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左束支起搏术中心电特征及中远期导线参数评价

Electrical characteristics of left bundle branch pacing and evaluation of leads parameters of mid-long term

摘要:

目的 本研究旨在探索左束支起搏的术中心电特征、中远期导线参数稳定性及并发症发生情况,评估其可行性及安全性.方法 连续入选2018年1月25日至2019年3月25日厦门大学附属心血管病医院心内科符合起搏适应证的患者,签署知情同意书后尝试行左束支起搏,如失败则改为右心室间隔部起搏.定义左束支起搏成功的标准:①起搏图形,单极起搏V1导联呈右束支传导阻滞(RBBB)形态;②刺激信号到左心室达峰时间(LVAT),高电压起搏下LVAT<70 ms,且分别以高电压、低电压起搏LVAT不变.详细记录患者的一般信息以及术中资料,包括起搏QRS波、LVAT、浦肯野电位(P电位)、PV间期以及电位振幅,导线单、双极参数.术后第3天,1、3、6个月以及1年定期随访,测试导线单、双极参数并记录随访期内并发症.结果 共113例患者行左束支起搏,成功102例,成功率90.3%.男50例,年龄(66.9±9.9)岁.其中房室传导阻滞(AVB)59例(59/113,52.2%),病态窦房结综合征(SSS)46例(46/113,40.7%),扩张型心肌病伴完全性左束支传导阻滞(CLBBB)8例(8/113,7.1%).左心室舒张末期内径(LVEDD)为(52.2±8.9) mm,左心室射血分数(LVEF)59.5%±16.8%.单极起搏V1导联为QR型或Qr型,起搏QRS时限(PQRSd)为(104.3±11.5) ms.LVAT(64.9±10.5) ms.LVEDD >55 mm组患者较正常者PQRSd及LVAT均延长.67例患者记录到P电位,28例出现损伤电流,PV间期(16.5±4.0) ms,P电位振幅(0.3±0.1)mV.SSS不伴CLBBB者记录到P电位的比例明显高于AVB者(92.7%对52.7%.P=0.000 2).术中测试导线单、双极参数均良好,49例患者阳极夺获阈值<2.5 V/0.5 mV.术后第3天单极阻抗[(700.0±154.0)Ω对(413.5±78.1)Ω,P<0.001]、双极阻抗[(804.0±129.0)Ω对(581.4±71.6)Q,P<0.001]均较术中明显下降;起搏阈值及感知参数变化无统计学意义.随访3~16(8.5±3.6)个月,单、双极起搏阈值、感知以及阻抗参数均稳定.术中发生一过性RBBB 12例(12/102,11.8%),无心肌穿孔、主动脉及冠状动脉损伤、导线脱位等并发症发生.结论 起搏图形以及LVAT结合P电位是判断左束支夺获的重要指标.左束支起搏手术成功率高,导线参数满意且中远期稳定性良好,并发症少,是一种值得推广的生理性起搏术式.

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abstracts:

Objective To evaluate the feasibility and safety of left bundle branch pacing (LBBP) by observations of the electric characteristics during implantation and the stability of leads parameters,as well as complications in mid-long tenn.Methods The patients with the indications of pacemaker implantation admitted in Department of Cardidogy in the Xiamen Cardiovascular Hospital were enrolled continuously from January 25th 2018 to March 25th 2019.After signing the informed consent,the patients received LBBP.The criteria for successful LBBP include:①Pacing pattern,unipolar pacing V1 showed right bundle branch block.②Stimulus to peak left ventricle activation time (LVAT) was <70 ms under high voltage pacing,and there was no change in LVAT pacing with high and low voltage respectively.The general information of patients and data of measurement during implantation were recorded.We followed up these patients at 3 days,1 month,3 months,6 months and 1 year after implantation respectively,to measure the parameters and record the complications.Results A total of 113 patients underwent LBBP,among whom 102 were successfully received LBBP with a successful rate of 90.3%.Fifty patients (44.2%) were male and average age was (66.9 ± 9.9) years old.LVEDD was (52.2 ± 8.9) mm and LVEF was 59.5% ± 16.8% before implantation.All patients with successful LBBP had a QR or Qr morphology in lead V1 when tip paced.LVAT was (64.9 ± 10.5) ms.The paced QRS duration and LVAT were longer in the patients with LVEDD>55 mm.P potentials were observed in 67 patients,among them 28 with injury current.PV interval was (16.5 ± 4.0) ms and amplitude of P potential was (0.3 ± 0.1) mV.The percentage of P potentials recorded in patients with SSS without LBBB was significantly higher than that in patients with AVB (92.7% vs 52.7%,P=0.0002).The parameters of both unipolar and bipolar leads were well measured during the implantation.The anode capture threshold was less than 2.5 V/0.5 mV in 47.9% of the patients both unipolar and bipolar.Impedance decreased significantly 3 days after implantation [(700.0 ± 154.0) Ω vs.(413.5 ± 78.1) Ω,(804.0+129.0) Ω vs.(581.4 ± 71.6) Ω,P<0.001)],meanwhile there were no statistically significant differences in pacing threshold and sensingparameters.These parameters were all stable in mid-long term follow-up.There were 12 patients had transient RBBB during implantation (12/102,11.8%).No myocardia perforation,aorta and coronary artery injury,lead dislocation.Conclusion Pacing pattern,QRS morphology,LVAT,and P potential are the key indicators of the LBB capture.LBBP has high success rate with satisfied,and stable lead parameters,and fewer complications in mid-long term observation.It deserves further study and promotion as a new approach to physiologic pacing.

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作者: 蔡彬妮 [1] 李琳琳 [1] 孟凡琦 [1] 常栋 [1] 李强 [1] 郭晋村 [1]
栏目名称: 希浦系统起搏
DOI: 10.3760/cma.j.issn.1007-6638.2019.05.007
发布时间: 2019-11-26
基金项目:
Guiding project of Fujian Science and Technology Department (2019D020,the project was funded by the Xiamen Municipal Health Commission.)福建省科技厅引导性项目
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