生理性起搏在心力衰竭患者中的应用  

Application of cardiac physiological pacing in patients with heart failure

作　　者：樊晓寒[1] 朱浩杰 FAN Xiao-han;ZHU Hao-jie(National Center for Cardiovascular Diseases,Fuwai Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100037,China)

机构地区：[1]国家心血管病中心、北京协和医学院、中国医学科学院阜外医院心律失常中心,北京100037

出　　处：《中国介入心脏病学杂志》2023年第12期946-950,共5页Chinese Journal of Interventional Cardiology

基　　金：国家自然科学基金项目(81970284);CSC临床研究专项基金项目(CSCF2020A01)。

摘　　要：临床实践中,对于宽QRS波、双心室电机械收缩不同步的心力衰竭患者,通过双心室起搏(BiVP)实现双心室电机械同步化的心脏再同步化治疗(CRT)目前已被多个国际心力衰竭和起搏指南推荐。BiVP-CRT经多项临床研究证实可有效改善心力衰竭患者心功能、减少心力衰竭再入院、逆转左心室重构、降低死亡风险。然而,BiVP-CRT手术仍面临着冠状窦插管失败、无理想靶静脉、膈神经刺激、左心室电极起搏阈值高、电极脱位等技术难点。另外,多年来研究发现约30%~40%患者BiVP-CRT术后心功能无显著改善,即CRT无反应。希浦系统起搏是近年来的研究热点,包括希氏束起搏(HBP)和左束支区域起搏(LBBAP)。HBP是目前最生理性的起搏技术,但由于希氏束解剖位置特点以及起搏电极和工具的限制,HBP的临床应用很难普及。LBBAP是国内原创的生理性起搏新术式,能够克服HBP的临床应用限制,获得HBP相似的生理性起搏效果。LBBAP根据有无左束支夺获进一步分为左束支起搏(LBBP)和左室间隔部起搏(LVSP),2种起搏术式均可以纠正左束支传导阻滞,缩窄QRS波。LBBAP起搏参数稳定可靠,远期失夺获风险小,展现了巨大的临床应用潜力,具备良好的临床应用前景,有望在未来成为应用最为广泛的生理性起搏技术。但是,目前仍缺乏大规模、多中心的随机对照研究证实LBBAP应用于心力衰竭患者进行再同步治疗的可行性和有效性。在临床实践中,BiVP、HBP、LBBAP 3种生理性起搏策略各有优势和不足,互为补充,对于不同临床特征的心力衰竭患者需选择不同的起搏治疗策略,以期提高心力衰竭患者接受CRT的反应率并改善临床预后。In clinical practice,cardiac resynchronization therapy(CRT)delivered by biventricular pacing(BiVP)has been recommended to be applied in patients with heart failure and wide QRS to achieve biventricular electromechanical synchrony.Multiple previous clinical studies have demonstrated that BiVP can eff ectively improve cardiac function,reverse left ventricular remodeling,and reduce risk of all-cause mortality and heart failure rehospitalization.However,BiVP still faces technical challenges,such as coronary sinus intubation failure,no ideal target vein,phrenic nerve stimulation,unacceptable pacing threshold of left ventricular electrode,and risk of lead dislodgement.In addition,prior studies have found that about 30%-40%of patients with BiVP have no significant improvement in cardiac function,namely,CRT non-response.Conduction system pacing(CSP)includes His bundle pacing(HBP)and left bundle branch area pacing(LBBAP).HBP is the most physiological pacing technique at present.Due to the anatomical location and the limitations of pacing electrodes and delivery tools,the clinical application of HBP is difficult to be popularized.LBBAP is a novel physiological pacing modality and can overcome the limitations of HBP and achieve similar physiological eff ects to HBP.LBBAP can be further divided into left bundle branch pacing(LBBP)and left ventricular septal pacing(LVSP),based on the presence of left bundle branch capture.These two pacing modalities can correct left bundle branch block(LBBB)and narrow QRS duration.LBBAP has stable pacing parameters and low risk of significantly increased thresholds or loss of capture,showing great potential of clinical application.However,large-scale randomized controlled studies are necessitated to provide more robust evidence to demonstrate the feasibility and efficacy of LBBAP applied in patients with heart failure.BiVP,HBP and LBBAP have their own advantages and disadvantages in clinical practice,which are complementary to each other.Pacing strategies should be individually selected for h

关 键 词：双心室起搏 希氏束起搏 左束支区域起搏 心脏再同步化治疗 

分 类 号：R54[医药卫生—心血管疾病]