心脏传导系统起搏领域最新研究进展2024.docx
心脏传导系统起搏领域最新研究进展2024心脏起搏是指植入人工心脏起搏器以完全或部分替代心脏的电兴奋和电传导，是治疗不可逆性缓慢性心律失常的重要方式。近年来，心脏起搏领域发展迅速，对传导系统起搏的研究和认识（包括相关解剖和生理学）有了显著进步。近期,JACCCHnEIeCtrOPhyS发表的一篇综述总结了传导系统起搏的最新进展。心脏传导系统起搏领域在过去几年中发生了迅速的变化。自最初描述希氏束起搏（HBP）靶向传导系统以来，左束支（LBBB）及其分支起搏的研究进展不断。对传导系统起搏的新认识，包括相关解剖和生理学，使生理性起搏成为所有起搏适应证的重要选择。Tawara发现了房室结，并建立了我们现在所理解的房室传导系统的概念（图1）。一种使用微型计算机断层扫描的方法为临床相关的传导系统解剖提供了有希望的方向。这些积累的见解使我们能够数字化重建虚拟房室传导系统，这对于传导系统起搏的发展至关重要（图2）。图1Tawara的插图及其3D重建mount2CofMjMCtionSystemPacgRightanterioroblique30Leftanterioroblique60RuaoscopkImages(A.8)showIheHis*bxfle(»dng(yUowarroMbads).Wit*oiAhadhdlcatethetetPbeBd工the(NSUIfbtCOOnMyartery.¼rtuM911btionimagesviewedfromthefight>trdorobliquedirection(CD)5wtheHundlePKi>9(rd).andleftbundlebranchPKing(white,grwn>.(C)TheestimatedlocationofcomponentsoftheatrcvenVlaihrconductionsyst«n(reftrV)SlPPlememXF冷Um3A).(D)TherelevMstruaurw.includingthemecnbracMSMPCUfnindep(MIriCMpidteif<.oftheconductionSyaernFro<niwgesCandDeithceM>XietoMtimMethatthePeKentHrhkoftricuspide9urgtMi>nInducrdWthemectuicalinteractionbetweenactivefixationle*dsJndXPUItrcupd(eaAet.includinginpbgement.PerfarMion.Jndentrapment.WiIbeirimisdifthelead<r<DItxdrwrtbCofnfnIR3。bvtwwnthptXandMito(uprtKmpdto>fUcs.OCifZIMd(9rM11>fixedwfficmtydftCMfo<ntf>trkutpAdauUAbo.ImWDsuggeststhePOtenMrhkofperfo<Mtonofthememborx)ftSePUfnd>fhgHi-budtePdC力0(AB)lmigesxrtesydDrChUMW-Hvn(CD)VtetUavnageswerecvteduangcommerdltyJVMJbieworksu<ix(2lUti3112.wnbn2.93.4；AMINCo.Ltd；ZmaftIncWthpasthocmodi6catbusr»gdediutedVoUfn4r«nd<rsgsoftware(SARA-EngIne.pkXmobilLLC).图2传导系统起搏NO.2使用HBP或左束支区域起搏（LBBaP）的传导系统起搏或可恢复或保留正常生理激活（图3）。LBBaP包括有明确左束支（LBB）夺获证据的LBBP,和无明确LBB夺获证据的左心室间隔部起搏（LVSP）。CINTRAL ILLUSTRATION CoMBet4 SyaMI PIdBr AM(NlMC Location and ECC Rmpomm Condition SntMl Pacing 3 SbOWnLBBB LBBP LBBP CS至三五先-4二 :二 MC 二二 “ jM m =FmMMI，.atJAm3CWMtF»»0<>>.图3传导系统起搏：显示传导系统起搏的解剖位置和心电图反应NO.3有研究在心衰合并完全性左束支传导阻滞（LBBB）患者中比较了HBP-心脏再同步疗法（CRT）和双心室起搏（BVP）-CRT对心室兴奋和急性血流动力学功能的影响。在23例患者中，18例HBP-CRT显著缩短了左心室激活时间（LVAT）o在这些患者中zHBP-CRT比BVP-CRT更有效地实现了心室再同步化。现有证据表明,当HBP-（CRT）可以成功矫正LBBB时，HBP-CRT有潜力提供更有效的心室再同步化并改善患者的心脏功能。NO.4与使用当前可用工具的HBP相比，LBBaP具有几个潜在的技术优势，包括低且稳定的阈值、治疗更多远端传导系统疾病的潜力以及可能更快的学习曲线。1.iang等人在主要由非缺血性心肌病引起的LBBB和左心室受损的患者中探索LBBaP和BVP的疗效。研究结果显示，与BVP相比，LBBaP使QRS时限显著更大幅度地缩短，QRS波面积减少更明显。NO.5虽然与HBP相比，LBBaP具有几个技术优势，但其导致的生理性双心室激活较少，因为右心室激活通常不通过传导系统发生。Ali等人的研究比较了HBP和LBBaP两种起搏模式，以确定延迟的右心室激活是否对心功能产生不利影响。研究结果显示，HBP较LBBaP产生更快的双心室激活，但LBBaP在降低LVAT方面不劣于HBP,LBBaP延迟的右心室激活并未对血流动力学反应产生不利影响。NO.6由于HBP的局限性,近年来LBB或左心室间隔的直接起搏作为一种生理性起搏方法受到越来越多的关注。与右心室起搏相比，LBBP和LVSP提供了更多的生理性心室激活，尽管右心室的激活延迟和QRS间期更宽，在V1中具有伪右束支传导阻滞(RBBB)形态。NO.7值得注意的是，确认传导系统夺获和恢复电同步对CRT的成功至关重要。确认希氏束夺获通常较为简单，在>90%的病例中观察到QRS形态的输出依赖性转换。NO.8心内膜希氏束和分支电位标测证明LBB夺获主要用作研究工具，但如果采用双导线植入技术，则可以实际应用。NO.9需要大规模随机临床试验，来确定心脏传导系统起搏在心动过缓和心衰治疗中的作用。A有7个小型随机临床试验探究了传导系统起搏(HBP或LBBP)在射血分数降低(LVEF<35%40%)和不同潜在传导异常心衰患者中的作用(表1)。表1传导系统起搏的的随机临床试验TABLB>RxidomifedCIMoITrUIforCSFOtMfNmm.YmSinF09«IUUMlRrimMytndpoMMporttfollow-up(>o)CcaMry1.ustgartenetM,*nHBPVSBVP29CRTmdicatnnFeaUNbtyQol12USA2015QRSd>130n«(28L8.1RB8B)QRSdNYHAWWTLVCF“SYNC"'刈9HBPVSBVP41OtTindkJtmQRSd12USA1.VEF235*IVEFat6mo.QRSd>120ECV2s<而MionCfNYHAII-IVdeathMUtnoMK-AtternMive."?HBPreVPSOLVC*)5%lMsbundleleadQftSd6Dennurk2021NYHAII-IVtfnpUtsuccessLV三F1.VSVMVHA6MWTHT-proBNPproceduretimefluor(»00Pyt>merJdUttondmMdmMMTMIBBPRESYNC/IBBPrBVP40IVF40%.NKMP.LB88.IVEFEd>meurements.NT-6OM2022NYHAII-IVproNP.NYMA.6MWT.QRSdvCRTreporaeIEVELAT.m2022CSPSBVP70LVBFs35¼.LBBB130tmorLVATLVESV1drat.orHFH6SpMnn48B8QRS»150WOfAVModeALTtRNATIVIHBPrBVP40PersitterrtMAVNA.LVEF18(crossoveritOwuAF.i,2022LVtFs40%.RSs<120mor9mo)RB8BNYHAII-IVHOK-HF.n2022tPvsno167PR*2ms.LVtF<40%.ZvOJQoLLVF.paems,12<owowMUKp*ongQRS»M0mOfRB8symptomaticpreference6mo)6MWT-wMktetAFMfUIIMM6AVKAXnMmnQlur<cdth?MntrtceQr(dv)Q;CVCJfdOMfOjUr;HFH,11m11faiu*MfpUUJtioaiAnfnU0i-出K*QVtnM*C6OA*21gKSymptOfWMCMfPltm*th1“2ftfSncBM；MIimC-HOntePRnge<CorvwySmmPKBMfUntecEnctroraatSXWKM-X-Qpt三udPmv(MtuMdforHMrtFf.IMPRCSniC,5tundSunckP*vVvw*MMrtu4armmqImCjteKMyncHortxjtnnTherapyUVfL-AYliftMrucuUrActVMtionTeSISE9WithRtywto9UlPgnorBfrCUurRcfynchrcruMcnn*wLVSVteftem11oUfSMot*oUNKMR-wdwWc3gv7c(kMy:MTpfT-*5WwIpro÷tyZtmr«<1CPept依NYMA.KYMAfmcttrulCtMkP-WQol-9Mfy011*tQRSQRSMfrMI；-QRS<MMkxtQRSi-QRSf>vytcnngtRMB5tunUetrMock；otrifafcrsmmMmTAin1MriIA计划中的和正在进行中的临床试验涵盖了大多数因高度房室传导阻滞（表2）或CRT（表3）而需要进行心室起搏的临床情况。表2正在进行或计划进行的传导系统起搏治疗缓慢性心律失常的临床试验TABLE4OngoingorPtMindClinicalTrialsforConductionSyStMnforBradyarrtiythmlasN*mNCTSUtutTr4tw4ttSiMFopvUtioaPrinMryCndpo*t62tnoHFollow-up(m)CwntryLE11BundlePaongSund*dRigMVentriaUjrPRngfOrHeMtFailureNcTosOlS660ReauAingLBBPvsRVP1IVfF50htMfe9reeAVBwithamidoMedRVP>90%LVESVKImpUntSUgsS.IaSUtyCVdeath.HFH.death.LVF.NT-pBNP.AFprogression.TRMR.leadPIArJfneterAQoL.ufety24QnddaPhyspavbNCTowM湖RecnMingH»/LBBPv1RVP200IvtF>50%.AVModePKMIVESV,tepulflash.AF.HFH.NYHA6MWT.NT0NP,QOLsafety12SpM>LEAPNCTO4S9S4S7RecrurtingLVSPVSRVP470LVEF>35%.secondOfthirdAVB.orJtriMJrrhytfwnuwithUOWVR.expectedVP>20%Combineddeath.HFH.JndLVEFDeath.HFH.combined3tandHFH.AF.LV£F.QOUSafety.QALY.CEA.BIA12NetherUfMhwotect-syncNCTO5585411NotreuitlngLBBPv$RVP4S08rady*hythmawithJmKWedRVP>40%Compos%HFH.andupgradetoCRTDWmCVdeath.HfH.IEPUrnsuccess,safety.LVEF,AF.CafdlopuUnonafyexerciseparameters24SouthKomLEAP*lodcNCTo473821RecruitingLBBPViRVP4S8LVEFS0%.AVBpatientswithanti(MtedRVP>40%Compositedejth.HFH.andupgradetoCRTDeathandHFH4JndupgradetoCRT,echoparameters,impbtSUCEs.wfety.deviceparameters,atrta(arrythms24OwwOptimPMingNcTO4624763RecruitingLBBPv$RVP683LVfF>35%.NYHAMil.secondorIhrtAVMociorpersistentOfpermanentAFWithVR<SObeats/minCombineddeath.HFH.JfMlPlCMEchoammeter.NT-p<o6NP.NYHAGMWTaQoLufety36CiWOTECTHFCSPvsRVP2.6IVEF>35¼.”bufdwQtVPC4rdiovdKuhrdeath.HFH.QOLuprde48UK.worldAVB-MnoVemnCgrMocKIXAP.LVSPrItVFmPatMnts*chAVConductionDeOrde11MHodl.ImpKtGLftBUnaeBrjncAreAPaongrghtVCmnaxJrPiangmAtnowmncuUrBiMIVTSVil<tVMitricuIjrnd(yttoUcvoUnM*;LVSPIaftWmrtCUUfWpQip×fMKaIftCfMr9urgtt>titfOPCiAKatg-PTOCFdofCardUcFunction)Mtf3BurtdUBrmcPacingtPatwmWtAtnovemncuUr8todi;PHYsPAVB-PhyuoogMP>ngforAVBlocktoPreventPicemikef-Indjced3dmyophy;PCM-PlKenJtorIMLCedCJrdMmyOPMhrPfIOTlCT-X-RvyMogtcMVenUS叼MWMrtcuiMpacingOuccaiwTrUiESUUsdforBfXrjr3TrMcfMmHMnFXltfFtOTECT-SYNCPrEnttWErMaofUftBundBrMKhArMPm。VruiIbghtVemrtcuLvPMI9onAUOuDetKMeMtFMjreRrogreuon.mdVentncuUrDyuynChrDnymPjtMncsWthSUtKUntaVcncncuUrPm9.OLV.QUalltr*We-yr;RVPn<VemnCUurPMng；TR.CnCUKldf9xgiutt0rtVP-WMhcuUrpktVRVMrtculMM;otherabbrvMkomMtoTAIm2MdX表3正在进行或计划进行的传导系统起搏治疗CRT的临床试验tablesOngoingOrHamedCUnicMTriMsforCSPforCJtTNjmeNCTSUtutTra«tnMnti3PpuMnPVtaMryCn<otOtheE*dp<AHlR>lw*tp(mo)CountryLIbHFNcTO5572957ReauttAngMMPVSGOMTSOKMP.lVFs35XHYHAfIII<3tnoGDMTSK.LUB%*h1.VEF535%ndfVAsHaBtthnota.LVCF.LVESV.LVEDV.NT-PfOaNP.MYHA.QoUsafety18OiHtS-CRTNCO526S52OReauMngHBPvsBVP120la.IR)VMHcationforCRT-D.RBB8LVEFQRSd.LVESV.LVEDV,MT-ProeNP6USAHOT-CRTNaO4561778EfWotmmtcomp<tHOTOTVS8VP100LVEFs35XLBB8QRSd>U0rreOrLVEF%50%.RVP>40%.NYHAIbWLVEF.9fety,w0sKH.death.VTVF.crossover.WYMA.QKSd.LVESVlO>L6USAReinveht-CRtNclOSg218NotreaurtngLBBPvsBVP20LVEF>35KLBB.NYHA>IVMPI6(otowc3molUSAHB-MUNCTO4409119ReouMngHkB8PvsBVP125LVEFs三XKYHAIkIV.1.BBB.orRVP>90%LV£F.QRSZnQWingLVEF.6MWT.HYHA.QoLQRSd.NTproNP.ttfc<y6DenmirltLbbap-AFHFNeTo5S49544RecruitingLBBPv$BVP60HeartUAure.IVtF<50%NYHAl-IV.permanentAF.QRSd<130ms.AVNAOfUowVRwttantIdpatdRVPX0%LVtFIfnptorVacess.safety,echoarameterqHT-pfoNP.death,andHFH6OWuCSMYNCNa0515565ReauMngHtaB8Pvs8VP60LVeFs35%Bn.NYHAIkNILVvolume.IVCF.NYHA.NT-ProBNP.6IVT.QolMyocjrmalwofire<fctribution.QRSd.arrtria.safety12StovenAaConsystcrtMeTO5187611RacruMngLBBP”BVP130IveFS35%LB8.QRSdB0morLVCFs三%.onLB.QRSd三r50msOC1.VtF<4O.AVBorLVEFsS%.NYHAIIMV.AF.QRSdZBofmCompositedeath.Ctfdtoctransplant.HFKLVtFLVEF.IVESV.COmMteOfdeath.CafMtraspUntHTH.QRSd.wptMfU*.NYHA12SfMinSifttyandEHectMfmsofleftBundleBnrPacingPittentsWithCardbcDyfUnCltoflandAVBlockNCTOSs53626NotreouitingLB8PVlBVP1LVEF<S0¾.HYHAIII.secondortirdAVB.orRVP>40%LVtFIVtSV.IrnpUnttucc*.dtandHFHvsafety.QRSd.TR12CMnaLeCaRTM0536S568RecruMngLBBPvsBVPIROtTMotion.KYHAIV.IB8QASd>130mornon-LB88QRSd.>150ms.orvSedQRSdCompositedeath.HFH4implantfMirelCCDre-IrterventtonProcedueWneafkxoscopytime.QRS46MWT.LVESV.ICDtherapies12BdgUnLTUNDLERTNCTo54”962RecnMngLBBPv8VPINIorItoMkJtionforCRT.LBB8CUTrmom<LVtF.CtMcMoutcone,6MV.QoLHFH.death.OdlMtfimpUmtMion.VAs.safety12S(MKPhystoSync-HFNcTO5572736NotfeauttngHfeZlMPvsBVP304LVEFs三XLB68,QRSd«130miCompositedMh.HFHiLVEFCost-effecteess.QoL.NYHA.6MWTNT-proNP.LVEFQRS<tCVCteatbindHFH.1.VAT12BrazftLeftvsLeftM0056S06S8NotrecruMngHkLB8PvsBVP2136LVEFs50¾.QRSda130msorIntkiated>40%orUPgrxetoCRTbecauseofRVP>40%ComposicededthjndMFHQoLdeath.HFHVandLVESVI:>HMCVdeath.HYHA6MW.NT5xoBKP.AF.COtherapies,eco66USA.CanadapmrnettrsCKDc*ctnpUrubIeCtecuortc(MCCOfiYSTOIT-COraljCttoCS)TStemPtgCBftrmtnoMjrRaynchrortatDnThenpjrlnStrtocDyiUicttonGdVAdtQRS(CRT-O-CMIKrsynchro-ru*onthrapydrfbtfUtor：CS-9fNC-ConducBionSyvtemVrwBMntacuUrforCv<ftReiynchroruitbq;GOMT-guMdr*cedm<lc4thtv*ptOirvctHllPJangJS«1AttemitwetoBarerfincuUrPxmghPJtteneSVHFrtFmdJTjpejlLBtt；H&RT-出*d.CorectvePjCetMBMtlakre；HOT-OIT-Hs<Pufc11eCcnducwnSyitmRICtlgOptMxcdTriaiofOdiftwrMtor*Afcn11wvaprICDtoManutteCMdkwvter-<fMbtr2lBU>.MHCtricM(lyofl*t8rvft*.wSRldnguAttermwhhPEVWntA*toiAMUtonJndMeanFjrt;LeCWn.Lelt8urle0chrejPadngforCMHBCteyrc)rvatbnTheQ(Iy：ARindcrruBdStUdHFT*NOlECRTTheleftL11d)eCmJbctey>rjtbnPwtrTrMjWEwUfESIUrtiam*3CMulT4(1IJTMIMPHlM11wrapyintjte11HV*NornkMwtFMkremdl8l<DVtoe*3mddivlfc心EMPImyocjrdMPerfUSionarming；RysbS)nc4<.CcnducifonSystemRKingXftnnSverciculvAeynchrcraxiMihPjtientsVtChroricHMrtSMyfiBNkCMT-OtT-ftcsy>r*jtbnCompNHoninl*8BAndNormalorMi<tyReducedVmMcUUfuntnVtCRTJS*.%tutrfvtnVA.wntta>*ryrv<a;VF.vm4cuhrf*>M*tfcv%VlYm*UUrOthar.trrtkrvasinTitte¼4.A此外，许多临床试验研究了传导系统起搏在特定临床情况下的疗效，如房颤（表4）,以及经导管主动脉瓣置换术后（表5）。表4正在进行或计划进行的传导系统起搏治疗房颤的试验TABLlOngoingorPlannedTrUlsforCSPforAFNamNCTStatusTrMtmenHSizePopulationPrimaryEndPOintOthtrEndpointsF0U0w<upCountryLBBAP-AFHFNCT05S49544RecruitingLB8PvsBVP60LVEF<50%tNYHAII-IV1PernMnemAFQRSd<130m$.AVNAorslowVRwithanticipatedRVPn40%LVEFImpUntsuccess,safety,echoparameters.NT-pcoNP.death,andHFH6ChinaCONoUCAFNeTOS467163NotrecruitingHtVLBBPVSBVP82LVEF<50%.QRSd120ms.PefAF(>6mo)refrt<xytoAADorfailedCAandAVNALVEFat6moHFH.CVdeath,LVESV.LVEDV.NYHA.6MWT.QoLNT-pcoBNP24Slovema.Austria.Bulgaria.Croatia.RomaniaRAFT-PAANeTO5428787NotrecruitingLBPvsBVP284AFandAVNA.NYHAl-lva.NT.proNP>6<X>400WHFHwithin12moNT-proBNPComPOSiteHFHanddeath.QoL.6MWT,echoparameters12CanadaAAO-M(UrrhythmiCdrugs；CA-the<efabUtion；CONDUCT-AF-ConductionSystemPKingVersusBivenvkuhfPKingAfterAvtoventhcuhrNodeAblMion.PefAF-PmiStemWUIbriUatkxRArTP4A«RMynchronoattonmPattentsWnhHFGAFTnalUru>r9cangPmndAVNAScrat49yWithLB8PComparedWithBiVPxing；ochrabbrrwti(a$mTabte15.表5正在进行或计划进行的TAVR后传导系统起搏临床试验TABLl7OngoingorPtanvwdCUnkatTrialsforCSPAftrTAVRNamNCTSUtufTratmntsSlMPopuUtk>nPrimaryEndpoirvtOtherEndpointsFOliOWHlpCountryPHYS-TAVlNCT04482816NotrecruitingHtsLBPvsRVP24TAVR.AVB.LVEF>50%CombinedsurvivalNYHA,6MWTLVEF.Sep<alflash.6MWT.NYHA.MR.NT-pcoBNP,HFH.QRSd.QL,GLS12SQainPLANETNCToSo24279RecruitingLB8PvsRVP30TAVR.LVEF50%,secondAVB.thirdAVBbfdycardcAFwithanticipatedRVP>20QRSdDeath.CVdeath.HFH.LVEF.echo.NYHA.NT-proBNP.6MWT.QoLarrhythmias24GermanyLeftBufXfteBRAVENCT05S41679LBPvsRVP46TAVR.bradycardiaorfirstAVB1secondAVBtypeIorII,highgradeAVB.orthirdAVBGLS.LVEF.safetyendpointsQoL.NYHA.6MWT.HFH.death.NT-pcoBNP,echoperimeters,deviceparameters18(ossoverat9mo)USANotreuitmgGLS-giobMIonQrtudnMstrmi；LeftBundleBRAVE-ComparBonofLeftBundleBcjnchAraVerueRatVcntricuUrSepUlPJCinginPMieMSVrtthMgh>de9reeConductionDiSeMeAfterTrJfBcJthetefAOnKValveR<pUce<nefW.PHYVTAVI-PhysialogiCMvsRightVemricuUrPxinginPattentsWltNormalVenthcubrFunctionR>stTAV1;PLANETLehBundleBranchAtmPxingSPatientsAfttrTAVR；TAVR,tramothtvJtxtkv<tvrepbcemmt；otherbbr¼vtominTaMn1-4.参考文献：1 .VijayaramanP,CheluMG,CurilaK,etal.CardiacConductionSystemPacing:KeyPoints.ACC.Aug22l20232 .PugazhendhiVijayaraman,MihalGChelu.etal.CardiacConductionSystemPacing:AComprehensiveUpdate.JACCClinElectrophysiol.2023Nov;9(11):2358-2387.
