CAJ | 학술논문

目的探讨不同类型束支阻滞对心脏再同步治疗(CRT)效果的影响.方法 159例难治性心力衰竭患者接受CRT治疗,其中6例已植入永久起搏器,其余153例患者根据体表心电图QRS波形态分为左束支阻滞(LBBB)、右束支阻滞(RBBB)、非特异性室内阻滞(IVCD)、右束支伴左侧分支阻滞(RBBB伴LHB)及室内伴左侧分支阻滞(IVCD伴LHB)5组,比较植入术前及术后6个月心功能(NYHA分级)、QRS时限、左心室射血分数(LVEF)、左心室舒张末期内径(LVEDD)、左心室收缩末期内径(LVESD)等指标的差异.结果 153例患者年龄21～ 84(61.43±12.54)岁,其中男118例,女35例.LBBB组治疗后心功能(3.13±0.55对2.84±0.65)、QRS时限[173.37±28.54)ms对(156.29±22.25)ms]及LVEF[(0.31±0.07)对(0.39±0.09)]、LVEDD[(73.09± 10.81) mm对(68.18± 11.36) mm]、LVESD[(61.38±11.60)mm对(55.20±13.25)mm]等均明显改善(P＜0.01).RBBB组治疗后各项指标未得到显著改善(P＞0.05),IVCD组与RBBB伴LHB组治疗后LVEF显著提高,LVEDD缩小(P＜0.05),而IVCD伴LHB组除QRS时限外,心功能、LVEF、LVEDD、LVESD等指标均得以改善(P＜0.05).此外,RBBB组与IVCD组超声心动图指标的改变不及LBBB组(P＜0.05),而RBBB伴LHB组及IVCD组超声心动图指标改善程度与LBBB组相近(P＞0.05).应用Cox回归分析显示LBBB者较其他束支阻滞类型生存期长(风险比0.30,95％可信区间0.12～0.77,P＜0.01).结论 LBBB者对CRT的反应性优于RBBB者,IVCD者疗效可能介于两者之间,而RBBB伴LHB或IVCD者疗效优于单纯RBBB或IVCD者.
목적 탐토불동류형속지조체대심장재동보치료(CRT)효과적영향.방법 159례난치성심력쇠갈환자접수CRT치료,기중6례이식입영구기박기,기여153례환자근거체표심전도QRS파형태분위좌속지조체(LBBB)、우속지조체(RBBB)、비특이성실내조체(IVCD)、우속지반좌측분지조체(RBBB반LHB)급실내반좌측분지조체(IVCD반LHB)5조,비교식입술전급술후6개월심공능(NYHA분급)、QRS시한、좌심실사혈분수(LVEF)、좌심실서장말기내경(LVEDD)、좌심실수축말기내경(LVESD)등지표적차이.결과 153례환자년령21～ 84(61.43±12.54)세,기중남118례,녀35례.LBBB조치료후심공능(3.13±0.55대2.84±0.65)、QRS시한[173.37±28.54)ms대(156.29±22.25)ms]급LVEF[(0.31±0.07)대(0.39±0.09)]、LVEDD[(73.09± 10.81) mm대(68.18± 11.36) mm]、LVESD[(61.38±11.60)mm대(55.20±13.25)mm]등균명현개선(P＜0.01).RBBB조치료후각항지표미득도현저개선(P＞0.05),IVCD조여RBBB반LHB조치료후LVEF현저제고,LVEDD축소(P＜0.05),이IVCD반LHB조제QRS시한외,심공능、LVEF、LVEDD、LVESD등지표균득이개선(P＜0.05).차외,RBBB조여IVCD조초성심동도지표적개변불급LBBB조(P＜0.05),이RBBB반LHB조급IVCD조초성심동도지표개선정도여LBBB조상근(P＞0.05).응용Cox회귀분석현시LBBB자교기타속지조체류형생존기장(풍험비0.30,95％가신구간0.12～0.77,P＜0.01).결론 LBBB자대CRT적반응성우우RBBB자,IVCD자료효가능개우량자지간,이RBBB반LHB혹IVCD자료효우우단순RBBB혹IVCD자.
Objective To discuss clinical outcome of cardiac resynchronization therapy(CRT) due to different types of bundle-branch block.Methods A total of 159 patients with refractory heart failure underwent CRT,among whom 6 cases had implanted pacemaker before and were excluded.Thus,153 cases were enrolled.According to their QRS morphology,they were classified into five groups:left bundle branch block (LBBB),right bundle branch block (RBBB),non-specific intraventricular conduction delay (IVCD),RBBB with a coexisting left hemiblock(LHB) and IVCD with LHB.Then we made a comparison of NYHA functional class,QRS duration (QRSd),left ventricular ejection fraction (LVEF),left ventricular end-diastolic diameter (LVEDD) and left ventricular end-systolic diameter(LVESD) before and 6 months after implantation.Results The study population was composed of 118 men and 35 women with a mean age of 21 ～ 84(61.43± 12.54),years.Those with LBBB had significant improvements as for NYHA functional class (3.13 ± 0.55 vs 2.84 ± 0.65),QRSd [(173.37 ± 28.54) ms vs (156.29 ± 22.25) ms],LVEF [(0.31 ± 0.07) vs (0.39 ± 0.09],LVEDD [(73.09 ± 10.81)mm vs(68.18± 11.36) mm] and LVESD [(61.38± 11.60) mm vs (55.20± 13.25) mm,P＜0.01].In contrast,no obvious change could be seen in pure RBBB group (P＞0.05).There is significant LVEF elevation and LVEDD reduction among the IVCD and RBBB with LHB groups(P＜0.05).As for the IVCD with LHB group,most parameters including NYHA functional class,LVEF,LVEDD and LVESD were significantly improved (P＜0.05)except for QRSd.Furthermore,in the pure RBBB and IVCD group,there were noted obviously less echocardiographic variable improvements compared with LBBB group(P＜0.05).While in RBBB and IVCD with coexisting LHB groups,the echocardiographic variable improvements were similar to those in LBBB group (P＞ 0.05).Multivariate Cox regression models proved that subjects with LBBB had a significantly better clinical outcome(HR 0.30,95％CI 0.12 to 0.77,P＜0.01).Conclusion Patients with LBBB showed significantly better response to CRT than those with RBBB,and those with IVCD had intermediate response compared with LBBB and RBBB.In addition,if patients with RBBB or IVCD also had LHB,their response to CRT was significantly better than if they had RBBB or IVCD alone.