心力衰竭心脏再同步（CRT)治疗 王建安 浙江大学医学院附属卲逸夫医院.

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1 心力衰竭心脏再同步（CRT)治疗 王建安 浙江大学医学院附属卲逸夫医院

2 主要内容 What is CRT? Is CRT an effective and efficient therapy for CHF？
Do CRT just improve functional status ? Update of Clinical trials and Reviews How to do an CRT operation? Procedures and tips Why are Insync III and Insync ICD the choice of CRT ?

3 什么是CRT治疗？ CRT心脏再同步治疗(Cardiac Resynchronization Therapy)又称为双心室起搏治疗(Biventricular Pacing)心力衰竭 30%进展性心衰患者存在左右心室收缩不协调。 结合射频、起搏、PTCA技艺，科技与经验的完美体现。

4 Why CRT? 目前对心衰没有非常好的解决方案 心脏移植供体难求、手术复杂、术后排异、费用昂贵 LVAD（左室辅助系统）仍在探索研究中
CRT 有大量的循证医学支持(Insync,Insync ICD,Miracle) -改善血液动力学、运动能力 -改善生活质量、降低住院率 、2004 New England Journal of Medicine -降低死亡和住院联合终点 -极大方便优化药物治疗 -显著降低心脏移植 J Heart Lung Transplant -降低因心衰进展导致的死亡率 2003 JAMA -降低所有原因的死亡率 International Journal of Cardiology 2004 Annals of Internal Medicine

5 心室不同步的发病情况和预后 左室收缩功能下降者中LBBB 常见 宽QRS全原因死亡率增加
Main purpose: Establish the problem of ventricular dysynchrony. Key messages: Ventricular dysynchrony as manifested by a wide QRS is more common in patients with moderate to severe impaired ventricular systolic function (LVSF); A wide QRS is associated with a poor prognosis, and impaired cardiac function. Additional information: Masoudi and colleagues used retrospective medical chart data of 19,710 pts Medicare beneficiaries hospitalized w/ HF and for whom LV systolic function was confirmed. LBBB present in 8% of those with preserved LV systolic function (diastolic HF) and in 24% of those with EF < 50% (p<0.001). Aaronson developed and validated a multivariable survival model for ambulatory advanced heart failure patients wait listed for a heart transplant. IVCD (QRS > 120 ms) present in 27% of the 268 pts in derivation sample, and in 53% of the 199 pts in validation sample. IVCD identified as contributing risk factor. Other studies have shown that fro the entire HF population about 15% have a wide QRS. Iuliano: 669 HF pts (ischemic or nonischemic cardiomyopathy, NYHA II-IV heart failure. Median followup of 45 mo. Prolonged QRS was associated w/ increase in mortality (49.3% vs 34.0%) and sudden death (24.8% vs 17.4%). LBBB was associated w/ worse survival but not sudden death.

6 Cumulative Mortality (%)
心脏不同步对预后的影响 Cumulative Mortality (%) 90-120 Days in Trial > 220 < 90 QRS Duration (msec) 100 90 80 70 60 120 180 240 300 360

7 心衰会有什么感觉? 限制患者日常生活能力… Let’s compare our heart to this donkey, and our body to the wagon that this donkey has to pull every day. A healthy heart is like an energetic donkey, which without fatigue, pulls the wagon full of weights. Conversely, a diseased heart will have difficulty meeting metabolic demands (or pulling the wagon).

8 利尿剂, ACE 抑制剂 好比减轻货车上的货物

9 ß受体阻滞剂 限制毛驴速度, 从而节约能量 限制速度 最小

10 地高辛 就像放在毛驴前面的萝卜，吸引毛驴快跑

11 正常心脏左右心室同时起搏，然而30%的 心衰右室先起搏，然后左室起搏， 导致心脏工作效率下降

12 Cardiac Dysynchrony: CRT
Atrio-ventricular: LA : LV AV Resynchronization Intra-ventricular: LVS:LVL Mechanical Resynchronization Inter-ventricular: RV:LV Electrical Resynchronization

13 再同步治疗带来益处的可能机制 心脏再同步 1. 改善室内同步 2. 改善房室同步 3. 改善室间同步 恢复机械和电同步

14

15 心脏再同步治疗增加了心脏的工作效率

16 如何达到心室同步 方法 心膜外途径 经静脉途径 需要开胸 创伤大 通过冠状静脉窦 需要特殊电极递送到靶静脉
Cardiac Resynchronization is achieved through atrial based, biventricular pacing. Standard pacing leads are placed in the right atrium and right ventricle. A specially designed left ventricular pacing lead is passed through the coronary sinus and into a tributary of the Great Cardiac Vein. Atrial based pacing is performed through both ventricular leads simultaneously and can be programmed unipolar or bipolar if either ventricular lead is a bipolar lead. InSync was developed to provide true cathodal pacing to two ventricular leads simultaneously. InSync employs Medtronic’s longest lived battery with Medtronic’s lowest current-drain circuit technology. The expanded connector allows direct connection to one atrial and two ventricular leads without the need for adapters or splitters.

17 双心室起搏电极放置位置 右房电极 冠状窦电极 右室电极

18 左侧图片是植入后3天胸片， 右侧是植入后3个月的图片
注意：心脏明显缩小 植入后胸片变化

19 治疗后心电图QRS宽度立即明显变狭，说明心室收缩不同步得到纠正
植入前后心电图变化 治疗前 治疗后 治疗后心电图QRS宽度立即明显变狭，说明心室收缩不同步得到纠正

20 二维四腔超声图：植入后1个月左室收缩末期容积明显减少，心室重塑开始得到逆转，心功能恢复
A:植入前左室收缩末期容积 B:植入一月后左室收缩末期容积

21 ACC/AHA/NASPE 2002 心脏再同步治疗指征
NYHA III/IV QRS 130 msec 左室舒张末期直径55mm LVEF 35% 药物治疗效果不佳，仍有症状 无论是缺血性心脏病（如冠心病等）或特发性扩张性心肌病、 AF 房颤病人均可。

22 心衰流行病学 中国成人患病率为 : 0.9% 估计中国心衰总人数约为 585万 男性 0.7 % ; 女性 1.0%
北中国：1.4%;南中国：0.5% 城市人口:1.1%;农村人口:0.8% 在西方国家，心衰患病率在1.5％－2%之间，美国有4.5百万心衰患者，每年新增40－70万 中华心血管病杂志 （1)：3-6

23 中国CRT 病人数估算 中国共36万患者适合CRT治疗！！！ 585百万 CHF 30%有 AF, 70% 没有 AF 12万 双心室起搏
30% 舒张性 70% 收缩性 410万 70% NYHA I/II 30% NYHA III/IV 120万 70% QRS<120ms 30% QRS>120ms 36万 CRT 70% 没有 AF 24万 CRT 30%有 AF, 12万 双心室起搏 中国共36万患者适合CRT治疗！！！

24 Update of Clinical Trials

25

26 Therapeutic Options in CHF
Heart failure Drugs Devices Genes 探索中

27 Devices For Long-term Management of CHF
Cardiac resynchronization Implantable cardioverter-defibrillator Left ventricular assist devices

28 Is CRT an effective and efficient therapy for CHF ?

29 心脏再同步治疗随机临床试验进展累计图 • 实际  计划
• 实际  计划 Main purpose: Show that a large number of patients have been studied in completed and ongoing randomized controlled studies of CRT. Use in conjunction with previous slide. Key messages: Nearly 3000 patients have been enrolled in randomized controlled clinical trials presented to date. When CARE-HF, another landmark trial assessing mortality and hospitalization, is reported, close to 4,000 patients will have been studied.

30 InSync /Insync ICD 心脏再同步化治疗临床 试验 MUSTIC MIRACLE /MIRACLE ICD COMPANION
前瞻性, 非随机 终点 : 安全性 , 有效性&可行性 MUSTIC 单盲,随机, 交叉 第一终点:功能性 ( 6 Minute Walk) MIRACLE /MIRACLE ICD 双盲，随机, 交叉 第一终点: 功能性 第二终点：最大氧耗，二尖瓣返流 COMPANION 前瞻，随机，1:2:2分组 第一终点：全原因死亡率和住院率复合终点

31 心脏再同步化治疗临床 入选标准 - *** 所有病人均采用ACEI/ARB治疗 N NYHA LVEF QRS 6M-W InSync
MUSTIC MIRACLE InSyncICD Meta N 103 131 453 84 1634 NYHA III / IV III II/ III / IV LVEF < 35% QRS >150 ms >130 ms - 6M-W < 450m <450m *** 所有病人均采用ACEI/ARB治疗

32 InSync 使InSync 通过FDA 独特性： 第一个经静脉心脏再同步系统的研究 结论： 特殊电极经静脉到达LV， 成功率为88%
基线 成功植入 CRT 中期随访 12个 月随访 独特性： 第一个经静脉心脏再同步系统的研究 结论： 特殊电极经静脉到达LV， 成功率为88% 一个月后随访，提高心功能分级，生活质量，6分钟 步行距离， 并保持到12个月 Almost everybody will have heard about the InSync Study. Ongoing, multicentre, prospective, controlled study to evaluate cardiac resynchronization In patients with dilated cardiomyopathy, inter- and intra-ventricular conduction disturbances (IVCDs), and congestive heart failure. Assess clinical effects of therapy in defined patient population. Evaluate safety and performance of the InSync system, including special pacemaker and left ventricular lead. Establish the feasibility of implanting the InSync system. Substudy objective: Assess whether baseline NYHA functional class influences clinical outcomes: 6 minute walk distance, Quality of Life, NYHA Functional class 使InSync 通过FDA

33 QRS波宽度下降 * * * * * p < versus基线值

34 6分钟行走距离增加 * * * ** * p < versus 基线值 ** p=0.01 versus 基线值

35 纽约心功能改善 * * * * * p < versus基线值

36 纽约心功能改善 % 入选病人 N=35 随访时间 100% 90% 80% 70% I 60% II 50% III 40% IV 30%
20% 10% 0% Baseline 1 Month 3 Months 随访时间

37 心室射血分数增加 p < 0.01 p < 0.01 p < 0.01 ACC 1999

38 InSync ICD(JACC 2002) 独特性: 第一个对带有特殊感知的多部位起搏的除颤器的研究 结论：
基线 植入 CRT 3 个月 独特性: 第一个对带有特殊感知的多部位起搏的除颤器的研究 结论： 安全性评估达到预定指标功能性改善 心功能 III/IV 级的病人与InSync 研究结果类似 II级心功能的病人得到令人鼓舞的结果(6分钟步行距离提高) Results will be presented in detail by Berthold Kramm.

39 MUSTIC ( 第一组: NSR) (NEJM 2002)
CRT ON CRT OFF Pt. 选择 基线 植入 随机 3 个月 3 个月 1 年 CRT OFF CRT ON Pt. 选择 独特性: 第一个对照研究评价CRT对严重心衰病人的疗效 结论： 双心室起搏明显提高运动耐量&生活质量 明显减少住院率 减少死亡率5%(6个月)

40 6分钟步行距离 (m)  = + 23 % P < 0.001 413 384 354 320 336 346 316 meters
500  = + 23 % P < 0.001 450 413 400 384 Active-Inactive 354 Inactive-Active 350 320 336 346 300 316 250 200 Baseline Rando Phase 1 Phase 2

41 生活质量(Minnesota 问卷)  = - 32 % P < 0.001 25.7 33.3 45.6 44.0 42.6
Score (0-105)) Baseline Rando Phase 1 Phase 2 15  = - 32 % P < 0.001 25.7 25 Active-Inactive 33.3 Inactive-Active 35 45.6 44.0 42.6 45 47.8 51.4 55

42 病人优先选择 P < 0.001 选择起搏 选择不起搏 无倾向 n = 48 (%) n = 41 85 n = 2 4 n = 5
10 P < 0.001

43 住院率 MUSTIC P < 0.05 氧耗量峰值 增加 8% (P<0.03) 降低2/3 (P<0.05)
1 st Phase of Inactive Active Cross-Over P < 0.05 心衰加重住院 9 3

44 MUSTIC ( 第二组: AF) 独特性: 第一个随机，对照研究房颤病人 结论： 双心室起搏明显提高运动耐量&生活质量 BiV RV
Pt. 选择 消融 &植入 随机 1 个月 3 个月 3个月 1 年 RV BiV Pt. 选择 独特性: 第一个随机，对照研究房颤病人 结论： 双心室起搏明显提高运动耐量&生活质量

45 MIRACLE (NEJM 2002) 独特性：双盲 结论： CRT组在6分钟步行距离，心功能分级，生活质量，运动平板时间，EF均有明显提高
成功植入 CRT ON 随机 1:1 12个月评估 CRT ON 6 个月 CRT. OFF 独特性：双盲 结论： CRT组在6分钟步行距离，心功能分级，生活质量，运动平板时间，EF均有明显提高 CRT的病人住院和治疗心衰的静脉用药减少 Resynchronization ON = VDD (Biventricular Pacing) Resynchronization OFF = VDI with a lower rate of 30 bpm The design of the study is focused on limiting those factors that could confound the efficacy data. The specific modes defined for use during the study were selected by investigators as being the most appropriate to isolate the effects of biventricular pacing from other confounding effects such as that of rate support. Rate Support: Every attempt will be made to insure that patients remain programmed to the mode to which they were randomized. In the event that a patient develops an indication for rate support and other medical management options have been exhausted, the device may be programmed to an appropriate mode insuring appropriate rate control. Blinding: This study will be double blinded to reduce the impact of placebo effect. Implanting physicians and staff responsible for programming the device will unavoidably know the mode to which the device is programmed. However, neither the patient nor the heart failure physician nor staff supervising the QoL assessment and 6 minute hall walk will have knowledge of the pacing mode assigned. Bias will be reduced by having CORE labs evaluate echocardiographic parameters, plasma neurohormone levels and metabolic exercise results.

46 MIRACLE 第一终点 Control CRT P Value 6分钟步行距离 + 10 + 39 0.005 生活质量评分 - 9
- 18 0.001 NYHA 分级(% improved) 38% 68% < 0.001 Key Points: Pre-specified objective met as all primary efficacy endpoints had a P0.05. The magnitude of the effect on the primary efficacy endpoints was not affected by the use of a beta-blocker, by whether the heart failure was of ischemic or non-ischemic origin, whether the intraventricular conduction delay was a left or right bundle branch pattern, or by the duration of the QRS. 完成预设目标 所有指标均P  0.05 结果不受下列因素影响 beta 受体阻滞剂的使用, 心衰病因,束支阻滞模式, QRS 宽度 Abraham WT, Fisher WG, Smith AL, et al. N Engl J Med 2002;346:

47 MIRACLE 第二终点 最大氧耗量提高 总的活动时间提高 -0.5 0.0 0.5 1.0 1.5 2.0 Control (n=145)
CRT (n=158) ml/kg/min P=0.009 总的活动时间提高 30 60 90 120 Control (n=146) CRT (n=159) seconds P=0.001 Key Points: (Note – a subset of the 453 patients provide the paired data) Peak VO2 had virtually no change in the Control group of patients compared with a 1.1 ml/kg/min improvement for CRT group patients. The treatment effect was statistically significant. Total exercise time during the cardiopulmonary exercise test showed similar results. A modest average improvement by Control group patients was overshadowed by an increase of over 1 minute by the patients receiving CRT. Other Information: Cardiopulmonary exercise results were assessed by a core laboratory (University of Cincinnati). All data are paired; data for the same patients are shown for each time point. 基线值 基线值 (ml/kg/min) (seconds) 13.7 ± 3.8 462 ± 217 14.0 ± 3.5 484 ± 209 Abraham WT, Fisher WG, Smith AL, et al. N Engl J Med 2002;346:

48 MIRACLE 第二终点 P<0.001 P<0.001 P=0.009 LVEDD LVEF MR Jet Area 8 1
% LVEDD LVEF 2 MR Jet Area 8 cm mm P<0.001 P<0.001 1 P=0.009 2 6 4 -1 -2 2 -2 -4 -3 -2 -4 -6 对照组 CRT 对照组 CRT 对照组 CRT (n=146) (n=155) (n=118) (n=116) (n=118) (n=116) Key Points: (Note – a subset of the 453 patients provide the paired data) Measures of both cardiac function and cardiac structure showed improvement with cardiac resynchronization. A 4.6 percentage point improvement in LVEF within the CRT group of patients contrasted significantly with a reduction of 0.2 percentage points in the Control group. Likewise, patients receiving CRT showed a reduction in mitral regurgitation (-2.7 cm2)that was statistically significantly greater than the modest improvement (-0.5 cm2) observed within the Control group of patients. The reduction in left ventricular end diastolic diameter of 3.5 mm for CRT patients was significant compared with no change on average for Control group patients. Other Information: Echocardiographic results are from a single observer at a core laboratory (University of Pennsylvania). All data are paired; data for the same patients are shown for each time point. While ventricular pacing spikes were often observed on the simultaneously recorded ECG, each echo study was blinded with regard to identity and analyzed individually and without reference to echocardiographic images or knowledge of measurements from other studies of the same patient. 基线值 (%) 基线值 (cm 2 ) 基线值 (mm) 22 ± 6 7.2 ± 4.9 69 ± 10 22 ± 6 7.6 ± 6.4 70 ± 10 Abraham WT, Fisher WG, Smith AL, et al. N Engl J Med 2002;346:

49 Miracle ICD 介绍(JAMA 2003) MIRACLE ICD研究设计与MIRACLE相似，是一个前瞻性、多中心、随机、双盲、平行对照的临床试验。 意在评价CRT、ICD联合治疗的安全性和临床疗效。 入选标准： NYHA Ⅲ－Ⅳ级的心衰患者（LVEF≤35％ ，LVED>55mm） 并且伴有IVCD（QRS>130m）和ICD植入指征。 评价终点 主要终点和次级终点与MIRACLE试验类同。 还增加了对心脏除颤器功能的评价（包括双室起搏抗心律失常的疗效）

50 369例患者被随机分组，182例为对照组(接受心脏除颤器治疗，但不接受CRT)，187例为试验组（联合CRT、心脏除颤器治疗）

51 生活质量评分改善 P<0.02

52 心功能分级改善 P<0.01 CRT-D改善NYAH 分级I级，ICD没有变化

53 峰值氧耗量改善 mL/Kg/Min P<0.05

54 运动踏板试验 P<0.001

55 Miracle ICD试验表明 CRT+ICD 较单纯ICD可以： 明显改善患者运动能力 明显降低NYHA 分级 明显提高生活质量

56 CRT逆转左室重构 LV 收缩和舒张末期容积 二尖瓣返流面积 Pacing No pacing 起搏 不起搏 起搏 不起搏 N = 25
Yu CM, et al, Circulation 2002;105:

57 JAMA 2003 Meta-analysis 资料来源： MEDLINE(1966-2002)
EMBASE( ) the Cochrane Controlled Trials Register The National Institutes of Heaith Clinical Trials.gov database FDA Web site reports presented at scientific meetings( ) 分析： 个随机临床（CONTAK CD,InSync ICD,MUSTIC,MIRACLE) 1634名病人 结论： 心脏再同步治疗能减少左室功能失调引起的 进行性伴症状性心衰病人的死亡率达51%

58 CRT治疗对具有心脏移植指征的病人的影响
Journal of Heart Lung Transplantation 2003

59 数据来源 符合心脏移植标准 EF<30% NYHA III/IV 长期药物治疗效果不佳 最大氧耗量<14ml/Kg/Min 收集Miracle 、Insync ICD、COMPANION及CONTAK-CD试验中作过上述检查并符合其标准的病例34例

60 双心室起搏后34人中23人(68%)VO2>14ml/Kg/Min,仅有两人（6%)还符合心脏移植标准

61 心脏同步起搏治疗6个月后NYHA 明显改善（P<0.0001)

62 治疗结果 86%的患者NYHA 改善为II或I级 68%的患者VO2改善，>14ml/Kg/Min
经双心室起搏治疗后34人中仅有2位还符合上述心脏移植标准（6%)

63 研究结论： 对重度心衰同时QRS>130ms，可能考虑为心脏移植的患 者中CRT可以改善心功能、氧摄取和NYHA 分级。 在此类患者中可以避免或推迟进行心脏移植 慢性心衰合并QRS波增宽的患者在考虑进行心脏移植时 应当评估是否进行CRT治疗。

64 国内移植状况 肾脏移植 5000-10000? 肝脏移植 200－500? 心脏移植 <100?
心脏再同步治疗？Insync III & Insync ICD? Too expensive for patients who are badly in need of help ?

65 Does CRT just improve functional and hemodynamic status ?

66 最新COMPANION的最终正式结果：发表在2004年5月的<New England Journal of Medicne>
研究设想：在进展性心衰合并QRS波增宽的患者中，当双心室起搏和理想药物治疗结合使用时： 单纯双心室起搏可以降低全原因死亡率和全原因住院率的复合终点 双心室起搏再加上ICD治疗后可以降低全原因死亡率和全原因住院率的复合终点

67 COMPANION: 研究设计 + 平行、随机临床试验 1 2 OPT Resynchronization Therapy
Resynchronization Therapy w/ ICD Backup 1 随机分组 目的: 评判是否双室  ICD 降低全原因住院和死亡率;降低心源性死亡;增加总生存率;改善运动能力 OPT = 最佳药物治疗 ICD = implantable cardioverter defibrillator. BVP = biventricular pacing. Bristow MR et al. Paper presented at American College of Cardiology. March 31, 2003; Chicago, Ill.

68 主要研究终点： CRT和CRT－D均明显降低全原因死亡率和全原因住院率的复合终点

69 CRT 和CRT-D均显著降低死亡率或心血管原因住院率

70 CRT 和CRT－D 均显著降低死亡率或心衰住院率

71 二级终点：全原因死亡率CRT-D可降低36％，P=0.003
CRT可以降低24%，P=0.059

72 CRT-D可以降低死亡率，其中2/3的 降低死亡率效应来自CRT （双室起搏） COMPANION试验结论
在中重度心衰、NYHA III/IV及QRS波增宽患者中，在全面药物治疗的基础上： CRT或CRT-D降低死亡率＋住院率 CRT-D可以降低死亡率，其中2/3的 降低死亡率效应来自CRT （双室起搏）

73 International Journal of Cardiology 荟萃分析
比JAMA荟萃分析更新的 International Journal of Cardiology 荟萃分析

74 分析(包括COMPANION 数据）发现CRT 可以降低总死亡率！！！

75 结 论 最新荟萃分析第一次表明双室起搏进行心脏再同步治疗可以在特定的心衰人群中降低全原因死亡率。现在可以推动双心室治疗到与ACEI 和Beta受体阻断剂相等的地步，即常规治疗，虽然仅局限于心衰合并LBBB的患者

76 心脏再同步治疗可以在特定的心衰人群中改善心脏功能和血液动力学状态，降低心衰住院率，降低全原因死亡率。
发表在2004年8月17日网络版Annals of Internal Medicine上的全面分析和回顾表明： 心脏再同步治疗可以在特定的心衰人群中改善心脏功能和血液动力学状态，降低心衰住院率，降低全原因死亡率。 Original Article

77 Implant Time (minutes) Center-based experience
CRT 手术步骤 随着经验增加，操作时间减少 P < 0.001 Implant Time (minutes) Main purpose: Explain the risks of a CRT system implant to referral clinicians. Based on MIRACLE study. Key messages: Chiefly due to varying anatomy, implants have been unsuccessful in 5% to 10% of patients atempted. Coronary sinus dissection or perforation occurred in 6% of the cases in MIRACLE, all were resolved without further complication. Two patients in MIRACLE (0.3%) died from procedure related complications as adjudicated by the Clinical Events Review Committee. During follow-up left ventricular lead dislodgement or other comlication required revision (replacement or repositioning) in nearly 6% of patients. All were successfully revised There is a learning curve. Implant times came down with increased center-based experience. Additional information: Center-based experience Abraham WT, et al. NEJM 2002;346: (MIRACLE)

78 心脏再同步治疗只对特发性扩张性心肌病有效吗？

79 Mean six-month outcomes of CRT in patients with HF of ischemic vs nonischemic etiology
Ischemic, baseline (n=34) Ischemic, 6 months* IDCM, baseline (n=40) IDCM, 6 months* NYHA class 3.1 2.2 3.2 2.3 QRS duration (ms) 175 158 178 164 QoL score 39 26 43 33 6-min walk (m) 305 422 258 362 LVEF (%) 21 30 23 32 QoL=quality of life *All differences between six months and baseline, p<0.05. Differences between ischemic and nonischemic groups at baseline and six months, NS. . . Am J Cardiol 2004; 93:

80 Mean two-year outcomes of CRT in patients with HF of ischemic vs nonischemic etiology
Ischemic (n=34) IDCM (n=40) HF hospitalization (days/y) 0.5 0.6 Hospitalizations per patient annually 0.1 0.2 Survival rate (%) 88.3 87.5 All differences nonsignificant . Am J Cardiol 2004; 93:

81 心脏再同步治疗会增加室性心律失常吗？

82 心脏再同步治疗不增加室性心律失常 分析1044患者 Odds ratio (CI): CONTAK CD MIRACLE ICD
0.92 (0.67 – 1.27) 在随访期间VT/VF的发生率 Main purpose: Address safety concern that CRT is pro-arrhythmic Key messages: No difference between CRT and no CRT in the number of patients with VT/VF events Additional information: These data come from a meta-analysis of CRT. The two studies combined assessed CRT in patients with a pre-existing indication fro an ICD. VT/VF events are collected in the devices’ (InSync ICD, Contak CD) diagnostics. Bradley DJ, et al. JAMA 2003;289:

83 CRT可以显著降低室性心律发生 American Journal of Cardiology 2004 ,94:

84 American Journal of Cardiology 2004 ,94:130-132

85 有了CRT治疗就可以不需要药物治疗了吗？

86 CRT治疗和药物治疗的关系 CRT 治疗需在心衰标准药物治疗基础上进行
CRT 治疗可以促进药物治疗调整，如促进B受体阻滞剂等药物更好地达到靶剂量而不必过分担忧心率、血压等 INSYNC III 诊断功能可以更好地监测患者病情，调整起搏参数和药物变化。

87 CRT “Ideal” CHF Therapy
Benchmarks CRT Outcomes Mortality Reduces Overall Death and Hospitalizations Q. O. L. Improves NYHA and Q. O. L Low or No Side Effects: High Compliance Disease Progression Reverse Remodeling of LV Echo Parameters Cost Effective Decreases Hospitalization and Out-patient Care