术前自身QRS波时限是起搏依赖患者心功能下降的预测因子
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Preoperative intrinsic QRS duration is a predictor of left ventricular function deterioration in patients dependent on right ventricular apical pacin
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    摘要:

    目的:探讨术前自身QRS波时限(intrinsic QRS duration,IQRSd)对右心室心尖部(right ventricular apex,RVA)起搏患者心功能下降的预测作用-方法:选取因三度房室传导阻滞(Ⅲ°AVB)植入双腔全自动型起搏器(DDD)或单腔同步型起搏器(VVI)患者42例-其中,末次随访时左室射血分数较术前下降的绝对值(ΔLVEF)≥5%的患者22例(ΔLVEF≥5%组,DDD 12例,VVI 10例),同期ΔLVEF<5%患者20例(ΔLVEF<5%组,DDD 11例,VVI 9例),两组比较,研究起搏引起心功能下降的可能原因和可能的预测因子-每例患者在起搏器植入术前行12导联心电图和超声心动图检查,术后随访时记录起搏心电图-超声心动图及右心室累积起搏比例-结果:两组患者平均随访77.3个月,ΔLVEF≥5%组左室射血分数(left ventricular ejection fraction,LVEF)由术前(64.20 ± 6.30)%降至(40.60 ± 10.00)%(P < 0.001),左房内径(left atrial diameter,LAD)由术前(34.77 ± 6.42)mm增大至(41.00 ± 7.45)mm(P < 0.001),左室舒张末期内径(left ventricular end-diastolic dimension,LVEDD)由术前(49.82 ± 4.86) mm明显增大至(55.59 ± 8.44) mm(P < 0.001),差异均有统计学意义;ΔLVEF<5%组LVEF由术前(65.40 ± 3.25)%降低至(64.94 ± 3.00)%(P = 0.543),LAD由术前(37.40 ± 4.84) mm增加至(38.15 ± 5.83) mm(P = 0.347),LVEDD由术前(48.30 ± 3.95) mm增加至(49.00 ± 3.87) mm(P = 0.090),变化均无统计学意义;四格表卡方检验提示植入起搏器后术前IQRSd≥110 ms组较术前IQRSd<110 ms组患者发生心功能下降比率更高(P = 0.002);Kaplan-Meier分析发现植入起博器后术前IQRSd≥110 ms患者较术前IQRSd<110 ms患者心功能下降发生时间更早-COX回归分析显示,术前IQRSd≥110 ms是左室收缩功能下降的独立预测危险因素(P < 0.05)-结论:RVA长期起搏可引起心脏结构改变和左室收缩功能下降;术前IQRSd≥110 ms患者左室收缩功能下降发生率高且时间更早,术前IQRSd≥110 ms是起搏依赖患者左室收缩功能下降的独立预测危险因子-

    Abstract:

    Objective:To investigate the predictive value of intrinsic QRS duration(IQRSd) for left ventricular function deterioration in patients dependent on right ventricular apical(RVA) pacing. Methods:In this study,42 patients with third degree atrioventricular block who underwent pacemaker implantation were included. Twenty-two patients with absolute reduction value of left ventricular ejection fraction(ΔLVEF)≥5% after pacing (group with ΔLVEF≥5%) and 20 patients with ΔLVEF<5% after pacing(group with ΔLVEF<5%) were enrolled to investigate the possible reasons or predictors for the cardiac function deterioration. The examination results of 12-lead electrocardiography and echocardiography,and clinical conditions were recorded for every patient before the implantation and during the follow-up. The cumulative pacing rate of pateints were also obtained at each follow-up visit. Results:After 77.3 months of follow-up,left ventricular ejection fraction(LVEF) decreased significantly from (64.20 ± 6.30)% to (40.60 ± 10.00)%(P < 0.001) while left atrial diameter (LAD) and left ventricular end-diastolic dimension(LVEDD) enlarged significantly in group with ΔLVEF≥5%[LAD:(34.77 ± 6.42)mm vs. (41.00 ± 7.45)mm;LVEDD:(49.82 ± 4.86)mm vs. (55.59 ± 8.44)mm;P < 0.001)]. However,the average LVEF,LAD and LVEDD levels in group with ΔLVEF<5% after pacing were not statistically different from those before pacing[LVEF:(65.40 ± 3.25)% vs. (64.94 ± 3.00)%;LAD:(37.40 ± 4.84)mm vs. (38.15 ± 5.83)mm;LVEDD:(48.30 ± 3.95)mm vs.(49.00 ± 3.87)mm]. Kaplan-Meier analysis revealed that LVEF diminution after pacing appeared significantly earlier in patients with IQRSd≥110 ms than that in patients with IQRS<110 ms. Chi Square Test showed the rate of LVEF diminution was significantly higher in patients with IQRSd≥110 ms than that in patients with IQRSd<110 ms(P < 0.05). COX regression analysis indicated that IQRSd≥110 ms was the independent predictor of left ventricular systolic function decrease (P < 0.05). Conclusion:Long-term RVA pacing leads to deterioration of left ventricular systolic function and cardiac remodeling. In patients with IQRSd≥110 ms,deterioration of left ventricular systolic function occured earlier and more serious than in those with IQRSd<110 ms. IQRSd≥110 ms is the independent predictor of LVEF reduction in patients dependent on right ventricular pacing.

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刘 群,吴红平,陈 震,王 垚,姜晓宏,侯小锋,邹建刚.术前自身QRS波时限是起搏依赖患者心功能下降的预测因子[J].南京医科大学学报(自然科学版),2012,(7):942-947

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  • 收稿日期:2012-03-02
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