Lieberman Randy, Padeletti Luigi, Schreuder Jan, Jackson Kenneth, Michelucci Antonio, Colella Andrea, Eastman William, Valsecchi Sergio, Hettrick Douglas A
Department of Cardiology, Harper University Hospital, Detroit, Michigan 48201, USA.
J Am Coll Cardiol. 2006 Oct 17;48(8):1634-41. doi: 10.1016/j.jacc.2006.04.099. Epub 2006 Sep 27.
We compared left ventricular (LV) systolic and diastolic function during right ventricular (RV), LV, and biventricular (BiV) pacing in patients with narrow QRS duration with and without LV dysfunction.
The optimal RV pacing lead location for patients with a standard indication for ventricular pacing remains controversial.
Left ventricular pressure and volume data were determined via conductance catheter during electrophysiology study in 31 patients divided into groups with ejection fraction (EF) > or =40% (n = 17) or EF <40% (n = 14). QRS duration was 91 +/- 18 versus 106 +/- 25 ms, respectively (p = NS). Hemodynamic data were recorded during atrial and dual chamber pacing from the RV apex, RV free wall, RV septum, LV free wall, and BiV.
In patients with EF > or =40%, RV pacing at 1 or more sites, but not LV free wall or BiV pacing, significantly (p < 0.05) impaired cardiac output (CO), stroke work (SW), EF, and LV relaxation compared with atrial overdrive pacing. Right ventricular pacing also impaired hemodynamics and LV function in patients with EF <40%. However, LV and BiV pacing increased CO, SW, EF, and LV +dP/dt(MAX) in patients with LV dysfunction. Left ventricular and BiV pacing enhanced an index of global LV cycle efficiency in patients with depressed EF. The detrimental hemodynamic effects of RV pacing were attenuated by selecting the optimal RV pacing site.
Right ventricular pacing worsens LV function in patients with and without LV dysfunction unless the RV pacing site is optimized. Left ventricular and BiV pacing preserve LV function in patients with EF >40% and improve function in patients with EF <40% despite no clinical indication for BiV pacing.
我们比较了QRS波时限狭窄且伴有或不伴有左心室功能障碍的患者在右心室（RV）、左心室（LV）和双心室（BiV）起搏时的左心室收缩和舒张功能。
对于有心室起搏标准适应证的患者，最佳右心室起搏导线位置仍存在争议。
在31例患者的电生理研究中，通过电导导管测定左心室压力和容积数据，这些患者被分为射血分数（EF）≥40%（n = 17）或EF<40%（n = 14）两组。QRS波时限分别为91±18毫秒和106±25毫秒（p = 无显著差异）。在心房和双腔起搏时，从右心室心尖、右心室游离壁、右心室间隔、左心室游离壁和双心室记录血流动力学数据。
在EF≥40%的患者中，与心房超速起搏相比，在1个或更多部位进行右心室起搏，但不是左心室游离壁或双心室起搏，显著（p<0.05）损害心输出量（CO）、每搏功（SW）、EF和左心室舒张功能。右心室起搏也损害了EF<40%患者的血流动力学和左心室功能。然而左心室和双心室起搏增加了左心室功能障碍患者的CO、SW、EF和左心室最大dp/dt。左心室和双心室起搏提高了EF降低患者的左心室整体循环效率指标。通过选择最佳右心室起搏部位，右心室起搏的有害血流动力学效应得到减弱。
除非优化右心室起搏部位，否则右心室起搏会使伴有或不伴有左心室功能障碍患者的左心室功能恶化。尽管双心室起搏无临床适应证，但左心室和双心室起搏可保留EF>40%患者的左心室功能，并改善EF<40%患者的功能。
