心臟起搏治療和預(yù)防心衰一crt的新適應(yīng)證黃德嘉,,

1、心臟起搏治療和預(yù)防心衰 一CRT的新適應(yīng)證,黃德嘉四川大學(xué)華西醫(yī)院心內(nèi)科,CRT11年：治療目標(biāo)的發(fā)展,治療嚴(yán)重心衰，Ⅲ-Ⅳ級心功 從Mustic到Care-HF預(yù)防心衰進(jìn)展：Ⅰ-Ⅱ級心功 MADIT-CRT,REVERSE預(yù)防心衰發(fā)生：無心衰癥狀，無左室功能障礙，但有常規(guī)起搏適應(yīng)癥或合并LBBB BIOPACE 2012,,,Patient

2、s with a previously implanted conventional pacing device and severe left ventricular dysfunction Chronic right ventricular pacing induces LV dyssyn chrony with deleterious effects on LV function.However, there are few d

3、ata concerning the effects of device upgrading from only right ventricular to biventricular pacing.Therefore, the consensus is that in patients with chronic right ventricular pacing who also present an indication for CRT

4、(right ventricular paced QRS,NYHA classIII,LVEF ≤35%,in optimized heart failure therapy) biventricular pacing is indicated.Upgrading to this pacing mode should partially revert heart failure symptoms and LV dysfunction.

5、,,過去植入常規(guī)心臟起搏器的病人，如果合并嚴(yán)重的左心功能不全，長期右室起搏可導(dǎo)致左心室失同步化而使左心功能惡化?，F(xiàn)在的共識是：對需要長期右室起搏的病人，如果心功能Ⅲ級，EF≤35%，QRS波為右室起搏圖形，為雙心室起搏的適應(yīng)證。升級后可部分改善心衰癥狀和左室功能。,,Patients with indication for permanent pacing for bradyarrhythmia, with heart fa

6、ilure symptoms and severely compromised left ventricular function。Studies specifically addressing this issue are lacking. It is important to distinguish what part of the clinical picture maybe secondary to the underlyin

7、g bradyarrhythmia rather than LV dysfunction. Once severe reduction of functional capacity as well as LV dysfunction have been confirmed, then it is reasonable to consider biventricular pacing for the improvement of symp

8、toms. Conversely, the detrimental effects of right ventricular pacing on symptoms and LV function in patients with heart failure of ischaemic origin have been demonstrated. The underlying rationale of recommending bive

9、ntricular pacing should therefore aim at avoiding chronic right ventricular pacing in heart failure patients who already have LV dysfunction.,,對有永久起搏適應(yīng)癥，合并心衰癥狀或嚴(yán)重左室功能障礙的病人，首先應(yīng)區(qū)分其癥狀是由于心動過緩所致或由于心功不全所致。如果能證實癥狀主要是由于心功能不全所致，有

10、理由相信雙室起搏可以改善癥狀。……雙心室起搏還可避免長期右心室起搏帶來的危害。,,Recommendations for the use of biventricular pacing in heart failure patients with aconcomitant indication for permanent pacing Heart failure patients with NYHA classes III-V symp

11、toms, low LVEF≤35%, LV dilatation and aconcomitant indication for permanent pacing (first implant or upgrading of conventional pacemaker). Class IIa: level of evidence C.,,對有常規(guī)永久起搏適應(yīng)癥同時合并心衰的病人，雙室起搏的推薦意見：Ⅱa C有常規(guī)永久起搏適應(yīng)癥（無

12、論是第一次植入或者是升級）; 心衰，心功能Ⅲ-Ⅳ級，LVEF≤35%,左室擴(kuò)大。,2008 ACC/AHA/HRS器械治療指南,CRT適應(yīng)癥Ⅰ類.LVEF≤0.35，QRS≥0.12S,經(jīng)最佳藥物治療，心功Ⅲ級或非臥床Ⅳ級，竇性心律。（A）,,Ⅱa類 1.LVEF≤0.35，QRS≥0.12S，經(jīng)最佳藥物治療，心功Ⅲ級或非臥床Ⅳ級，房顫。（B） 2. LVEF≤0.35，經(jīng)最佳藥物治療，心功Ⅲ級或非臥

13、床Ⅳ級，QRS不寬,有常規(guī)起搏適應(yīng)證,并長期依賴心室起搏（C）。,,Ⅱb類 LVEF≤0.35，經(jīng)最佳藥物治療，心功Ⅰ級或Ⅱ級，因病情而需要植入常規(guī)起搏器或ICD，并且預(yù)計將長期依賴心室起搏。（C）,既往無心衰病史患者起搏器植入后的心衰病死率和住院率,Freudenberger RS et al Am J Cardiol 2005;95:671-674,Single=3,093Dual=8,333Not paced (cont

14、rols)=11,566,評價心臟起搏的臨床試驗,CTOPP（加拿大）UKPACE（英國）MOST（美國）,大型臨床試驗結(jié)果的意義,雙腔起搏(生理性起搏)盡管維持了房室順序收縮功能，但不能改善存活率，降低腦卒中的發(fā)生率長期右室心尖起搏，增加發(fā)生房顫和心衰的危險,DAVIDDeath or First Hospitalization for New or Worsened CHF,,,,,,,Hazard ratio (

15、95% CI), 1.61 (1.06-2.44),0,6,12,18,Months,Cumulative Probability,0.4,0.3,0.2,0.1,0,250256,159158,7690,2125,No. at RiskDDDRVVI,Wilkoff B, et al. JAMA. 2002; 288: 3115-3123,DDDR,VVI,MOST亞組研究,DDDR組:心室累積起搏>40%，心衰住

16、院增加3倍(p=0.02)每增加10%，心衰住院增加54%VVIR組心室累積起搏>80%，心衰住院增加2.6倍。每增加10%，心衰住院增加96%,MOST Sub-Study,Sweeney MO, et al. Circulation 2003, in press,MOST Sub-Study,Sweeney MO, et al. Circulation 2003, in press,REVERSE 入選條件（共610

17、例）,心功 NYHA Ⅰ或Ⅱ級LVEF≤40%，左室舒張末徑≥55mmQRS＞120ms,REVERSE試驗:左心室重構(gòu)指標(biāo)的改善支持在輕度心衰病人中使用CRT,REVERSE remodeling outcome supports CRT in mildest heart failure——2008 ACC, Steve Stiles,隨訪一年：臨床指標(biāo),惡化 不變 改善CRT on

18、 16% 30% 54%CRT off 21% 39% 40%,,,,,左心室重構(gòu)指標(biāo),CRT on CRT off P LVESV指數(shù)（m1/m2) -18.4 -1.3 <0.0001 LVEDV指數(shù)（m1/m2)

19、 -20.5 -1.4 <0.0001 LVEF(百分點） +3.8 +0.6 <0.0001,,,,,BIOPACE試驗(Biventricular pacing for atrioventricular block to prevent cardi

20、ac desynchronization),假設(shè)：長期右室起搏具有導(dǎo)致心室重構(gòu)及以后發(fā)生心衰的危險，雙室起搏可降低這種危險性。依據(jù)：在永久起搏人群，因新發(fā)心衰而住院的發(fā)生率 MOST（病竇） 3年 10% UK-PACE（房室阻滯） 5年 20%,BIOPACE試驗的目的,在具有常規(guī)起搏適應(yīng)癥患者，采用雙心室起搏預(yù)防心臟的不同步性，與常規(guī)右心室起搏比較，可否改善病人的臨床結(jié)果。,,,,實驗設(shè)計：多中心隨機(jī)單盲，

21、平行對照 雙心室起搏VS常規(guī)右心室起搏入選病例 1800隨訪 4年,入選標(biāo)準(zhǔn),有常規(guī)起搏器植入的適應(yīng)癥。>2/3時間需要心室起搏LVEF 無限制QRS寬度 無限制,終點,一級終點：全因死亡率二級終點：心血管病死亡率 住院率（任何原因，心血管疾病，心衰） 6分

22、鐘步行距離（12和24月） 生活質(zhì)量問卷評估 永久性房顫發(fā)生率 超聲指標(biāo) 手術(shù)和器械相關(guān)并發(fā)癥,,,BIOPACE實驗的意義和啟示,在植入普通起搏器人群中，通過雙室起搏，糾正右室起搏導(dǎo)致的心室不同步及心臟重構(gòu)可能改善長期依賴右室起搏病人的預(yù)后在已有心衰或LVEF降低，有

23、常規(guī)起搏適應(yīng)癥，或更換起搏器的病人，雙室起搏可作為首選（Ⅱa）,Upgrade from RV to BiVPacingRD-CHF Study: Design,CazeauS, LeclercqC, LelloucheD, FossatiF, AnselmeF, SiotPH, MolloL, DaubertC Cardiostim2004,Upgrade from RV to BiVPacingRD-CHF Study: Res

24、ults,CazeauS, LeclercqC, LelloucheD, FossatiF, AnselmeF, SiotPH, MolloL, DaubertC Cardiostim2004,將常規(guī)起搏器升級為CRT后減少房性心律失常,CRT前 CRT后 P房性心律失常發(fā)作次數(shù)（次/年） 181±50 50±20.2

25、 <0.05EF 26±5.3% 31±7% <0.001 ——Yannopoulos Detal . JACC 2007 ;50:1246,,,,,關(guān)于升