Application of left bundle branch pacing in heart failure with mildly reduced ejection fraction and left bundle branch block
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摘要: 目的 探讨左束支起搏(LBBP)在完全性左束支传导阻滞(CLBBB)合并射血分数轻度降低型心力衰竭(HFmrEF)患者中的临床应用。 方法 连续入选2017年1月—2022年12月于浙江大学医学院附属邵逸夫医院符合CLBBB合并HFmrEF的患者78例，评估导线参数和超声心动图指标。 结果 51例患者成功行LBBP(LBBP组)，27例患者仅指南导向药物治疗(GDMT组)。术中LBBP电极(0.7±0.3) V/0.4ms，R波感知幅度(6.1±4.5) mV，阻抗(584.1±165.3)Ω。术后QRS时限较术前差异有统计学意义[(120.0±16.3) ms vs (169.9±18.8) ms，P < 0.01]。随访2年，LBBP电极阈值、感知幅度均无明显差异。心功能分级及超声心动图参数LBBP组与GDMT组比较均有统计学差异。 结论 LBBP在CLBBB合并HFmrEF的患者中的应用是安全有效的。
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关键词:
- 心脏起搏，人工 /
- 左束支起搏 /
- 完全性左束支传导阻滞 /
- 射血分数轻度降低型心力衰竭 /
- 机械同步性
Abstract: Objective To explore the clinical application of left bundle branch pacing(LBBP) in heart failure with mildly reduced ejection fraction(HFmrEF) and complete left bundle branch block(CLBBB). Methods We consecutively recruited 78 patients with HFmrEF and CLBBB from January 2017 to December 2022 in Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University and explored LBBP parameter changes and clinical outcomes. Results Fifty-one patients received LBBP successfully, while twenty-seven patients received only guideline-directed medical therapy. The acute pacing threshold was(0.7±0.3) V/0.4ms, and the sensed potentials were(6.1±4.5) mV, and the impedance was(584.1±165.3) Ω. During follow-up of 24 months, the threshold and sensed potentials had no significant difference compared with the measurements at implantation respectively. Median NYHA functional class and echocardiography parameters improved in LBBP group compared with GDMT group. Conclusion LBBP is feasible and safe in patients with HFmrEF and CLBBB. -
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表 1 两组术前基线资料
Table 1. General data
例(%), X±S 项目 LBBP组(51例) GDMT组(27例) P 年龄/岁 71.2±8.1 75.4±11.8 0.17 男性 33(64.7) 17(63.0) 0.88 BMI/(kg/m2) 26.0±1.6 25.2±8.2 0.28 NT-proBNP/(pg/mL) 3 337.9±3 650.8 3 298.4±3 860.1 0.45 QRS波时限/ms 169.9±18.8 171.5±16.1 0.78 心功能NYHA分级 2.5±0.7 2.4±0.8 0.98 6 min步行试验距离/m 362.7±108.5 348.1±102.6 0.83 LVEDd/mm 59.5±6.2 59.8±8.5 0.89 LVEF/% 44.3±2.9 44.9±3.6 0.44 合并疾病 高血压 35(68.6) 17(63.0) 0.62 糖尿病 21(41.2) 13(48.1) 0.56 冠心病 18(35.3) 13(48.1) 0.28 慢性肾功能不全 15(29.4) 9(33.3) 0.72 
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表 2 不同时间LBBP电极参数
Table 2. LBBP electrode parameters at different times
X±S 时间 阈值/V 感知幅度/mV 阻抗/Ω 术中基线 0.7±0.3 6.1±4.5 584.1±165.3 术后1个月 1.2±1.7 6.6±2.8 491.9±113.61) 术后3个月 1.2±1.6 6.2±2.7 493.9±91.71) 术后6个月 0.9±0.5 7.2±2.7 463.0±94.41) 术后1年及以上 0.9±0.3 7.5±4.0 471.8±77.01) 与术中基线比较，1)P < 0.05。
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表 3 LBBP起搏前后的左心室及左右心室间同步性指标
Table 3. Indicators before and after LBBP pacing
X±S 指标 术前 LBBP起搏后 P GLS/% -(11.1±9.4) -(15.4±4.0) 0.03 PSD/ms 101.4±46.8 78.3±25.3 < 0.01 IVMD>40ms/例(%) 31(72.1) 5(11.6) < 0.01 IVMD/ms 51.3±22.4 22.1±21.0 < 0.01
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表 4 比较LBBP组与GDMT组心脏超声指标
Table 4. Cardiac ultrasound indicators between LBBP group and GDMT group
X±S 指标 LBBP组(51例) GDMT组(27例) P LVEF/% 基线 44.3±2.9 44.9±3.6 0.44 随访1个月 49.2±9.3 43.7±4.9 < 0.01 随访3个月 54.7±10.7 44.5±9.1 < 0.01 随访6个月 54.0±11.7 42.9±7.6 < 0.01 随访1年 54.4±10.9 41.7±11.4 < 0.01 随访2年 53.7±12.8 40.4±13.7 < 0.01 LVEDd/mm 基线 59.5±6.2 59.8±8.5 0.89 随访1个月 56.9±5.8 58.3±8.1 0.35 随访3个月 54.3±4.5 58.2±9.9 0.02 随访6个月 53.7±9.6 59.4±13.9 < 0.01 随访1年 53.0±7.9 59.7±11.8 < 0.01 随访2年 52.6±7.5 60.3±12.7 < 0.01 三尖瓣反流/(m/s) 基线 2.6±0.6 2.5±0.7 0.63 随访1个月 2.4±0.4 2.4±0.5 0.75 随访3个月 2.5±0.6 2.6±0.5 0.66 随访6个月 2.5±0.5 2.6±0.6 0.46 随访1年 2.4±0.6 2.5±0.4 0.72 随访2年 2.7±0.6 2.7±0.7 0.73 右室收缩压/mmHg 基线 33.0±13.9 30.5±8.3 0.79 随访1个月 28.5±7.5 32.3±8.7 0.23 随访3个月 30.8±12.6 33.8±16.5 0.72 随访6个月 30.8±10.0 32.9±10.6 0.53 随访1年 30.4±11.9 30.3±9.8 0.81 随访2年 32.8±18.1 32.6±18.7 0.29
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