Heart Rhythm:心脏再同步化治疗远期死亡率变异颇大

2012-12-05 高晓方译 Heart Rhythm

心律转复除颤器心脏再同步化治疗死亡率左束支传导阻滞

　　　 　　美国学者的一项研究表明，心律转复除颤器（CRT-D）再同步化治疗之后，远期死亡率依据基线传导缺陷和重塑反应而存在较大变异。论文于2012年11月26日在线发表于《心律》（Heart Rhythm）杂志。 　　此项研究对MADIT-CRT亚组患者进行了评估。MADIT-CRT对1820例接受心脏再同步除颤器（CRT-D）或仅除颤器（ICD）治疗的患者进行了比较。在左束支传导

　　心脏再同步化治疗　

　　美国学者的一项研究表明，心律转复除颤器（CRT-D）再同步化治疗之后，远期死亡率依据基线传导缺陷和重塑反应而存在较大变异。论文于2012年11月26日在线发表于《心律》（Heart Rhythm）杂志。

　　此项研究对MADIT-CRT亚组患者进行了评估。MADIT-CRT对1820例接受心脏再同步除颤器（CRT-D）或仅除颤器（ICD）治疗的患者进行了比较。在左束支传导阻滞（LBBB）和非LBBB的患者中，利用Cox比例回归分析评估治疗效果对死亡率的影响。在1196例于1年时复查超声心动图的患者中，通过基线传导和1年左室收缩末期容积（LVESV）变化分析CRT-D对远期死亡率的影响。

　　结果显示，CRT-D未降低总体死亡率（P=0.72）。在伴LBBB和CRT-D的761例患者中，对临床协变量进行校正之后死亡率呈降低趋势。在出现（有效者）和未出现（无效者）LVESV减小≥30%的患者中进一步评估CRT-D对死亡率的影响。CRT-D显著降低了LBBB有效者的死亡率（P=0.027），LBBB无效者则无此效应。与之相反，CRT-D使非LBBB有效者的死亡率出现升高趋势；非LBBB无效者的死亡率则显著升高（P=0.011）。



Objectives
To clarify influences on long-term mortality after cardiac resynchronization therapy with implantable defibrillator (CRT-D), we assessed MADIT-CRT patient outcomes by baseline conduction abnormality and one-year post-treatment remodeling.
Background
Long-term mortality data after CRT-D in minimally symptomatic patients are limited.
Methods
MADIT-CRT followed 1820 patients assigned to CRT-D or defibrillator (ICD)-only. Using Cox proportional regression analysis, treatment effects (CRT-D vs. ICD-only) on mortality were evaluated in patients with left bundle branch block (LBBB) and non-LBBB. Among 1196 patients with echocardiography repeated at one year, effect of CRT-D on later mortality (landmark analysis) was analyzed by baseline conduction and one-year change in left ventricular end-systolic volume (LVESV).
Results
Overall mortality was not reduced by CRT-D: hazard ratio (HR) for CRT-D: ICD-only = 0.94, p=0.72. Among 761 patients with LBBB and CRT-D, mortality trended lower (HR 0.71, p=0.10) after adjustment for clinical covariates. Effect of CRT-D on mortality was further evaluated in patients who did (responders) and did not (hypo-responders) have reduction in LVESV by ≥30%. LBBB responders (n=323) had significantly reduced mortality with CRT-D: HR 0.36, p=0.027; LBBB hypo-responders (n=182) did not (HR 0.99). By contrast, non-LBBB responders (n=89) trended towards more deaths with CRT-D: HR 2.11, p=0.22. Non-LBBB hypo-responders (n=118) had significantly worsened mortality: HR 3.72, p=0.011.
Conclusion
In MADIT-CRT, late mortality with CRT-D varied markedly with baseline conduction defect and remodeling response. Patients with both LBBB and substantially reduced LVESV had improved mortality. Those with non-LBBB or with LBBB and less-reduced LVESV had unchanged or worsened mortality after CRT-D.                  

作者：高晓方译



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