2021年希氏束浦肯野纤维系统起搏(全文).docxVIP

2021年希氏束浦肯野纤维系统起搏(全文) 引言： 心脏起搏传导系统疾病会导致该系统受损和功能障碍，进而引起一系列临床综合征，严重时可能危及患者生命。尽管心脏起搏系统疾病的病理生理机制多种多样，但对于这种非可逆性器质性改变的患者，心脏起搏器植入术是目前唯一有效的治疗方法。心脏起搏器是一种植入体内的电子治疗仪器，可用于治疗某些心律失常、心脏功能障碍或药物难治性充血性心力衰竭等。 希浦系统起搏： 希浦系统起搏是一种起搏器，它可以根据设定程序激动心脏的不同部位，以模拟近似正常的传导和起搏顺序激动心脏。通过将起搏电极植入希浦系统中并产生类似于正常生理激动顺序起搏，心电图表现为窄QRS波，因此目前被认为是最接近生理的起搏方式。 传统起搏技术的弊端： 对于患有心脏传导系统疾病的患者，如何选择合适的心室起搏部位一直是起搏器治疗的一个难题。由于起搏电极容易到达右心室，因此右心室起搏（RVP）是既往最常用的传统起搏方式，其已经在临床上应用超过50年的时间。然而，RVP在左室侧壁激动前，先激动了右室心尖部或室间隔，使心脏左、右心室电－机械活动不同步，造成人为的类似左束支传导阻滞（LBBB）改变，这使得左、右心室出现非同步化收缩，从而影响这类患者左心室功能，增加远期死亡率。研究表明，RVP患者中有高达20％的患者会出现起搏器诱导性心肌病（PICM）。 Biventricular pacing (BVP), also known as cardiac resynchronization therapy (CRT), improves the synchronous contraction of the left and right ventricles by pacing the right ventricle with an endocardial electrode and the left ventricle with an epicardial electrode placed on the lateral base of the left ventricle through the coronary sinus branch. It can shorten the QRS duration and left ventricular activation time in patients with left bundle branch block (LBBB). A meta-analysis of 3,872 heart failure patients with LBBB showed that BVP therapy reduced all-cause mortality by 34% (HR: 0.66; 95% CI: 0.55-0.78) [3]. However, the range of QRS duration shortening by BVP is limited, and it does not truly restore left ventricular activation time to normal physiological levels. In addition, because BVP paces the ventricular muscle rather than the hearts conduction system, it does not conform to the normal electrophysiological characteristics of the heart. When BVP is used in patients with normal QRS duration or mild QRS prolongation, it may actually prolong ventricular activation time and worsen asynchronous contraction, ultimately increasing mortality in this group of patients [4]. Although this implantation method is technically successful in 90% of patients, clinical improvement or reversal of left ventricular remodeling is achieved in less than two-thirds of patients. The reasons for this reaction may inclu