背景:对于合并完全性左束支传导阻滞的心力衰竭患者,心脏再同步化治疗是一种重要的治疗方法。如果这些病人也有房性心动过速,如何选择治疗策略值得讨论。
方法:一名70岁出头的中国女性因反复发作的胸闷和哮喘而入院1年。体格检查和实验室检查显示颈静脉充盈,肺部啰音,心脏边界向左扩大,下肢水肿和N末端B型利钠肽升高。心电图显示房性心动过速和左束支传导阻滞。超声心动图显示左心室增大和左心室收缩功能障碍。在获得知情同意后,研究小组决定的治疗策略是使用双室心脏再同步治疗,并且不干预房性心动过速,以左束支区域起搏作为备用。由于扭曲和狭窄的冠状静脉分支,传统的双心室起搏失败,然后,左束支区域起搏尝试成功。1年的随访超声心动图显示收缩功能改善。这个病人的结果是有利的,但在这种情况下,介入策略的选择值得探讨。
结论:对于合并左束支传导阻滞和房性心动过速的心力衰竭患者,左束支区起搏可替代传统的双心室起搏用于心脏再同步化治疗,治疗效果显著。然而,在制定战略时需要考虑多种因素,包括窦性心律下是否有束支传导阻滞,房性心动过速消融的成功率和复发率,心脏再同步治疗的反应,不同策略的成本,和器械植入问题。
BACKGROUND: For patients with heart failure combined with complete left bundle branch block, cardiac resynchronization therapy is an important therapeutic method. If these patients also have atrial tachycardia, how to choose a treatment strategy deserves discussion.
METHODS: A Chinese woman in her early 70s was admitted due to recurrent episodes of chest distress and asthma for 1 year. Physical and laboratory examinations showed filling of the jugular vein, lung rales, left enlargement of the heart boundary, edema of the lower limbs and elevation of N-terminal pro b-type natriuretic peptide. An electrocardiogram showed atrial tachycardia and a left bundle branch block. An echocardiography revealed enlargement of the left ventricle and left ventricular systolic dysfunction. After obtaining informed consent, the treatment strategy decided upon by the team was to use biventricular cardiac resynchronization therapy treatment and to not intervene for the atrial tachycardia, with left bundle branch area pacing as a backup. Due to twisted and narrow coronary vein branches, traditional biventricular pacing failed, and then, left bundle branch area pacing was attempted successfully. A follow-up echocardiography at 1 year showed improved systolic function. The outcomes for this patient are favorable, but the choice of interventional strategy is worthy of discussion in this
case.
CONCLUSIONS: For patients with heart failure combined with left bundle branch block and atrial tachycardia, left bundle branch area pacing can replace traditional biventricular pacing for cardiac resynchronization therapy treatment, and the therapeutic effect is significant. However, multiple factors need to be considered when formulating strategies, including whether there is bundle branch block under sinus rhythm, the success and recurrence rate of atrial tachycardia ablation, the response of cardiac resynchronization therapy, the costs of different strategies, and instrument implantation issues.