Derval Nicolas, Duchateau Josselin, Mahida Saagar, Eschalier Romain, Sacher Frederic, Lumens Joost, Cochet Hubert, Denis Arnaud, Pillois Xavier, Yamashita Seigo, Komatsu Yuki, Ploux Sylvain, Amraoui Sana, Zemmoura Adlane, Ritter Philippe, Hocini Mélèze, Haissaguerre Michel, Jaïs Pierre, Bordachar Pierre
From the Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, LIRYC, L'Institut de rythmologie et modélisation cardiaque, Université de Bordeaux, France (N.D., J.D., F.S., J.L., H.C., A.D., X.P., S.Y., Y.K., S.P., S.A., A.Z., P.R., M. Hocini, M. Haissaguerre, P.J., P.B.); Liverpool Heart and Chest Hospital, Liverpool, United Kingdom (S.M.); CHU Clermont-Ferrand, Clermont-Ferrand, France (R.E.); and Maastricht University Medical Center, The Netherlands (J.L.).
Circ Arrhythm Electrophysiol. 2017 Jun;10(6). doi: 10.1161/CIRCEP.117.005073.
In contrast to patients with left bundle branch block (LBBB), heart failure patients with narrow QRS and nonspecific intraventricular conduction delay (NICD) display a relatively limited response to cardiac resynchronization therapy. We sought to compare left ventricular (LV) activation patterns in heart failure patients with narrow QRS and NICD to patients with LBBB using high-density electroanatomic activation maps.
Fifty-two heart failure patients (narrow QRS [n=18], LBBB [n=11], NICD [n=23]) underwent 3-dimensional electroanatomic mapping with a high density of mapping points (387±349 LV). Adjunctive scar imaging was available in 37 (71%) patients and was analyzed in relation to activation maps. LBBB patients typically demonstrated (1) a single LV breakthrough at the septum (38±15 ms post-QRS onset); (2) prolonged right-to-left transseptal activation with absence of direct LV Purkinje activity; (3) homogeneous propagation within the LV cavity; and (4) latest activation at the basal lateral LV. In comparison, both NICD and narrow QRS patients demonstrated (1) multiple LV breakthroughs along the posterior or anterior fascicles: narrow QRS versus LBBB, 5±2 versus 1±1; =0.0004; NICD versus LBBB, 4±2 versus 1±1; =0.001); (2) evidence of early/pre-QRS LV electrograms with Purkinje potentials; (3) rapid propagation in narrow QRS patients and more heterogeneous propagation in NICD patients; and (4) presence of limited areas of late activation associated with LV scar with high interindividual heterogeneity.
In contrast to LBBB patients, narrow QRS and NICD patients are characterized by distinct mechanisms of LV activation, which may predict poor response to cardiac resynchronization therapy.
与左束支传导阻滞（LBBB）患者相比，QRS波狭窄且伴有非特异性室内传导延迟（NICD）的心力衰竭患者对心脏再同步治疗的反应相对有限。我们试图使用高密度电解剖激动标测图比较QRS波狭窄且伴有NICD的心力衰竭患者与LBBB患者的左心室（LV）激动模式。
52例心力衰竭患者（QRS波狭窄[n = 18]、LBBB[n = 11]、NICD[n = 23]）接受了具有高密度标测点（左心室387±349个）的三维电解剖标测。37例（71%）患者可进行辅助瘢痕成像，并结合激动标测图进行分析。LBBB患者通常表现为：（1）左心室在室间隔处单一激动突破（QRS波起始后38±15毫秒）；（2）右向左经室间隔激动延长，无直接左心室浦肯野纤维活动；（3）左心室内激动均匀传播；（4）左心室基底部外侧最晚激动。相比之下，NICD和QRS波狭窄患者均表现为：（1）沿后束或前束有多个左心室激动突破：QRS波狭窄组与LBBB组分别为5±2个与1±1个，P = 0.0004；NICD组与LBBB组分别为4±2个与1±1个，P = 0.001）；（2）有早期/ QRS波前左心室电图及浦肯野电位；（3）QRS波狭窄患者激动传播迅速，NICD患者激动传播更不均匀；（4）存在与左心室瘢痕相关的有限晚期激动区域，个体间异质性高。
与LBBB患者相比，QRS波狭窄和NICD患者具有独特的左心室激动机制，这可能预示着对心脏再同步治疗反应不佳。
