| Object:By measuring the change of mitral regurgitation (MR) for patients with biventricular pacing combined with atrioventricular nodal (AVN) conduction.We want to know whether and why can we further improve MR and then get a better response of cardiac resynchronization therepy(CRT).Method:We assessed patients who underwent CRT device implantation at the first affiliated hospital of Kunming Medical College between November 2014 and March 2016 who accord with the CRT class I of the 2013 ACCF/AHA/HRS guidelines.46 patients were randomly divided into AVN group and control group.25 patients in the resting state with the titration type to increase the atrial-ventricular delay(AVd) CRT, until we get the narrowest QRS complex. Another 21 patients were traditional CRT models AVd and Inter-ventricular delay (VVd) optimization, optimization of conventional three-chamber pacemaker programmed. All patients were followed up at the 1,3,6,12 month afrer the operation,after the first year,we will follow up once a year.Every time,we will respectively get the 12-lead electrocardiogram, collect echocardiogram images and measurement to evaluate the mitral valve regurgitation (vena contract width,?Jet area, proximal isovelocity surface area), tening area, the maximal rate of left ventricle pressure rise (Dp/dt),left ventricular ejection fraction(LVEF),Systolic spherical index(SSI),record the CRT system parameters. To evaluate the patient’s heart function classification (NYNA),6 minutes walking distance (6MWT), The Minnesota Living With Heart Failure Questionnaire (MLHFQ), record the change of the postoperative medication and the state of an illness. We analyze data by using SPSS 17.0 statistical software package,and P<0.05 was considered statistically significant sentence.Results:1. November 2014 to March 2014, a total of 46 patients with CRT-D/P(36 cases of male,10 female, age 54.15±10.16 years).Among them,5 cases are ischemic cardiomyopathy,41 cases are Dilated Cardiomyopathy(DCM). The AVN group of 25 cases (20 male,5 female, age54.92±10.90 years).Control group 21cases (malel6 cases,5 cases were female, age 54.05±8.57 years).The average follow-up time of 10.5 ±2.94 months.At the end of follow-up,2 case (8%) in AVN group was re-hospitalized for heart failure,2 case (8%) of the control group was re-hospitalized because of the infections of operation skin,2 cases (9.5%)were re-hospitalized due to heart failure, they were all discharged with a better health condition.2.The 6 months follow-up after CRT implantation, both groups of NYHA,MLHFQ,6MWT are all improved compared with pre-implaned. NYHA:AVN group:6 month 1.68±0.48 vs. pre-implanted 3.00±0.41, P< 0.001;control group:6 month 1.81±0.40 vs. pre-implanted 2.95±0.38, P< 0.001. MLHFQ:AVN group 6 month 20.67±10.01 vs. pre-implant 33.22±14.85, P< 0.05;control group 6 month 27.50±2.64 vs. pre-implant 41.00±10.54, P< 0.05.6MWT:AVN group 6 month 390.00±54.42m vs. pre-implanted 293.33±84.92m, P<0.05;control group pre-implanted 281.50±2.64 m vs.6 month 338.50±8.96m, P< 0.05.The improvement of NYHA, MLHFQ have no statistical significance between two group.But the exercise tolerance of AVN group is better than control group.3.Two groups of patients during 6 months follow-up,the QRS complex are all obviously improved, AVN group pre-implanted 180.00±16.75ms,6 month 130.22±17.35ms, P< 0.001, vs control group pre-implanted 171.00±31.80ms,6 month 136.00±6.16ms, P< 0.001).6 months follow-up of improving of QRS complex duration,the reduction of QRS duration. AVN group is better than control group(AVN group 49.78±22.27ms vs. control group 35.00+25.65ms,P< 0.05).4. The MR degree in both groups during 6 month follow-up were all reduced compared with pre-implantation (P<0.05). The reduction of vena contract width (VCW) of AVN group was obviously better, the difference was statistically significant.But the improvement of the effective regurigition of area (EROA)and the volume of mitral regurigition (MRRV)in AVN group and the control group were not significant (P> 0.05). In patients included in this study, the degree of MR grading by VCW,we shall definite level 0 is no regurgitation, grade 1 is mild, level 2 or moderate, and level 3 is severe regurgitation.There are about 89.1% patients combined with different degrees of MR, among them,19 patients (41.3%) was improvement at least 1 level. The two groups of patients’ tenting area(TA) were improved in 6 months follow-up compared with pre-implanted.Which the AVN group pre-implanted 3.28±0.55cm2 vs. 6 month 2.92±0.52 cm2;the control group pre-implanted 3.25 ±0.37 cm2 vs.6 month 2.75± 0.26 cm2, (P< 0.05).The reduction of TA between the two groups (control group 0.5±0.11 cm2 vs. AVN group 1.36±0.84 cm2) has no statistical significance (P< 0.05).5. The 6 months follow-up after CRT implantation,two groups of patients’ Left ventricular ejection fraction (AVN pre-implanted 27.67±3.91% vs.6 month 34.94±11.07%, P< 0.05;control group pre-implanted 34.50 ±3.69% vs.6 month 36.50 ±1.58%, P> 0.05) and the maximal rate of Left ventricle pressure rise(Dp/dt)(AVN pre-implanted 513.08±115.35 mmHg/s vs.6 month 622.09±109.80 mmHg/s;control group pre-implanted 522.05±214.98 mmHg/s vs.6 month569.20±270.69 mmHg/s, P < 0.05) have been improved, but the difference between the two groups has no statistical significance (P> 0.05). The average change of LVEF (AVN group-7.27±11. 76%vs. control group-2.0±5.27%) and Dp/dt (AVN group-109.00±174.95 mmHg/s vs. control group-47.15±55.71 mmHg/s) of the two groups have increased, but the difference between the two groups has no statistical significance (P> 0.05).The systolic spherical index in two groups of 6 month follow-up have increased (AVN pre-implanted 1.34±0.20 vs.6 month 1.54±0.32; control group pre-implanted 1.16±0.13 vs.6 month 1.24±0.90, P< 0.05), the mean systolic spherical index changes between the two groups (AVN group-2.205±0.246 vs. control group-0.075±0.047) have no significant difference (P> 0.05).We use the peak time of 12 segments of the left ventricular standard deviation (Ts - SD12) to evaluate left ventricular interior synchronicity. Two groups of patients’ Ts-SD12 are improved compared with before operation, with statistical significance (P< 0.001).Among them, the mean Ts-SD12 change comparison between groups has no statistical difference (P> 0.05).6.The change of EROA have correlation with the improve of LVEF (p< 0.05, r= 0.541);the reduction of EROA have correlation with the improvement of the Ts-SD12 (p< 0.05, r= 0.331)), the correlation coefficient is 0.331.Conclusions:In post-implanted CRT patients with congestive heart failure who with sinus rhythm and without valvular disease, biventricular pacing with ventricular fusion by intrinsic atrioventricular nodal conduction can further reduce MR on the base of CRT, may be beneficial for improving the long-term outcome and reply of patients with CRT. Biventricular pacing with ventricular fusion by intrinsic atrioventricular nodal conduction can increase left ventricular systolic function and improve the patients’ quality of life. |
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