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目的 应用常规超声心动图及组织多普勒定量评价个体优化设定室间(VV)间期的心脏再同步化起搏治疗效果。方法 26例经再同步化起搏治疗的重度充血性心力衰竭患者,三腔起搏器安置术后先采用起搏器默认参数,术后1周内在超声指导下进行个体起搏参数优化。优化时,先根据二尖瓣前向血流频谱形态及速度时间积分(VTIMv)得出最佳房室(AV)间期后,再根据主动脉流速时间积分(VTIAo)及组织多普勒测量得出的收缩不同步指数(SDI)判定双室顺序起搏时个体最佳VV间期。结果 26例重度充血性心力衰竭患者经个体优化后,最佳VV间期均为左心室提前起搏,范围在4～40ms,个体差异明显。个体优化设定VV间期后VTIAo和做功指数(MPI)测值分别为(22.3±4.5)cm、(0.78±0.18),双室同步起搏时的测值分别为(20.8±4.9)cm、(0.86±0.17),两者比较差异有统计学意义(t=-5.055、3.217,P均<0.05)。VTIAo进一步增大,MPI则进一步减小;经个体优化最佳VV间期后室间机械延迟(IVMD)、SDI、收缩后缩短现象(PSS)测值分别为(-24±19)ms、(12.1±2.9)、(30.8±16.7)%,双室同步起搏时的测值分别为(-32±19)ms、(14.3±2.6)、(38.3±16.3)%,两者比较差异有统计学意义(t=-3.370、4.592、3.250,P均<0.01)。心室内及心室间同步性进一步改善,IVMD、SDI、PSS更加减小。结论 经个体优化设定心室起搏顺序后,心脏再同步化治疗效果更好,心室的收缩协调性得到了最大程度的改善。常规超声心动图,尤其是频谱多普勒,在个体优化中发挥主导作用,组织多普勒能够定量评价心室收缩同步性,阐释发生血流动力学变化的机械运动机制,在同步化治疗过程中发挥的作用不可替代。
Objective To quantitatively evaluate the effect of cardiac resynchronization pacing in interventricular septum (VV) interval by using routine echocardiography and tissue Doppler. Methods Twenty - six patients with severe congestive heart failure treated by resynchronization pacing were enrolled in this study. The pacemaker default parameters were used after placement of the three - chamber pacemaker. Individual pacing parameters were optimized under ultrasound guidance within one week after operation. Optimized, the best AV interval was obtained according to the spectral shape of the anterior mitral flow and the velocity time integral (VTIMv), and then the VTIAo and Tissue Doppler were measured The resulting systolic nonsynchrony index (SDI) was used to determine the best individual VV interval in dual ventricular pacing. Results The optimal VV interval was left ventricular premature pacing in 26 patients with severe congestive heart failure, ranging from 4 to 40 ms. The individual differences were significant. VTIAo and MPI were (22.3 ± 4.5) cm, (0.78 ± 0.18) and (20.8 ± 4.9) cm, respectively, in ambulatory synchronized pacemaker, (0.86 ± 0.17), the difference between the two groups was statistically significant (t = -5.055, 3.217, P <0.05). VTIAo further increased and MPI decreased further. After optimization of individual optimal VV interval, IVMD, SDI and PSS were -24 ± 19ms, ( 12.1 ± 2.9) and (30.8 ± 16.7)%, respectively. The measured values of simultaneous biventricular pacing were -32 ± 19 ms, (14.3 ± 2.6) and (38.3 ± 16.3)%, respectively Significance (t = -3.370, 4.592, 3.250, P <0.01). Intraventricular and ventricular systolic further improved, IVMD, SDI, PSS more reduced. Conclusions Cardiac resynchronization therapy is more effective and ventricular systolic coordination is improved to the greatest extent after the individual has optimized the ventricular pacing sequence. Conventional echocardiography, especially spectral Doppler, plays a leading role in individual optimization, and tissue Doppler quantifies the systolic synchrony, interprets the mechanistic motor mechanism of haemodynamic changes, and in the course of synchronized therapy The role of play irreplaceable.