超声心动图机械同步性指标与心脏再同步化治疗临床疗效的相关性研究
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摘要
背景心室机械同步性可以通过超声心动图等方法评价。单中心研究发现,超声心动图评价心脏机械同步性,能够鉴别哪些患者可以从心脏再同步化治疗(CRT)中获益。但是前瞻、多中心、非随机对照研究证实,心脏机械同步性指标不能用于筛选CRT患者和预测反应性。目的探讨超声心动图机械同步性指标与CRT临床疗效的相关性。方法选取2009年6月—2013年6月北京大学人民医院心脏中心行CRT的慢性心力衰竭患者124例,根据患者治疗后6个月随访时的临床效果和超声心动图结果分为无反应组34例、有反应组48例、超反应组42例。收集患者一般资料,治疗后采用超声心动图评价机械同步性指标。采用多因素Logistic回归分析CRT无反应及超反应影响因素。结果 3组患者治疗后6个月QRS波时限、心室间机械延迟(IVMD)、主动脉瓣血流速度时间积分(VTIAV)、左房室瓣血流速度时间积分(VTIMV)比较,差异均无统计学意义(P>0.05);3组患者治疗后6个月左心室射血分数(LVEF)、心率校正左心室舒张充盈时间(DFT/RR)、EA峰重叠比例、室间隔后壁机械延迟(SPWMD)、左心室射血前时间(LVPEP)比较,差异均有统计学意义(P<0.05)。多因素Logistic回归分析结果显示,CRT后QRS波时限延长与CRT无反应有回归关系〔OR=4.383,95%CI(1.013,18.963)〕,DFT/RR≥55%〔OR=3.609,95%CI(1.124,11.584)〕和EA峰重叠比例<10%〔OR=5.267,95%CI(1.400,19.820)〕与CRT超反应有回归关系(P<0.05)。结论慢性心力衰竭患者对CRT反应性不同,27.4%的患者对CRT无反应,33.9%的患者对CRT超反应。CRT后QRS波时限延长与CRT无反应相关,DFT/RR≥55%和EA峰重叠比例<10%与CRT超反应相关。
Background Ventricular mechanical synchrony can be evaluated by methods such as echocardiography.A single-center study found that using echocardiography to assess cardiac mechanical synchrony could identify which patients could benefit from cardiac resynchronization therapy(CRT).However,prospective,multicenter,non-randomized controlled studies have confirmed that cardiac mechanical synchrony parameters cannot be used to screen CRT patients and predict the reactivity.Objective To explore the role of echocardiographic mechanical synchrony parameters to the clinical efficiency of CRT patients.Methods We retrospectively studied 124 patients with chronic heart failure who underwent CRT from the Department of Cardiovascular of Peking University People's Hospital from June 2009 to June 2013.Based on the clinical effect and echocardiographic assessments in the six months follow-up after the treatment,we allocated them into non-responders group(34 patients),responders group(48 patients) and super-responders group(42 patients).General data of the patients were collected,and mechanical synchrony parameters were evaluated by echocardiography before and after the treatment.Multivariate Logistic regression analysis was used to analyze the influencing factors of CRT non-responsers and super-responders.Results There were no differences in QRS duration,inter-ventricular mechanical delay(IVMD),velocity time integral of aortic valve(VTIAV),and velocity time integral of mitral valve(VTIMV) among three groups in the six months after the treatment(P>0.05).The differences in left ventricular ejection fraction(LVEF),diastolic filling time/RR interval(DFT/RR),EA peak overlap ratio,septum posterior wall mechanical delay(SPWMD),and left ventricular pre-ejection period(LVPEP)were significant among three groups in the six months after the treatment(P<0.05).Multivariate Logistic analysis showed that there was a regression relationship between QRS duration prolong after CRT and non-response to CRT [OR=4.383,95%CI(1.013,18.963)];DFT/RR ≥ 55% [OR=3.609,95%CI(1.124,11.584)] and EA wave peak overlap ratio<10% [OR=5.267,95%CI(1.400,19.820)] were related to super-response to CRT(P<0.05).Conclusion Patients with chronic heart failure have different response to CRT.And 27.4% of patients have no response to CRT,and 33.9% of patients are classified as super-responders to CRT.QRS duration prolong after CRT is related to the non-response to CRT,and DFT/RR ≥ 55% and EA wave peak overlap ratio<10% are related to super-response to CRT.
Background Ventricular mechanical synchrony can be evaluated by methods such as echocardiography.A single-center study found that using echocardiography to assess cardiac mechanical synchrony could identify which patients could benefit from cardiac resynchronization therapy(CRT).However,prospective,multicenter,non-randomized controlled studies have confirmed that cardiac mechanical synchrony parameters cannot be used to screen CRT patients and predict the reactivity.Objective To explore the role of echocardiographic mechanical synchrony parameters to the clinical efficiency of CRT patients.Methods We retrospectively studied 124 patients with chronic heart failure who underwent CRT from the Department of Cardiovascular of Peking University People's Hospital from June 2009 to June 2013.Based on the clinical effect and echocardiographic assessments in the six months follow-up after the treatment,we allocated them into non-responders group(34 patients),responders group(48 patients) and super-responders group(42 patients).General data of the patients were collected,and mechanical synchrony parameters were evaluated by echocardiography before and after the treatment.Multivariate Logistic regression analysis was used to analyze the influencing factors of CRT non-responsers and super-responders.Results There were no differences in QRS duration,inter-ventricular mechanical delay(IVMD),velocity time integral of aortic valve(VTIAV),and velocity time integral of mitral valve(VTIMV) among three groups in the six months after the treatment(P>0.05).The differences in left ventricular ejection fraction(LVEF),diastolic filling time/RR interval(DFT/RR),EA peak overlap ratio,septum posterior wall mechanical delay(SPWMD),and left ventricular pre-ejection period(LVPEP)were significant among three groups in the six months after the treatment(P<0.05).Multivariate Logistic analysis showed that there was a regression relationship between QRS duration prolong after CRT and non-response to CRT [OR=4.383,95%CI(1.013,18.963)];DFT/RR ≥ 55% [OR=3.609,95%CI(1.124,11.584)] and EA wave peak overlap ratio<10% [OR=5.267,95%CI(1.400,19.820)] were related to super-response to CRT(P<0.05).Conclusion Patients with chronic heart failure have different response to CRT.And 27.4% of patients have no response to CRT,and 33.9% of patients are classified as super-responders to CRT.QRS duration prolong after CRT is related to the non-response to CRT,and DFT/RR ≥ 55% and EA wave peak overlap ratio<10% are related to super-response to CRT.
引文
[1]MOLLEMA S A,BLEEKER G B,VAN DER WALL E E,et al.Usefulness of QRS duration to predict response to cardiac resynchronization therapy in patients with end-stage heart failure[J].Am J Cardiol,2007,100(11):1665-1670.DOI:10.1016/j.amjcard.2007.06.071.
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[3]SONNE C,BOTT-FLUGEL L,HAUCK S,et al.Threedimensional echocardiographic optimization improves outcome in cardiac resynchronization therapy compared to ECG optimization:a randomized comparison[J].Pacing Clin Electrophysiol,2014,37(3):312-320.DOI:10.1111/pace.12281.
[4]WHITE J A,YEE R,YUAN X P,et al.Delayed enhancement magnetic resonance imaging predicts response to cardiac resynchronization therapy in patients with intraventricular dyssynchrony[J].J Am Coll Cardiol,2006,48(10):1953-1960.DOI:10.1016/j.jacc.2006.07.046.
[5]PITZALIS M V,IACOVIELLO M,ROMITO R,et al.Ventricular asynchrony predicts a better outcome in patients with chronic heart failure receiving cardiac resynchronization therapy[J].J Am Coll Cardiol,2005,45(1):65-69.DOI:10.1016/j.jacc.2004.09.058.
[6]RICKARD J,KUMBHANI D J,POPOVIC Z,et al.Characterization of super-response to cardiac resynchronization therapy[J].Heart Rhythm,2010,7(7):885-889.DOI:10.1016/j.hrthm.2010.04.005.
[7]CASTELLANT P,FATEMI M,BERTAULT-VALLS V,et al.Cardiac resynchronization therapy:“nonresponders”and“hyperresponders”[J].Heart Rhythm,2008,5(2):193-197.DOI:10.1016/j.hrthm.2007.09.023.
[8]PONIKOWSKI P,VOORS A A,ANKER S D,et al.2016 ESCguidelines for the diagnosis and treatment of acute and chronic heart failure:the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology(ESC).Developed with the special contribution of the Heart Failure Association(HFA)of the ESC[J].Eur J Heart Fail,2016,18(8):891-975.DOI:10.1002/ejhf.592.
[9]MAREK J J,SABA S,ONISHI T,et al.Usefulness of echocardiographically guided left ventricular lead placement for cardiac resynchronization therapy in patients with intermediate QRS width and non-left bundle branch block morphology[J].Am J Cardiol,2014,113(1):107-116.DOI:10.1016/j.amjcard.2013.09.024.
[10]TAYAL B,GORCSAN J 3rd,DELGADO-MONTERO A,et al.Mechanical dyssynchrony by tissue Doppler cross-correlation is associated with risk for complex ventricular arrhythmias after cardiac resynchronization therapy[J].J Am Soc Echocardiogr,2015,28(12):1474-1481.DOI:10.1016/j.echo.2015.07.021.
[11]PU L J,WANG Y,ZHAO L L,et al.Left univentricular pacing for cardiac resynchronization therapy using rate-adaptive atrioventricular delay[J].J Geriatr Cardiol,2017,14(2):118-126.DOI:10.11909/j.issn.1671-5411.2017.02.006.
[12]MELE D,BERTINI M,MALAGùM,et al.Current role of echocardiography in cardiac resynchronization therapy[J].Heart Fail Rev,2017,22(6):699-722.DOI:10.1007/s10741-017-9636-1.
[13]URBANEK B,KACZMAREK K,KLIMCZAK A,et al.Potential benefit of optimizing atrioventricular&interventricular delays in patients with cardiac resynchronization therapy[J].Indian J Med Res,2017,146(1):71-77.DOI:10.4103/ijmr.IJMR_1560_14.
[14]RICKARD J,BARANOWSKI B,WILSON TANG W H,et al.Echocardiographic predictors of long-term survival in patients undergoing cardiac resynchronization therapy:what is the optimal metric?[J].J Cardiovasc Electrophysiol,2017,28(4):410-415.DOI:10.1111/jce.13175.
[15]CHAN P S,KHUMRI T,CHUNG E S,et al.Echocardiographic dyssynchrony and health status outcomes from cardiac resynchronization therapy:insights from the PROSPECTtrial[J].JACC Cardiovasc Imaging,2010,3(5):451-460.DOI:10.1016/j.jcmg.2009.08.012.
[16]KANDALA J,UPADHYAY G A,ALTMAN R K,et al.QRSmorphology,left ventricular lead location,and clinical outcome in patients receiving cardiac resynchronization therapy[J].Eur Heart J,2013,34(29):2252-2262.DOI:10.1093/eurheartj/eht123.
[17]VAN EVERDINGEN W M,WALMSLEY J,CRAMER M J,et al.Echocardiographic prediction of cardiac resynchronization therapy response requires analysis of both mechanical dyssynchrony and right ventricular function:a combined analysis of patient data and computer simulations[J].J Am Soc Echocardiogr,2017,30(10):1012-1020,e2.DOI:10.1016/j.echo.2017.06.004.
[18]VAN BOMMEL R J,BAX J J,ABRAHAM W T,et al.Characteristics of heart failure patients associated with good and poor response to cardiac resynchronization therapy:a PROSPECT(predictors of response to CRT)sub-analysis[J].Eur Heart J,2009,30(20):2470-2477.DOI:10.1093/eurheartj/ehp368.
[19]DAMY T,GHIO S,RIGBY A S,et al.Interplay between right ventricular function and cardiac resynchronization therapy:an analysis of the CARE-HF trial(cardiac resynchronization-heart failure)[J].J Am Coll Cardiol,2013,61(21):2153-2160.DOI:10.1016/j.jacc.2013.02.049.
[20]ACHILLI A,PERALDO C,SASSARA M,et al.Prediction of response to cardiac resynchronization therapy:the selection of candidates for CRT(SCART)study[J].Pacing Clin Electrophysiol,2006,29(Suppl 2):S11-19.DOI:10.1111/j.1540-8159.2006.00486.x.
[21]HAUGAA K H,EDVARDSEN T,SMISETH O A.Mechanical dyssynchrony-resurrected as a flashing and rocking parameter to predict prognosis after cardiac resynchronization therapy[J].Eur Heart J Cardiovasc Imaging,2017,18(10):1118-1119.DOI:10.1093/ehjci/jex198.(收稿日期:2019-02-28;修回日期:2019-04-16)
[2]DELNOY P P,RITTER P,NAEGELE H,et al.Association between frequent cardiac resynchronization therapy optimization and long-term clinical response:a post hoc analysis of the clinical evaluation on advanced resynchronization(CLEAR)pilot study[J].Europace,2013,15(8):1174-1181.DOI:10.1093/europace/eut034.
[3]SONNE C,BOTT-FLUGEL L,HAUCK S,et al.Threedimensional echocardiographic optimization improves outcome in cardiac resynchronization therapy compared to ECG optimization:a randomized comparison[J].Pacing Clin Electrophysiol,2014,37(3):312-320.DOI:10.1111/pace.12281.
[4]WHITE J A,YEE R,YUAN X P,et al.Delayed enhancement magnetic resonance imaging predicts response to cardiac resynchronization therapy in patients with intraventricular dyssynchrony[J].J Am Coll Cardiol,2006,48(10):1953-1960.DOI:10.1016/j.jacc.2006.07.046.
[5]PITZALIS M V,IACOVIELLO M,ROMITO R,et al.Ventricular asynchrony predicts a better outcome in patients with chronic heart failure receiving cardiac resynchronization therapy[J].J Am Coll Cardiol,2005,45(1):65-69.DOI:10.1016/j.jacc.2004.09.058.
[6]RICKARD J,KUMBHANI D J,POPOVIC Z,et al.Characterization of super-response to cardiac resynchronization therapy[J].Heart Rhythm,2010,7(7):885-889.DOI:10.1016/j.hrthm.2010.04.005.
[7]CASTELLANT P,FATEMI M,BERTAULT-VALLS V,et al.Cardiac resynchronization therapy:“nonresponders”and“hyperresponders”[J].Heart Rhythm,2008,5(2):193-197.DOI:10.1016/j.hrthm.2007.09.023.
[8]PONIKOWSKI P,VOORS A A,ANKER S D,et al.2016 ESCguidelines for the diagnosis and treatment of acute and chronic heart failure:the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology(ESC).Developed with the special contribution of the Heart Failure Association(HFA)of the ESC[J].Eur J Heart Fail,2016,18(8):891-975.DOI:10.1002/ejhf.592.
[9]MAREK J J,SABA S,ONISHI T,et al.Usefulness of echocardiographically guided left ventricular lead placement for cardiac resynchronization therapy in patients with intermediate QRS width and non-left bundle branch block morphology[J].Am J Cardiol,2014,113(1):107-116.DOI:10.1016/j.amjcard.2013.09.024.
[10]TAYAL B,GORCSAN J 3rd,DELGADO-MONTERO A,et al.Mechanical dyssynchrony by tissue Doppler cross-correlation is associated with risk for complex ventricular arrhythmias after cardiac resynchronization therapy[J].J Am Soc Echocardiogr,2015,28(12):1474-1481.DOI:10.1016/j.echo.2015.07.021.
[11]PU L J,WANG Y,ZHAO L L,et al.Left univentricular pacing for cardiac resynchronization therapy using rate-adaptive atrioventricular delay[J].J Geriatr Cardiol,2017,14(2):118-126.DOI:10.11909/j.issn.1671-5411.2017.02.006.
[12]MELE D,BERTINI M,MALAGùM,et al.Current role of echocardiography in cardiac resynchronization therapy[J].Heart Fail Rev,2017,22(6):699-722.DOI:10.1007/s10741-017-9636-1.
[13]URBANEK B,KACZMAREK K,KLIMCZAK A,et al.Potential benefit of optimizing atrioventricular&interventricular delays in patients with cardiac resynchronization therapy[J].Indian J Med Res,2017,146(1):71-77.DOI:10.4103/ijmr.IJMR_1560_14.
[14]RICKARD J,BARANOWSKI B,WILSON TANG W H,et al.Echocardiographic predictors of long-term survival in patients undergoing cardiac resynchronization therapy:what is the optimal metric?[J].J Cardiovasc Electrophysiol,2017,28(4):410-415.DOI:10.1111/jce.13175.
[15]CHAN P S,KHUMRI T,CHUNG E S,et al.Echocardiographic dyssynchrony and health status outcomes from cardiac resynchronization therapy:insights from the PROSPECTtrial[J].JACC Cardiovasc Imaging,2010,3(5):451-460.DOI:10.1016/j.jcmg.2009.08.012.
[16]KANDALA J,UPADHYAY G A,ALTMAN R K,et al.QRSmorphology,left ventricular lead location,and clinical outcome in patients receiving cardiac resynchronization therapy[J].Eur Heart J,2013,34(29):2252-2262.DOI:10.1093/eurheartj/eht123.
[17]VAN EVERDINGEN W M,WALMSLEY J,CRAMER M J,et al.Echocardiographic prediction of cardiac resynchronization therapy response requires analysis of both mechanical dyssynchrony and right ventricular function:a combined analysis of patient data and computer simulations[J].J Am Soc Echocardiogr,2017,30(10):1012-1020,e2.DOI:10.1016/j.echo.2017.06.004.
[18]VAN BOMMEL R J,BAX J J,ABRAHAM W T,et al.Characteristics of heart failure patients associated with good and poor response to cardiac resynchronization therapy:a PROSPECT(predictors of response to CRT)sub-analysis[J].Eur Heart J,2009,30(20):2470-2477.DOI:10.1093/eurheartj/ehp368.
[19]DAMY T,GHIO S,RIGBY A S,et al.Interplay between right ventricular function and cardiac resynchronization therapy:an analysis of the CARE-HF trial(cardiac resynchronization-heart failure)[J].J Am Coll Cardiol,2013,61(21):2153-2160.DOI:10.1016/j.jacc.2013.02.049.
[20]ACHILLI A,PERALDO C,SASSARA M,et al.Prediction of response to cardiac resynchronization therapy:the selection of candidates for CRT(SCART)study[J].Pacing Clin Electrophysiol,2006,29(Suppl 2):S11-19.DOI:10.1111/j.1540-8159.2006.00486.x.
[21]HAUGAA K H,EDVARDSEN T,SMISETH O A.Mechanical dyssynchrony-resurrected as a flashing and rocking parameter to predict prognosis after cardiac resynchronization therapy[J].Eur Heart J Cardiovasc Imaging,2017,18(10):1118-1119.DOI:10.1093/ehjci/jex198.(收稿日期:2019-02-28;修回日期:2019-04-16)