Derval Nicolas, Bordachar Pierre, Lim Han S, Sacher Frederic, Ploux Sylvain, Laborderie Julien, Steendijk Paul, Deplagne Antoine, Ritter Philippe, Garrigue Stephane, Denis Arnaud, Hocini Mélèze, Haissaguerre Michel, Clementy Jacques, Jaïs Pierre
Hopital Cardiologique du Haut Lévêque, CHU Bordeaux, Pessac, France.
Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
J Cardiovasc Electrophysiol. 2014 Sep;25(9):1012-1020. doi: 10.1111/jce.12464. Epub 2014 Jul 24.
Recent studies have demonstrated that left ventricular (LV) pacing site is a critical parameter in optimizing cardiac resynchronization therapy (CRT). The present study evaluates the effect of pacing from different LV locations on QRS duration (QRSd) and their relationship to acute hemodynamic response in congestive heart failure patients.
Thirty-five patients with nonischemic dilated cardiomyopathy and left bundle branch block referred for CRT device implantation were studied. Eleven predetermined LV pacing sites were systematically assessed in random order: epicardial: coronary sinus (CS); endocardial: basal and mid-cavity (septal, anterior, lateral, and inferior), apex, and the endocardial site facing the CS pacing site. For each patient QRSd and +dP/dtmax during baseline (AAI) and DDD LV pacing at 2 atrioventricular delays were compared. Response to CRT was significantly better in patients with wider baseline QRSd (≥150 milliseconds). Hemodynamic response was inversely correlated to increase of QRSd during LV pacing (short atrioventricular [AV] delay: r = 0.44, P < 0.001; long AV delay: r = 0.59, P < 0.001). Compared to baseline, LV pacing at the site of shortest QRSd significantly improved +dP/dtmax (+18 ± 25%, P < 0.001) but was not superior to other conventional strategy (lateral wall, CS pacing, and echo-guided) and was inferior to a hemodynamically guided strategy.
In our study, we have demonstrated that changes of QRSd during LV pacing correlated with acute hemodynamic response and that LV pacing location was a primary determinant of paced QRSd. Although QRSd did not predict the maximum hemodynamic response, our results confirm the link between electrical activation and hemodynamic response of the LV during CRT.
最近的研究表明，左心室（LV）起搏部位是优化心脏再同步治疗（CRT）的关键参数。本研究评估了不同左心室部位起搏对充血性心力衰竭患者QRS波时限（QRSd）的影响及其与急性血流动力学反应的关系。
对35例因CRT装置植入而转诊的非缺血性扩张型心肌病和左束支传导阻滞患者进行了研究。以随机顺序系统评估了11个预先确定的左心室起搏部位：心外膜：冠状窦（CS）；心内膜：基底部和心腔中部（间隔、前壁、侧壁和下壁）、心尖，以及与CS起搏部位相对的心内膜部位。比较了每位患者在基线（AAI）时以及在2种房室延迟下进行DDD左心室起搏时的QRSd和 +dP/dtmax。基线QRSd较宽（≥150毫秒）的患者对CRT的反应明显更好。血流动力学反应与左心室起搏期间QRSd的增加呈负相关（短房室 [AV] 延迟：r = 0.44，P < 0.001；长AV延迟：r = 0.59，P < 0.001）。与基线相比，在QRSd最短的部位进行左心室起搏显著改善了 +dP/dtmax（+18 ± 25%，P < 0.001），但并不优于其他传统策略（侧壁、CS起搏和超声引导），且不如血流动力学引导策略。
在我们的研究中，我们证明了左心室起搏期间QRSd的变化与急性血流动力学反应相关，并且左心室起搏部位是起搏QRSd的主要决定因素。虽然QRSd不能预测最大血流动力学反应，但我们的结果证实了CRT期间左心室电激活与血流动力学反应之间的联系。
