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摘要: 目的 通过单中心长期随访，探讨永久希氏束起搏(His-bundle pacing，HBP)的长期有效性和安全性。方法 回顾性分析2018年8月—2019年12月于西安交通大学第二附属医院心血管内科接受永久起搏器植入的患者，其中58例行HBP，66例行右室间隔部起搏。观察术中QRS波时限、手术成功率，随访术后即刻、1年、2年、3年时的心室起搏阈值、阻抗、感知以及手术相关并发症。结果 67例患者拟行HBP，最终有58例植入成功(成功率85.6%)，HBP组术前QRS波时限(95.5±18.5) ms，术后QRS波时限(103.6±15.1) ms，差异无统计学意义。右室间隔起搏组术前QRS波时限(101.8±26.9) ms，术后QRS波时限(145.2±11.8) ms，明显延长(P < 0.05)。术后即刻及1年、2年、3年HBP组心室起搏阈值分别为(0.83±0.43) V/0.4ms、(0.97±0.31) V/0.4ms、(1.11±0.39) V/0.4ms、(1.28±0.56) V/0.4ms，阈值逐年升高(P < 0.001)，2例阈值升高至2.5 V/1.0ms，未发生失夺获。HBP组1例患者发生囊袋感染，两组术后随访均无电极脱位、心脏穿孔等其他并发症发生。结论 HBP是最具生理性的起搏方式，但是其长期随访有起搏阈值升高风险。Abstract: Objective To investigate the long-term efficacy and safety of permanent His-bundle pacing(HBP).Methods In a retrospective study, patients who underwent permanent pacemaker implantation at the Department of Cardiology, Second Affiliated Hospital of Xi'an Jiaotong University between August 2018 and December 2019 were enrolled. Among them, 58 patients received His bundle pacing(HBP), while 66 patients received right ventricular septal pacing. The QRS durations and implantation success rate were observed. The threshold, impedance, R wave sensing, and related complications were monitored immediately post-implantation as well as at 1-year, 2-year, and 3-year after operation.Results Of 67 patients who planned to undergo HBP, 58 were successfully implanted(85.6% success rate). The preoperative QRS duration was 95.5±18.5 ms and postoperative QRS duration was 103.6±15.1 ms in the HBP group, with no statistical significance. In the right ventricular septal pacing group, the duration of QRS wave before operation was(101.8±26.9) ms, and the duration of QRS wave after operation was(145.2±11.8) ms(P < 0.05). The ventricular pacing thresholds were(0.83±0.43) V/0.4ms, (0.97±0.31) V/0.4ms, (1.11±0.39) V/0.4ms and(1.28±0.56) V/0.4ms in the HBP group immediately and at 1, 2 and 3 years after surgery, respectively, and the thresholds were increased year by year(P < 0.001). The threshold increased to 2.5V /1.0ms in 2 cases, and no loss occurred. One patient in HBP group developed sac infection, and no other complications such as electrode dislocation and heart perforation occurred in both groups.Conclusion HBP is considered the most physiological pacing mode, although it carries the potential risk of increasing in pacing threshold in long-term follow-up.
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表 1 患者基线资料
Table 1. Baseline characteristics
X±S, 例(%) 项目 HBP组
(58例)右室间隔部起搏组(66例) P值 年龄/岁 70.1±10.4 68.1±11.8 0.322 男性 25(43.1) 37(56.1) 0.150 病态窦房结综合征 20(34.5) 21(31.8) 0.753 房室传导阻滞 34(58.6) 36(54.5) 0.648 二度Ⅱ型房室传导阻滞 13(22.4) 10(15.1) 0.352 三度房室传导阻滞 21(36.2) 26(39.4) 心房颤动伴长间歇 4(6.9) 9(13.6) 0.222 高血压 32(55.2) 41(62.1) 0.501 冠心病 24(41.4) 19(28.8) 0.142 
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表 2 两组手术前后QRS时限比较
Table 2. QRS duration before and after operation
ms, X±S QRS波时限 HBP组(58例) 右室间隔部起搏组(66例) 术前 95.5±18.5 101.8±26.9 术后 103.6±15.11) 145.2±11.82) 与右室间隔部起搏组比较，1)P < 0.05；与本组术前比较，2)P < 0.05。
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表 3 两组患者随访起搏参数变化
Table 3. Changes of pacing parameters in two groups during follow-up
X±S 项目 HBP组
(58例)右室间隔部起搏组
(66例)心室起搏阈值/(V/0.4 ms) 术后即刻 0.83±0.43 0.72±0.27 术后1年 0.97±0.311) 0.69±0.22 术后2年 1.11±0.391) 0.68±0.21 术后3年 1.28±0.561) 0.70±0.22 心室感知/mV 术后即刻 8.05±4.10 8.98±3.05 术后1年 9.96±6.42 9.03±3.39 术后2年 8.75±5.75 8.88±3.27 术后3年 8.43±5.81 8.87±3.28 心室电极阻抗/Ω 术后即刻 728.7±136.8 681.2±147.2 术后1年 507.3±82.61) 510.7±107.11) 术后2年 499.1±85.51) 496.5±99.41) 术后3年 479.5±72.81) 489.1±98.71) 与术后即刻比较，1)P < 0.05。
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