The impact and predictive value of left ventricular activation time on the mid-to long-term left ventricular function after pacemaker therapy in patients with heart failure
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摘要: 目的 探讨刺激至左室达峰时间(sti-LVAT)对心力衰竭(心衰)患者起搏术后左心功能中远期预后的影响。方法 回顾性分析我院2019年1月—2023年5月收治的具有高心室起搏比例的起搏器植入患者89例。根据起搏部位分为左束支区域起搏(LBBAP)组(42例)、右室间隔部起搏(RVSP)组(13例)和右室心尖部起搏(RVAP)组(34例)。比较3组的基线资料、术中电生理参数和术后6个月左心功能等相关指标的差异。结果 术中LBBAP组起搏QRS宽度最窄，其次是RVSP组和RVAP。术中3组的单极阻抗有显著差异(P=0.005)。与基线相比，LBBAP组术后6个月左室舒张末期内径(LVEDD)、左房内径(LAD)和N末端B型脑钠肽前体(NT-proBNP)均显著下降[LVEDD：(48.12±6.51) mm vs (50.45±7.96) mm，P=0.001；LAD：(40.05±5.92) mm vs (42.02±7.20) mm，P=0.002；NT-proBNP：219.50(89.75，472.50) pg/mL vs 1 166.50(683.75，2 125.00) pg/mL，P=0.001]，左室射血分数(LVEF)显著升高[(62.95±4.99)% vs (58.31±9.36)%，P < 0.001]；RVAP组术后6个月LAD显著增加[(42.82±5.24) mm vs (41.06±5.59) mm，P=0.009]，LVEF则显著下降[(56.91±7.18)% vs (60.38±7.13)%，P=0.041]；RVSP组术后6个月的LVEDD、LAD和LVEF则变化不明显。术中发现，LBBAP组sti-LVAT最短[(74.45±12.90) ms]，其次是RVSP组[(94.69±11.00) ms]和RVAP组[(100.21±11.44) ms]，3组间差异明显(P < 0.001)。线性回归分析显示，sti-LVAT与术后6个月的ln(NT-proBNP)、LVEDD和LAD水平呈正相关(r=0.674、0.512、0.400，均P < 0.001)，与6个月的LVEF呈负相关(r=-0.510，P < 0.001)。多元线性回归分析显示，sti-LVAT可正向预测术后6个月NT-proBNP(b=0.051，β=0.646，P < 0.001)和LVEDD值(b=0.157，β=0.423，P < 0.001)。结论 LBBAP可显著改善心衰患者起搏术后的左心功能，减轻心室重构；sti-LVAT对高心室起搏比例的心衰患者术后6个月的左心功能有较好的预测价值。Abstract: Objective To investigate the impact of stimulus to left ventricular activation time(sti-LVAT) on the mid-to long-term prognosis of left ventricular function after pacemaker therapy in patients with heart failure.Methods A retrospective analysis was conducted on 89 patients who underwent pacemaker implantation with a high ventricular pacing ratio at our hospital from January 2019 to May 2023. According to the pacing site, they were divided into the LBBAP group(n=42), RVSP group(n=13), and RVAP group(n=34). Differences in baseline data, intraoperative electrophysiological parameters, and postoperative 6-month left ventricular function parameters were compared among the three groups.Results The LBBAP group had the shortest pacing QRSd during the procedure, followed by the RVSP group and RVAP group. Significant differences in unipolar impedance during the procedure were observed among the three groups(P=0.005). Compared to baseline, the LBBAP group had a significant decrease in LVEDD, LAD, and NT-proBNP after 6 months [LVEDD: (48.12±6.51) mm vs (50.45±7.96) mm, P=0.001; LAD: (40.05±5.92) mm vs (42.02±7.20) mm, P=0.002; NT-proBNP: 219.50(89.75, 472.50) pg/mL vs 1 166.50(683.75, 2 125.00) pg/mL, P=0.001], and a significant increase in LVEF [(62.95±4.99)% vs (58.31±9.36)%, P < 0.001]. The RVAP group had a significant increase in LAD [(42.82±5.24) mm vs (41.06±5.59) mm, P=0.009] and a significant decrease in LVEF [(56.91±7.18)% vs (60.38±7.13)%, P=0.041] after 6 months; there were no significant changes in LVEDD, LAD, and LVEF in the RVSP group after 6 months. During the procedure, the LBBAP group had the shortest sti-LVAT [(74.45±12.90) ms], followed by the RVSP group [(94.69±11.00) ms] and RVAP group [(100.21±11.44) ms], with significant differences among the three groups (P < 0.001). Linear regression analysis showed that sti-LVAT was positively correlated with ln(NT-proBNP), LVEDD, and LAD after 6 months (r=0.674, 0.512, 0.400, P < 0.001), and negatively correlated with 6-month LVEF (r=-0.510, P < 0.001). Multivariate linear regression analysis showed that sti-LVAT could positively predict 6-month NT-proBNP (b=0.051, β=0.646, P < 0.001) and LVEDD values (b=0.157, β=0.423, P < 0.001).Conclusion LBBAP can significantly improve left ventricular function and reduce ventricular remodeling after pacemaker therapy in patients with heart failure. sti-LVAT has good predictive value for left ventricular function in patients with heart failure and a high ventricular pacing ratio.
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图 2 术中sti-LVAT与术后6个月NT-proBNP水平和心脏超声参数的相关性分析
Figure 2. Correlation analysis between intraoperative sti-LVAT and postoperative NT-proBNP levels and cardiac ultrasound parameters at 6 months
表 1 临床基线资料的比较
Table 1. Comparison of clinical baseline characteristics
例(%), X±S, M(P25, P75) 项目 LBBAP组(42例) RVSP组(13例) RVAP组(34例) P 年龄/岁 72.21±10.00 70.00±10.15 76.26±7.05 0.086 男性 22(52.38) 6(46.15) 16(47.06) 0.870 高血压 32(76.19) 10(76.92) 29(85.29) 0.670 糖尿病 17(40.48) 2(15.38) 9(26.47) 0.208 冠心病 8(19.05) 2(15.38) 3(8.82) 0.461 脑梗死 5(11.90) 1(7.69) 0(0.00) 0.096 吸烟 11(26.19) 3(23.08) 6(17.65) 0.653 血清肌酐/(μmol/L) 81.55(66.90，95.45) 75.60(63.45，81.50) 76.35(66.50，111.45) 0.451 谷丙转氨酶/(U/L) 23.00(16.75，34.25) 23.00(14.50，35.50) 20.00(12.25，24.25) 0.334 NT-proBNP/(pg/mL) 1 166.50(683.75，2 125.00) 1 010.00(577.50，1 605.00) 1 075.00(684.50，2 212.50) 0.855 QRS时限/ms 122.31±36.66 117.92±30.03 113.18±30.01 0.497 超声心动图 LVEDD/mm 50.45 ± 7.96 49.31 ± 5.81 50.21 ± 6.36 0.879 LAD/mm 42.02 ± 7.20 39.62 ± 5.47 41.06 ± 5.59 0.478 LVEF/% 58.31 ± 9.36 58.92 ± 7.97 60.38 ± 7.13 0.560 CO/(L/min) 3.63(3.02，4.25) 3.48(2.94，4.38) 4.35(3.27，5.30) 0.112 MR平均分级 1 1 1 0.404 TR平均分级 1 1 1 0.350 
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表 2 3组术中相关参数的比较
Table 2. Comparison of intraprocedural parameters among the three groups
例(%), X±S, M(P25, P75) 项目 LBBAP组(42例) RVSP组(13例) RVAP组(34例) P 手术时间/min 135.00(113.75，181.25) 115.50(87.50，172.50) 102.50(85.00，125.00) < 0.001 QRSd/ms 107.00(99.75，121.25) 160.00(126.00，168.50) 164.50(153.00，178.25) < 0.001 sti-LVAT/ms 74.45±12.90 94.69±11.00 100.21±11.44 < 0.001 双腔起搏器 32(76.19) 12(92.31) 28(82.35) 0.471 起搏参数 R波感知/mV 11.80(7.90，15.00) 11.80(9.10，15.05) 12.50(8.98，14.63) 0.854 起搏阈值/V 0.60(0.50，0.80) 0.60(0.50，0.70) 0.55(0.50，0.83) 0.599 单级阻抗/Ω 727.00(589.00，850.00) 780.00(520.00，855.50) 842.00(751.50，993.25) 0.005
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表 3 3组基线和6个月随访心脏超声参数及NT-proBNP比较
Table 3. Comparison of baseline data and 6-month follow-up results of echocardiography parameters and NT-proBNP in three groups
例(%), X±S, M(P25, P75) 项目 基线 术后6个月 P值 LBBAP组(42例) LVEDD/mm 50.45±7.96 48.12±6.51 0.001 LAD/mm 42.02±7.20 40.05±5.92 0.002 LVEF/% 58.31±9.36 62.95±4.99 < 0.001 CO/(L/min) 3.63(3.02，4.25) 5.08(4.47，5.57) < 0.001 MR平均分级 1 0 0.003 TR平均分级 1 1 0.352 NT-proBNP/(pg/mL) 1 166.50(683.75，2 125.00) 219.50(89.75，472.50) 0.001 RVSP组(13例) LVEDD/mm 49.31±5.81 51.00±5.60 0.363 LAD/mm 39.62±5.47 39.31±6.49 0.803 LVEF/% 58.92±7.97 56.54±7.10 0.140 CO/(L/min) 3.48(2.94，4.38) 4.65(4.18，5.45) 0.001 MR平均分级 1 1 1.000 TR平均分级 1 1 0.584 NT-proBNP/(pg/mL) 1 010.00(577.50，1 605.00) 780.00(530.00，1 900.00) 0.561 RVAP组(34例) LVEDD/mm 50.21±6.36 51.91±5.67 0.058 LAD/mm 41.06±5.59 42.82±5.24 0.009 LVEF/% 60.38±7.13 56.91±7.18 0.041 CO/(L/min) 4.35(3.27，5.30) 4.87(4.23，5.58) 0.050 MR平均分级 1 1 0.044 TR平均分级 1 1 0.020 NT-proBNP/(pg/mL) 1 075.00(684.50，2 212.50) 1 407.00(852.75，2 707.50) 0.397
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表 4 术后6个月NT-proBNP水平的多元回归模型
Table 4. A multiple regression model for NT-proBNP levels at 6 months after surgery
项目 B BE β t P F 调整后R2 sti-LVAT 0.051 0.007 0.646 7.860 < 0.001 12.684 0.443 年龄 0.016 0.012 0.107 1.327 0.188 QRSd 0.005 0.004 0.121 1.237 0.219 术前LVEF -0.007 0.069 -0.045 -0.468 0.641 术前LAD -0.006 0.020 -0.030 -0.323 0.747 术前LVEDD -0.001 0.021 -0.004 -0.035 0.973
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表 5 术后6个月LVEDD的多元回归模型
Table 5. A multiple regression model for LVEDD levels at 6 months after surgery
项目 B BE β t P F 调整后R2 sti-LVAT 0.157 0.029 0.423 5.355 < 0.001 14.352 0.477 年龄 -0.047 0.054 -0.069 -0.871 0.386 QRSd 0.024 0.017 0.128 1.417 0.160 术前LVEF -0.273 0.069 -0.362 -3.923 < 0.001 术前LAD 0.122 0.081 0.124 1.518 0.133 术前ln(NT-proBNP) 0.184 0.662 0.024 0.278 0.782
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