心脏起搏治疗和预防心衰一crt的新适应证-黄德嘉--幻灯.pptVIP

心脏起搏治疗和预防心衰一CRT的新适应证黄德嘉四川大学华西医院心内科

CRT11年：治疗目标的发展治疗严重心衰，Ⅲ-Ⅳ级心功从Mustic到Care-HF预防心衰进展：Ⅰ-Ⅱ级心功MADIT-CRT,REVERSE预防心衰发生：无心衰症状，无左室功能障碍，但有常规起搏适应症或合并LBBBBIOPACE2012

PatientswithapreviouslyimplantedconventionalpacingdeviceandsevereleftventriculardysfunctionChronicrightventricularpacinginducesLVdyssynchronywithdeleteriouseffectsonLVfunction.However,therearefewdataconcerningtheeffectsofdeviceupgradingfromonlyrightventriculartobiventricularpacing.Therefore,theconsensusisthatinpatientswithchronicrightventricularpacingwhoalsopresentanindicationforCRT(rightventricularpacedQRS,NYHAclassIII,LVEF≤35%,inoptimizedheartfailuretherapy)biventricularpacingisindicated.UpgradingtothispacingmodeshouldpartiallyrevertheartfailuresymptomsandLVdysfunction.

过去植入常规心脏起搏器的病人，如果合并严重的左心功能不全，长期右室起搏可导致左心室失同步化而使左心功能恶化。现在的共识是：对需要长期右室起搏的病人，如果心功能Ⅲ级，EF≤35%，QRS波为右室起搏图形，为双心室起搏的适应证。升级后可部分改善心衰症状和左室功能。

Patientswithindicationforpermanentpacingforbradyarrhythmia,withheartfailuresymptomsandseverelycompromisedleftventricularfunction。Studiesspecificallyaddressingthisissuearelacking.ItisimportanttodistinguishwhatpartoftheclinicalpicturemaybesecondarytotheunderlyingbradyarrhythmiaratherthanLVdysfunction.OnceseverereductionoffunctionalcapacityaswellasLVdysfunctionhavebeenconfirmed,thenitisreasonabletoconsiderbiventricularpacingfortheimprovementofsymptoms.Conversely,thedetrimentaleffectsofrightventricularpacingonsymptomsandLVfunctioninpatientswithheartfailureofischaemicoriginhavebeendemonstrated.TheunderlyingrationaleofrecommendingbiventricularpacingshouldthereforeaimatavoidingchronicrightventricularpacinginheartfailurepatientswhoalreadyhaveLVdysfunction.

对有永久起搏适应症，合并心衰症状或严重左室功能障碍的病人，首先应区分其症状是由于心动过缓所致或由于心功不全所致。如果能证实症状主要是由于心功能不全所致，有理由相信双室起搏可以改善症状。……双心