| ObjectTo assess the function of biventricular pacing dynamic combined of with atrioventricular nodal conduction function and improve the efficacy of the cardiac pacing, to provide scientific basis for the soft/hard ware and application technique of CRT-P/D system.Method1. From2012January to2013September, we continuously selected the patients who are admitted to the First Affiliated Hospital of Kunming Medical University and accorded with the CRT I A indication of the2013ACCF/AHA/HRS guidelines.30cases were successfully implanted the CRT-P/D. All the patients’CRT model was optimized (to AVd and Wd model) in rest-state after the moment, CRT AVd increased through the titration control-program.Until biventricular pacing and atrioventricular node intrinsic conduction had been excited ventricle, we got the narrowest "true fusion QRS wave group" and "3-Chamber&4-site Pacing".2.30patients were randomly divided into dynamic balance group and non-dynamic balance group, with15cases in each group. Method of dynamic balance: analysis of dynamic electrocardiogram (ecg) was made to establish a negative correlation mathematical functions between PR interphase and R-R interphase.Then the delta value of individual coefficient was found, on the base of fixed value of AVd optimized programme CRT system. According to the last inter beat intervals measured AV delay quantity, automatically adjust next biventricular pacing AVd values of CRT system, striving to dual chamber pacing AVd gradually automatic combinedly the natural pass the time required for PRd of atrial to be excited by atrioventricular.15patients with dynamic optimization as mentioned above were set to dynamic group; The group that did not make the dynamic optimization of15patients was set to the control group.3. Before the CRT operation,2kinds of both mode optimization/after three and six months, all patients were required to take the ECG,24h Holter, echocardiography and exploratio. We also got the information in PRd QRS wave morphology/width,CRT system parameters, and evaluated the cardiac synchronization and multiple ultrasonic measurement value of the cardiac function. Then we completed the detail of patients in NYHA heart function classification using6minutes walking distance measurement, Minnesota quality of life scores of heart failure and recorded postoperative medication and condition changes of patients.4. We analyze data by using SPSS17.0statistical software package, P<0.05. Result1. From2012January to2013September,30cases of CRT-D/P patients were included (male20cases, female10cases, age57.42±10.34years):27patients with dilated cardiomyopathy;3cases patients with ischemic cardiomyopathy;15cases of Dynamic balance group (male10cases, female5cases, age58.47±16.79years);14patients with dilated cardiomyopathy,1cases of ischemic cardiomyopathy;15cases of non contrast group (male15cases, female5cases, age54.60±12.32years), including13patients with dilated cardiomyopathy,1cases of ischemic cardiomyopathy. The baseline characteristics comparison between the two groups P>0.05. All patients received the shortest follow-up of6months, the longest of12months, an average of8±2months of follow-up.2. At the end of follow-up survey,1case in the dynamic balance group was re-hospitalized for heart failure;1patients of the control group was re-hospitalized for the drug adverse reactions and then they were improved and discharged(the hospitalization rate was respectively7%and7%, P<0.001);1cases in control group occurred diaphragmatic muscle stimulation(3%). The diaphragmatic stimulation disappeared after the left ventricular pacing voltage was turned down to maintain effective pacing. There were no deaths in two groups (0%and0%).3. After the comparing of CRT before implantation and traditional AVd optimization method, the width of QRS wave in the two groups of patients both atrioventricular node was narrower. The immediate width of QRS in the dynamic optimization of both groups was narrower than CRT before implantation (138.33±21.83ms and182.67±20.02ms, P<0.001); The immediate width of QRS after optimized was more narrow than the traditional AVd optimization method (138.33±21.83ms and169.13＋20.31ms, P<0.001). In the control group, the immediate width of QRS after optimized was narrower than CRT before implantation (133.33±13.58ms and174.33±15.69ms, P<0.001); The immediate width of QRS after optimized was narrower than the traditional AVd optimization (133.33±13.58ms and159.27±20.70ms, P<0.001). Dynamic group and the control group of QRS wave width narrow-degree had no significant difference. Two groups of initial optimal width of QRS wave after the QRS wave width and preoperative difference had no significant difference (45.87±26.44ms and42.73±12.26ms, P=0.641); the two group first optimized the width of QRS and traditional AVd optimization method of QRS wave width difference had no significant difference (31.80±19.51ms and28.07±13.91ms, P=0.559).4. After the comparing of the first optimized immediately, both Ts-SD12and AVTI values improved in30patients after6months. The Ts-SD12in the dynamic balance group is117.20±42.78ms and147.40±37.70ms, P<0.001; AVTI is20.49±4.30cm and18.25±2.14cm, P=0.024; In the control group, the Ts-SD12is116.80±36.26ms and154.27±29.71ms, P=0.002; AVTI is19.09±2.05cm and17.36±2.53cm, P=0.004. But both Ts-SD12and AVTI values after the optimized immediately, the difference between the dynamic group and control group had no statistical significance (147.40±37.70ms and154.27±29.71ms, P=0.588;18.25±2.14cm and17.36±2.53cm, P=0.392). The comparison of6months follow-up measurement value, difference in dynamic group and control group also had no significant (117.20±42.78ms and116.80±36.26ms, P=0.937;20.49±4.30cm and19.09±2.05cm, P=0.245).5. CRT preoperatively, after immediately optimized, with3months,6months follow-up detection of ultrasonic index comparison, including left atrial diameter, left ventricular end-diastolic diameter, interventricular septum thickness, ventricular septal motion rate, left ventricular posterior wall thickness, left ventricular wall motion after rate, left ventricular short axis reduced rate, left ventricular ejection fraction measurements and so on, the difference of inter-group improved (P<0.05), but the difference between the groups had no significance (P>0.05).6. Compared with the CRT preoperative and the first optimized immediately, New York Heart Function Assessment of all patients with follow-up of6months in two groups were improved----in the dynamic group (1.6±0.5and3.2±0.6and2.7±0.6, P<0.05) and in the control group (1.5±0.5and3.2±0.4and2.6±0.6, P<0.05). Compared with the first optimized instantly, the6MWT in the two groups of patients followed up for6months improved (the dynamic group379.67±28.75m and337±25.13m, P<0.001; the control group381±30.66m and346.47±31.98m, P<0.001); Compared with the first optimized instantly, MLHF in the two groups-of patients was improved after6months (the dynamic group28±10.73and36.87±16.44, P<0.001; the control group25.33±15.61and36.67±20.91, P=0.002).The difference of the indexes between the two groups with follow-up of6months was not significant (NYNA1.6±0.5and1.5±0.5;6MWT379.67±28.75mand381±30.66m;MLHF28.00±10.73and25.33±15.61,P>0.05).7. Compared with the first optimization after24hour dynamic electrocardiogram, dynamic balance group with the best "true fusion QRS wave" accounted for the proportion of total cardiac. And it is higher than the control group (80.67%and52.67%, P=0.001);"ventricular false convergence" between the two groups accounted for the proportion of total cardiac was lower than2%, and there was no significant difference (1.28%and1.74%, P=0.427). Conclusion1. With sinus rhythm in patients with CHF were treated by CRT and both the " atrioventricular node priority" allowed100%"true fusion" and "false fusion" biventricular pacing capture classic mode. This type lead to narrower QRS wave" atrioventricular node priority" made the QRS wave more stable and significant constriction. 2. Biventricular pacing both atrioventricular nodal intrinsic conduction is simple, noninvasive and safe. The patients implanted CRT with narrower QRS wave can improve heart function and quality of life and the response rate. There is an increasing trend to benefit to the patients with implementation of biventricular pacing "atrioventricular node priority". Even if the CRT system software does not support individual dynamic balance of atrioventricular node intrinsic conduction, just optimize the CRT in the resting state AVd, with the non dynamic balance "atrioventricular node priority". However, it improved the patient’s condition and the response rate of CRT still has important value.3.Dynamic balance of atrioventricular node intrinsic conduction "3Chamber&4site Pacing" mode can make up for the patient’s own PRd dynamic change and pacemaker AVd contradiction fixed, and improve biventricular pacing stimulus and AV node conduction "really inherent fusion QRS wave". It is possible to overcome CRT inherent system defects without physiological pacing and improve the total effect of the treatment of heart failure.4. The dynamic balance for biventricular pacing atrioventricular node intrinsic conduction to adapt to the crowd:①With the maintenance of sinus rhythm in patients in the most of time;②Without severe degree atrioventricular block; The preoperative QRS wave width is not obvious or biventricular pacing in patients with narrow QRS wave did not shrink obviouly;④After the dual chamber pacing dynamic balance of atrioventricular node intrinsic conduction, QRS can be further narrower in the patients;⑤The defect of left ventricular electrodeposition and other CRT system had no response to traditional mode of CRTpatients. |
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