永久HIS起搏临床应用

永久HIS起搏临床应用进展,中国医学科学院阜外医院国家心血管病中心任晓庆,一、希氏束,DHBP(direct His bundle pacing/ pure HBP)直接HBP/纯HBP：对于DHBP的定义各文献中概念基本一致,二、希氏束起搏（HBP）定义,起搏信号与QRS之间有等电位线，Vp-V间期几乎等于H-V间期起搏QRS波与自身的一致增高起搏输出可能使部份患者的QRS波变宽带周边内膜起搏,Ann Noninvasive Electrocardiol 2012;17(2):7078J Interv Card Electrophysiol (2011) 31:255262Journal of Cardiovascular Electrophysiology Vol. 17, No. 1, January 2006,DHBP(direct His bundle pacing/ pure HBP)直接HBP,DHBP(direct His bundle pacing/ pure HBP)直接HBP,HIS束,HIS束,正常心肌,胶原纤维鞘,HIS束组织学：HIS束在中心纤维体由Purkinje细胞纵向排列构成，外包裹胶原纤维，缺乏正常的心肌细胞“裸露”的HIS束是HBP电极能够精确定位的基础,James TN, Sherf L. Fine structure of the His bundle. Circulation 1971; 44:928,正常心肌,三、HIS束组织解剖,HIS束组织解剖,Arbeiten aus der medizinischen klinik zu leipzig 1893; 1:1449Jena, Germany 1906; 9:114156Kardiol Pol 2012; 70, 5: 472476,HIS束,RBB,LBB,四、His 束尸体组织解剖,HIS束的解剖：位于室间隔膜部上方，上与A-V node紧邻，下与左右束支相接“裸露”的HIS束是HBP电极能够精确定位的基础,Correa de Sa DD, et al. Autopsy analysis of the implantation site of a permanent selective direct his bundle pacing lead. Circ Arrhythm Electrophysiol. 2012 Feb;5(1):244-6.,His 束尸体组织解剖,A, The formalin-fixed tissue block containing the conduction system shows the direct His bundlepacing (DHBP) lead having been unscrewed, leaving behind a fibrous sheath where the lead tip had been actively fixed (arrow). Thelead insertion site is 9 mm above the TV leaflet.,Correa de Sa DD, et al. Autopsy analysis of the implantation site of a permanent selective direct his bundle pacing lead. Circ Arrhythm Electrophysiol. 2012 Feb;5(1):244-6.,His 束尸体组织解剖,B, Masson trichrome (x1) staining demonstrates the proximity of the DHBP lead to the His bundle. The His bundle stains red and is indicated by the asterisk. The arrow points to the TV leaflet. The MS and scar issue are stained blue.,Correa de Sa DD, et al. Autopsy analysis of the implantation site of a permanent selective direct his bundle pacing lead. Circ Arrhythm Electrophysiol. 2012 Feb;5(1):244-6.,His 束尸体组织解剖,C, Masson trichrome (x100). Screw puncture sites are seen surrounding the His bundle (arrows). There is evidence of afibrous response within the bundle (blue staining) adjacent to the screw holes. Metallic specks shed by the screw are seen adjacent tothe screw hole (inset hematoxylin and eosin stain, 400). MS indicates membranous septum; TV, tricuspid valve; V, ventricular septum.,Correa de Sa DD, et al. Autopsy analysis of the implantation site of a permanent selective direct his bundle pacing lead. Circ Arrhythm Electrophysiol. 2012 Feb;5(1):244-6.,HBP解剖定位：电极头端定位三尖瓣瓣叶上方心房侧，直接接触到HIS束，未整体越过三尖瓣，螺旋头端在室间隔膜部上端,Circ Arrhythm Electrophysiol. 2012;5:244-246.,五、HIS束尸体解剖,HIS束尸体解剖,A, All 3 leads are visualized with exposure of the free wall of the right atrium. The forceps is gripping theposterior TV leaflet. The DHBP lead is implanted on the atrial side of the valve leaflet,Correa de Sa DD, et al. Autopsy analysis of the implantation site of a permanent selective direct his bundle pacing lead. Circ Arrhythm Electrophysiol. 2012 Feb;5(1):244-6.,HIS束尸体解剖,B, Following formalin fixation, the membranousseptum was transilluminated from the left ventricle, showing the insertion of the DHBP lead at the superior-most extent of the membranousseptum. CS indicates coronary sinus; DHBP, direct His bundle pacing lead; RA, right atrial pacing lead; RV, right ventricular pacinglead; TV, tricuspid valve.,Correa de Sa DD, et al. Autopsy analysis of the implantation site of a permanent selective direct his bundle pacing lead. Circ Arrhythm Electrophysiol. 2012 Feb;5(1):244-6.,六、希氏束起搏影像,希氏束起搏超声影像,Figure 3 AV = atrioventricular; CT = computed tomography; HB = His Bundle; IVS = Interventricular septum; RCC = Right coronary cusp; TV = tricuspid valve.,Pugazhendhi Vijayaraman , Gopi Dandamudi , Terry Bauch , Kenneth A. Ellenbogen,Imaging evaluation of implantation site of permanent direct His bundle pacing lead,Heart Rhythm, Volume 11, Issue 3, 2014, 529 - 530,/10.1016/j.hrthm.2013.01.027,希氏束起搏CT影像,电压理论增加电压输出后，导线头端激动范围扩大激动了远端正常传导系统,七：电压与起搏范围,低电压输出,高电压输出,HBP纠正房室传导阻滞或束支传导阻滞的机制：,机制一：1971年发表“希氏束纵向分离学说”，即在希氏束内已纵向分离为左右束支，部分束支传导阻滞的部位就发生在希氏束内或近HIS束主干 机制二：导线头端位于HIS束处且接近阻滞部位远端的正常组织，高电压输出导致激动范围扩大激动了远端正常传导束机制三：部分RBBB患者通过起搏融合后使原来RBBB消失，而非真正的HBP,Europace (2010) 12, 527533 James TN, Sherf L. Fine structure of the His bundle. Circulation 1971; 44:928,HBP机制纠正束支传导阻滞,HBP纠正RBBB,输出电压1.3V 升高到2.0V后RBBB消失,通过起搏间隔融合后使原来RBBB消失，而非真正的HBP,八、希氏束起搏的优势,一、HBP理论上实现了心脏的电和机械同步，包括房室同步、室间同步和室内同步，是最生理的起搏方式二、避免心室起搏依赖造成心功能不全或加重以及心律失常（保护心功能）三、HBP纠正近端室内传导阻滞，宽QRS变窄，恢复心脏同步性，治疗心衰四、电极未越过三尖瓣，避免三尖瓣返流（保护三尖瓣）,国外研究：HBP较RVAP改善心肌血流二尖瓣返流和左室同步性,Francesco Zanon, Europace (2008) 10, 580587,SPECT,组织多普勒和UCG,TDI测定提示左室同步性HBP优于RVAP,HBP,RVAP,2010年荟萃分析AVB伴宽QRS有52%81%的患者通过HBP使QRS波形态变窄、纠正了束支阻滞2013年 小样本量文献报导纠