ppt心衰合并房颤患者crt治疗课件.ppt

1、心衰合并房颤患者CRT治疗,新疆医科大学第一附属医院心脏中心汤宝鹏 教授,房颤与心衰的关系,心衰促使房颤的发生,心衰导致心房的结构和电生理发生重构。这些重构包括心房扩大、心房不应期的缩短,心房传导的减慢,心房复极各向异性的程度加重。这些改变促使并维持房颤的发生。实验研究发现,心衰能够导致多种离子通道电生理特性发生改变,如L2型Ca2+电流,短暂性钾电流(Ito)及缓慢延迟整流性钾电流(IKs)密度降低,而短暂内向Na+/Ca2+交换电流增加,这些变化导致房颤的发生率和持续时间均明显增加。房颤促使心衰的发生房颤时,心室率控制不佳、不规则心室起搏、心房收缩功能消失,均能降低心室收缩功能并加重心衰。

2、,Am J Cardio.2003;91(6A):2D-8D,XUGENG 2009-12-12,房颤心衰互为影响,心衰 房颤心房电生理的异常心房结构改变容量和压力负荷房颤 心衰AV失同步心室率控制欠佳心率变异,一般人群中房颤的发生率为0.4%心血管病患者的房颤的发生率为4%心衰患者中的房颤的发生率为10-50%Maisel WH,Stevenson LW Atrial fibrillation in heart failure:epidemiolody,pathopyhsiology and rationale for therapy.Am J Cardio.2003;91(6A):2D-8

3、D,心衰患者房颤的发病率,房颤发病率随心功能的降低增加,XUGENG 2009-12-12,房颤心衰常常同时存在,CRT植入者中，永久性房颤约占20%,Christophe Leclercq and Phipippe Mabo,Cardiac resynchronization therapy and atrial fibrillation.Do we have a final answer.European Heart Journal 2008 29,1597-1599,心衰合并房颤患者CRT治疗,CRT能否减少心衰患者房颤的发生？CRT对心衰合并房颤患者是否可行有效？对永久性房颤患者如何使

4、用CRT治疗？,心衰合并房颤的患者，我们有几个问题需要思考？,CRT随机对照试验累计病例数,CRT随机对照试验累计病例数约6000例，房颤病人只占5%,CRT 能否减少心衰患者房颤的发生？,法国Kis等进行的临床研究显示,心脏再同步治疗(CRT)后6个月,晚期心衰的房颤患者临床获益显著,左房和左室重构也显著改善。但是,多达93%的患者并未转复为窦性心律。该研究纳入74例晚期心衰的房颤患者,患者平均年龄为68岁,其中男性67例,患者均接受CRT。在CRT前和CRT后6个月分别对患者进行纽约心脏学会(NYHA)心功能分级、生活质量评分及6分钟步行距离等临床指标的评估,还进行超声检查,以确定患者的左

5、室射血分数(LVEF)、左室直径和左房直径。,Cardiac resynchronisation therapy in chronic atrial fibrillation:impact on left atrial size and reversal to sinus rhythm,Heart 2006;92:490494.doi:10.1136/hrt.2005.064816,结果显示,在CRT后6个月,患者的NYHA心功能分级、生活质量评分、6分钟步行距离及LVEF均显著改善。另外,左房和左室舒张末和收缩末直径在CRT后6个月也均显著改善(P0.01)。在进行CRT时,90%的持续房颤

6、患者(18/20例)转复为窦性心律。但在随访期间,72%(13/18例)又转为房颤,且均未自行转为窦性心律。因此,只有7%(5/74例)患者转为窦性心律。,CRT可使晚期心衰房颤患者临床获益 但仅7%的患者转复为窦性心律,CRT对心衰合并房颤患者是否可行有效？,MUltisite Stimulation In Cardiolopathies trial（MUSTIC）,METHODS Of 131 patients included,42/67 in sinus rhythm(SR)and 33/64 in atrial fibrillation(AF)were followed up lon

7、gitudinally at 9 and 12 months by 6-min walked distance,peak oxygenuptake(peak VO2),quality of life by the Minnesota score,NYHA class,echocardiography,and left ventricular ejection fraction by radionuclide technique.RESULTS At 12 months,all SR and 88%of AF patients were programmed to BiV pacing.Comp

8、aredwith baseline,the 6-min walked distance increased by 20%(SR)(p 0.0001)and 17%(AF)(p 0.004);the peak VO2 by 11%(SR)and 9%(AF);quality of life improved by 36%(SR)(p 0.0001)and 32%(AF)(p 0.002);NYHA class improved by 25%(SR)(p 0.0001)and 27%(AF)(p 0.0001).The ejection fraction improved by 5%(SR)and

9、 4%(AF).Mitralregurgitation decreased by 45%(SR)and 50%(AF).Conclusions.We found a significant sustained benefit in exercise tolerance quality of life from BiV over a 12-month follow-up period.A reduction in mitral regurgitation and an improvement in ejection fraction were also observed.Hospitalizat

10、ions for HF were fewer during BiV pacing.Whether these favorable results translate into an improved survival remains to be established.,(J Am Coll Cardiol 2002;40:111 8)2002 by the American College of Cardiology Foundation,房颤合并心衰CRT治疗 窦律、房颤组对比,Received 24 June 2007;revised 1 February 2008;accepted 1

11、0 March 2008;online publish-ahead-of-print 4 April 2008,MulticentreLongitudinalObservationalStudy(MILOS)2006,窦律、房颤组对比,723例，561例窦律/162例房颤，平均随访25月。BV 88%结果 SR VS AF 两组均改善6分钟步行距离、LVEF；改善NYHA分级。,XUGENG 2009-12-12,Comparison of Usefulness of Cardiac Resynchronization Therapy in Patients With Atrial Fibri

12、llation and Heart Failure Versus Patients With Sinus Rhythm and Heart Failure.Am J Cardiol 2007;99:12521257,2007年Delnoy等对96例窦律和 167例房颤CRT比较研究，观察 12个月 两组生存率和住院率相似。,房颤合并心衰CRT治疗窦律、房颤组对比,房颤病人是否和病窦病人同样受益,2008年Upadhyay等在 JACC发表了一项荟萃分析2487篇报道5个临床研究报告，1164例病人资料。结论是同窦性心律患者一样，房颤CRT治疗也同样能明显改善射血分数和NYHA分级。,房颤心衰C

13、RT荟萃分析,研究基线表,房颤病人是否和病窦病人同样收益,全因死亡率比较：房颤组微高，与窦律组比较无统计学差异,All-cause mortality.A total of 85 deaths were reported across the included studies at 1 year(41 among AF patients and 44 in sinus rhythm patients).Although there wasincreased mortality in patients with AF,the calculation of risk did not reach s

14、tatistical significance(risk ratio:1.57,95%CI:0.87 to 2.81,p 0.13)(Fig.2).There was no significant heterogeneity between studies(I2 47.5%).Among 4 studies that reported cause of death,approximately 79%(weighted average)were from cardiovascularcauses,including stroke(1820,22).,房颤病人是否和病窦病人同样收益,左室射血分数比

15、较：房颤组与窦律组均改善，房颤组更明显,Ejection fraction.The LVEF improved significantly across all studies for both patients in sinus rhythm and patients in AF.Average LVEF increased from 25.3%to 35.2%in patients with AF and from 24.6%to 33.8%for those in sinus rhythm.Although patients in AF had slightly higher LVEF

16、at baseline,they also showed a slightly greater change in LVEF(0.39%greater change in LVEF vs.those in sinus rhythm,95%CI:0.22 to 0.55,p 0.0001)(Fig.3).There was a significant degree of heterogeneity for this outcome(I2 97.1%).Notably,the method of calculatingLVEF was not reported in standard fashion and could notbe compared between studies.,NYHA心功能分级比较：房颤组与窦律组均改善约1级，窦律组更明显,Change in NYHA functional class.Four studies reported data on NYHA functional class(1820,22).At baseline,patients in AF had