The protective effect on cardiac function of left bundle branch pacing in patients with ventricular pacing dependency
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摘要:
目的：观察左束支起搏(left bundle branch pacing，LBBP)对心室起搏依赖患者心功能的保护作用并探讨可能的机制。方法：选取2018年8月—2021年2月因房室传导阻滞或慢心室率房颤行心脏永久起搏器植入术的42例患者纳入本研究， 依据起搏部位分为LBBP组(19例)和右心室起搏(right ventricular pacing，RVP)组(23例)，其中RVP组包括右心室流出道间隔部起搏(right ventricular septal pacing，RVSP)11例和右心室心尖部起搏(right ventricular apical pacing，RVAP)12例。比较术前和术后两组患者的QRS波时限(QRSd)、左心室射血分数(LVEF)、左心室舒张末内径(LVEDD)和收缩末内径(LVESD)；在随访末对两组患者应用实时三维超声评估左右心室间和左心室内的机械同步性，并比较两组间的差异。结果：全部患者平均随访时间(22.27±10.28)个月；LBBP组LVEF术前术后无显著变化，RVP组术后LVEF较术前显著下降[(54.09±9.27)% vs(. 58.94± 10.01)%，P=0.011]，两组的LVEDD、LVESD较术前无显著变化；LBBP组QRSd较术前无显著变化，RVP组QRSd较术前显著增宽[(147.83±19.76)ms vs(. 124.04±31.10)ms，P=0.003]，且明显宽于LBBP组[(115.79±14.27)ms，P＜0.001]；LBBP组的左心室达峰时间(left ventricular activation time，LVAT)明显短于 RVSP 患者的 LVAT[(65.25±19.79)ms vs(. 80.91±10.44)ms，P=0.003]。 LBBP 和 RVP 组的心室间机械延迟(inter-ventricular mechanical delay，IVMD)存在显著差异[(-12.66±15.99)ms vs(. 15.13± 19.12)ms，P＜0.001]，LBBP 组的左心室 16 节段达最小收缩容积的时间标准差(standard deviation of time to minimum systolic volume in 16 segments of left ventricle，Tmsv16-SD)和心率校正后的Tmsv16-SD(Tmsv16-SD/R-R)均小于RVP组，分别为[(23.35± 9.34)ms vs(. 37.31±22.95)ms，P=0.021；(2.65±0.92)ms vs(. 4.04±2.48)ms，P=0.030]。相关分析显示QRSd、Tmsv16-SD、Tmsv16- SD/R-R与LVEF存在显著的负相关(P＜0.05)，与LVEDD及LVESD存在显著的正相关(P＜0.05)。结论：LBBP较RVP能更好地保护心室起搏依赖患者的术后心功能，可能与LBBP能更好地维持心脏的电和机械同步有关。
Abstract:
Objective：To observe the protective effect of left bundle branch pacing(LBBP)on cardiac function in patients with ventricular pacing dependency and explore the possible mechanism. Methods：A total of 42 patients undergoing permanent cardiac pacemaker implantation due to atrioventricular block or slow heart rate of atrial fibrillation in Suzhou Municipal Hospital from August 2018 to February 2021 were enrolled in this study. According to the pacing site，the patients were divided into LBBP group(19)and right ventricular pacing(RVP)group(23)including 11 of right ventricular outflow tract septal pacing(RVSP)and 12 of right ventricular apical pacing(RVAP).The preoperative and postoperative QRS duration(QRSd)，left ventricular ejection fraction(LVEF)，left ventricular end diastolic diameter(LVEDD)and end systolic diameter(LVESD)were compared between groups. At the end of follow- up，real-time three-dimensional ultrasound was used to assess inter-ventricular and intra-ventricular mechanical synchrony.Results： The mean follow-up time was(22.27±10.28)months. LVEF in LBBP group had no significant change before and after operation，LVEF in RVP group was significantly decreased[(54.09±9.27)% vs(. 58.94±10.01)%，P=0.011]. LVEDD and LVESD in the two groups had no significant change after operation. The baseline QRSd were similar between two groups. The paced QRSd in LBBP group was similar with the baseline QRSd，but significantly narrower than that in RVP group[(115.79±14.27)ms vs(. 147.83±19.76)ms，P=0.000]. Left ventricular activation time(LVAT)in LBBP group was significantly shorter than that in RVSP patients[(65.25±19.79)ms vs(. 80.91± 10.44)ms，P=0.003]. Inter-ventricular mechanical delay(IVMD)was significantly different between LBBP and RVP groups[(-12.66± 15.99)ms vs.(15.13±19.12)ms，P=0.000]. Standard deviation of time to minimum systolic volume in 16 segments of left ventricle (Tmsv16- SD)and Tmsv16- SD after heart rate correction(Tmsv16- SD/R -R)in LBBP group were smaller than those in RVP group [(23.35±9.34)ms vs(. 37.31±22.95)ms，P=0.021]，[(2.65±0.92)ms vs(. 4.04±2.48)ms，P=0.030]. Correlation analysis showed that QRSd，Tmsv16-SD，Tmsv16-SD/R-R were significantly negatively correlated with LVEF(P ＜ 0.05)，and significantly positively correlated with LVEDD and LVESD(P ＜ 0.05). Conclusion：LBBP can protect cardiac function better than RVP in patients with ventricular pacing dependency，which may be related to LBBP’s ability to better maintain cardiacelectrical and mechanical synchrony.
