1、心脏起搏治疗和预防心衰 一CRT的新适应证,黄德嘉四川大学华西医院心内科,CRT11年：治疗目标的发展,治疗严重心衰，-级心功 从Mustic到Care-HF预防心衰进展：-级心功 MADIT-CRT,REVERSE预防心衰发生：无心衰症状，无左室功能障碍，但有常规起搏适应症或合并LBBB BIOPACE 2012,Patients with a previously implanted conventional pacing device and severe left ventricular dysfunction Chronic right ventricular pacing indu
2、ces LV dyssyn chrony with deleterious effects on LV function.However, there are few data 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 fo
3、r CRT(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.,过去植入常规心脏起搏器的病人，如果合并严重的左心功能不全，长期右室起搏可导致左心室失同步化而使左心功能恶化。现在的共识是：对需要长期右室起搏的病人，如果
4、心功能级，EF35%，QRS波为右室起搏图形，为双心室起搏的适应证。升级后可部分改善心衰症状和左室功能。,Patients with indication for permanent pacing for bradyarrhythmia, with heart failure symptoms and severely compromised left ventricular function。Studies specifically addressing this issue are lacking. It is important to distinguish what part of t
5、he clinical picture maybe secondary to the underlying 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 symptoms. Conversely, the detrim
6、ental 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 biventricular pacing should therefore aim at avoiding chronic right ventricular pacing in heart failure patients w
7、ho already have LV dysfunction.,对有永久起搏适应症，合并心衰症状或严重左室功能障碍的病人，首先应区分其症状是由于心动过缓所致或由于心功不全所致。如果能证实症状主要是由于心功能不全所致，有理由相信双室起搏可以改善症状。双心室起搏还可避免长期右心室起搏带来的危害。,Recommendations for the use of biventricular pacing in heart failure patients with aconcomitant indication for permanent pacing Heart failure patients wi
8、th NYHA classes III-V symptoms, low LVEF35%, LV dilatation and aconcomitant indication for permanent pacing (first implant or upgrading of conventional pacemaker). Class IIa: level of evidence C.,对有常规永久起搏适应症同时合并心衰的病人，双室起搏的推荐意见：a C有常规永久起搏适应症（无论是第一次植入或者是升级）; 心衰，心功能-级，LVEF35%,左室扩大。,2008 ACC/AHA/HRS器械治疗
9、指南,CRT适应症类.LVEF0.35，QRS0.12S,经最佳药物治疗，心功级或非卧床级，窦性心律。（A）,a类 1.LVEF0.35，QRS0.12S，经最佳药物治疗，心功级或非卧床级，房颤。（B） 2. LVEF0.35，经最佳药物治疗，心功级或非卧床级，QRS不宽,有常规起搏适应证,并长期依赖心室起搏（C）。,b类 LVEF0.35，经最佳药物治疗，心功级或级，因病情而需要植入常规起搏器或ICD，并且预计将长期依赖心室起搏。（C）,既往无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,
10、Single=3,093Dual=8,333Not paced (controls)=11,566,评价心脏起搏的临床试验,CTOPP（加拿大）UKPACE（英国）MOST（美国）,大型临床试验结果的意义,双腔起搏(生理性起搏)尽管维持了房室顺序收缩功能，但不能改善存活率，降低脑卒中的发生率长期右室心尖起搏，增加发生房颤和心衰的危险,DAVIDDeath or First Hospitalization for New or Worsened CHF,Hazard ratio (95% CI), 1.61 (1.06-2.44),0,6,12,18,Months,Cumulative Prob
11、ability,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亚组研究,DDDR组:心室累积起搏40%，心衰住院增加3倍(p=0.02)每增加10%，心衰住院增加54%VVIR组心室累积起搏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,S
12、weeney MO, et al. Circulation 2003, in press,REVERSE 入选条件（共610例）,心功 NYHA 或级LVEF40%，左室舒张末径55mmQRS120ms,REVERSE试验:左心室重构指标的改善支持在轻度心衰病人中使用CRT,REVERSE remodeling outcome supports CRT in mildest heart failure2008 ACC, Steve Stiles,随访一年：临床指标,恶化 不变 改善CRT on 16% 30% 54%CRT off 21% 39% 40%,左心室重构指标,CRT on CRT
13、off P LVESV指数（m1/m2) -18.4 -1.3 0.0001 LVEDV指数（m1/m2) -20.5 -1.4 0.0001 LVEF(百分点） +3.8 +0.6 2/3时间需要心室起搏LVEF 无限制QRS宽度 无限制,终点,一级终点：全因死亡率二级终点：心血管病死亡率 住院率（任何原因，心血管疾病，心衰） 6分钟步行距离（12和24月） 生活质量问卷评估 永久性房颤发生率 超声指标 手术和器械相关并发症,BIOPACE实验的意义和启示,在植入普通起搏器人群中，通过双室起搏，纠正右室起搏导致的心室不同步及心脏重构可能改善长期依赖右室起搏病人的预后在已有心衰或LVEF降低，
14、有常规起搏适应症，或更换起搏器的病人，双室起搏可作为首选（a）,Upgrade from RV to BiVPacingRD-CHF Study: Design,CazeauS, LeclercqC, LelloucheD, FossatiF, AnselmeF, SiotPH, MolloL, DaubertC Cardiostim2004,Upgrade from RV to BiVPacingRD-CHF Study: Results,CazeauS, LeclercqC, LelloucheD, FossatiF, AnselmeF, SiotPH, MolloL, DaubertC Cardiostim2004,将常规起搏器升级为CRT后减少房性心律失常,CRT前 CRT后 P房性心律失常发作次数（次/年） 18150 5020.2 0.05EF 265.3% 317% 0.001 Yannopoulos Detal . JACC 2007 ;50:1246,关于升级的建议,尽早考虑慢性心衰，心功/级。心室起搏依赖。,电池耗竭时考虑心功级。LVEF降低。3. 一般情况尚可，预期存活期较长。,暂不考虑长期右室起搏后，心功能良好，LVEF正常。2 .DDD可经常转换为AAI工作模式。3. 其他疾病导致预后差。,
