Kamath Ganesh S, Cotiga Delia, Koneru Jayanthi N, Arshad Aysha, Pierce Walter, Aziz Emad F, Mandava Anisha, Mittal Suneet, Steinberg Jonathan S
Al-Sabah Arrhythmia Institute and Division of Cardiology, St. Luke's and Roosevelt Hospitals, Columbia University College of Physicians and Surgeons, New York, NY, USA.
J Am Coll Cardiol. 2009 Mar 24;53(12):1050-5. doi: 10.1016/j.jacc.2008.12.022.
This study sought to determine the incidence of ineffective capture using 12-lead Holter monitoring and to assess whether this affects response to cardiac resynchronization therapy (CRT).
Cardiac resynchronization therapy is used in patients with atrial fibrillation (AF), prolonged QRS duration, and heart failure in the setting of ventricular dysfunction. The percentage of ventricular pacing is used as an indicator of adequate biventricular (BiV) pacing. Although device counters show a high pacing percentage, there may be ineffective capture because of underlying fusion and pseudo-fusion beats.
We identified 19 patients (age 72 +/- 8 years, ejection fraction 18 +/- 5%), with permanent AF who underwent CRT. All patients received digoxin, beta-blockers, and amiodarone for rate control; device interrogation showed >90% BiV pacing. Patients had a 12-lead Holter monitor to assess the presence of effective (>90% fully paced beats/24 h) pacing. At 12 months post-CRT, the New York Heart Association functional class was reassessed and an echocardiogram was obtained and compared with pre-CRT.
Only 9 (47%) patients had effective pacing. The other 10 (53%) patients had 16.4 +/- 4.6% fusion and 23.5 +/- 8.7% pseudo-fusion beats. Long-term responders (> or =1 New York Heart Association functional class improvement) to CRT had a significantly higher percentage of fully paced beats (86.4 +/- 17.1% vs. 66.8 +/- 19.1%; p = 0.03) than nonresponders.
Pacing counters overestimate the degree of effective BiV pacing in patients with permanent AF undergoing CRT therapy. Only patients with complete capture responded clinically to CRT. These findings have important implications for the application of CRT to patients with permanent AF and heart failure.
本研究旨在确定使用12导联动态心电图监测无效夺获的发生率，并评估其是否影响心脏再同步治疗（CRT）的反应。
心脏再同步治疗用于患有心房颤动（AF）、QRS波时限延长且伴有心室功能障碍的心力衰竭患者。心室起搏百分比用作双心室（BiV）起搏充分性的指标。尽管设备计数器显示起搏百分比很高，但由于潜在的融合波和伪融合波，可能存在无效夺获。
我们纳入了19例接受CRT的永久性AF患者（年龄72±8岁，射血分数18±5%）。所有患者均接受地高辛、β受体阻滞剂和胺碘酮以控制心率；设备问询显示BiV起搏>90%。患者进行12导联动态心电图监测以评估有效起搏（>90%完全起搏搏动/24小时）的存在情况。在CRT治疗后12个月，重新评估纽约心脏协会功能分级，并获取超声心动图并与CRT治疗前进行比较。
仅9例（47%）患者有有效起搏。其他10例（53%）患者有16.4±4.6%的融合波和23.5±8.7%的伪融合波。CRT的长期反应者（纽约心脏协会功能分级改善≥1级）的完全起搏搏动百分比（86.4±17.1%对66.8±19.1%；p = 0.03）显著高于无反应者。
起搏计数器高估了接受CRT治疗的永久性AF患者有效BiV起搏的程度。只有完全夺获的患者对CRT有临床反应。这些发现对CRT在永久性AF和心力衰竭患者中的应用具有重要意义。
