心脏再同步治疗反应评估与电机械激活映射在 24 小时内设备植入：一项试点研究。
Cardiac Resynchronization Therapy Response Assessment with Electromechanical Activation Mapping within 24 Hours of Device Implantation: A Pilot Study.
机构信息
Ultrasound Elasticity Imaging Laboratory, Department of Biomedical Engineering, Columbia University, New York, New York.
Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York.
出版信息
J Am Soc Echocardiogr. 2021 Jul;34(7):757-766.e8. doi: 10.1016/j.echo.2021.02.012. Epub 2021 Mar 4.
BACKGROUND
Cardiac resynchronization therapy (CRT) response assessment relies on the QRS complex narrowing criterion. Yet one third of patients do not improve despite narrowed QRS after implantation. Electromechanical wave imaging (EWI) is a quantitative echocardiography-based technique capable of noninvasively mapping cardiac electromechanical activation in three dimensions. The aim of this exploratory study was to investigate the EWI technique, sensitive to ventricular dyssynchrony, for informing CRT response on the day of implantation.
METHODS
Forty-four patients with heart failure with left bundle branch block or right ventricular (RV) paced rhythm and decreased left ventricular ejection fraction (LVEF; mean, 25.3 ± 9.6%) underwent EWI without and with CRT within 24 hours of device implantation. Of those, 16 were also scanned while in left ventricular (LV) pacing. Improvement in LVEF at 3-, 6-, or 9-month follow-up defined (1) super-responders (ΔLVEF ≥ 20%), (2) responders (10% ≤ ΔLVEF < 20%), and (3) nonresponders (ΔLVEF ≤ 5%). Three-dimensionally rendered electromechanical maps were obtained under RV, LV, and biventricular CRT pacing conditions. Mean RV free wall and LV lateral wall activation times were computed. The percentage of resynchronized myocardium was measured by quantifying the percentage of the left ventricle activated within 120 msec of QRS onset. Correlations between percentage of resynchronized myocardium and type of CRT response were assessed.
RESULTS
LV lateral wall activation time was significantly different (P ≤ .05) among all three pacing conditions in the 16 patients: LV lateral wall activation time with CRT in biventricular pacing (73.1 ± 17.6 msec) was lower compared with LV pacing (89.5 ± 21.5 msec) and RV pacing (120.3 ± 17.8 msec). Retrospective analysis showed that the percentage of resynchronized myocardium with CRT was a reliable response predictor within 24 hours of implantation for significantly (P ≤ .05) identifying super-responders (n = 7; 97.7 ± 1.9%) from nonresponders (n = 17; 89.9 ± 9.9%).
CONCLUSION
Electromechanical activation mapping constitutes a valuable three-dimensional visualization tool within 24 hours of implantation and could potentially aid in the timely assessment of CRT response rates, including during implantation for adjustment of lead placement and pacing outcomes.
背景
心脏再同步治疗（CRT）反应评估依赖于 QRS 波群变窄标准。然而，三分之一的患者尽管植入后 QRS 变窄但仍未得到改善。机电波成像（EWI）是一种基于定量超声心动图的技术，能够无创地在三维空间中绘制心脏机电激活图。本探索性研究的目的是研究 EWI 技术，该技术对心室不同步敏感，可在植入当日提供 CRT 反应信息。
方法
44 例心力衰竭伴左束支传导阻滞或右心室（RV）起搏节律和左心室射血分数（LVEF）降低（平均 25.3±9.6%）的患者在植入设备后 24 小时内接受了 EWI 检查，其中 16 例还在左心室（LV）起搏时进行了扫描。随访 3、6 和 9 个月时 LVEF 的改善定义为（1）超应答者（ΔLVEF≥20%），（2）应答者（10%≤ΔLVEF<20%）和（3）无应答者（ΔLVEF≤5%）。在 RV、LV 和双心室 CRT 起搏条件下获得三维呈现的机电图。计算 RV 游离壁和 LV 外侧壁激活时间。通过测量 QRS 起始后 120 毫秒内激活的左心室百分比来量化同步心肌的百分比。评估同步心肌百分比与 CRT 反应类型之间的相关性。
结果
在 16 例患者的所有三种起搏条件下，LV 外侧壁激活时间均存在显著差异（P≤.05）：双心室起搏时的 LV 外侧壁激活时间（73.1±17.6 msec）低于 LV 起搏（89.5±21.5 msec）和 RV 起搏（120.3±17.8 msec）。回顾性分析显示，植入后 24 小时内 CRT 时的同步心肌百分比是一种可靠的反应预测指标，可显著（P≤.05）将超应答者（n=7；97.7±1.9%）与无应答者（n=17；89.9±9.9%）区分开来。
结论
机电激活图构成了植入后 24 小时内有价值的三维可视化工具，有可能有助于及时评估 CRT 反应率，包括在植入期间调整导联放置和起搏效果。
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