再同步治疗的挑战和思考课件幻灯

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1、再同步治疗的挑战和思考王东琦西安交通大学医学院第一附属医院EvidenceForHeartFailure在美国，每年因心衰就诊3.4百万，死亡30万。一年再住院率50%，中重度心衰年死亡率近30%。≥65岁者患病率6~10%。QRS≥120ms患者全因死亡率增加约33%。……EvidenceForCRTEF≤35%，QRS≥120ms，经理想药物治疗,NYHAIII~IV:提高心功能分级，改善生活质量，增加活动耐量。降低死亡率和住院率。提高生存率。如何让更多患者受益？IMPROVEHFToexaminepatientandcardiologyprac

2、ticecharacteristicspredictiveofCRTuseineligiblepatientsinanoutpatientregistryofsystolicheartfailurepatientsFonarowGC,etal.CircHeartFail.2008;1:98–106.PercentofIndicatedPatients(%)PercentofIndicatedPatientsReceivingCRT(CRT-D/CRT-P)atBaselineIMPROVEHFBaselinePerformanceonCRTAllPr

3、actices(BaselineReview)39.39%FonarowGC,etal.CircHeartFail.2008;1:98–106.IMPROVEHFRegistryLessthan40%ofCRT-eligiblepatientsreceivedadeviceatbaselineassessment•In1/3ofIMPROVEHFoutpatientpractices,notasingleeligiblepatientreceivedaCRTdeviceatbaseline手术成功率在RCTS纳入的4000多例中，CRT（经CS植入L

4、V电极技术）的成功率88％－92％：鞘管难以插入CS冠状静脉狭窄或闭锁难以进入靶血管分支或脱位膈肌刺激115°135°AmpCS60°Straight115°60°135°AmpCSAttainStarFix®Firstactivefixationleft-heartleadMoreplacementoptionsVeinsizesVeinlocationsSoft,polyurethanedeployablelobes5Frleadbody,5.3FrelectrodewithtipsealForCRT-Ddevices,theavailableL

5、Vpacepolaritiesare:LVtiptoLVringLVtiptoRVcoilLVringtoRVcoilForCRT-Pdevices,theavailableLVpacepolaritiesare:LVtip/RVringUnipolar(LVtip/Can)Bipolar(LVtip/LVring)PacingVectorProgrammabilityLV环至RV线圈LV头端至RV线圈LV头端至LV环Non-responder,trueorfalse?40consecutiveCRT-DpatientsadmittedtoCleve

6、landClinicHFICUMetCRTindicationsatimplantImplantedforatleast3months(mean19months)IncreasedLVEDVfrompre-implantbaselineAveraged1.2HFhospitalizations87.5%withLVleadinlateralorpostero-lateralpositionBiventricularpaced96%oftimeAcute,serialechoandinvasivehemodynamicmeasurementsinCRT

7、ONandCRTOFFmodesHiddenbenefit:whenCRTturnedoff,hemodynamic,ECG&echoparametersworsenedPCWPP<0.001CardiacOutputP<0.001P<0.001QRSWidthP<0.001LVFillingTimeMullensW,etal.JAmCollCardiol2009;53:600-607启示RCTS并未观察反映CRT疗效的敏感指标。对于某些急性疾病，一种指标就容易反映其疗效。但对于那些慢性疾病则不敏感。窄QRS波心衰心功能3级、4级，左室射血分数减低，

8、窄QRS波心衰患者中，30%UCG提示有收缩失同步。仍而，对于窄QRS波心衰患者是否可以从双室起搏治疗中受益