The Application Of Orbital Implantation Of Left Endocardial Electrode For Cardiac Resynchronization Therapy

Objective Left ventricular endocardial electrode implantation has become an important alternative replacement measure for conventional left ventricular epicardial electrode implantation failure and treatment for cardiac resynchronization therapy(CRT)or cardiac resynchronization therapy with defibrillator(CRT-D)non-response.However,there is no safe,effective and uniform surgical method has been established yet.The purpose of this study is to investigate the clinical efficacy of orbital method implantation of left ventricular endocardial electrodes in patients with chronic heart failure who can not receive conventional implantation of CRT/CRT-D left ventricular epicardial electrodes or did not respond to CRT,and analyze and compare the effect and complications of left ventricular epicardial electrode implantation during the same period,and find the clinical characteristics of patients who respond to cardiac resynchronization therapy.Methods A total of 36 chronic heart patients were selected during March 1,2017 to January 1,2019 in our hospital,who received the CRT/CRT-D treatment,which were in line with the I class indications of the Chinese guidelines for diagnosis and treatment of heart failure,with 28 dilated cardiomyopathy(DCM)cases and 10 ischemic cardiomyopathy cases.According to whether the CRT/CRT-D left ventricular electrodes were implanted through the coronary sinus(CS),they were divided into left ventricular endocardial electrode implantation group(experimental group)(7 cases)and left ventricular epicardial electrodes implanted group(control group)(29 cases).In the experimental group,patients who were unable to implant the left ventricular epicardial electrode via CS,were completed the left ventricular endocardial electrode implantation through the orbital method(OM)by piercing the interatrial septum successively and builting femoral vein-interatrial septum-aortic and subclavian vein-interatrial septum-left ventricular orbit,and then implanted in the general method of right atrium(RA)and right ventricular(RV)electrode.In the control group,left ventricular epicardial electrodes were implanted by conventional surgery via CS,and then right atrial(RA)and right ventricular(RV)electrodes were implanted by conventional route.SPSS19.0 statistical software was used to analyze the incidence of cardiac function indicators,electrocardiogram,cardiac color doppler ultrasound parameters and major unconscious cerebrovascular events(MACCE)between the two groups before and after 1 week,3 months and 12 months,and to determine the efficacy of the two groups.Multivariate Logistic regression analysis was used to investigate the clinical characteristics of patients who responded to CRT/ CRT-D implantation.Results(1)Clinical data of patients in the two groups: Age,gender,DCM,ischemic cardiomyopathy,hypertension,diabetes,and heart function NYHA classification(? ? ? level),cerebrovascular event,electrocardiogram(duration of P wave,QRS interval,atrial fibrillation,complete left bundle branch block(CLBBB),cardiac ultrasound index(stroke volume(SV),left ventricular ejection fraction(LVEF),left ventricular end-diastolic diameter(LVEDD),pulmonary artery pressure(PAH),mitral regurgitation),the proportion of parameter optimization,the CRT-D cases,double ventricular pacing have no significant difference(P>0.05).(2)CRT/CRT-D implantation was successful in all patients,and 12 months' follow-up was completed after surgery.(3)All 7 patients in the experimental group were successful implanted with CRT/CRT-D endocardial electrode by OM,and the implanted site was the posterior lateral wall of the left ventricle.1 week after the operation,the QRS interval was significantly narrower than before,LVEF was significantly increased,LVEDD and PAH were decreased,with fewer NYHA classification(??? level)and mitral regurgitation with moderately severe patients(all P < 0.05),heart palpitations,chest tightness and other clinical symptoms improved significantly;3 months later,compared with preoperative data,the P wave interval and QRS interval were significantly narrower than before,LVEF was significantly increased,LVEDD and PAH were decreased,with fewer NYHA classification(??? level)and mitral regurgitation with moderately severe patients(all P<0.05);and compared with the data of 1 week after surgery,LVEF increased and LVEDD decreased further(all P< 0.05).12 months later,compared with preoperative data,the P wave interval and QRS interval were significantly narrower than before,LVEF was significantly increased,LVEDD and PAH were decreased,with fewer NYHA classification(??? level)and mitral regurgitation with moderately severe patients(all P<0.05).Compared with 1 week after the operation,LVEF was further increased and LVEDD was further decreased at 12 months after the operation.The QRS interval was further narrower at 12 months after the operation compared with 3 months after the operation.(4)All the 29 patients in the control group were implanted with left ventricular epicardial electrode via CS,and the implanted site was lateral vein or lateral posterior vein.1 week after the operation,the P wave interval and QRS interval were significantly narrower than before,SV and LVEF were significantly increased,LVEDD and PAH were decreased,with fewer NYHA classification(??? level)patients(all P<0.05),while there was no significant difference in the reduction of mitral regurgitation(P>0.05);3 months later,compared with preoperative data,the P wave interval and QRS interval were significantly narrower than before,LVEF was significantly increased,LVEDD was decreased,with fewer NYHA classification(??? level)and mitral regurgitation with moderately severe patients(all P<0.05),while there was no significant difference in PAH reduction;and compared with the data of 1 week after surgery,the P wave interval and QRS interval are further narrowed,SV and LVEF increased,LVEDD and PAH decreased further(all P<0.05).12 months later,compared with preoperative data,the P wave interval and QRS interval were significantly narrower than before,SV and LVEF were significantly increased,LVEDD and PAH were decreased,with fewer NYHA classification(??? level)and mitral regurgitation with moderately severe patients(all P<0.05).Compared with 1 week after the operation,the P wave interval and QRS interval were significantly narrower than before,LVEF was significantly increased,with fewer NYHA classification(??? level)and mitral regurgitation with moderately severe patients,but PAH was increased(all P<0.05)at 12 months after the operation.The P wave interval and QRS interval were further narrower,LVEF was increased further,while SV was decreased,LVEDD and PAH were increased at 12 months after the operation compared with 3 months after the operation(all P<0.05).(5)Compared with the control group,the experimental group showed significant differences in QRS interval decrease and LVEF increase at 1 week,3 months and 12 months after the operation(all P<0.05).The reduction of LVEDD was more significant in the experimental group 12 months after surgery(P<0.05).The mitral regurgitation(moderate and severe)was significantly improved in the experimental group after 1 week and 3 months later(all P<0.05).The incidence of MACCE events was lower in the experimental group at 3 and 12 months after surgery(all P<0.05).Two groups of NYHA class(???),duration of P wave,SV,PAH difference have no statistical significance(P>0.05).(6)Multivariate Logistic regression analysis showed that among the patients who responded after CRT/ CRT-D implantation,female patients with QRS interval ?170ms had better benefits.(7)One patient in the experimental group had left ventricular electrode perforation after surgery,and the bedside cardiac ultrasound showed a small amount of pericardial effusion,which improved after the left ventricular electrode was reset,while the other patients had no obvious complications.MACCE events were followed up in the two groups 12 months after the operation,and the risk of ventricular arrhythmia,cerebral embolism and cardiogenic death in the experimental group was lower than that in the control group(all P<0.05).Conclusions In this study,compared with the conventional left ventricular epicardial electrode implantation group,orbital implantation of the left ventricular endocardial electrode showed a more significant improvement effect on QRS interval and LVEF,and the incidence of long-term MACCE events(ventricular arrhythmia,cerebral embolism events,risk of cardiogenic death,etc.)was relatively lower.At the same time,there was a better CRT/CRT-D benefit between female patients and QRS interval?170ms,which could provide clinical guidance.Except for one case of left ventricular electrode perforation,the other patients had no significant postoperative complications.Orbital implantation of the left ventricular endocardial electrode(CRT/CRT-D)is safe and effective,and is an important auxiliary method for the implantation of the left ventricular epicardial electrode that cannot be implanted through the coronary sinus or CRT non-response.