摘要目的 观察动态优化VV间期心脏再同步治疗(CRT)对慢性心力衰竭(CHF)患者心功能及神经内分泌因子影响的短中远期疗效.方法 选择2011年8月至2014年10月人住陕西省人民医院心内科的CHF患者38例,接受CRT治疗.于术后3、15 d、1、3、6、12个月进行AV、VV间期优化,术后1个月内所有患者采用默认及优化VV间期随机、自身前后交叉起搏,1个月结束之后,全部患者用优化AV和VV间期起搏,观察心功能、心脏同步性、神经内分泌因子变化.结果 第1个月结束时,与默认VV间期组相比,优化组的左心室射血分数(LVEF)增加(0.28±0.05对0.32±0.05,P＜0.05),左心室12节段组织速度达峰时间标准差(Ts-SD)改善[(49.5±20.6)ms对(35.6±18.6)ms,P＜0.05],左、右心室机械延迟时间改善(IVMD)[(27.2±10.2)ms与(22.3±8.7)ms,P＜0.05],神经内分泌因子(AngⅡ、NT-proBNP)也较默认组明显改善(P＜0.05).术后3个月优化VV间期与术前及术后1个月未优化时相比,Ts-SD、IVMD继续改善(P＜0.05,P＜0.01),同时,左心室舒张末期内径(LVEDD)、左心室收缩末期内径(LVESD)、LVEF、二尖瓣反流面积(MR)也明显改善(P＜0.05).术后6、12个月优化VV间期与术前及术后1个月未优化时相比,LVEDD、LVESD、LVEF、主动脉瓣前向血流速度时间积分(VTI)、MR、TsSD、IVMD均更进一步的改善,且12个月时改善更加明显(P＜0.05).优化后3、6、12个月随着时间的推移与术前及术后1个月未优化时相比,神经内分泌因子均有进一步下降(P＜0.05).结论 CRT植入术后早期优化AV/VV间期对改善患者心脏的同步性及心功能非常有意义,且心脏功能随着优化治疗时间延长逐步改善,从而认为对CRT患者中远期加强随访优化AV/VV间期仍至关重要.

abstractsObjective To assess short-,mid-and long-term clinical effect of dynamical VV delay optimization on cardiac function and neuroendocrine factors during cardiac resynchronization therapy(CRT) in patients with congestive heart failure.Methods Thirty-eight patients with congestive heart failure were treated with CRT.All patients were regularly performed AV and VV delay optimization at 3th days,15th days,1th,3th,6thand 12th months after implantation of CRT.First of all,all patients were programmed for optimal AV delay.Randomized and crossover trial with default VV delay or individualized optimal VV delay was used at 1th month after implantation of CRT.Then,all patients were accepted optimal AV and VV delay pacing.During the follow-up,indexes of ventricular synchronization,cardiac functional parameters and neuroendocrine factors were measured.Results Compared with the default VV delay group at one month after implantation of CRT,left ventricular ejection fraction(LVEF),standard deviation of time-to-peak systolic velocity of 12 LV segments(Ts-SD) and interventricular mechanical delay(IVMD) improved significantly in optimal VV delay group(P＜0.05)and neuroendocrine factors,such as plasma angiotensin Ⅱ (Ang Ⅱ) and N terminal pro-brain natriuretic peptide (NTproBNP) also improved significantly(P＜0.05).Compared with pre-operation and 1th month post-operation without optimization,Ts-SD and IVMD continued to improve significantly at 3th months post-operation with optimization(P＜0.05 or P＜0.01).Meanwhile,the left ventricular end-diastolic diameter(LVEDD),the left ventricular end-systolic diameter(LVESD),LVEF and mitral regurgitation area(MR) also improved significantly(P＜0.05 or P＜0.01).Compared with pre-operation and 1th month post-operation without optimization,LVEDD,LVESD,LVEF,aortic valve forward flow velocity time integral (VTI),MR,Ts-SD and IVMD improved significantly at 6th months and 12th months post-operation with optimization(P＜0.05 or P＜0.01).Compared with pre-operation and 1th month post-operation without optimization,over time,neuroendocrine factors declined gradually at 3th,6th and 12th months post-operation with optimization(P＜0.05 or P＜0.01).Conclusion Early optimization AV and VV delay can improve patient's cardiac synchronization,which is crucial to improve heart function.Heart function improves gradually with the extension of optimizing CRT therapy.Therefore,it is very important to strengthen the mid-and longterm follow-up and optimize AV and VV delay in patients implanted CRT with congestive heart failure treated.