Foley Paul W X, Muhyaldeen Sahrkaur A, Chalil Shajil, Smith Russell E A, Sanderson John E, Leyva Francisco
Department of Cardiology, University of Birmingham, Good Hope Hospital, Rectory Road, Sutton Coldfield, Birmingham, West Midlands B75 7RR, UK.
Europace. 2009 Apr;11(4):495-501. doi: 10.1093/europace/eup037.
To determine the effects of upgrading from right ventricular (RV) pacing to cardiac resynchronization therapy (CRT) in patients with heart failure.
Patients with heart failure [age 67.3 +/- 9.6 years (mean +/- SD), NYHA class III or IV, left ventricular ejection fraction (LVEF) <or= 35%, QRS >or= 120 ms] underwent de novo CRT (n = 336) or upgrading from RV pacing [n = 58; VVIR in 24, DDDR in 34] to CRT. The endpoint of death from any cause or major cardiovascular events, cardiovascular death or hospitalization for heart failure, and cardiovascular death or death from any cause was determined after a maximum follow-up of 7.7 years. No differences emerged between the de novo CRT and the upgrade-to-CRT groups with respect to any of the clinical endpoints. The de novo CRT and upgrade-to-CRT groups derived similar improvements in NYHA class [-1.2 vs. -1.3 (mean), both P < 0.0001), 6 min walking distance [75.9 (P < 0.0001) vs. 46.4 (P = 0.0205) m], and quality of life scores [-25.2 vs. -18.7 (both P < 0.0001)] 1 year after implantation. Response rates using a combined clinical score (>or=1 NYHA classes or >or=25% increase in 6 min walking distance plus survival with freedom from heart failure hospitalizations for 1 year) were 73.2% and 75.4%, respectively (P = NS). There were reductions in left ventricular end-systolic volume [median of 20.3 mL (P = 0.0012) and 22.7 mL (P = 0.0066), respectively] and improvements in LVEF [median of 2.9% and 9.3%, respectively (both P < 0.0001)].
In patients with heart failure who are RV-paced, upgrading to CRT is associated with a similar long-term risk of mortality and morbidity to patients undergoing de novo CRT. Symptomatic improvements and degree of reverse remodelling are also comparable.
确定心力衰竭患者从右心室起搏升级为心脏再同步治疗（CRT）的效果。
心力衰竭患者[年龄67.3±9.6岁（均值±标准差），纽约心脏协会（NYHA）心功能分级III或IV级，左心室射血分数（LVEF）≤35%，QRS波时限≥120毫秒]接受初次CRT治疗（n = 336）或从右心室起搏升级为CRT治疗[n = 58；其中VVIR模式24例，DDDR模式34例]。在最长7.7年的随访后，确定任何原因导致的死亡或重大心血管事件、心血管死亡或因心力衰竭住院以及心血管死亡或任何原因导致的死亡等终点事件。初次CRT治疗组和升级为CRT治疗组在任何临床终点方面均未出现差异。初次CRT治疗组和升级为CRT治疗组在植入后1年时，NYHA心功能分级均有相似改善[-1.2对-1.3（均值），P均<0.0001]，6分钟步行距离分别增加[75.9（P<0.0001）米对46.4（P = 0.0205）米]，生活质量评分分别降低[-25.2对-18.7（P均<0.0001）]。使用综合临床评分（≥1个NYHA心功能分级或6分钟步行距离增加≥25%加上1年内心力衰竭未住院存活）的反应率分别为73.2%和75.4%（P = 无显著差异）。左心室收缩末期容积均有所减少[中位数分别为20.3毫升（P = 0.0012）和22.7毫升（P = 0.0066）]，LVEF均有所改善[中位数分别为2.9%和9.3%（P均<0.0001）]。
在接受右心室起搏的心力衰竭患者中，升级为CRT治疗与接受初次CRT治疗的患者具有相似的长期死亡和发病风险。症状改善和逆向重构程度也相当。
