Parsai Chirine, Bijnens Bart, Sutherland George Ross, Baltabaeva Aigul, Claus Piet, Marciniak Maciej, Paul Vince, Scheffer Mike, Donal Erwan, Derumeaux Geneviève, Anderson Lisa
Department of Cardiology, St George's Hospital, Blackshaw Road, SW17 0QT London, UK.
Eur Heart J. 2009 Apr;30(8):940-9. doi: 10.1093/eurheartj/ehn481. Epub 2008 Nov 11.
To date, most published echocardiographic methods have assessed left ventricular (LV) dyssynchrony (DYS) alone as a predictor for response to cardiac resynchronization therapy (CRT). We hypothesized that the response is instead dictated by multiple correctable factors.
A total of 161 patients (66 +/- 10 years, EF 24 +/- 6%, QRS > 120 ms) were investigated pre- and post-CRT (median of 6 months). Reduction in NYHA Class >/=1 or LV reverse remodelling (end-systolic volume reduction >/= 10%) defined response. Four different pathological mechanisms were identified. Group1: LVDYS characterized by a pre-ejection septal flash (SF) (87 patients, 54%). Elimination of SF (77 of 87 patients) resulted in reverse remodelling in 100%. Group 2: short-AV delay (21 patients, 13%) resolution (19 of 21 patients) resulted in reverse remodelling in 16 of 19. Group 3: long-AV delay (16 patients, 10%) resolution (14 of 16 patients) resulted in NYHA Class reduction >/=1 in 11 with reverse remodelling in five patients. Group 4: exaggerated LV-RV interaction (15 patients, 9%) reduced post-CRT. All responded clinically with fall in pulmonary artery pressure (P = 0.003) but did not volume respond. Group 5: patients with none of the above correctable mechanisms (22 patients, 14%). None responded to CRT.
CRT response is dictated by correction of multiple independent mechanisms of which LVDYS is only one. Long-axis DYS measurements alone failed to detect 40% of responders.
迄今为止，大多数已发表的超声心动图方法仅将左心室（LV）不同步（DYS）评估为心脏再同步治疗（CRT）反应的预测指标。我们推测，反应实际上是由多个可纠正因素决定的。
共对161例患者（66±10岁，射血分数24±6%，QRS>120 ms）在CRT前后（中位数为6个月）进行了研究。纽约心脏协会（NYHA）心功能分级降低≥1级或左心室逆向重构（收缩末期容积减少≥10%）定义为反应。识别出四种不同的病理机制。第1组：以射血前期室间隔闪烁（SF）为特征的左心室不同步（87例患者，54%）。消除SF（87例患者中的77例）后，100%的患者出现逆向重构。第2组：短房室延迟（21例患者，13%）得到纠正（21例患者中的19例），19例中有16例出现逆向重构。第3组：长房室延迟（16例患者，10%）得到纠正（16例患者中的14例），11例患者的NYHA心功能分级降低≥1级，5例患者出现逆向重构。第4组：左心室-右心室相互作用过度（15例患者，9%）在CRT后减轻。所有患者临床症状均有改善，肺动脉压下降（P = 0.003），但容量反应不佳。第5组：无上述可纠正机制的患者（22例患者，14%）。无一例对CRT有反应。
CRT反应是由多种独立机制的纠正所决定的，其中左心室不同步只是其中之一。仅进行长轴不同步测量未能检测出40%的有反应者。
