心力衰竭的起搏治疗1课件.pptVIP

胸片比较 CRT治疗随机临床试验 据此ESC将CRT列为宽QRS心衰I类指征 轻中度心功能不全患者 REVERSE研究 多中心、前瞻性、双盲、随机对照试验 入选患者：心功能I~II级，QRS ≥120 ms、EF ≤40% LVEDD ≥55mm 研究设计 结果 结果 临床症状 左室缩末容积指数 MADIT-CRT研究 结 果 结 果 结果提示 CRT使CLBBB患者死亡率和心衰率下降 室内传导阻滞和CRBBB的患者未能从中获益 * 2013 ESC CRT适应证 * 2013 ESC CRT适应证 房颤心律 充分药物治疗基础上,LVEF≤ 35%， QRS ≥120ms，NYHA心功能III-IV患者 为保证100%心室起搏，建议行房室结消融 CRT过程中存在的问题 膈肌刺激 左室阈值升高 CRT起搏比例过低 对CRT无反应的处理 心外膜起搏相关的心律失常 膈神经刺激 膈肌刺激的发生率13% 部分患者因隔离刺激无法使用CRT 12%的患者需要重置电极 解决方法： 安置时严格测试 改变起搏极性或电压 应用四级起搏电极 左室心内膜起搏 LV环至RV线圈 LV头端至RV线圈 LV头端至LV环 改变起搏极性 应用左室四极导管可以提供更多选择 Shetty A K et al. Europace 2011;13:992-996 对CRT无反应的原因 双室起搏比例与生存率 双室起搏比例与生存率 房颤对生存率的影响 CRT起搏比例低 房速和房颤是双室起搏比例低的主要原因 电极位置与CRT预后 CRT的潜在促心律失常作用 小样本报道 原因 右室心内膜起搏—左室心外膜起搏增加QTd 瘢痕相关的折返性心律失常 左室电极位于电的缓慢传导区 在安置CRT后出现反复室速或室颤需要考虑到！ 结语 CRT是宽QRS心衰患者的一线治疗方案 达到左室逆重构的比例有60-80% 可以改善临床症状、改善预后 膈肌刺激、阈值升高等问题尚待解决 左室心内膜起搏是否可以替代心外膜起搏尚待研究 植入式心脏埋藏除颤器 * Heart failure can be considered one of the most significant healthcare challenges of today with an increasing incidence and prevalence in both the United States and Europe. Presently, heart failure is the only major cardiovascular disease that is increasing in both incidence and prevalence. In the U.S. alone, over 400,000 new cases are diagnosed each year and over five million patients currently suffer from this progressive disease. Despite advances in the management of heart failure, the annual mortality from this chronic illness is over 250,000. * While estimates vary from limited studies on the proportion of heart failure patients who also have ventricular dyssynchrony--usually left bundle branch--it appears to be fairly significant, and certainly is in excess of the rate found in the general population. Ventricular dyssynchrony is defined here as the existence of left or right bundle branch block or other intraventricular conduction delays manifested by a QRS duration of 120 ms or more. - - - - Shamim (Royal Brompton in London) followed 172