Clinical efficiency of left bundle branch pacing in patients with heart failure and atrioventricular block
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摘要: 目的 观察左束支起搏(LBBP)对慢性心力衰竭(心衰)合并持续性高度房室传导阻滞或三度房室传导阻滞患者的近中期临床疗效。方法 入选慢性射血分数降低的心衰合并持续性高度房室传导阻滞或三度房室传导阻滞需行起搏治疗的患者，分为LBBP组及常规双心室心脏同步化治疗(CRT)组。比较LBBP组起搏植入术中及随访6个月、12个月时各项起搏参数的变化。比较两组患者起搏治疗前后心电图QRS波时限，纽约心功能分级(NYHA)、左室舒张末期内径(LVEDD)、左室收缩末期内径(LVESD)、左室短轴缩短率(FS)、左室射血分数(LVEF)、血清B型脑钠肽(BNP)水平。结果 共有21例患者入组，术前两组患者年龄、性别、合并疾病、服用药物情况、QRS波时限、NYHA心功能分级、LVEDD、LVESD、FS、LVEF、BNP水平无显著差异(P＞0.05)。LBBP组术中QRS波时限与术前比较明显缩窄(P＜0.05)；随访6、12个月发现，LBBP组QRS波时限、LBBP单极夺获左束支阈值、心室电极头端单极感知均稳定，电极头端阻抗与术中比较无显著变化(P＞0.05)；两组患者术后随访6、12个月，其NYHA心功能分级、LVEDD、LVESD、FS、LVEF、BNP水平均较术前有显著改善(P＜0.05)。术中及术后随访6、12个月，LBBP组QRS时限较CRT组稍缩短(P＜0.05)；随访6个月时，LBBP组患者NYHA分级情况较CRT组改善(P＜0.05)，BNP水平降低(P＜0.05)，两组患者LVEDD、LVESD、LVEF无显著差异(P＞0.05)。随访12个月，两组患者NYHA心功能分级、LVEDD、LVESD、FS、LVEF、BNP水平无显著差异(P＞0.05)。结论 LBBP对于慢性射血分数降低的心衰合并持续性高度房室传导阻滞或三度房室传导阻滞患者治疗效果与传统CRT相似。Abstract: Objective This study was aimed to explore the efficiency of left bundle branch pacing(LBBP) in patients with heart failure and persistent high-grade or third-degree atrioventricular block.Methods Patients with chronic heart failure and high-grade atrioventricular block requiring pacemaker treatment were enrolled in the study from March 2018 to December 2020, and were randomly divided into LBBP group and cardiac synchronization therapy(CRT) group. QRS wave duration, left ventricular end-diastolic diameter(LVEDD), left ventricular ejection fraction(LVEF), cardiac function classification, pacemaker parameters, and serum brain natriuretic peptide(BNP) level were compared between the two groups during follow-up.Results A total of 21 patients were enrolled. There were no significant differences in age, gender, co-morbidity, drug use, QRS duration, NYHA cardiac function grade, LVEDD, LVESD, FS, LVEF and BNP levels between the two groups(P > 0.05) before surgery. QRS duration in LBBP group was significantly narrower compared with that before surgery(P < 0.05). During the follow-up of 6 months and 12 months, it was found that QRS duration, the threshold of LBBP unipolar capture of left bundle branch and the unipolar perception of ventricular electrode tip in LBBP group were stable, and the impedance of electrode tip had no significant change compared with that during surgery(P > 0.05). The NYHA cardiac function grading, LVEDD, LVESD, FS, LVEF and BNP levels in two groups were significantly improved after 6 and 12 months of postoperative follow-up compared with those before surgery(P < 0.05 or P < 0.01). The duration of QRS in LBBP group was slightly shorter than that in CRT group(P < 0.05). During 6-month follow-up, the NYHA grading in LBBP group was improved compared with that in CRT group(P < 0.05), while the BNP level was decreased(P < 0.05). There were no significant differences in LVEDD, LVESD and LVEF between the two groups(P > 0.05). After 12 months of follow-up, there were no significant differences in NYHA cardiac function grading, LVEDD, LVESD, FS, LVEF and BNP levels between the two groups(P > 0.05).Conclusion The clinical efficiency of LBBP in patients with chronic heart failure and persistent high-grade atrioventricular block or third-degree atrioventricular block is similar to that of conventional CRT.
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图 1 LBBP植入术后即时和12个月胸片
Figure 1. Chest X-ray at immediate1 and 2 months after LBBP implantation
表 1 两组患者术前一般临床资料
Table 1. General data
例(%), X±S 项目 LBBP组(8例) CRT组(13例) P值 年龄/岁 70.0±15.6 66.2±12.1 0.533 男性 5(62.5) 8(61.5) 0.965 LVEDD/mm 64.9±6.9 61.5±8.5 0.361 LVESD/mm 56.4±6.3 54.0±8.3 0.496 LVEF/% 27.9±7.2 26.6±6.3 0.677 FS/% 13.6±3.7 13.1±3.6 0.741 BNP/(pg·mL-1) 1253.1±832.9 1318.9±913.9 0.870 NYHA分级 0.925 Ⅲ 6(75.0) 10(76.9) Ⅳ 2(25.0) 3(23.1) QRS波时限/ms 128.4±16.5 124.6±19.7 0.835 缺血性心肌病 1(12.5) 2(15.4) 0.853 高血压 2(25.0) 4(30.7) 0.775 糖尿病 2(25.0) 3(23.1) 0.920 房颤 1(12.5) 2(15.4) 0.853 药物治疗 ARNI 8(100.0) 13(100.0) 利尿剂 8(100.0) 13(100.0) 降糖药 2(25.0) 3(23.1) 0.920 抗血小板药物 2(25.0) 4(30.7) 0.775 口服抗凝药 1(12.5) 2(15.4) 0.853 
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表 2 LBBP组患者起搏参数随访情况
Table 2. Follow-up of pacing parameters in patients in LBBP group
X±S 项目 术中 术后6个月 P值 术后12个月 P值 QRS波时限/ms 114.6±5.2 114.8±3.4 0.955 114.5±6.8 0.968 LBBP单极夺获左束支阈值/[(V·(0.42 ms)-1] 0.8±0.2 0.7±0.3 0.371 0.7±0.2 0.294 单极电极头端阻抗/Ω 631.3±133.6 597.5±108.9 0.588 601.3±98.2 0.617 电极头端单极感知/mV 9.1±3.4 9.8±3.5 0.721 8.8±2.8 0.814
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表 3 两组术中和术后临床情况
Table 3. Clinical conditions of the two groups before and after operation
例(%), X±S 项目 LBBP组(8例) CRT组(13例) 术中 术后6个月 术后12个月 术中 术后6个月 术后12个月 QRS波时限/ms 114.6±5.21) 114.8±3.41) 114.5±6.81) 125.3±9.4 126.7±5.7 126.8±6.0 NYHA分级 Ⅰ 0(0) 2(25.0) 2(25.0) 0(0) 1(7.7) 2(15.4) Ⅱ 0(0) 5(62.5) 6(75.0) 0(0) 4(30.8) 9(69.2) Ⅲ 6(75.0) 1(12.5) 0(0) 10(76.9) 7(53.8) 2(15.4) Ⅳ 2(25.0) 0(0) 0(0) 3(23.1) 1(7.7) 0(0) LVEDD/mm 64.9±6.9 50.5±4.1 47.8±7.3 61.5±8.5 53.9±8.2 50.4±7.1 LVESD/mm 56.4±6.3 38.1±4.9 32.5±5.9 54.0±8.3 42.0±8.7 37.7±6.5 FS/% 13.6±3.7 24.6±5.7 28.0±3.5 26.6±6.3 21.5±3.7 24.7±4.6 LVEF/% 27.9±7.2 48.4±9.2 54.8±5.5 13.1±3.6 43.2±6.6 49.0±7.5 BNP/(pg·mL-1) 1253.1±832.92) 311.9±254.12) 181.1±67.72) 1318.9±913.9 571.2±199.2 219.6±124.4 与CRT组同时间段比较，1)P＜0.01，2)P＜0.05。
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