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中华心脏与心律电子杂志

中华心脏与心律电子杂志 ›› 2024, Vol. 12 ›› Issue (02) : 102 -112. doi: 10.3877/cma.j.issn.2095-6568.2024.02.006

临床研究

连续起搏记录技术在左束支起搏中的应用：不同深度间隔起搏的电生理特点
沈佳波1, 江隆福1,†(), 吴昊1, 李恒栋1, 张璐1, 钟进彦1, 卓珊珊1, 郑南1, 张越琳1   
  1. 1. 315000　宁波，宁波市第二医院心内科
  • 收稿日期:2023-10-15 出版日期:2024-06-25
  • 通信作者: 江隆福
  • 基金资助:
    浙江省基础公益研究计划(LGF22H020009); 宁波市第二医院华美研究基金(2023HMKY26)

Application of continuous pacing recording technique in left bundle branch pacing: electrophysiological characteristics of pacing at different septal depth

Jiabo Shen1, Longfu Jiang1,†(), Hao Wu1, Hengdong Li1, Lu Zhang1, Jinyan Zhong1, Shanshan Zhuo1, Nan Zheng1, Yuelin Zhang1   

  1. 1. Department of Cardiology, Ningbo No.2 Hospital, Ningbo 315000, China
  • Received:2023-10-15 Published:2024-06-25
  • Corresponding author: Longfu Jiang
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沈佳波, 江隆福, 吴昊, 李恒栋, 张璐, 钟进彦, 卓珊珊, 郑南, 张越琳. 连续起搏记录技术在左束支起搏中的应用：不同深度间隔起搏的电生理特点[J]. 中华心脏与心律电子杂志, 2024, 12(02): 102-112.

Jiabo Shen, Longfu Jiang, Hao Wu, Hengdong Li, Lu Zhang, Jinyan Zhong, Shanshan Zhuo, Nan Zheng, Yuelin Zhang. Application of continuous pacing recording technique in left bundle branch pacing: electrophysiological characteristics of pacing at different septal depth[J]. Chinese Journal of Heart and Heart Rhythm(Electronic Edition), 2024, 12(02): 102-112.

目的

评估使用连续起搏记录技术鉴别电极在不同间隔深度所出现的各种起搏模式的可行性及其电生理特征。

方法

连续纳入2021年4月至2023年9月宁波市第二医院有永久起搏器植入适应证并使用连续起搏和记录技术拟行左束支起搏（LBBP）的患者。记录标准12导联体表心电图及心腔内电图，比较LBBP植入过程中6种不同深度间隔起搏［分为右心室间隔起搏（RVSP）组、中间隔起搏（IVSP1和IVSP2）组、左心室间隔起搏（LVSP）组、非选择性LBBP（NSLBBP）组和选择性LBBP（SLBBP）组］的刺激到V6导联R波峰值时间（Stim-V6RWPT）、刺激到V1导联R波峰值时间、刺激到QRS波末端时间（Stim-QRSd）及V6-V1峰间期的差异。

结果

出现6种起搏模式转化的患者共201例（83.4%，201/241），年龄（74.1±9.7）岁，其中男占57.2%（115/201）。发现NSLBBP组和SLBBP组的Stim-V6RWPT显著短于RVSP组、IVSP1组、IVSP2组和LVSP组［（68.8±8.7） ms对（68.3±8.8）ms对（104.5±10.3） ms对（90.6±13.0） ms对（85.4±11.8） ms对（82.2±10.3） ms，P＜0.001］。IVSP2组Stim-QRSd最窄［（134.3±14.8） ms］，而不是NSLBBP组（137.4±16.4）ms。

结论

通过不间断起搏技术鉴别电极位于不同间隔深度的各种起搏模式是可行的。该6种起搏模式的特点各不相同，其中LBBP与LVSP的电生理特点明显不同，应该是两种完全不同的起搏模式，因此不应将LBBP与LVSP归入左束支区域起搏这个概念。

关键词: 心脏起搏，人工, 左束支起搏, 左侧间隔起搏, 中间隔起搏, 连续起搏记录技术
Objective

To identify various pacing modalities of different interventricular septum and evaluate their electrophysiological characteristics using continuous pacing and recording technique.

Methods

All of the patients with symptomatic bradycardia were consecutively enrolled from April 2021 to September 2023, and attempted to do left bundle branch (LBB) pacing (LBBP) in Ningbo No.2 Hospital using continuous pacing and recording technique. In the standard 12-lead electrocardiogram and intracardiac electrocardiogram, stimulus to V6 R wave peak time (Stim-V6RWPT), stimulus to V1 R wave peak time, stimulus to QRS end duration (Stim-QRSd), and V6-V1 interpeak were documented and compared during implantation, which was divided into right ventricular septal pacing (RVSP), intraventricular septal pacing (IVSP1 and IVSP2), left ventricular septal pacing (LVSP), non-selective LBBP (NSLBBP), and selective LBBP (SLBBP).

Results

Eighty-three point four percent (201/241) patients with six pacing modality transitions were included, (74.1±9.7) years old, and 115 (57.2%, 115/201) of them were male. The Stim-V6RWPT of NSLBBP and SLBBP were significantly shorter than RVSP, IVSP1 and IVSP2 [(68.8 ± 8.7) ms vs. (68.3 ± 8.8) ms vs. (104.5±10.3) ms, vs. (90.6±13.0) ms, vs. (82.2 ± 10.3) ms, P＜0.001]. Stim-QRSd was the narrowest in IVSP2 [(134.3 ± 14.8) ms] instead of NSLBBP [(137.4 ± 16.4) ms].

Conclusion

It is feasible to distinguish various pacing modalities at different interventricular septum using uninterrupted pacing technique. Electrophysiological evidence from our study shows that the characteristics of these six pacing modalities are different, especially LBBP and LVSP. Therefore, LBBP and LVSP should not be brought under the LBB area pacing umbrella.

Key words: Cardiac pacing,artificial, Left bundle branch pacing, Left ventricular septal pacing, Intraventricular septal pacing, Continuous pacing technique
图1 透视下植入左束支起搏导线的过程（1A为三尖瓣造影；1B为拧入起搏导线位点；1C为鞘管造影确定电极深度）
图2 不同深度间隔起搏的电生理特点（从右侧间隔起搏逐渐向选择性左束支起搏的整个变化过程）RVSP为右侧间隔起搏，IVSP为中间隔起搏，LVSP为左侧间隔起搏，NSLBBP为非选择性左束支起搏，SLBBP为选择性左束支起搏，LBB为左束支，RWPT为R波达峰时间，EGM为心腔内电图
图3 左束支电极拧入室间隔期间连续不间断记录心电图和心腔内电图的变化特点RVSP为右侧间隔起搏，IVSP为中间隔起搏，LVSP为左侧间隔起搏，NSLBBP为非选择性左束支起搏，SLBBP为选择性左束支起搏，LBB为左束支，RWPT为R波达峰时间，EGM为心腔内电图
表1 左束支起搏患者的基本临床资料
项目 数值
例数 201
年龄（岁，
x¯±s
）		 74.1±9.7
男性［例（%）］ 115（57.2）
起搏器适应证［例（%）］
房室传导阻滞 139（69.2）
病态窦房结综合征 55（27.4）
心房颤动伴长RR间期 9（4.4）
心力衰竭 7（3.5）
合并疾病［例（%）］
高血压 127（63.2）
糖尿病 53（26.4）
心肌病 9（4.5）
冠心病 27（13.4）
心房颤动 54（26.9）
左心室射血分数（%，
x¯±s
）		 63.1±10.1
左心室舒张末期内径（mm，
x¯±s
）		 49.6±7.2
QRS波形态［例（%）］
窄QRS波 136（67.6）
右束支传导阻滞 35（17.4）
左束支传导阻滞 30（14.9）
非特异性室内传导延迟 4（2.0）
表2 左束支起搏患者手术相关参数的临床特征
项目 数值
例数 201
PoLBB发生率［例（%）］ 139（69.2）
PoLBB-V间期（ms，
x¯±s
）		 25.1±8.2
PoLBB-V6RWPT（ms，
x¯±s
）		 63.8±8.3
PoLBB 振幅［mV，M（Q1，Q3）］ 0.2（0.1，0.4）
Stim-V6RWPT缩短时间（ms，
x¯±s
）		 14.7±5.5
初始LBB夺获阈值（V/0.5 ms，
x¯±s
）		 0.8±0.5
初始LVS夺获阈值（V/0.5 ms，
x¯±s
）		 1.3±0.9
初始心室感知（mV，
x¯±s
）		 8.1±3.8
初始阻抗（Ω，
x¯±s
）		 780.5±165.9
最终LBB夺获阈值（V/0.5 ms，
x¯±s
）		 0.6±0.5
最终LVS夺获阈值（V/0.5 ms，
x¯±s
）		 0.7±0.3
最终心室感知（mV，
x¯±s
）		 15.3±6.8
最终阻抗（Ω，
x¯±s
）		 728.4±127.7
电极深度（mm，
x¯±s
）		 14.9±2.9
穿孔发生率［例（%）］ 10（4.9）
表3 不同间隔深度起搏模式下的心电图参数比较
项目 RVSP IVSP1 IVSP2 LVSP NSLBBP SLBBP
例数 201 201 201 201 201 201
Stim-V6RWPT（ms，
x¯±s
）		 104.5±15.0 90.6±13.0 85.4±11.8 82.2±10.3 68.8±8.7 68.3±8.8
Stim-V1RWPT（ms，
x¯±s
）		 NA NA 106.8±12.4 113.7±12.5 110.2±13.7 119.7±17.3
V6-V1峰间期（ms，
x¯±s
）		 NA NA 21.0±8.8 32.2±11.2 42.6±12.1 51.5±15.4
Stim-QRSd（ms，
x¯±s
）		 148.2±16.4 135.2±15.1 134.3±14.8 139.5±15.1 137.4±16.4 148.7±19.5
图4 在穿室间隔过程中出现的6种起搏模式的心电图特征Stim-V6RWPT为刺激到V6导联R波达峰时间，Stim-V1RWPT为刺激到V1导联R波达峰时间，Stim-QRSd为刺激到QRS波末端时间；RVSP为右侧间隔起搏，IVSP为中间隔起搏，LVSP为左侧间隔起搏，NSLBBP为非选择性左束支起搏，SLBBP为选择性左束支起搏，RWPT为R波达峰时间，EGM为心腔内电图
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