心脏再同步治疗对心肌复极的影响及其潜在致心律失常作用  

Potential proarrhythmic effects of cardiac resynchronization therapy and relevant mechanisms

作　　者：吕家高[1] 林立[1] 白融[1,2] Wee Siong Teo Ruth Kam 王琳[1] 

机构地区：[1]武汉华中科技大学同济医学院附属同济医院心内科,430030 [2]Department of Cardidogy,National Heart Centre,Singapore

出　　处：《中华心律失常学杂志》2006年第2期124-129,共6页Chinese Journal of Cardiac Arrhythmias

基　　金：湖北省科技攻关课题资助项目(2004AA304B09)

摘　　要：目的以双心室起搏为核心技术的心脏再同步治疗技术(CRT)用于治疗慢性心力衰竭(CHF)时可能引起心肌复极异常而具有潜在的致心律失常危险性。本研究以接受CRT的CHF患者为对象,观察反映心肌复极特性的心电图指标在不同部位起搏时的变化及差异,并结合患者转归探讨其意义。方法21例接受CRT和/或CRT-D治疗的CHF患者入选。在植入术过程中或者复查时,将CRT装置分别程控为右心室心内膜起搏(RV-Endo)、左心室心外膜起搏(LV-Epi)和双心室起搏(Biv),同步记录12导联心电图,测量心电图上反映复极时间和复极差异的指标QT间期、JT间期和Tp-e间期,并在不同起搏部位间比较这些参数的差异。结果准确反映心肌复极时间的JT间期和公认代表心肌跨室壁复极离散的Tp-e间期均在LV-Epi起搏时最长[(341.78±61.69)ms,(199.70±62.44)ms],Biv起搏时次之[(325.86±59.19)ms,(184.89±74.08)ms],RV-Endo起搏时最短[(286.14±38.68)ms,(146.41±31.16)ms],三者比较差异有统计学意义(P<0.0001)。QT间期的变化有类似趋势但差异无统计学意义。在(29.18±18.38)个月的随访期中,共发生4例死亡,其中1例猝死,1例发生“心律失常风暴”并最终死于无休止性室性心动过速。结论在CHF患者已有器质性心肌病变的基础上,左心室心外膜起搏和目前CRT采用的双心室起搏延长心肌复极时间并增大跨室壁心肌复极离散,从而为促进恶性心律失常的发生提供了“基质”。Objective Cardiac resynchronization therapy （CRT） alters ventricular repolarization and thus may predispose to development of malignant ventricular arrhythmia in chronic heart failure （CHF） patients. This study attempts to characterize these repolarization abnormalities on ECG to support this hypothesis. Methods Twenty-one patients with CRT devices （either pacemaker or implantable cardioverter-defibrillator） implanted for CHF were studied. Post operatively or during the follow-up visit, the device was programmed to fight ventficular endocardial （RV-Endo） pacing, left ventricular epicardial （LV-Epi） pacing, biventricular （Bi-v） pacing respectively and 12 lead ECG was recorded. The following ECG parameters were measured and compared among the different pacing sites： QT interval; JT interval; and Tp-e interval. The patients were fol- lowed-up for their clinical outcome. Results Pacing site-dependent differences were noted in both JT interval [ （341.78 ±61.97）ms for LV-Epi pacing, （325.86± 59.69 ）ms for Biv pacing vs（286. 14 ± 38.68 ）ms for RV-Endo pacing, P 〈0. 000 1 ] and Tp-e interval [ （ 199.70 ± 62.44） ms for LV-Epi pacing, （ 184.89 ± 74.08 ） ms for Biv pacing vs（ 146. 41 ±31.06）ms for RV-Endo pacing, P 〈0. 000 1 ]. There was a similar trend for QT interval which failed to reach the statistical significance. During （29. 28 ± 18. 38） months follow-up, out of 4 deaths ： one patient died suddenly outside hospital ; another one suffered from “cardiac arrhythmic storm” and finally died from the incessant ventricular tachycardias. Conclusions LV epicardial and biventricular pacing prolong ventricular repolarization time and increase ventricular transmural dispersion of repolarization, which contribute to the arrhythmogenic substrates and support the development of malignant arrhythmias in CHF patients who receive CRT.

关 键 词：心脏再同步治疗 心外膜起搏 心力衰竭 TP-E间期 跨室壁复极离散 

分 类 号：R541.6[医药卫生—心血管疾病] R541.7[医药卫生—内科学]