优化左心室心内膜刺激在对心脏再同步治疗反应不佳的缺血性患者中优于优化的心外膜刺激：一项结合磁共振成像、电解剖接触标测和血流动力学研究以确定心内膜导线放置位置的研究

Optimized Left Ventricular Endocardial Stimulation Is Superior to Optimized Epicardial Stimulation in Ischemic Patients With Poor Response to Cardiac Resynchronization Therapy: A Combined Magnetic Resonance Imaging, Electroanatomic Contact Mapping, and Hemodynamic Study to Target Endocardial Lead Placement.

作者信息

Behar Jonathan M, Jackson Tom, Hyde Eoin, Claridge Simon, Gill Jaswinder, Bostock Julian, Sohal Manav, Porter Bradley, O'Neill Mark, Razavi Reza, Niederer Steve, Rinaldi Christopher Aldo

机构信息

Department of Imaging Sciences and Biomedical Engineering, King's College London & Guy's and St Thomas' Hospital, London, United Kingdom.

出版信息

JACC Clin Electrophysiol. 2016 Dec;2(7):799-809. doi: 10.1016/j.jacep.2016.04.006.

OBJECTIVES

The purpose of this study was to identify the optimal pacing site for the left ventricular (LV) lead in ischemic patients with poor response to cardiac resynchronization therapy (CRT).

BACKGROUND

LV endocardial pacing may offer benefit over conventional CRT in ischemic patients.

METHODS

We performed cardiac magnetic resonance, invasive electroanatomic mapping (EAM), and measured the acute hemodynamic response (AHR) in patients with existing CRT systems.

RESULTS

In all, 135 epicardial and endocardial pacing sites were tested in 8 patients. Endocardial pacing was superior to epicardial pacing with respect to mean AHR (% change in dP/dt vs. baseline) (11.81 [-7.2 to 44.6] vs. 6.55 [-11.0 to 19.7]; p = 0.025). This was associated with a similar first ventricular depolarization (Q-LV) (75 ms [13 to 161 ms] vs. 75 ms [25 to 129 ms]; p = 0.354), shorter stimulation-QRS duration (15 ms [7 to 43 ms] vs. 19 ms [5 to 66 ms]; p = 0.010) and shorter paced QRS duration (149 ms [95 to 218 ms] vs. 171 ms [120 to 235 ms]; p < 0.001). The mean best achievable AHR was higher with endocardial pacing (25.64 ± 14.74% vs. 12.64 ± 6.76%; p = 0.044). Furthermore, AHR was significantly greater pacing the same site endocardially versus epicardially (15.2 ± 10.7% vs. 7.6 ± 6.3%; p = 0.014) with a shorter paced QRS duration (137 ± 22 ms vs. 166 ± 30 ms; p < 0.001) despite a similar Q-LV (70 ± 38 ms vs. 79 ± 34 ms; p = 0.512). Lack of capture due to areas of scar (corroborated by EAM and cardiac magnetic resonance) was associated with a poor AHR.

CONCLUSIONS

In ischemic patients with poor CRT response, biventricular endocardial pacing is superior to epicardial pacing. This may reflect accessibility to sites that cannot be reached via coronary sinus anatomy and/or by access to more rapidly conducting tissue. Furthermore, guidance to the optimal LV pacing site may be aided by modalities such as cardiac magnetic resonance to target delayed activating sites while avoiding scar.

目的

本研究旨在确定心脏再同步治疗（CRT）反应不佳的缺血性患者左心室（LV）导线的最佳起搏部位。

背景

在缺血性患者中，左心室内膜起搏可能比传统CRT更具优势。

方法

我们对已有CRT系统的患者进行了心脏磁共振成像、有创电解剖标测（EAM），并测量了急性血流动力学反应（AHR）。

结果

共对8例患者的135个心外膜和心内膜起搏部位进行了测试。在心内膜起搏与心外膜起搏方面，平均AHR（dP/dt相对于基线的变化百分比）方面，心内膜起搏优于心外膜起搏（11.81 [-7.2至44.6] 对6.55 [-11.0至19.7]；p = 0.025）。这与相似的首次心室去极化（Q-LV）（75毫秒 [13至161毫秒] 对75毫秒 [25至129毫秒]；p = 0.354）、更短的刺激-QRS间期（15毫秒 [7至43毫秒] 对19毫秒 [5至66毫秒]；p = 0.010）以及更短的起搏QRS间期（149毫秒 [95至218毫秒] 对171毫秒 [120至235毫秒]；p < 0.001）相关。心内膜起搏的平均最佳可实现AHR更高（25.64 ± 14.74% 对12.64 ± 6.76%；p = 0.044）。此外，在同一部位心内膜起搏的AHR明显大于心外膜起搏（15.2 ± 10.7% 对7.6 ± 6.3%；p = 0.014），起搏QRS间期更短（137 ± 22毫秒对166 ± 30毫秒；p < 0.001），尽管Q-LV相似（70 ± 38毫秒对79 ± 34毫秒；p = 0.512）。由于瘢痕区域导致的夺获失败（经EAM和心脏磁共振成像证实）与不良的AHR相关。