起搏器植入术后心脏结构和心功能变化研究

【作者】 王蔚；

【导师】 葛均波；

【作者基本信息】 复旦大学 ， 内科学， 2008， 博士

【摘要】 第一部分不同步部位右心室起搏对心脏结构和左心室功能影响的研究研究目的评价在心功能正常的患者中,右心室心尖部(RVA)起搏和右心室流出道(RVOT)起搏对心脏各个心腔的大小、心脏射血功能及心室间和心室内同步性的影响。了解起搏治疗后,心室舒张功能及舒张同步性的变化。资料与方法选取符合起搏器植入指征者82人,其中男性46名(占56%),女性,36名(占44%)。年龄在32～87岁,平均69.26±11.55岁。除外心房颤动和严重心功能不全患者。术前进行常规生化检查,并常规超声心动图检查,测量各心腔大小、射血分数、心室收缩同步性指标、以及舒张功能和舒张同步性等数据并保存。在心导管室行常规起搏器植入手术。术中分别测量电极导管到达心尖部、流出道所需要的X线曝光时间及各部位起搏时阈值、阻抗、R波幅度、QRS时限等。根据随机分组表确定患者入选心尖部或是流出道。术后6个月随访起搏参数利上述超声心动图指标。结果1.流出道起搏电极到达理想位置所用时间要显并长于心尖部起搏。2.起搏阈值在手术即时,RVOT组要高于RVA组(P＜0.05),术后随访时,两组间没差别。在术时RVOT组阻抗要低于RVA组、术后阻抗依然低于RVA(P＜0.05)。R波幅度不论两组之间还是各自与术前相比均没有统计学意义。QRS时限在RVOT组利RVA组间没有统计学意义。3.心脏各腔室大小:左房(left atrium,LA)各内径在RVOT与RVA两组之间无变化((P＞0.05));左心室(left ventricle,LV)舒张期的前后径在RVOT组术后较术前有减少(P＜0.05),与RVA两组间比较没有统计学差异;右心房各个腔径都没有明显统计学差异,右心室的左右径在RVOT组术后较术前略有增加(P＜0.05),但与RVA两组间比较没有统计学差异。4.心功能比较:在不同部位起搏时,LVEDV、LVESV、EF、SV、CO两组之间比较均没有统计学差异。在各组内术后与术前对照,RVOT组EF有减少(P＜0.05),RVA组EF没有变化:SV在RVA组减少(P＜0.05),RVOT组也下降(P＜0.01)。5.心室间同步性比较:不同部位起搏两组间的A-P、PPEI、APEI均没有统计学意义(P＞0.05),但与术前自身对照时,两组A-P、PPEI、APEI均增加(P＜0.001)。说明不同部位起搏均会造成心室间不同步现象,但是两个不同起搏部位之间没有差别。6.心室内不同步:Ts-SD在RVA组无变化,在RVOT组术后Ts-SD增加(P＜0.05)。IVST、IVST-MAX、及校正后的IVST、IVST-MAX两组术后均较术前增加(P＜0.05),但两组之间没有统计学差异。说明起搏都可以引起心室内同步性改变,但不同部位之间没有差别。7.术前Ts-SD＞32.6的患者进行亚组分析:RVOT组左房的左右径较术前增加,RVOT组右室的左右径较术前增加,RVA组的左室左右径较术前增加(P＜0.05),左室舒张期前后径术后RVOT组较RVA组小,两组之间差异有意义(P＜0.05)。其余四个腔室的内径大小没有发现具有统计学意义的改变。不同部位起搏及术前术后EF、SV、CO均无明显差异(P＞0.05)。在心室间同步性方面,在RVOT及RVA两组之间没有差别,但术前术后相比,两组PPEI及APEI均较术前增加(P＜0.05),A-P在RVOT组无变化。Ts-SD无变化。8.舒张功能:两组起搏患者之间的左室的舒张功能没有统计学差异(P＞0.05)。但RVA组术后E峰较术前减少(P＜0.01)。不论哪个部位起搏,各组都有多个舒张不同步指标较术前明显改变。说明只要行右室起搏会造成左室舒张同步性改变,但此改变与起搏部位无关。结论右心室不同部位起搏是一个有争议的问题。我们的研究显示,不论是心尖部起搏还是流出道起搏都可以得到满意而稳定的起搏功能,只是流出道起搏电极放置的时间略长于心尖部起搏。不同的起搏部位都对心脏各个腔室内径有不同的影响,但这种改变极其轻微,临床意义不大。起搏都可以造成EF或SV减少,但不同起搏部位之间没有统计学意义的差异。不同部位起搏在心室间和心室内不同步方面没有表现出有统计学意义的差异,但不论是RVOT还是RVA起搏,术后较术前改变均有统计学意义。对于起搏器植入术之前就存在有不同步情况的一组人群进行亚组分析,得出的结论与前面的结论相似,没有显示出不同部位起搏带来心功能及左室收缩同步性的恶化趋势。在进行起搏治疗之后,不同起搏部位两组间舒张功能及舒张期不同步现象没有差别,但与术前相比,各组均表现出不同程度的左室舒张同步性改变。总之对心功能正常的患者来说,任何部位的起搏没有引起有临床意义的心房心室内径的改变,心功能未受影响,但心室收缩和舒张的同步性发生了改变。然而,右心室流出道起搏没有显示出比心尖部起搏更优越。因此,对技术水平有限,经济条件困难的广大地区来说,心尖部起搏依然是一个可选择的起搏部位。目前进入流出道起搏的时代还为时过早。第二部分实时三维超声心动图评价起搏患者心脏功能及心脏收缩同步性的临床研究研究目的探讨在不合并明显结构性心脏病变且左室收缩功能正常的患者中,行永久起搏器植入术前后,左室整体及节段性收缩活动的变化特点及收缩同步性情况。并进一步对心房心室不同部位起搏患者的实时三维超声心动图容量一时间曲线进行分析,探讨实时三维超声心动图在评价患者左室机械收缩同步性方面的应用价值。资料和方法选取心功能正常的起搏器植入术患者21例,其中男14例,女7例。术前及术后1个月,3个月行常规二维心脏超声心动图检查,并应用Philips IE33超声诊断仪进行三维超声心动图检查,显示完整的左心室进行图像采集,收集4个相邻的15°×60°的窄角立体图像,依次叠加形成全容积成像三维数据库存档,脱机用在机附带的QLAB 6.0软件进行三维图像分析。分别计算左室16节段各时相的容积,并自动显示左室整体及16节段容积—时间曲线,计算各节段的收缩期位移的平均值、标准差、最大值及最小值。结果所有入组患者,术前其左室容积、搏出量及左室射血分数均在正常范围。左室整体位移大小也在正常范围,且在各节段之间分布均一,各节段的位移的平均值及标准差测量结果无统计学差异(P＜0.05)。左室各节段达到最小容积时间在各节段之间分布均一,各节段的位移的平均值及标准差测量结果无统计学差异(P＜0.05)。1个月及3个月时,患者的左室容积、搏出量及LVEF与术前比均无统计学差异,各节段位移及左室整体位移及其标准差也无统计学变化(P＞0.05)。在1个月及3个月时,患者的左室16节段、12节段及基底段6节段的Tmsv之间的最大差值或各节段的标准差均无统计学变化(P＞0.05),表明在起搏3个月后,患者仍能保持与术前相仿的左室收缩同步性。对不同部位心房起搏患者进行亚组分析发现,无论在右室流出道起搏或者右室心尖起搏,其左室整体收缩功能及收缩同步性均无统计学差异(P＞0.05)。但在右心耳起搏患者中,术后左室基底段后侧壁及中间段下壁位移增大,而中间段前间隔的位移均减小并达到统计学差异(术前vs术后:左室基底段后侧壁4.1±0.5mm vs 5.6±0.8mm,P=0.03,中间段下壁4.3±0.4mm vs 5.2±0.6mm,P=0.04,中间段前间隔5.1±0.4mm vs 4.6±0.8mm,P=0.02)。而在房间隔起搏患者中,术后左室基底段前间隔的位移增大,中间段下壁的位移均减小并达到统计学差异(术前vs术后:左室基底段前间隔3.9±0.6mm vs 5.3±0.6mm,P=O.02,中间段下壁4.4±0.6mm vs 3.6±0.7mm,P=0.03)。其余节段的收缩期位移均无统计学差异(P＞0.05)。结论三维超声可以更清晰的反映心脏的整体变化情况,在起搏器植入术后,右心室无论选择哪个部位起搏,患者的心脏功能及收缩同步性均未发生明显变化。但对房间隔的不同部位起搏,带来不同的心室收缩节段性位移的不同变化,这些变化会带来怎样的临床结果还有待于我们进行长期更进一步的观察。但目前仍可以认为右室流出道起搏并不是心功能正常的患者所必需选择的起搏部位。更多还原

【Abstract】 The First Part Study the difference of ventricular function and structure between right ventricular apex pacing and outflow tract pacingAimsTo compare changes of ventricular function between patients without cardiac failure,paced in either right ventricular apex(RVA) or outflow tract(RVOT).To observe how cardiac chambers changed,and if right outflow pacing was better than right ventricular apex in patients with normal heart function.How would ventricular diastolic function change?MethodsEighty-two patients without prior heart failture were included in the study,including 46 male (56 percent),36 female(44 percent),from 32 years old to 87 years old,on an average of 69.26±11.55 years old.Atrial fibrillation was excluded.All these patients were randomized to RVA group or RVOT group.Then echocardiography was examed before pacemaker implantation,and after six months later echocardiography was repeated.The conventional biological and chemical examination were performed before the pacing operation.Through echocardiography,the sizes of the four cavities,ejection fraction,and pulmonary pre-ejection time(PPET),aortic pre-ejection time(APET) and their difference(AP), Ts-SD,LVEDV,LVESV,SV and CO were measured.The pacemaker parameters such as thresholds,impedances,R-range,QRS widen were measured at follow-up.Results1.The time to inseart the lead to satisfactional site of RVOT was longer than to RVA.2.Pacing threshold in RVOT was higher than RVA(P＜0.05) in operation time.No difference between two group after six months later.Impedances was lower in RVOT than in RVA,no matter how before or after pacemaker implantation.QRS widen was no difference between two group(P＞0.05).3.The heart structure were measured by echocardiography.There are no significant statistical different change in LA and RA.Anteroposterior diameter of LV in diastolic was decreased in RVOT than in RVA group(P＜0.05).Left and right diameter of right ventricle was increased in RVOT group than in RVA group(P＜0.05).The other sizes of heart were of no significant statistical difference.4.About cardiac function:there are no significant statistical difference compared with pre-operation in LVEDV,LVESV,CO,and no significant difference between two group RVA and RVOT.EF is decreased in RVOT group than pre-operation(P＜0.05).And SV was decreased in two group than pre-operation(P＜0.05).5.There were no significant difference between two group in A-P,PPET and APET.But compared with pre-operation,A-P,PPET and APET were increased in two group(P＜0.001).It means anywhere pacing can cause dissynchronization between two ventricles.6.There were no significant difference between two group in Ts-SD.Compared with pre-operation,IVST and IVST-MAX were increased in two group(P＜0.001).But there was no significant different between two group.It means anywhere pacing can cause dissynchronization in left ventricle.7.Preoperative Ts-SD＞32.6ms of the subgroup analysis of patients:In RVOT group,left and right diameter of left atrium was increased than in RVA group.Right ventricular diameter was increased in RVA than pre-operative.Left ventricular diastolic diameter was slightly decreased in RVOT group.There were no differences between the two groups.The other four sizes of the cavity were no significant changes(P＞0.05).Pacing in different parts of pre-operative and postoperative,EF,SV,CO did not change.There was no difference between the two groups in the inter-ventricular synchrony.Compared with pre-operation,PPEI and APEI were increased in two group.AP no change in the RVOT group.Ts-SD unchanged.8.Diastolic function:There was no significant difference in ventricular diastolic function between the two groups.But no matter which part of pacing,the group has a number of indicators about left ventricular asynchrony is significant changed.But this change has nothing to do with the site of pacing.ConclusionsRight ventricular pacing in different parts is a controversial issue.Our research shows that both apical pacing or outflow tract can be satisfied with the stability and function of the pacing. The pacing in different parts can cause each heart chamber a different but the most minor change, that show less clinical significance.Pacing can cause SV or EF reduced,but no significantly statistical difference in different parts of pacing.There were no significantly statistical differences in sync between right and left ventricles or inter ventricle.But significantly statistical differences in sync were showed in two groups than pre-operation Analysis the sub-group which Ts-SD＞32.6 before the pacemaker implantation,the conclusions were similar to those in front.There is no deterioration in synchronization and function of heart in two group.There was no significantly statistical difference in diastolic function and sync between two group.But varying degrees changed in diastolic sync after pacemaker implantation was showed significantly difference than before operation in all groups.For patients with normal heart function,anyplace pacing did not cause significantly changes in sizes of four heart cavities and heart function,but synchronization in systolic and diastolic were changed.Right ventricular outflow tract pacing has not shown better than apical pacing.As a result,the regions which the level of technology is limited,economic conditions is not rich,apical pacing is still a reliable pacing site.At present,into the outflow tract of pacing era is too early. The second part Using Real-time 3D echocardiography evaluated heart function and heart contraction synchronization in patients with right ventricular pacingResearch purposesIn patients without significantly change in the structure of heart and normal cardiac function, explore changes in ventricular systolic function and the characteristics of simultaneous contraction of the situation before and after pacemaker implantation.And further on the various pacing sites of pacemaker patients with real-time 3D echocardiography capacity-time curve analysis of real-time 3D echocardiography in the evaluation of patients with left ventricular systolic synchronicity of the mechanical aspects of the application.Information and methodsA total of 21 patients with normal cardiac function and pacemaker implantation were selected, of which 14 cases of male and female 7 cases.Cardiac echocardiography was measured preoperative and postoperative one month,three months.The instruments included conventional two-dimensional echocardiography,ultrasound diagnostic apparatus of Philips IE33 3D echocardiography,used in machines with the QLAB 6.0 3-D image analysis software.Acquisition of left ventricular 16 were calculated by sub-paragraph 16 of the left ventricle each time the volume and left ventricular automatically show overall and 16 of the volume - time curve(as shown in Figure 1),the calculation of the sections of the contraction Displacement of the mean, standard deviation,maximum and minimum.These values are measured three times in a row from the average of measurementsResultsIn the group of patients with left ventricular volume,and the risk of a left ventricular ejection fraction is normal.The overall size of the left ventricular displacement is the normal range,and between the various segments of the same uniform,each section of the displacement and the average standard deviation of the measurement results no significant difference(p＜0.05).Sections of the left ventricle to a minimum volume of time in between sections of the same uniform distribution(p＜0.05).One month and three-month real-time 3D echocardiography follow-up: compared with the former,with left ventricular volume,the risk of LVEF and no significant difference,displacement and sections of the left ventricle and the overall displacement There was no standard deviation also change(P＞0.05).To different parts of atrial pacing,pacing in the right atrial appendage patients,compared with the preoperative and postoperative left ventricular base of the wall after the middle of the wall and displacement increased,and the interval before the middle of the displacement are reduced.And to achieve significant difference(in the former vs after:the basement of the left ventricular wall after 4.1±0.5ram vs 5.6±0.8mm,P= 0.03.the middle of the wall under 4.3±0.4mm vs 5.2±0.6mm,P= 0.04,Before the middle of the interval 5.1±0.4mm vs 4.6±0.Smm,P = 0.02).In the interval pacing patients,compared with the preoperative and postoperative left ventricular basement of the interval before the displacement increased,the middle of the wall under the displacement and to reduce the significant difference (in the former vs after:Left Room basement before the interval of 3.9±0.6mm vs 5.3±0.6mm,P = 0.02,the middle of the wall under 4.4±0.6mm vs 3.6±0.7mm,P = 0.03).The remaining segment of the systolic displacement was no significant difference(P＞0.05).ConclusionIn patients with normal heart function,the apex and outflow pacing,the volume of the left ventricle,the LVEF,as well as the overall and left ventricular segmental contraction has not changed,but different parts of the atrium and the right atrial appendage from the interval risk arising from different segments of the left ventricle contraction change.Therefore,the outflow pacing heart function in the normal population is not necessary to choose the pacing site.The different parts of atrial pacing will bring what about the clinical significance which need us to explore further.更多还原