传统起搏部位及方式的利与弊(黄德嘉)

传统起搏部位及方式的利与弊,黄德嘉 四川大学华西医院心内科,传统起搏部位,心室：右室心尖心房：右心耳,传统起搏方式,右心室起搏：VVI（R）心房为基础的起搏：DDD（R）、AAI（R）,传统起搏部位和方式的优点,已应用30年； 手术操作较简单； X光照射时间短； 术中和术后并发症很少； 制造商有长期丰富的经验：导线,右室心尖起搏LBBB，使血液动力学指标恶化,dp/dt （Wiggins. Am J physiol.1925:73c） 心输出量 （Rosenqvist. Am H J 1988:116） 左心功能（Tantengco, JACC 2001:2093） 儿童、左心功能、解剖正常，随访10年，与正常对照 组织学改变（Karpawich; PACE,1999:1372）,0,20,40,60,80,LV volume (ml),LV pressure (mm Hg),NSR,RVA Pace,Peschar JACC 2003,Prinzen PACE 2002,Max,*,*,1,0,0,0,1,1,0,0,1,2,0,0,1,3,0,0,1,4,0,0,1,5,0,0,-,1,5,0,0,-,1,4,0,0,-,1,3,0,0,-,1,2,0,0,-,1,1,0,0,-,1,0,0,0,LV dP/dt min,LV dP/dt max,NSR,RVP,LV Performance and Peak dp/dt (Max and Min),Normal Myocardium,RVA Pacing: Histology,起搏部位和方式的选择,双心室起搏 vs 右室心尖起搏； 右室间隔和游离壁起搏； 心房不同部位的起搏 vs 右心耳起搏； 起搏方式的优化,LV VOLUME,LV PRESSURE (mmHg),PT. # 4 PV Loops and RV vs Bi-V,Lieberman,RV Apex Low LV,RV Apex/LV High,循证医学时代对起搏治疗的认识和评价,对适应证的认识和评价 起搏方式的选择 心功能 房颤 生活质量 心衰住院 死亡率 脑卒中,问题,DDD优于VVI吗? DDD与AAI比较 病窦综合征病人，哪一种起搏方式好?,Danish Study,Study Population (n=225),Randomised to AAI (n= 110),Randomised to VVI (n= 115),Danish Study Overall survival by pacing mode,Andersen H, et al. Lancet 1997; 350: 1210-16.,Danish Study Cardiovascular death by pacing mode,Andersen H, et al. Lancet 1997; 350: 1210-16.,Time (years),p = 0.0065,Atrial pacing,Ventricular pacing,0,2,4,6,8,10,0,0-2,0-4,0-6,0-8,1-0,Cumulative survival,Number of patients at risk during follow-up Atrial Ventricular,Danish Study Cumulative risk of PAF by pacing mode,Andersen H, et al. Lancet 1997; 350: 1210-16.,Danish Study Cumulative risk of chronic AF by pacing mode,Andersen H, et al. Lancet 1997; 350: 1210-16.,Danish试验结论,对病窦综合征，AAI起搏对降低死亡率,减少房颤,血栓栓塞并发症和心衰均有益处,CTOPP Study Protocol,Patients undergoing first IPG implant n=2,568,Ventricular-Based Pacing n = 1,474,Physiologic Pacing n = 1,094,Follow for an average of 3 years and compare: Stroke or death due to cardiovascular causes Death from any cause Atrial fibrillation Hospitalization for HF,CTOPP Cumulative Risk of Stroke or Cardiovascular Death,Cumulative Risk,Years after Randomization,0,1,2,3,4,0,0.1,0.2,0.3,0.4,P = 0.33,Ventricular pacing,Physiologic pacing,Connolly S et al. N Engl J Med 2000; 342: 1385-91.,No. at risk: Ventricular pacing 1474 1369 1259 847 366 Physiologic pacing 1094 1005 954 637 287,CTOPP Cumulative Risk of any AF,Cumulative Risk,0,0.1,0.2,0.3,0.4,0,1,3,4,Years after Randomization,P = 0.05,Ventricular pacing,Physiologic pacing,Connolly S et al. N Engl J Med 2000; 342: 1385-91.,No. at risk: Ventricular pacing 1474 1276 1127 731 303 Physiologic pacing 1094 936 857 559 250,2,CTOPP Cumulative Risk of Chronic AF,Skanes A, et al. J Am Coll Cardiol 2001; 38: 167-72.,Cumulative Risk,Years Since Randomization,0,1,2,3,4,0.0,0.1,0.2,0.3,0.4,Number V 1474 1317 1180 779 331 At Risk P 1094 975 906 601 269,P = 0.016,Ventricular pacing,Physiologic pacing,CTOPP试验结论,生理性起搏(DDD)与心室起搏(VVI)比较,不降低心血管病死亡率和脑卒中发生率 DDD起搏组房颤发生率较低,Mode Selection Trial in Sinus Node Dysfunction MOST,MOST Protocol,Patients Undergoing Initial IPG Implant for SND n=2010,Dual-Chamber Pacing n=1014,Ventricular Pacing n=996,Follow for a median of 33 months and compare: Death from any cause or non fatal stroke Composite of death, stroke, or hospitalization for HF Atrial fibrillation Heart Failure score Pacemaker syndrome Quality of Life,MOST Total Mortality or Stroke,0,6,12,18,24,30,36,42,48,54,60,0.00,0.10,0.20,0.30,0.40,0.50,Months,Event Rate,P = 0.48 Adjusted P = 0.32,Ventricular pacing,Dual-chamber pacing,Lamas G, et al. N Engl J Med 2002; 346: 1854-62.,MOST CHF Hospitalization,Lamas G, et al. N Engl J Med 2002; 346: 1854-62.,0,6,12,18,24,30,36,42,48,54,60,0.00,0.10,0.20,0.30,0.40,0.50,Months,Event Rate,P = 0.13 Adjusted P = 0.02,Ventricular pacing,Dual-chamber pacing,MOST Atrial Fibrillation,Lamas G, et al. N Engl J Med 2002; 346: 1854-62.,MOST试验结论,在病窦综合征，双腔起搏可降低房颤发生率，轻度改善生活质量 双腔起搏不降低死亡率，脑卒中和心衰发生率,Dual-Chamber and VVI Implantable Defibrillator Trial DAVID,DAVID Trial Protocol,760 assessed for eligibility,250 excluded149 Did not meet Rx criteria55 refused46 Other,510 eligible,4 Not randomized2 Required pacing1 Inadequate defibrillation threshold 1 Decided not to implant,VVI-40 (n=256),DDDR-70 (n= 250),1 had pacing mode set to DDD1 LTF10 Discontinued intervention5 Bradycardia1 CHF and AF1 Brady induced Torsade1 Heart Tx workup1 AF w rapid V response1 multiple shocks due to double counting,3 had pacing mode set to VVI2 LTF5 Discontinued intervention1 Angina1 CHF and Lead Failure1 CHF Hospitalization1 Exacerbation of VT1 Lead Migration,Wilkoff B, et al. JAMA. 2002; 288: 3115-3123.,DAVID Trial Inclusion Criteria,ICD indicated patients No indication for antibradycardia pacing LVEF 40% No persistent or frequent, uncontrolled AF,Wilkoff B, et al. JAMA. 2002; 288: 3115-3123.,DAVID Trial Baseline Patient Characteristics,Wilkoff B, et al. JAMA. 2002; 288: 3115-3123.,DAVID Trial Drug Therapy 6 Months Post Randomization,Wilkoff B, et al. JAMA. 2002; 288: 3115-3123.,DAVID,Death or First Hospitalization for New or Worsened CHF,Hazard ratio (95% CI), 1.61 (1.06-2.44),0,6,12,18,Months,Cumulative Probability,0.4,0.3,0.2,0.1,0,250 256,159 158,76 90,21 25,No. at Risk DDDR VVI,Wilkoff B, et al. JAMA. 2002; 288: 3115-3123.,DDDR,VVI,DAVID Trial Results,Wilkoff B, et al. JAMA. 2002; 288: 3115-3123.,DAVID,First Hospitalization for New or Worsened CHF,Hazard ratio (95% CI), 1.54 (0.97-2.46),0,6,12,18,Months,Cumulative Probability,0.4,0.3,0.2,0.1,0,250 256,155 156,74 89,21 24,No. at Risk DDDR VVI,Wilkoff B, et al. JAMA. 2002; 288: 3115-3123.,DDDR,VVI,DAVID,Death From Any Cause,Wilkoff B, et al. JAMA. 2002; 288: 3115-3123.,DAVID,Wilkoff B, et al. JAMA. 2002; 288: 3115-3123.,DIVID试验结论,对左心功能不全,无常规心动过缓起搏适应证的病人,长期右室心尖起搏有害,MOST亚组研究,假说:右室心尖起搏产生类似LBBB情况QRS增宽，破坏了心室的同步性，可能增加发生心衰和房颤的危险性，对病人预后有不良影响,MOST亚组研究方法,植入起搏器前，测量基础QRS宽度，将QRS120ms者随机分为2组 DDDR组702例，VVIR组640例 计算累计心室起搏的%,MOST亚组研究,DDDR组: 心室累积起搏40%，心衰住