Mair Helmut, Sachweh Joerg, Meuris Bart, Nollert Georg, Schmoeckel Michael, Schuetz Albert, Reichart Bruno, Daebritz Sabine
Department of Cardiac Surgery, University of Munich, Marchioninistr. 15, 81377 Munich, Germany.
Eur J Cardiothorac Surg. 2005 Feb;27(2):235-42. doi: 10.1016/j.ejcts.2004.09.029.
Biventricular pacing has demonstrated improvement in cardiac function in treating congestive heart failure (CHF). Two different operative strategies (coronary sinus vs. epicardial stimulation) for left ventricular (LV) pacing were compared.
Since April 1999, a total of 86 patients (pts, age: 63+/-10 years) with depressed systolic LV function (mean ejection fraction 24+/-9%), left bundle-branch-block (mean QRS 182+/-22 ms) and congestive heart failure NYHA III or higher were enrolled. For biventricular stimulation coronary sinus (CS) leads were placed in 79 pts. Nine of these devices were converted to surgical epicardial LV-leads, because of CS-lead failure. In 7 patients epicardial LV-leads were initially implanted surgically, accounting for a total of 16 pts with surgical placed epicardial steroid-eluting LV-leads. For these, a limited left-lateral thoracotomy (7+/-4 cm) was used. Thirty-three (38%) pts had an indication for a defibrillator. The mean follow-up time was 16.4+/-15.4 months (0.1-45 months), representing 107.1 patient-years.
In the biventricular pacing mode, QRS duration decreased to 143+/-16 ms (P<0.001). Threshold capture of the CS-leads increased significantly compared to surgically placed epicardial leads (18 month control: 2.2+/-1.4V/0.5 ms vs. 0.7+/-0.3V/0.5 ms), which had no increase in threshold (P<0.001). At the 18 month follow-up 7 CS-leads had a threshold of >4V/0.5 ms vs. epicardial leads which were under 1.1V/0.5 ms, except for one (1.8V/0.5 ms). After CS-lead implantation 25 LV-lead related complications occurred, (failed implantation, CS-dissection, loss of pacing capture, diaphragm stimulation or lead dislodgment), vs. one dislodgement after surgical epicardial lead placement (P<0.05). Correct lead positioning (obtuse marginal branch area) was achieved in all surgical epicardial placements but only in 70% with CS-leads (P<0.03). In the follow up period, 9 pts died (4 cardiac related). Heart transplantation was necessary in 4 pts due to deterioration of the cardiomyopathy.
Surgical epicardial lead placement revealed excellent long-term results and a lower LV-related complication rate compared to CS-leads. Although, the approach via limited thoracotomy for biventricular pacing is associated with 'more surgery', it is a safe and reliable technique and should be considered as an equal alternative.
双心室起搏已证明在治疗充血性心力衰竭（CHF）方面可改善心脏功能。比较了两种不同的左心室（LV）起搏手术策略（冠状窦起搏与心外膜刺激）。
自1999年4月以来，共纳入86例患者（年龄：63±10岁），其左心室收缩功能降低（平均射血分数24±9%），左束支传导阻滞（平均QRS波时限182±22毫秒），且为纽约心脏协会（NYHA）III级或更高等级的充血性心力衰竭患者。对于双心室刺激，79例患者植入了冠状窦（CS）导线。其中9例因CS导线故障而转换为手术植入的心外膜左心室导线。7例患者最初通过手术植入心外膜左心室导线，共有16例患者通过手术植入了带类固醇洗脱的左心室心外膜导线。对于这些患者，采用有限的左外侧开胸手术（7±4厘米）。33例（38%）患者有植入除颤器的指征。平均随访时间为16.4±15.4个月（0.1 - 45个月），总计107.1患者年。
在双心室起搏模式下，QRS波时限降至143±16毫秒（P<0.001）。与手术植入的心外膜导线相比，CS导线的阈值捕获显著增加（18个月时对照：2.2±1.4V/0.5毫秒 vs. 0.7±0.3V/0.5毫秒），而心外膜导线阈值无增加（P<0.001）。在18个月随访时，7根CS导线的阈值>4V/0.5毫秒，而心外膜导线除1根（1.8V/0.5毫秒）外均低于1.1V/0.5毫秒。植入CS导线后发生25例左心室导线相关并发症（植入失败、CS夹层、起搏捕获丧失、膈肌刺激或导线脱位），而手术植入心外膜导线后发生1例脱位（P<0.05）。所有手术植入的心外膜导线均实现了正确的导线定位（钝缘支区域），但CS导线仅70%实现了正确定位（P<0.03）。在随访期间，9例患者死亡（4例与心脏相关）。4例患者因心肌病恶化需要进行心脏移植。
与CS导线相比，手术植入心外膜导线显示出优异的长期效果和较低的左心室相关并发症发生率。尽管通过有限开胸进行双心室起搏的方法涉及“更多手术操作”，但它是一种安全可靠的技术，应被视为同等的替代方法。
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