Haghjoo Majid, Bonakdar Hamid Reza, Jorat Mohammad Vahid, Fazelifar Amir Farjam, Alizadeh Abolfath, Ojaghi-Haghjghi Zahra, Esmaielzadeh Maryam, Sadr-Ameli Mohammad Ali
Department of Pacemaker and Electrophysiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, PO Box: 15745-1341, Mellat Park, Vali-E-Asr Avenue, Tehran 1996911151, Iran.
Europace. 2009 Mar;11(3):356-63. doi: 10.1093/europace/eun375. Epub 2009 Jan 9.
It is currently recommended to implant the left ventricular (LV) pacing lead at the lateral wall. However, the optimal right ventricular (RV) pacing lead location for cardiac resynchronization therapy (CRT) remains controversial. We sought to investigate whether optimizing the site for placement of the RV lead could further improve the long-term response to CRT in patients with advanced heart failure.
Between October 2006 and December 2007, a total of 73 consecutive patients with standard indication for CRT were enrolled. The enrolled patients were divided into two groups based on the RV lead location. There were 50 patients in RV apex (RVA) group and 23 patients in RV high septum (RVHS). The primary study endpoint was a decrease in LV end-systolic volume (LVESV) by >15% at 6-month follow-up. The secondary endpoints were improvement in New York Heart Association (NYHA) class by >or=1 point and decrease in brain-type natriuretic peptide (BNP) levels by >50% after CRT. At 6-month follow-up, improvement in NYHA class by >or=1 point (RVA: 72% vs. RVHS: 74%, P = 0.76), decrease in LVESV by >or=15% (RVA: 65% vs. RVHS: 64%, P = 0.76), and decrease in BNP level by >50% (RVA: 70% vs. RVHS: 69%, P = 0.88) were observed in similar proportion of the two groups. When we separately assessed the significance of RV pacing site in three LV stimulation sites, there were no significant differences in terms of clinical improvement (62 vs. 64%, P = 0.74) and decrease in LVESV by >15% (63 vs. 62%, P = 0.78) between RVA and RVHS pacing when the LV stimulation site was lateral cardiac vein. In anterolateral vein pacing site, the RVA stimulation was associated with higher clinical (88 vs. 47%, P = 0.05), echocardiographic (75 vs. 32%, P = 0.02), and neurohormonal responses (80 vs. 50%, P = 0.04) compared with that in RVHS site. When LV was paced from posterolateral vein, RVHS pacing was superior to RVA in terms of the clinical improvement (85 vs. 35%, P = 0.01), echocardiographic response (72 vs. 30%, P = 0.01), and decrease in BNP levels (75 vs. 50%, P = 0.04).
The present study did not show any difference between RVA and RVHS pacing sites in terms of overall improvement in clinical outcome and LV reverse remodelling following CRT. However, effect of RV lead location on CRT response varies depending on LV stimulation site.
目前建议将左心室（LV）起搏导线植入侧壁。然而，心脏再同步治疗（CRT）中右心室（RV）起搏导线的最佳位置仍存在争议。我们试图研究优化RV导线植入部位是否能进一步改善晚期心力衰竭患者对CRT的长期反应。
2006年10月至2007年12月，共纳入73例符合CRT标准适应证的连续患者。根据RV导线位置将入选患者分为两组。右心室心尖部（RVA）组50例，右心室高间隔部（RVHS）组23例。主要研究终点是随访6个月时左心室收缩末期容积（LVESV）减少>15%。次要终点是CRT后纽约心脏协会（NYHA）心功能分级改善≥1级以及脑钠肽（BNP）水平降低>50%。随访6个月时，两组中NYHA心功能分级改善≥1级（RVA组：72% vs. RVHS组：74%，P = 0.76）、LVESV减少≥15%（RVA组：65% vs. RVHS组：64%，P = 0.76）以及BNP水平降低>50%（RVA组：70% vs. RVHS组：69%，P = 0.88）的比例相似。当我们分别评估三个LV刺激部位中RV起搏部位的意义时，在左心室刺激部位为心侧静脉时，RVA起搏与RVHS起搏在临床改善（62% vs. 64%，P = 0.74）以及LVESV减少>15%（63% vs. 62%，P = 0.78）方面无显著差异。在前外侧静脉起搏部位，与RVHS部位相比，RVA刺激的临床反应（88% vs. 47%，P = 0.05）、超声心动图反应（75% vs. 32%，P = 0.02）和神经激素反应（80% vs. 50%，P = 0.04）更高。当从后外侧静脉起搏左心室时，就临床改善（85% vs. 35%，P = 0.01）、超声心动图反应（72% vs. 30%，P = 0.01）和BNP水平降低（75% vs. 50%，P = 0.04）而言，RVHS起搏优于RVA起搏。
本研究未显示RVA和RVHS起搏部位在CRT后临床结局的总体改善和左心室逆向重构方面存在任何差异。然而，RV导线位置对CRT反应的影响因左心室刺激部位而异。
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