| Background: Long-term right ventricular pacing(RVP)can lead to asynchrony of cardiac contractions,and eventually lead to pacemaker-induced cardiomyopathy(PICM),which seriously affects the daily life of patients and increase the patient's heart hrelated to the occurrence of PICM,and choosing appropriate surgical methods to avoid or reduce the occurrence of PICM both have profound effects on the prognosis and survival rate of patients.His-bundle pacing(HBP),as a physiological pacing method,has gradually gained attention in recent years.Does HBP benefit for patients with PICM and Ventricular pacing dependent(ventricular pacing ratio ? 40%)and permanent atrial fibrillation combined with heart failure with reduced ejection fraction(HFr EF)patients? There are relatively few studies on clinically related topics now.Objective: By comparative analyzing the clinical baseline data and follow-up data of patient with or without PICM,clarify the independent predictors of PICM,and the prognosis of long-term follow-up of the two groups.Find out the difference in mortality and readmission rate of heart failure between the two groups of people to know the prognosis of PICM to guide the next clinical treatment finally.By comparative analysis of the clinical indicators of patients with PICM before and after His-Purkinje system pacing replacement therapy,clarify the safety and effectiveness of the upgrade treatment of His-Purkinje system pacing(including his bundle pacing and left bundle branch pacing).Clarify whether there is a difference in the therapeutic value of the HisPurkinje system pacing upgrade treatment for the patient with PICM with(or without)atrial fibrillation.Clarify the effectiveness,safety,and differences of treatment for the patients with his bundle pacing(HBP)and traditional pacing(TP),including biventricular pacing in patients with ventricular pacing dependent(ventricular pacing ratio ? 40%)and permanent atrial fibrillation combined with heart failure with reduced ejection fraction(HFr EF)patients,to guide clinical further treatment,choose better pacing methods to improve the quality of life,and reduce the rate of readmission and death of patients with high heart failure rate.Materials and MethodsIn the first part,continuously select the patient who was admitted to the Department of Arrhythmia,the First Affiliated Hospital of Dalian Medical University from January2010 to January 2016.There were 782 patients with single-or dual-chamber permanent pacing due to atrioventricular block(AVB).78 Patients with heart failure with preoperative ejection fraction decreased(LVEF<50%)were excluded,and 53 cases of cardiomyopathy that already existed due to other underlying causes such as valvular disease,alcoholic/chemical,viral,dilated,arrhythmia,etc were excluded.80 cases of patients with an irregular follow-up of clinical parameters were excluded.Follow up the 571 patients enrolled,and divide them into PICM group and non-PICM group according to whether or not PICM occurred.Collect these information before pacemaker implantation: clinical general information of patients(including Gender,age,accompanying diseases,type of arrhythmia),echocardiographic parameters,the left ventricular end-diastolicdiameter(LVEDD),left atrial anteroposterior diameter(LAD),and the left ventricular ejection fraction(LVEF)by the Simpson biplane method;pre-implantation ECG parameters(QRS duration,QTC duration),pacing ratio(RVP%),pacing mode,and follow-up indicators.Collect the following information after pacemaker implantation: Echo-cardiographic parameters;left ventricular end-diastole Inner diameter(LVEDD),left atrium anteroposterior diameter(LAD),left ventricular ejection fraction(LVEF)measured by Simpson biplane method;After implantation,the ECG parameters(QRS duration,QTC duration).Then analysis independent predictors of pacemaker-induced cardiomyopathy(PICM),follow up of the enrolled patients to compare the prognosis between the PICM and non-PICM groups.In the second part,patients with PICM were continuous enrolled from January 2018 to March 2020 in the first affiliated hospital of Dalian Medical University.36 cases were enrolled in patients who underwent pacing treatment with the His-Purkinje system pacing(his bundle and left bundle branch area).The analysis included pre-implantation echocardiographic parameters: LVEDD,LAD,and LVEF by Simpson biplane method,electrocardiogram measurement(QRS duration),and New York Heart Association(NYHA)classification.Analysis changes in various indicators before and after the upgrade to evaluate the effectiveness and safety of the system replacement upgrade treatment.In the third part,61 patients with brady-arrhythmias,permanent AF and HFr EF were continuously enrolled from January 2017 to July 2019 and followed up for at least 12 months in the department of the First Affiliated Hospital of Dalian Medical University from January 2017 to July 2019.They were followed up before surgery and 1 month,3months,6 months,12 months,and 18 months after surgery(at least 12 months).Compare the general baseline data,the changes in QRS duration,NYHA classification,and other indicators before and after treatment between the 37 patients in the HBP group and 24 patients in the TP group.Compare standard ultrasound of the two groups Cardiogram examination.Based on the guidelines of the American Society of Echocardiography,measure the LVEDD,LAD,and LVEF by the Simpson biplane method.Measure the index parameters of the maximum degree of mitral regurgitation(MR)and tricuspid regurgitation(TR)at the apical four-chamber view.Follow up to collect pacing lead displacement and post-operative complications,pacemaker parameters such as threshold,perception,and impedance.Record patient infection,thrombosis,stroke,lead dislocation,perforation,pacemaker replacement,heart failure rehospitalization,death,and other events.According to the baseline treatment,TP is subdivided into the biventricular pacing(BVP)and right ventrcular pacing(RVP)group.Compare the effects of the HBP group and the two subgroups on the above indicators,then conclude.ResultsPart 11.Baseline characteristics of the researchAmong 782 patients with atrioventricular block who received permanent pacemaker implantation,78 patients with preoperative LVEF <50%,excluding other new heart diseases that lead to decreased heart function after surgery;53 cases of cardiomyopathy caused by other diseases(valvular disease,myocardial infarction,alcoholic/chemical,viral,dilated,arrhythmia,etc.)before and after surgery;80 cases of irregular ECG and echocardiogram follow-up indicators after operation were excluded.571 cases were included in this research finally.According to the diagnostic criteria of PICM,the patient with the symptom that the preoperative LVEF baseline of patients in this research was ?50%,and the postoperative follow-up echocardiographic LVEF ? 40 %would be considered as the occurrence of PICM.According to whether PICM occurred,571 patients were divided into PICM(n=53,9.28%)group and non-PICM(n=518,90.72%)group.The follow-up time of the non-PICM group was 5.53(3.54-7.30)years,and the LVEF decreased from(57.79±2.87)% to(55.87±3.03)%;the follow-up time of the PICM group was 6.08(4.69-8.05)years,and the LVEF was decreased from(55.87±3.03)% to(33.81±5.39)%,and there was no difference in the follow-up time between the two groups.Baseline indicators: There was no statistical difference between the two groups in the aspects of gender,age,combined with underlying diseases diabetes,hypertension,chronic kidney disease,coronary heart disease,stroke.The proportion of patients in the PICM group with preoperative atrial flutter or atrial fibrillation was significantly higher than that of the non-PICM group(41.51% vs.22.01%,P=0.002).Comparison between non-PICM group and PICM group: There were significant statistical differences in these indicator: baseline LBBB(6.95% vs.15.09%,P=0.034),RV pacing ratio(67.07±38.42% vs.92.20±18.66%,P<0.001),baseline LVEDD(47.57±5.25 mm vs.51.19±5.15 mm,P<0.001),baseline LVEF(57.79±2.87% vs.55.87±3.03%,P<0.001).Follow-up indicators: There were significant statistical differences in these indicator:QRS duration after pacing(143.47±33.14 ms vs.172.91±33.49 ms,P<0.001),QTC interval time after pacing(477.02±50.83 ms vs.507.17±44.83 ms,P<0.001),follow-up LVEDD(48.10±5.19 vs.56.57±6.58,P<0.001),follow-up LVEF(54.38±5.11% vs.33.81±5.39%,P<0.001).2.Logistic analysis of the incidence of PICM and factors.In the multivariate logistic regression analysis,these data including atrial fibrillation(OR 2.20;95% CI,1.10-4.33;P=0.024),Baseline LVEF(OR 0.89;95% CI,0.81,0.98;P=0.022),baseline LVEDD(OR 1.09;95% CI,1.02-1.16;P=0.010),QRS duration after pacing(PQRSD)(OR 1.02;95% CI,1.01-1.03;P=0.008),a higher right ventricular pacing ratio(RVP%)(OR 1.03;95% CI,1.01-1.06;P=0.003)suggest an independent predictor of PICM.From the analysis of the ROC curve,the cut-off points for predicting the risk of PICM were baseline LVEDD(49mm),baseline LVEF(52%),PQRSD(165ms),and RVP%(90%).atrial fibrillation,PQRS ?165 ms,LVEDD?49 mm,baseline LVEF?52%,RVP%?90% significantly increased the incidence of PICM.Moreover,as the number of combined predictors increases,the incidence of PICM also increases,which exists a positive correlation between them.PICM long-term prognosis and clinical follow-up results: The average follow-up time during the entire follow-up period is 5.56(3.66-7.35)years,and heart failure readmission are 11.58% and 67.92% respectively.Compared with the non-PICM group,the PICM group had a significant increase in the incidence of heart failure readmission(HR 2.86;95% CI 1.71-4.78,P<0.001)significantly increased.Part 21.Comparison before and after the upgrade treatment of His-Purkinje system pacing For patients with PICM that have occurred,the pacing replacement upgrade treatment of the His-Purkinje system was carried out.36 cases were enrolled,and 34 cases were successfully treated,with a success rate of 94%.Among them(29 cases underwent HBP,5 cases of left bundle branch pacing),34 patients were followed up for 12.52 ± 5.4months after the pacing upgrade of His-Purkinje system.There was no postoperative infection,no lead dislocation,perforation,pericardial tamponade,and other complications be found.The average age was 69.7 ± 13.8 years,of which 21 cases(61.8%)with permanent atrial fibrillation and the proportion of ventricular pacing in patients with atrial fibrillation is 87.3%.If there is no self-rhythm during the operation(<30beats/min),the pacing mapping method is used to find the His bundle area;If the block site is low or the his bundle pacing threshold is high,the left bundle branch area pacing is used.The results showed that the postoperative QRS duration after the upgrade of the His-Purkinje system was significantly shorter than that before the upgrade(184.22 ±23.67ms to 120.52±16.67 ms,P<0.001),and LVEDD was significantly shorter than before the upgrade(59.29±7.74 mm to 53.91±5.92 mm,P<0.001),LAD was also shorter than before the upgrade(47.44±7.14 mm to 45.56±7.78 mm,P=0.01),LVEF was significantly higher than before upgrade(33.76±7.54% to 40.41±9.06%,P<0.001),NYHA classification significantly was improved from before the upgrade(2.55±0.51 to 2.05±0.45,P<0.001).2.Comparison of follow-up indicators and clinical parameters between PICM with atrial fibrillation and non-atrial fibrillation groups21/34 patients(61.76%)of PICM with atrial fibrillation,LVEF was significantly increased from baseline 34.71% ± 6.38% to 40.57 ± 9.38%,(P<0.001);QRS duration was significantly reduced from 185.35±21.79 ms to 119.35±16.26 ms,(P<0.001);LVEDD was significantly reduced from 59.67±7.74 mm to 54.05±5.88 mm(P<0.001).In 13/34 cases in the non-atrial fibrillation group,LVEF was increased significantly from baseline 32.23±9.18% to 40.15±8.90%(P<0.001);QRS duration was significantly reduced from 182.08±28.98 ms to 122.83±18.95 ms(P<0.001);LVEDD was decreased significantly from 58.96±8.03 mm to 53.69±6.22mm(P<0.001).However,there is no significant difference in these aspects between PICM combined with atrial fibrillation group and non-atrial fibrillation group: degree of improvement of LVEF(5.86±8.30% vs.7.92%±9.04%,P=0.504),degree of improvement of LVEDD(5.62±7.43 mm vs.5.27%±7.30 mm,P=0.890)and degree of improvement of QRS duration(66.00±19.17 ms vs.59.25±25.49 ms,P=0.386),the improvement of NYHA(0.63±0.84 vs.0.56%±0.65,P=0.799).Part 31.Comparison of pacemaker implantation results and complications between the two groups37 cases were successfully treated with HBP,and the success rate of HBP was 88.10%.There were 24 cases of selective(S-HBP),and the rest were non-selective(NS-HBP).The His bundle wire threshold was increased among 2 cases in the 3 months postoperative when followed up,but the wire position returned to normal after adjusting the position of the wire.A total of 5 cases of HBP treatment were not successfully transferred to the TP group(one of which was CLBBB)and received traditional CRT-P treatment.There were 24 cases in the TP group,7 cases in CRT-P,8 cases in CRT-D,and the remaining 9 cases underwent ventricular single-chamber pacing for economic reasons.All 61 patients completed the follow-up for(18.12±4.45)months.During the follow-up,there were no pacing lead displacement,infection,thrombosis,perforation,acute left heart failure,sudden death,and other events.In the HBP group,5 patients with heart failure were readmission,of which 2 patients were admitted to the hospital for heart failure caused by a lung infection,and 4 patients in the TP group were readmission with heart failure.There were no significant differences in gender,age,comorbid diseases,ECG characteristics,drug treatment,and B-type natriuretic peptide levels between the two groups(P>0.05).2.Pacemaker implantation results,parameters and complications in HBP group and the TP groupPacemaker parameters such as threshold,perception,and impedance at the time of implantation and the last follow-up were recorded of the two groups of patients.The threshold at the last follow-up of the HBP group was slightly higher than that at the time of implantation(1.69±0.97 V to 1.84±0.66 V,P=0.059);the threshold of the HBP group was higher when the pacemaker was implanted than the TP group(1.69±0.97 V vs.0.85±0.12 V,P=0.001)by comparison between groups;The perception in the HBP group was lower than that in the TP group(4.85±2.08 MV vs.9.63 ± 5.49 MV,P=0.001;4.56±1.94 MV vs.9.93±5.76 MV,P=0.001)when the pacemaker was implanted and the last follow-up;the HBP group had longer operation time(61.10±32.03 min vs.48.94±21.75 min,P=0.025).3.Comparison of QRS duration,cardiac structure,and cardiac function between the HBP group and the TP group before and after operationAmong 61 patients,24 were in the TP group and 37 were in the HBP group.Compared with the TP group,the QRS duration of the HBP group was shortened(P<0.001),NYHA was improved more significantly(P<0.001),and the reduction of LVEDD is more obvious(P<0.001),the improvement of TR is more obvious(p<0.001),the improvement of MR is more significant(P=0.017),LVEF was increased more significantly(P<0.001).Among them,11 patients(29.73%)recovered to normal values(LVEF?50%)after the operation,while in patients with traditional biventricular pacing therapy,only 1 patient(6.67%)returned to normal cardiac function.The median time for heart function to return to normal in the HBP group was 6±3.5 months after surgery.3.Comparison of QRS duration,cardiac structure,and cardiac function between HBP and BVPThere were 37 cases in the HBP group and 15 cases in the biventricular pacing(CRT-P/CRT-D)group.Comparing the two groups,there was no difference on QRSD,NYHA classification,LAD size,LVEDD size,LVEF,TR,MR before operation(P>0.05),the LAD changes of the two groups were not significant(P>0.05),the reduction of LVEDD in HBP group was significantly than the BVP group(10.13±4.80 vs.6.00±3.00,P=0.003).MR of both groups were improved(P<0.001,P=0.024),and there was no statistical difference between two groups.TR was significantly improved after surgery in HBP group(P<0.001),and slightly improved in BVP group(P=0.171);the LVEF in the HBP group increased more significantly than before(12.25±4.59%,8.07±6.83%,P=0.013).5.Comparison of QRS duration,cardiac structure,and cardiac function between HBP and RVPThere were 37 cases in HBP group and 9 cases in RVP group.The QRS duration in RVP group was significantly widened after implantation(114.44 ± 21.11 ms to 151.78± 15.85 ms,P<0.001);the NYHA classification of RVP group was lower than that before operation(2.78±0.97 to 3.56±0.73,P=0.043),the NYHA classification in HBP group was significantly improved after operation(3.27±0.43 to 2.28±0.70,P<0.001).In terms of echocardiographic indicators,LVEDD in the RVP group was significantly broadened after implantation(58.00 ± 9.11 mm to 65.78 ± 8.60 mm,P<0.001),while LVEDD in HBP group was reduced(61.86±6.68 mm to 51.73±7.65 mm,P<0.001);LVEF in HBP group was significantly higher than that before operation(30.86±5.59%to 43.11±6.78%,P<0.001),while LVEF of RVP group was lower than before operation(32.56±6.25% to 26.78±5.38%,P=0.006);LVEF of RVP group was lower than that before operation(32.56±6.25% to 26.78±5.38%,P=0.006);the degree improvement of mitral valve regurgitation in HBP group was more obvious than that before operation(2.28±1.54 to 1.05±0.97,P<0.001,1.46±0.96 to 0.68±0.77,P<0.001),while RVP pacing group did not improve after surgery,and even deteriorated(1.44±0.88 to 2.11±0.78,P=0.051;1.44±1.13 to 2.0±1.00,P=0.247).ConclusionPart 11.Permanent RVP can lead to PICM,even in people with preoperative LVEF preservation(?50%),the disease incidence is high.Compared with non-PICM patients,PICM patients have a poor long-term prognosis,with a high heart failure readmission rate.2.Multivariate analysis of the presence of preoperative atrial fibrillation,baseline LVEF,baseline LVEDD,PQRSD,RVP% suggests independent predictor of PICM.atrial fibrillation,baseline LVEF?(52%),baseline LVEDD?(49mm),PQRSD(?165ms),RVP%(?90%)significantly increased the incidence of PICM.Moreover,as the number of combined predictors increases,the incidence of PICM increases,and the symptoms of PICM are not obvious at the beginning of the onset of PICM.Changes in related indicators and parameters should be regularly detected as soon as possible after the operation to avoid the occurrence of PICM.Part 21.For patients who have occurred PICM,His-Purkinje system(HBP or LBBP)upgrade treatment should be actively considered to effectively avoid the dangers of TP and successfully reverse the cardiac function of patients with PICM.2.PICM combined with atrial fibrilation(VP?40%)may produce clinical benefits similar to sinus rhythm when the pacing upgrade of the His-Purkinje system is performed.Part 31.For the patients with brady-arrhythmias,permanent atrial fibrilation and HFr EF,HBP therapy is safe and effective.As a physiological cardiac pacing method,it produces fine hemodynamic characteristics by reducing the electromechanical asynchrony of the left ventricle,which is more helpful to the heart rate management of patients with heart failure.2.Compared with RVP,HBP can significantly improve NYHA,QRS duration,LVEDD,LVEF,MR,TR.Even compared with biventricular pacing(BVP),HBP also takes a more obvious therapeutic effect on the improvement of the above indicators.3.What's more gratifying is that HBP can restore the LVEF of some patients to normal indicators,which is unmatched by traditional pacemakers. |
PDF Full Text Request