心脏再同步治疗除颤器在永久性心房颤动患者中的应用。
Cardiac resynchronization therapy defibrillators in patients with permanent atrial fibrillation.
机构信息
Department of Advanced Biomedical Sciences, Federico II University of Naples, Corso Umberto I, 40, Naples, 80138, Italy.
Villa Maria Care & Research, Cotignola, Italy.
出版信息
ESC Heart Fail. 2021 Dec;8(6):5204-5212. doi: 10.1002/ehf2.13599. Epub 2021 Sep 12.
AIMS
There are conflicting data on the benefit of cardiac resynchronization therapy (CRT) in heart failure (HF) patients with permanent atrial fibrillation (AF). We aimed to compare patient outcomes according to the presence or absence of permanent AF at device implantation.
METHODS AND RESULTS
We retrospectively analysed remote monitoring data from 1141 CRT defibrillators. Propensity score with inverse-probability weighting method was used to balance AF and sinus rhythm (SR) groups. Analysis endpoints included total mortality, appropriate defibrillation shocks, and CRT percentage. There were 229 patients (20.1%) in the AF group and 912 patients (79.9%) in the SR group. Compared with SR patients, AF patients were older (median age, 77 vs. 72 years, P < 0.001), more frequently male (82.5% vs. 75.5%, P = 0.02), and had higher heart rate (75.7 vs. 71.0 b.p.m., P < 0.001). Of the 229 AF patients, 162 (70.7%) received suboptimal CRT (<98%) and 67 (29.3%) had adequate CRT (≥98%). During a median follow-up of 24 months, total mortality did not differ between AF and SR groups (propensity-score-weighted hazard ratio, HR 1.32 [95% confidence interval, 0.82-2.15], P = 0.25). The risk of appropriate shocks was significantly higher in the AF group with <98% CRT than in the SR group (weighted-HR, 1.99 [1.21-3.26], P = 0.006) and was similar in the AF group with ≥98% CRT versus the SR group (1.29 [0.66-2.53], P = 0.45). During follow-up, sinus rhythm was recovered in 23 patients in the AF group (10%) after a median time of 106 (42-256) days. The rate of sinus rhythm recovery in the AF group was 4.5 (95% CI, 2.8-6.7) per 100 patient-years; the rate of permanent AF occurrence in the SR group was 2.5 (95% CI, 1.9-3.3) per 100 patient-years.
CONCLUSIONS
Although mortality was similar across patient groups, patients with permanent AF and suboptimal CRT had twofold higher risk of appropriate shocks than SR patients or AF patients with CRT ≥ 98%.
目的
心脏再同步治疗（CRT）在永久性心房颤动（AF）心力衰竭（HF）患者中的获益存在矛盾的数据。我们旨在根据植入设备时是否存在永久性 AF 来比较患者的结局。
方法和结果
我们回顾性分析了 1141 例 CRT 除颤器的远程监测数据。使用逆概率加权法进行倾向评分以平衡 AF 和窦性节律（SR）组。分析终点包括总死亡率、适当的除颤电击和 CRT 百分比。AF 组有 229 例患者（20.1%），SR 组有 912 例患者（79.9%）。与 SR 患者相比，AF 患者年龄更大（中位数年龄，77 岁 vs. 72 岁，P < 0.001），更常为男性（82.5% vs. 75.5%，P = 0.02），心率更高（75.7 次/分 vs. 71.0 次/分，P < 0.001）。229 例 AF 患者中，162 例（70.7%）接受了亚最佳 CRT（<98%），67 例（29.3%）接受了充分 CRT（≥98%）。在中位随访 24 个月期间，AF 组和 SR 组的总死亡率无差异（倾向评分加权风险比，HR 1.32 [95%置信区间，0.82-2.15]，P = 0.25）。在 CRT <98%的 AF 组中，适当电击的风险明显高于 SR 组（加权 HR，1.99 [1.21-3.26]，P = 0.006），而在 CRT ≥98%的 AF 组与 SR 组相似（1.29 [0.66-2.53]，P = 0.45）。在随访期间，AF 组中有 23 例（10%）患者在中位数为 106（42-256）天的时间后恢复了窦性节律。AF 组窦性节律恢复率为 4.5（95%CI，2.8-6.7）/100 患者年；SR 组永久性 AF 发生率为 2.5（95%CI，1.9-3.3）/100 患者年。
结论
尽管死亡率在各患者组之间相似，但永久性 AF 和 CRT 效果不佳的患者发生适当电击的风险是 SR 患者或 CRT ≥98%的 AF 患者的两倍。
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