Song Bing-Xue, Wang Xia-Xia, An Yi, Zhang Ying-Ying
Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China.
World J Clin Cases. 2022 Jul 16;10(20):7090-7096. doi: 10.12998/wjcc.v10.i20.7090.
Left bundle branch pacing (LBBP) is a physiological pacing method that has emerged in recent years. It is an ideal choice for patients with complete left bundle branch block who are in need of cardiac resynchronization therapy (CRT). Moreover, LBBP is superior in maintaining physiological ventricular activation and can effectively improve heart function and quality of life in patients with pacemaker-induced cardiomyopathy. However, LBBP in pacing-dependent patients who already have cardiac dysfunction has not been well assessed.
A 69-year-old male patient presented with symptoms of chest tightness, palpitation and systolic heart failure with New York Heart Association class III for 1 mo. The 12-lead electrocardiogram showed atrial fibrillation with third-degree atrioventricular block and ventricular premature beat. Holter revealed a right bundle branch block, atrial fibrillation with third-degree atrioventricular block, frequent multifocal ventricular premature beats, Ron-T and ventricular tachycardia. The echocardiogram documented an enlarged left atrium and left ventricle and a low left ventricular ejection fraction. Coronary angiography indicated a stenosis of 30% in the middle left anterior descending artery. Apparently, a CRT-D pacemaker was the best choice for this patient according to previous findings. However, the patient was worried about the financial burden. A single-chamber pacemaker with LBBP was selected, with the plan to take amiodarone and upgrade with dual-chamber implantable cardioverter-defibrillator or CRT-D at an appropriate time. During the follow-up at 3 mo after LBBP, the patient showed an improvement in cardiac function with slight improvement in echocardiography parameters, and the New York Heart Association functional class was maintained at I. Moreover, the patient no longer suffered from chest tightness and palpitation. Holter showed decreased ventricular arrhythmia of less than 5%.
LBBP might be used in patients with heart failure and a high-degree atrioventricular block as an alternative to conventional CRT.
左束支起搏（LBBP）是近年来出现的一种生理性起搏方法。对于需要心脏再同步治疗（CRT）的完全性左束支传导阻滞患者而言，它是理想选择。此外，LBBP在维持生理性心室激动方面具有优势，并且能有效改善起搏器介导的心肌病患者的心功能及生活质量。然而，对于已存在心脏功能障碍的起搏依赖患者，LBBP尚未得到充分评估。
一名69岁男性患者，出现胸闷、心悸症状及收缩性心力衰竭1个月，纽约心脏病协会心功能分级为Ⅲ级。12导联心电图显示房颤伴三度房室传导阻滞及室性早搏。动态心电图显示右束支传导阻滞、房颤伴三度房室传导阻滞、频发多源性室性早搏、Ron-T现象及室性心动过速。超声心动图显示左心房和左心室增大，左心室射血分数降低。冠状动脉造影显示左前降支中段狭窄30%。显然，根据既往研究结果，CRT-D起搏器是该患者的最佳选择。然而，患者担心经济负担。遂选择单腔LBBP起搏器，并计划服用胺碘酮，待时机合适时升级为双腔植入式心律转复除颤器或CRT-D。在LBBP术后3个月的随访中，患者心功能有所改善，超声心动图参数略有改善，纽约心脏病协会心功能分级维持在Ⅰ级。此外，患者不再有胸闷和心悸症状。动态心电图显示室性心律失常减少至5%以下。
LBBP可用于心力衰竭合并高度房室传导阻滞的患者，作为传统CRT的替代方法。
