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LBBBBIOPACE 2012 Patients 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 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 for 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，如果心功能级，EF35%，QRS波为为右室起搏图图形，为为双心室起搏的适应证应证 。升级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 the 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 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 biventricular pacing should therefore aim at avoiding chronic right ventricular pacing in heart failure patients who 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 with 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%,左室扩扩大。2008 ACC/AHA/HRS器械治疗指南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;95:671-674Single=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DAVID Death or First Hospitalization for New or Worsened CHFHazard ratio (95% CI), 1.61 (1.06-2.44)061218MonthsCumulative Probability0.40.30.20.10250 256159 15876 9021 25No. at Risk DDDR VVIWilkoff B, et al. JAMA. 2002; 288: 3115-3123DDDRVVIMOST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-StudySweeney MO, et al. Circulation 2003, in pressP=0.047Cum%Vp at 30 days and subsequent HFH events DDDR/Normal QRS0.80.8250.850.8750.90.9250.950.9751012243648MonthsProportion event-freeCum%Vp 40MOST Sub-StudySweeney MO, et al. Circulation 2003, in pressP=0.0046Cum%Vp at 30 days and subsequent HFH events VVIR/Normal QRS0.80.8250.850.8750.90.9250.950.9751012243648MonthsProportion event-freeCum%Vp 80REVERSE 入选条件（共610例 ） 心功 NYHA 或级 LVEF40%，左室舒张末径55mm QRS120msREVERSE试验:左心室重构指标的改善支持在轻度 心衰病人中使用CRTREVERSE 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 off P LVESV指数（m1/m2) -18.4 -1.3 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，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 BiVPacing RD-CHF Study: DesignCazeauS, LeclercqC, LelloucheD, FossatiF, AnselmeF, SiotPH, MolloL, DaubertC Cardiostim2004SCREENING CHF, PM at ERI LV dys-synchrony n = 56SUCCESSFUL IMPLANT N = 44NYHA III (37)/IV (7) LVEF 25 9% IV Delay 57 24ms LVPE Delay 202 38ms 23 DDDR (SR) 21 VVIR (AF)M0 RANDOMIZATIONRVBiVM3 EVALUATIONBiVRVM6 EVALUATIONUpgrade at Battery Depletion, Randomized Crossover TrialUpgrade from RV to BiVPacing RD-CHF Study: ResultsCazeauS, 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%