白求恩国际和平医院.ppt

,CRT-D超反应者更换时的选择：CRT-D还是CRT-P?,白求恩国际和平医院,王冬梅2012-3-17,猝死的主要相关因素CRT-P/D超反应定义及发生率CRT-D的电击治疗状况CRT-P/D的相关问题CRT-D更换的选择,一、猝死的主要相关因素,心衰患者的猝死率1,2,3,4,1 MERIT-HF Study Group.Effect of metroprolol CR/XL in chronic heart failure.Lancet.1999;353:2001-2007.2 CIBIS Investigations and Committees.The cardiac insufficiency bisprolol study II(CIBIS-II).Lancet.1999;353:9-13.3 Packer M,Bristow MR,Cohn JN,et al.The effect of carvedilol on morbitity and nortality in patients with chronic heart failure.U.S.Carvedilol Heart Failure Study Group.N Engl J Med.1996;334:1349-1355.4 The RALE Investigators.Effectiveness of spironolactone added to an aniotensin-converting enzyme inhibitor and a loop diuretic for severe chronic congestive heart failure(the Randomized Aldactone Evaluation StudyRALES.Am J Cardiol.1997;78:902.,1 Gorgels,PMA Out-of-hospital cardiac arrest-the relevance of heart failure.The Maastricht Circulatory Arrest Registry.European Heart Journal.2003;24:1204-1209.,LVEF,%SCA Victims,7.5%,5.1%,2.8%,1.4%,LVEF与SCA的相关性1,SCA危险性增加了5倍,心衰伴频发室早，SCA风险更高,Maggioni AP.Circulation.1993;87:312-322.,Oregon Sudden Unexpected Death Study(SUDS),2011AHA,Dr Sumeet S Chugh,111 例，mean age 69 years，coronary disease，ICD10%,ICD protection likely needed,even if LVEF improves,二、CRT-P/D超反应定义及发生率,302例，随访22 11个月（6 to 53）,发生率 判定标准负反应：22%LVESV 无应答：21%LVESV 0%14%有应答:35%LVESV 15%29%超应答：22%LVESV 30%,JACC Vol.53,No.6,2009,Long-Term Prognosis After CRT Is Related to the Extent of Left Ventricular Reverse Remodeling at Midterm Follow-Up,JACC Vol.53,No.6,2009,判定标准无应答：LVEF 无改善有应答：LVEF 10%超应答：LVEF15%,340 例，Age:69 10 years56%ICM NYHA class 3.1 0.519%PAFQRS duration:156 34 ms89%with LBBB LVEF:28 6.5%,Pascal Defaye,MD,Cardiology Department,University Hospital of Grenoble,Grenoble,France,Long-term follow-up of 340 patients with CRT:predisposing factors of super-response,结 果,无应答：84 例(25%)有应答：194 例(57%)，（包括45 例NYHA 心功能降低和住院次数减少，但LVEF 没达标）超应答：62 例(18%),Pascal Defaye,MD,Cardiology Department,University Hospital of Grenoble,Grenoble,France,Basal Left Ventricular Diastolic Functions Predicts Super-response To CRT,104例，随访6个月超应答：17.5%(LVESV 30%)有应答：41.7%(LVESV 15 29%)无应答：34.0%(LVESV 0%14%)负应答：6.8%(LVESV),Hacettepe Univ Faculty of Medicine,Ankara,Turkey,超应答：1322%,超应答判定标准（super-responders,hyper responders）LVEF 20%50，or24倍LVESV 30%LVEDV 20%,Europace(2009)11,343349Heart Rhythm20085:193 7.Am Heart J 2008;155:507 14.,三、CRT-D的电击治疗状况,Identification of super-responders to CRT:the importance of symptom duration and left ventricular geometry,超应答10例 ICD放电1例（不适当放电）其他组77例 ICD放电7例（适当放电2例）,Europace(2009)11,343349,判定标准：超应答：LVEF 45%，绝对值2倍,LVESV 15%.无应答：LVESV 15%or因心衰住院 or 死亡,87例，随访1年,110例，随访212个月,Downloaded from on September 22,2011,超应答：LVEF10%,LVESV30%or LVEDV 20%,Characteristics and long-term outcome of echocardiographic super-responders to CRT:real world experience,Downloaded from on September 22,2011,结 果,ICD合适放电24例（22.6%）,左室明显逆重构的超应答患者，若经历ICD合适治疗，继续应用ICD是必须的,LVEF 30%随访 20 个月与基础值比较改善 35%58 patients(21.5%)改善10%102 patients(37.8%)合适的 ICD 治疗LVEF 35%13/58 例(23.2%)P 0.03,Schaer BA,et al.Eur J Heart Fail,2010.,ICD的治疗情况,Schaer BA,et al,Eur J Heart Fail 2010,ICD的治疗情况,ICD的治疗情况,2011年HRS报道的2500个中心，88804例植入CRT-D或ICD患者，随访2.51.3年，22%患者接受合适的电击治疗。,心梗3例（占6.4%）,160例,沈阳军区总医院白求恩国际和平医院,死亡47例（29.38%）,猝死16例（占34%）,心衰12例（占25.5%）,心外16例（占34%）,2001.4 2011.12,四、CRT-P/D的相关问题,ICD治疗效价比,ICD治疗存在的问题,不适当放电的危险 ICD电风暴 与电极或脉冲发生器相关的并发症 焦虑与抑郁的发生率25%80%（症状 明显者15%40%，极少数 自杀、自毁）技术因素（婴幼儿）、需多次更换、导 线粗大 价格昂贵等电池提前耗竭,Gerold Mnnig,et al.Heart Rhythm 2005;2:497504 James P.Daubert,et al.Am Heart J 2007;153:S53-8,心外膜起搏的致室性心律失常作用,A：单纯左室起搏比右室起搏 QT间期明显延长B：BIV起搏诱发 R on T 室早二联律C：发生TdPD：由RV程控为BIV后QT间期 延长并出现R on T室早,.,Medina-Ravell,et al,Circulation,2003,107:740-746Rivero-Ayerza M,.Circulation,20043,109(23):2924Di Cori A,J Interv Card Electrophysiol,2005,12(3):231Mykytsey A,J Cardiocasc Electrophysiol,2005,16(6):655Peichl P,J Cardiocasc Electrophysiol,2007,18(2):218Bortone A,PACE,200629(3):327Kantharia BK,Europace,2006,8(8):625,致心律失常的电生理机制,跨室壁复极离散度（TDR）增加：由于心室肌电生理的异质性，特别是M细胞动作电位的特点，心外膜起搏或双心室起搏导致具有不同电生理性质的心室肌层电激动顺序发生改变，并引起TDR增加。QT间期延长：左室心外膜起搏时的QTc比右室心内膜、双室起搏时明显延长。,Fish JM,et al,Circulation,2004,109:2136-2142.,超应答患者左室心外膜起搏的弊端有否？,五、CRT-D更换的选择,CRT-D更换时评估,CRT-D,CRT-P,风险-益处,下列情况应考虑继续更换CRT-D,二级预防更换前临床及程控显示有正确的治疗事件者缺血性心脏病LVEF、NYHA仍较差或曾反复者除颤电极导线正常，无或很少误治疗患者意愿,下列情况可考虑更换CRT-P,Super-responder一级预防更换前临床及程控无治疗事件者非缺血性心脏病CRT术后至更换前心功能及左室重构逆转等指标长期稳定患者知情同意,CRT-D更换成CRT-P仍需慎重！,谢谢,