心脏再同步治疗中多部位起搏益处的机制性见解：电基质和左心室激活速率的重要性。
Mechanistic insights into the benefits of multisite pacing in cardiac resynchronization therapy: The importance of electrical substrate and rate of left ventricular activation.
作者信息
Sohal Manav, Shetty Anoop, Niederer Steven, Lee Angela, Chen Zhong, Jackson Tom, Behar Jonathan M, Claridge Simon, Bostock Julian, Hyde Eoin, Razavi Reza, Prinzen Frits, Rinaldi C Aldo
机构信息
Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom; Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom,.
Division of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom.
出版信息
Heart Rhythm. 2015 Dec;12(12):2449-57. doi: 10.1016/j.hrthm.2015.07.012. Epub 2015 Jul 9.
BACKGROUND
Multisite pacing (MSP) of the left ventricle is proposed as an alternative to conventional single-site LV pacing in cardiac resynchronization therapy (CRT). Reports on the benefits of MSP have been conflicting. A paradigm whereby not all patients derive benefit from MSP is emerging.
OBJECTIVE
We sought to compare the hemodynamic and electrical effects of MSP with the aim of identifying a subgroup of patients more likely to derive benefit from MSP.
METHODS
Sixteen patients with implanted CRT systems incorporating a quadripolar LV pacing lead were studied. Invasive hemodynamic and electroanatomic assessment was performed during the following rhythms: baseline (non-CRT); biventricular (BIV) pacing delivered via the implanted CRT system (BIV(implanted)); BIV pacing delivered via an alternative temporary LV lead (BIV(alternative)); dual-vein MSP delivered via 2 LV leads; MultiPoint Pacing delivered via 2 vectors of the quadripolar LV lead.
RESULTS
Seven patients had an acute hemodynamic response (AHR) of <10% over baseline rhythm with BIV(implanted) and were deemed nonresponders. AHR in responders vs nonresponders was 21.4% ± 10.4% vs 2.0% ± 5.2% (P < .001). In responders, neither form of MSP provided incremental hemodynamic benefit over BIV(implanted). Dual-vein MSP (8.8% ± 5.7%; P = .036 vs BIV(implanted)) and MultiPoint Pacing (10.0% ± 12.2%; P = .064 vs BIV(implanted)) both improved AHR in nonresponders. Seven of 9 responders to BIV(implanted) had LV endocardial activation characterized by a functional line of block during intrinsic rhythm that was abolished with BIV pacing. All these patients met strict criteria for left bundle branch block (LBBB). No nonresponders exhibited this line of block or met strict criteria for LBBB.
CONCLUSION
Patients not meeting strict criteria for LBBB appear most likely to derive benefit from MSP.
背景
在心脏再同步治疗（CRT）中，左心室多部位起搏（MSP）被提议作为传统单部位左心室起搏的替代方法。关于MSP益处的报道一直存在矛盾。一种并非所有患者都能从MSP中获益的模式正在出现。
目的
我们试图比较MSP的血流动力学和电学效应，以确定更可能从MSP中获益的患者亚组。
方法
对16例植入了包含四极左心室起搏导线的CRT系统的患者进行研究。在以下节律期间进行有创血流动力学和电解剖评估：基线（非CRT）；通过植入的CRT系统进行双心室（BIV）起搏（BIV（植入））；通过替代的临时左心室导线进行BIV起搏（BIV（替代））；通过2根左心室导线进行双静脉MSP；通过四极左心室导线的2个向量进行多点起搏。
结果
7例患者在BIV（植入）时相对于基线节律的急性血流动力学反应（AHR）<10%，被视为无反应者。有反应者与无反应者的AHR分别为21.4%±10.4%和2.0%±5.2%（P<.001）。在有反应者中，两种形式的MSP均未比BIV（植入）提供更多的血流动力学益处。双静脉MSP（8.8%±5.7%；与BIV（植入）相比，P=.036）和多点起搏（10.0%±12.2%；与BIV（植入）相比，P=.064）均改善了无反应者的AHR。9例对BIV（植入）有反应的患者中有7例在自身节律期间左心内膜激活的特征为功能性阻滞线，该阻滞线在BIV起搏时消失。所有这些患者均符合左束支传导阻滞（LBBB）的严格标准。无反应者均未表现出这种阻滞线或符合LBBB的严格标准。
结论
未符合LBBB严格标准的患者似乎最有可能从MSP中获益。
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