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目的:探讨术前自身QRS波时限(intrinsic QRS duration,IQRSd)对右心室心尖部(right ventricular apex,RVA)起搏患者心功能下降的预测作用。方法:选取因三度房室传导阻滞(Ⅲ°AVB)植入双腔全自动型起搏器(DDD)或单腔同步型起搏器(VVI)患者42例。其中,末次随访时左室射血分数较术前下降的绝对值(ΔLVEF)≥5%的患者22例(ΔLVEF≥5%组,DDD 12例,VVI 10例),同期ΔLVEF<5%患者20例(ΔLVEF<5%组,DDD 11例,VVI 9例),两组比较,研究起搏引起心功能下降的可能原因和可能的预测因子。每例患者在起搏器植入术前行12导联心电图和超声心动图检查,术后随访时记录起搏心电图、超声心动图及右心室累积起搏比例。结果:两组患者平均随访77.3个月,ΔLVEF≥5%组左室射血分数(left ventricular ejection fraction,LVEF)由术前(64.20±6.30)%降至(40.60±10.00)%(P<0.001),左房内径(left atrial diameter,LAD)由术前(34.77±6.42)mm增大至(41.00±7.45)mm(P<0.001),左室舒张末期内径(left ventricular end-diastolic dimension,LVEDD)由术前(49.82±4.86)mm明显增大至(55.59±8.44)mm(P<0.001),差异均有统计学意义;ΔLVEF<5%组LVEF由术前(65.40±3.25)%降低至(64.94±3.00)%(P=0.543),LAD由术前(37.40±4.84)mm增加至(38.15±5.83)mm(P=0.347),LVEDD由术前(48.30±3.95)mm增加至(49.00±3.87)mm(P=0.090),变化均无统计学意义;四格表卡方检验提示植入起搏器后术前IQRSd≥110 ms组较术前IQRSd<110 ms组患者发生心功能下降比率更高(P=0.002);Kaplan-Meier分析发现植入起博器后术前IQRSd≥110ms患者较术前IQRSd<110 ms患者心功能下降发生时间更早。COX回归分析显示,术前IQRSd≥110 ms是左室收缩功能下降的独立预测危险因素(P<0.05)。结论:RVA长期起搏可引起心脏结构改变和左室收缩功能下降;术前IQRSd≥110 ms患者左室收缩功能下降发生率高且时间更早,术前IQRSd≥110 ms是起搏依赖患者左室收缩功能下降的独立预测危险因子。
Objective: To investigate the predictive value of preoperative QRS duration (IQRSd) on the decline of cardiac function in patients with right ventricular apex (RVA) pacing. Methods: Forty-two patients with dual-chamber automatic pacemaker (DDD) or single-chamber synchronized pacemaker (VVI) underwent third-degree AV block were selected. Among them, 22 patients (ΔLVEF ≥ 5%, DDD 12, VVI 10), patients with ΔLVEF less than 5% at the last follow-up had a decreased left ventricular ejection fraction (LVEF) ≥5% (ΔLVEF <5%, DDD 11, VVI 9). The possible causes and possible predictors of cardiac function decline after pacing were compared between the two groups. Each patient underwent 12-lead electrocardiogram and echocardiography before the pacemaker implantation. The pacing electrocardiogram, echocardiography and right ventricular cumulative pacing rate were recorded at follow-up. Results: The average follow-up time was 77.3 months in both groups. The left ventricular ejection fraction (LVEF) decreased from (64.20 ± 6.30)% to (40.60 ± 10.00)% in pretreatment group (P <0.001) ), Left atrial diameter (LAD) increased from (34.77 ± 6.42) mm to (41.00 ± 7.45) mm before operation (P <0.001), left ventricular end-diastolic dimension ) From preoperative (49.82 ± 4.86) mm to (55.59 ± 8.44) mm (P <0.001), the differences were statistically significant; LVEF decreased from 65.40 ± 3.25% to LAD decreased from (37.40 ± 4.84) mm to (38.15 ± 5.83) mm before surgery (P = 0.347), while LVEDD decreased from (48.30 ± 3.95) mm to (49.00% ± 3.87) mm (P = 0.090). There was no significant difference between the two groups in the chi square test. The chi square test showed that the heart failure occurred in IQRSd≥110 ms before implanted pacemaker (P = 0.002). Kaplan-Meier analysis showed preoperative IQRSd≥110ms postoperative pacemaker implantation was earlier in patients with cardiac function decline than preoperative IQRSd <110ms. COX regression analysis showed that preoperative IQRSd≥110 ms was an independent predictor of LV systolic function decline (P <0.05). Conclusion: Long-term pacing of RVA can cause cardiac structural changes and decreased left ventricular systolic function. Preoperative left ventricular systolic dysfunction in patients with IQRSd≥110 ms is associated with a high incidence and earlier time. Preoperative IQRSd≥110 ms is associated with left pacing Independent predictive risk factors for decreased contractile function.