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心力衰竭双心室再同步化治疗的长期死亡率及特点的多中心研究

A multi-center study on the long-term mortality and related risk factors in patients with chronic heart failure receiving resynchronization therapy

摘要:

目的 分析心力衰竭(心衰)双心室再同步化治疗(CRT)的长期死亡率及特点.方法 纳入2001年3月至2012年6月分别在白求恩国际和平医院、沈阳军区总医院和解放军第二五一医院3个医疗中心住院行CRT的心衰患者,观察其死亡情况并分析死亡原因(心原性和非心原性)及超声心动图指标.采用Kaplan-Meier法估计生存率,采用log-rank对生存曲线分布是否相同进行检验,logistic回归分析多因素对CRT术后死亡的影响.结果 本研究共入组心衰患者200例,其中男154例,女46例,平均年龄(60.57±11.75)岁,随访0.5~12年.总死亡率为25.50% (51/200),其中心原性死亡36例(70.59%),非心原性死亡13例(25.49%),不明原因死亡2例(3.92%).心原性死亡比例明显高于非心原性死亡(x2=53.12,P<0.01).CRT术前,心原性死亡患者以非缺血性心肌病(NICM)为主,占77.78%(28/36),非心原性死亡患者以缺血性心肌病(ICM)为主,占84.62%(11/13),两者比较差异有统计学意义(P<0.01).心原性死亡患者年龄较非心原性死亡患者轻(P<0.01).与非心原性死亡患者比较,心原性死亡患者左心房舒张末期内径(LAEDD)和左心室舒张末期内径(LVEDD)较大(P均<0.01),左心室射血分数较低(P<0.05),肺动脉收缩压较高(P<0.05).ICM患者死亡20例,占33.90% (20/59),NICM患者死亡31例,占21.98%(31/141),前者死亡率高于后者,但差异无统计学意义(P=0.06).NICM死亡的患者以心原性死亡为主(28例),而ICM死亡的患者死因则较为分散.入选患者中行CRT-P(单纯CRT而无除颤功能)者152例,行CRT-D(CRT+除颤功能)者48例,二者性别、年龄、病史、心功能指标、实验室检查指标等差异均无统计学意义(P均> 0.05).植入CRT-D的48例患者中死亡11例,占全部死亡病例的21.57%,植入CRT-P的152例患者中死亡40例,占全部死亡病例的78.43%.行CRT-P的患者总死亡率高于行CRT-D的患者(x2=3.13,P<0.01),死亡原因构成比,行CRT-D的患者以非心原性死亡为主,行CRT-P的患者以心原性死亡为主(x2=2.66,P<0.01),其中行CRT-D的患者猝死发生率较行CRT-P的患者低(x2=2.16,P<0.01).单因素和多因素Cox回归分析发现年龄、病程、术前QRS时限和纽约心脏协会心功能分级是CRT术后心衰患者发生心原性死亡的预测因子(P均<0.05).结论 心衰CRT全因死亡率为25.50%,其中ICM患者死亡率高于NICM患者.死因以心脏性猝死发生率为最高,CRT-D猝死发生率较CRT-P低,心原性死亡患者术前左心房、心室重构及心功能的指标较非心原性死亡患者差.

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abstracts:

Objective To analyze long-term mortality and patients characteristics of cardiac resynchronization therapy (CRT) for patients with chronic heart failure.Methods In-patients with chronic heart failure who received CRT in the three medical centers (Bethune International Peace Hospital,General Hospital of Shenyang Military Command of Chinese People's Liberation Army,and 251 Hospital of People's Liberation Army)from March 2001 to June 2013 were included.Mortality and related causes,echocardiographic parameters were analyzed.Results A total of 200 patients were treated with CRT therapy (154 males,mean age (60.57 ± 11.75) years),59 cases suffered from ischemic cardiomyopathy (ICM),patients were followed up from 0.5 to 12 years.The all-cause mortality rate was 25.50% (51/200),20 out of 59 (33.90%) ICM patients died,as compared with 31 deaths out of 141 (21.98%) in non-ischemic cardiomyopath (NICM) patients.Thirty-six patients died due to cardiac death (70.59%),in which sudden death occurred in 21 patients (41.18%).Non-cardiac death occurred in 13 patients (25.49%),two patients died due to unknown reasons (3.92%).Incidence of cardiac death was significantly higher than non-cardiac death (P <0.01).The main cause for cardiac death was NICM (28/36,77.78%),while the main cause of non-cardiac death was ICM (11/13,84.62%,P <0.01).Patients died due to cardiac death were younger (P < 0.01) and had larger left atrial end-diastolic diameter (LAEDD) and left ventricular end-diastolic diameter (LVEDD) (P < 0.01),lower left ventricular ejection fraction (LVEF) (P < 0.05),higher pulmonary artery pressure (P < 0.05) compared to patients with non-cardiac death.One hundred and fifty-two cases received CRT-P and 48 cases received CRT-D,there were no significant differences in gender,the course of heart failure,serum creatinine levels,pre-operative and post-operative QRS duration and so on between the CRT-P and CRT-D groups (all P > 0.05).Eleven out of the 48 cases with CRT-Ddied during the following-up (21.57%),while 40 out of 152 cases with CRT-P died (78.43%) during the following-up (x2 =3.13,P < 0.01).The proportional mortality rate in cause of death in patients with CRT-D was non-cardiac while in those with CRT-P was cardiac (x2 =2.66,P < 0.01),sudden death rate was also significantly higher in CRT-P group than in CRT-D group (x2 =2.16,P < 0.01).By using single-and multiple-factor Cox regression analysis,age,disease course,pre-operation QRS duration and NYHA classification were predictors of cardiac death(all P < 0.05).Conclusions The all-cause mortality of CRT is 25.50% in this patient cohort,mortality rate was higher in ICM patients than in NICM patients.Sudden cardiac death rate was the highest mortality reason.The mortality rate of patients with CRT-P was significantly higher than in patients with CRT-D.In comparison with patients of non-cardiac death,patients of cardiac death had larger left atrium and left ventricle and worse heart function before CRT implantation.

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作者: 齐书英 [1] 王冬梅 [1] 于海波 [2] 丁超 [1] 田福利 [3] 汝磊生 [1] 李洁 [1] 张宾 [3] 韩雅玲 [2]
作者单位: 白求恩国际和平医院心内科,石家庄,050082 [1] 沈阳军区总医院心内科 [2] 解放军第二五一医院心内科 [3]
期刊: 《中华心血管病杂志》2016年44卷11期 951-955页 MEDLINEISTICPKUCSCD
栏目名称: 临床研究
DOI: 10.3760/cma.j.issn.0253-3758.2016.11.010
发布时间: 2016-12-13
基金项目:
河北省科技支撑计划项目(11276124D)Science and Technology Support Project of Hebei Province
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