左束支起搏和右室心尖部起搏在老年房室传导阻滞患者中的临床疗效比较

Efficacy comparison of left bundle branch pacing and right ventricular apical pacing for elderly patients with atrioventricular block

关键词:  左束支起搏  右室心尖部起搏  老年  房室传导阻滞

Key words:  left bundle branch pacing  right ventricular apical pacing  elderly  atrioventricular block

摘要:

目的比较左束支起搏（left bundle branch pacing, LBBP）和右室心尖部起搏（right ventricular apical pacing, RVAP）治疗老年房室传导阻滞（atrioventricular block, AVB）患者的临床效果。 方法回顾性分析2016年1月—2021年6月因AVB于同济大学附属第十人民医院行永久起搏器植入术256例患者（≥65岁）的临床资料,根据起搏方式将患者分为RVAP组（n=121）和LBBP组（n=135）。比较两组起搏方式的临床疗效。 结果两组患者基线资料均无明显统计学差异。两组患者的起搏参数（阈值、感知和阻抗）在术中、术后7d、术后1年差异均无统计学意义（均P>0.05）,但LBBP组患者术后QRS波群时限明显缩短（均P<0.001）。术后1年随访中,与RVAP组相比,LBBP组起搏术式显著改善患者心功能,如左室射血分数、左心室舒张末期内径、NT-proBNP表达水平（均P<0.05）。此外,LBBP组和RVAP组相比,并发症发生率和起搏器依赖患者比例无显著差异（均P>0.05）,但LBBP患者术后1年内再住院率显著降低(P=0.004)。进一步行Logistic回归分析发现LBBP起搏术式与老年AVB患者的再住院率有关（全部进入模式P=0.014,向前逐步回归模式P=0.010）。Kaplan-Meier累积事件曲线的比较显示RVAP和LBBP的累积再住院率有显著统计学差异（P=0.003）。ROC曲线分析也揭示了不同起搏术式对老年AVB患者的再住院率有预测价值（P=0.011,AUC=0.703,灵敏度=0.857,特异度=0.550）。 结论与传统RVAP相比,LBBP起搏术式治疗老年AVB患者具有更好的安全性和稳定性,可有效改善患者心功能,降低患者再住院率。

Abstract:

ObjectiveTo compare the efficacy of left bundle branch pacing(LBBP) and right ventricular apical pacing(RVAP) in the treatment of elderly patients with atrioventricular block(AVB). MethodsThe clinical data of 256 patients aged ≥65 years with atrioventricular block who underwent permanent pacemaker implantation in Shanghai Tenth peoples Hospital from January 2016 to June 2021 were retrospectively analyzed, including 121 cases treated with RVAP and 135 cases treated with LBBP. The clinical efficacy was compared between the two groups. ResultsThere was no significant statistical difference in baseline data between the two groups. There were no significant difference in the pacing parameters, including threshold, perception and impedance, between the two groups during operation, 7d after operation, and 1 year after operation(all P>0.05), while the postoperative QRS complex after operation in in the LBBP group was significantly shortened(all P<0.001). During the 1 year follow-up, compared with RVAP group, the cardiac function of patients, including ventricular ejection fraction, left ventricular end-diastolic diameter and serum NT-proBNP level, was significantly better improved in LBBP group(all P<0.05). In addition, there was no significant difference in the incidence of complications and the proportion of pacemaker-dependent patients between two groups(both P>0.05). The rate of readmission within 1 year after surgery in LBBP group was significantly lower(P=0.004), which was confirmed by Logistic regression analysis(entry model P=0.014, forward stepwise model P=0.010). Kaplan-Meier cumulative event curves showed a statistically significant difference in the cumulative hospital readmission between RVAP and LBBP(P=0.003). ROC curve analysis also revealed that pacing methods had a predictive value for the readmission rate of elderly AVB patients(AUC=0.703, P=0.011) with a sensitivity of 0.857 and specificity of 0.550. ConclusionCompared with traditional RVAP, LBBP pacing in the treatment of elderly patients with AVB has good safety and stability, can effectively improve the cardiac function of patients, and reduce the rate of readmission, which is worthy of clinical promotion.