in NYHA functional class was 0.06, 95% CI: 0.04 to 0.08, p 0.0001) (Fig. 4,房顫病人是否和病竇病人同樣收益,房顫病人是否和病竇病人同樣收益,明尼蘇達(dá)心衰問卷評分（MLWHF）比較：房顫組與竇律組均改善，竇律組更明顯,6MWD分級比較：房顫組與竇律組均改善，竇律組更明顯,對永久性房顫患者如何使用 CRT治療,CRT 治療需要100%起搏嗎,目的：是要確定特定的

20、雙心室起搏心力衰竭患者中受益情況 (HF) 方法：研究者用事后分析（post-hoc）的方式分析了兩項(xiàng)試驗(yàn) CRT RENEWAL Cardiac Resynchronization Therapy Registry Evaluating Patient Response with RENEWAL Family Devices REFLEx ENDOTAK RELIANCE G Evaluation of Handling and Electrical Performance Study；n = 1812 接受心臟再同步化治療（CRT）患者的死亡和HF住院治療數(shù)據(jù)。 他們通過應(yīng)用Kaplan-

21、Meier生存分析，根據(jù)雙室起搏百分比的四分位數(shù)對研究對象進(jìn)行分組。研究隊(duì)列由年齡為72 11歲的研究對象組成；72%為男性，67%有冠狀動(dòng)脈疾病?；仡櫺苑治鲂乃ナТ鷥敿叭蛩劳雠c雙室起搏比例的關(guān)系,Journal of the American College of Cardiology Vol. 53, No. 4, 2009 2009 by the American College of Cardiology Foundation ISSN 0735-1097/09 Published by Elsevier Inc. doi:10.1016/j.jacc.2008.09.043,Pat

22、ients BV pace 92 or 92,All Patients： 起搏比例不同，患者生存率， 住院率全因死亡率,Q1: pacing 0%-92% Q2: pacing 93%-97% Q3: pacing 98%-100% Q4: pacing 100,無房性心律失常病史的各組患者的生存率,J Am Cardiol 2009;53:355-60,Q2 to Q4 versus Q1, HR: 0.68, P=0.02 Q3 to Q4 versus Q2, HR: 0.66, p=0.01 Q4 versus Q2 to Q3, HR: 0.66, p=0.04,心衰雙心室起搏為什么

23、有效,心衰中束支傳導(dǎo)阻滯非常常見 (30%53%)，導(dǎo)致心功能受損 VEST研究中,QRS 200 ms的死亡率比90ms 高出5倍 CHF右室起搏時(shí)左室激動(dòng)延遲會(huì)導(dǎo)致左室收縮/舒張不協(xié)調(diào)， CRT 可以改善傳導(dǎo)，改善心功能 左室起搏與右室起搏同步降低QRS寬度，減少室內(nèi)、室間不同步,CRT術(shù)后房顫的困難,最大和有效的雙腔起搏奪獲是保證CRT治療反應(yīng)必要的基礎(chǔ)； 房顫由于房室失同步和快速的心室率導(dǎo)致雙心室起搏奪獲的不可靠； 被認(rèn)為是有效的CRT起搏奪獲可能是室性融合波或偽融合波,治療心衰,藥物治療 心律控制和節(jié)律控制 房室結(jié)消融/房顫消融 起搏程序 提高雙室同步性,CRT術(shù)后房顫治療策略,植入

24、CRT植入后保證雙心室同步起搏,措施包括： 1.消融房室結(jié)以造成三度AVB 2. 消融肺靜脈等電位以根治房顫 3. 應(yīng)用大劑量的 受體阻滯劑或地高辛，使自身房 室傳導(dǎo)延緩 4.開啟脈沖發(fā)生器中保證雙心室起搏功能的程序,房室結(jié)消融 確保CRT的起搏奪獲。 房室結(jié)消融 沒有心室融合波或假性融合波，保證雙心室有效起搏。 PAVE study（2005年）： 房室結(jié)消融在房顫心衰CRT中改善6分鐘步行距離 、 生活質(zhì)量和LVEF。 新近研究（2008年 Ferreira 和 2008年 Gasparini,CRT術(shù)后房顫房室結(jié)消融,房室結(jié)消融在房顫心衰CRT中改善預(yù)后,入選標(biāo)準(zhǔn),因慢性房顫（持續(xù)未間斷

25、至少1個(gè)月）進(jìn)行完全性房室結(jié) 消融的患者，造成完全性傳導(dǎo)阻滯 (a biventricular pacing system (n = 103) or a right ventricular pacing system (n = 81). 藥物治療穩(wěn)定,6分鐘步行距離450 m. 知情同意,NYHA class IV. 6分鐘步行距離 450 m 已植入或考慮植入ICD者, 禁忌急癥開胸手術(shù). 人工瓣膜置換術(shù)后,排除標(biāo)準(zhǔn),The study endpoints were change in the 6-minute hallway walk test, quality of life, and

26、left ventricular ejection fraction. . Patient characteristics were similar (64% male; age: 69 10 years, ejection fraction: 0.46 0.16; 83%, NYHA Class II or III). At 6 months postablation,步行距離顯著改善(m)BIV vs RV,射血分?jǐn)?shù)：BiV 組較RV組改善EF值更加顯著,死亡率,在3年的研究期間，17.9% RV 起搏患者versus 8.9% 雙室起搏患者死亡,24,baseline,31,0.46 0

27、.13,0.41 0.13) vs,結(jié)論,2008年 Ferreira 研究,131例心衰患者CRT分三組治療 竇律 78例 房顫并房室結(jié)消融 26例 房顫無房室結(jié)消融 27例 結(jié)果： 三組心功能分級均明顯改善,Ferreira AM.et al.,Benefit of cardiac resynchronization therapy in atrialfibrillation patients vs. patients in sinus rhythm: the roleof atrioventricular junction ablation. Europace 2008 10, 8098

28、15,Benefit of cardiac resynchronization therapy in atrial fibrillation patients vs. patients in sinus rhythm: the role of atrioventricular junction ablation,提示 房顫心衰CRT 適合行房室結(jié)消融,Ferreira 研究 : 心衰住院和生存率,Ferreira AM.et al Europace 2008 10, 809815,2008年 Gasparini 研究,2008年 Gasparini 在 EHJ上報(bào)道 CRT對慢性房顫心衰患者的

29、長期生 存率和房室結(jié)消融在其中的作用，平均隨訪34月。 1285例：1042例竇律 / 243例房顫， 房顫：118例房室結(jié)消融 / 125例藥物控制心率。 結(jié)果： CRT在竇律和房顫組死亡率相似。 房室結(jié)消融加CRT治療較單獨(dú)CRT治療提高總生存率，原因是減少了心衰死亡率,Gasparini M, Auricchio A, Metra M, et al. Multicentre Longitudinal Observational Study (MILOS) Group. Long-term survival in patients undergoing cardiac resynchron

30、ization therapy: the importance of performing atrio-ventricular junction ablation in patients with permanent atrial fibrillation. Eur Heart J. 2008;29(13):1644-52,Gasparini 研究房室結(jié)消融在房顫心衰CRT改善預(yù)后,Gasparini M, Auricchio A, Metra M, et al. Long-term survival in patients undergoing cardiac resynchronizati

31、on therapy: the importance of performing atrio-ventricular junction ablation in patients with permanent atrial fibrillation. Eur Heart J. 2008;29(13):1644-52,Pulmonary-Vein Isolation for AtrialFibrillation in Patients with Heart Failure,Methods In this prospective, multicenter clinical trial, we ran

32、domly assigned patients with symptomatic, drug-resistant atrial fibrillation, an ejection fraction of 40% or less, and New York Heart Association class II or III heart failure to undergo either pulmonary-vein isolation or atrioventricular-node ablation with biventricular pacing.All patients complete

33、d the Minnesota Living with Heart Failure questionnaire (scores range from 0 to 105, with a higher score indicating a worse quality of life) and underwent echocardiography and a 6-minute walk test (the composite primary end point). Over a 6-month period, patients were monitored for both symptomatic

34、and asymptomatic episodes of atrial fibrillation. Conclusions Pulmonary-vein isolation was superior to atrioventricular-node ablation with biventricular pacing in patients with heart failure who had drug-refractory atrial fibrillation,n engl j med 359;17 october 23, 2008,提示肺靜脈前庭隔離+雙室起搏治

35、療為CRT術(shù)后房顫的患者提供了一種新的治療手段,肺靜脈前庭隔離+雙室起搏治療效果優(yōu)于房室結(jié)消融+雙室起搏治療,房室結(jié)消融 VS 房顫消融,PABA-CHF 研究,n engl j med 359;17 october 23, 2008,提示肺靜脈前庭隔離+雙室起搏治療為CRT術(shù)后房顫的患者提供了一種新的治療手段,起搏程序提高雙室起搏比例,器械功能最大限度提高雙室再同步比例 心室感知反應(yīng)（ Ventricular Sense Response VSR) 用于心室感知事件時(shí)維持雙室起搏 心房跟蹤恢復(fù) ( Atrial Tracking Recovery ATR) 用于心房不應(yīng)期感知事件恢復(fù)雙室起搏 房顫傳導(dǎo)反應(yīng)（ Conducted AF Response CAFR) 減少因房顫快速下傳時(shí)雙室起搏喪失,心室感知反應(yīng)（ VSR)工作原理,感知電極（通常為右心室電極，當(dāng)然根據(jù)程控也可以為左心室電極或雙心室電極）感知到心室自主電活動(dòng)后觸發(fā)雙心室起搏脈沖的發(fā)放。 VSR的VV間期不可以程控，固定在感知后8m