Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom; National University Heart Centre, Singapore.
Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom.
Int J Cardiol. 2014 Feb 1;171(2):184-91. doi: 10.1016/j.ijcard.2013.11.128. Epub 2013 Dec 7.
Patients with congenitally corrected transposition of the great arteries (ccTGA) are at high risk of heart block requiring subpulmonary left ventricular (LV) pacing. Long-term right ventricular (RV) pacing in congenitally normal hearts is associated with LV dysfunction. We examined the effects of univentricular subpulmonary LV pacing on the systemic RV in a ccTGA cohort.
ccTGA patients with two echocardiographic studies at least 6 months apart were included. Records of 52 patients, 22 with pacing, were retrospectively reviewed. Seven patients with biventricular pacing were included for comparison.
The LV-Paced Group experienced deterioration in the RV fractional area change (RVFAC) (28.7 ± 10.0 vs. 21.9 ± 9.1%; P=0.003), systemic atrioventricular valve regurgitation (P=0.019) and RV dilatation (end-diastolic area 32.7 ± 8.7 vs. 37.2 ± 9.0 cm(2); P=0.004). There was a corresponding deterioration in NYHA class (P=0.013). Multivariate Cox regression analysis showed that pacing was an independent predictor of deteriorating RV function and RV dilation (hazard ratio 2.7(10-7.0) and 4.7(1.1-20.6) respectively). None of these parameters changed significantly in the Un-paced Group. The CRT Group showed improvement in RVFAC (22.0% to 30.7% (P=0.030) and NYHA class (P=0.030), despite having lower baseline RVFAC (22.0±5.7 vs. 31 ± 9.7%; P=0.025) and greater dyssynchrony (RV total isovolumic time 13.4 ± 2.1 vs. 9.3 ± 4.2s/min; P=0.016) when compared to the Un-Paced Group.
Univentricular subpulmonary LV pacing in patients with ccTGA predicted deterioration in RV function and RV dilatation over time associated with deteriorating NYHA class. Alternative primary pacing strategies such as biventricular pacing may need consideration in this vulnerable group already highly prone to mortality from systemic RV failure.
患有先天性矫正性大动脉转位（ccTGA）的患者存在需要肺动脉瓣下左心室（LV）起搏的心脏传导阻滞的高风险。在先天性正常心脏中，长期右心室（RV）起搏与 LV 功能障碍有关。我们在 ccTGA 队列中研究了单心室肺动脉瓣下 LV 起搏对系统 RV 的影响。
至少有两次超声心动图研究相隔 6 个月的 ccTGA 患者被纳入。回顾性分析了 52 例患者的记录，其中 22 例接受了起搏治疗。为了比较，还纳入了 7 例双心室起搏患者。
LV 起搏组的 RV 射血分数（RVFAC）（28.7±10.0 比 21.9±9.1%；P=0.003）、系统房室瓣反流（P=0.019）和 RV 扩张（舒张末期面积 32.7±8.7 比 37.2±9.0cm2；P=0.004）恶化。NYHA 分级也相应恶化（P=0.013）。多变量 Cox 回归分析显示，起搏是 RV 功能和 RV 扩张恶化的独立预测因素（危险比分别为 2.7（10-7.0）和 4.7（1.1-20.6））。在未起搏组中，这些参数均无显著变化。尽管 CRT 组的基线 RVFAC（22.0%±5.7 比 31±9.7%；P=0.025）和更明显的不同步（RV 总等容收缩时间 13.4±2.1 比 9.3±4.2s/min；P=0.016）较低，但 RVFAC（22.0%至 30.7%（P=0.030）和 NYHA 分级（P=0.030）有所改善。与未起搏组相比。
ccTGA 患者的单心室肺动脉瓣下左心室起搏预测随着时间的推移 RV 功能和 RV 扩张的恶化，NYHA 分级恶化。在这个已经容易因全身 RV 衰竭而死亡的高危组中，可能需要考虑替代的主要起搏策略，如双心室起搏。
