Potential proarrhythmic effects of biventricular pacing
Potential proarrhythmic effects of biventricular pacing
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DOI：
10.1016/j.jacc.2005.08.035
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发表时间：
2005-12-20
影响因子：
24
通讯作者：
Antzelevitch, C
中科院分区：
文献类型：
--
作者：
Fish, JM;Brugada, J;Antzelevitch, C
包括右心室内起搏和左心室心外膜起搏的复苏治疗可改善充血性心力衰竭患者的心输出量、生活质量和纽约心脏协会心功能分级。虽然大量的注意力已经被引导到显示机械益处和微调双心室起搏配置和方案，但是很少注意到逆转左心室壁的激活方向的后果。最近的基础科学和临床研究表明，逆转左心室壁的激活方向具有预防作用。正常激动序列的恢复缩短了QT间期并增加了现有的跨壁复极离散度，从而在长QT条件下产生了折返性心律失常的底物和触发因素。一些双心室起搏导致的R-on-T期外收缩和室性快速性心律失常诱导的病例报告支持这一观察结果，并引起了对双心室起搏在特定病例中可能具有预防作用的担忧，特别是当与QT间期延长相关时。我们在这篇综述中的重点是目前了解跨室壁复极的异质性，存在于整个左心室壁，这种分散的复极是如何放大的结果逆转的正常激活序列，以及如何这些基本的实验结果可能适用于接受心脏再同步化治疗的患者。
Resynchronization therapy involving right ventricular endocardial and left ventricular epicardial pacing improves cardiac output, quality of life, and New York Heart Association functional class in patients with congestive heart failure. Although a great deal of attention has been directed at showing the mechanical benefits and in fine-tuning the biventricular pacing configuration and protocol, little attention has been focused on the consequences of reversing the direction of activation of the left ventricular wall. Recent basic science and clinical studies have shown a proarrhythmic effect of reversing the direction of activation of the left ventricular wall. Reversal of the normal activation sequence prolongs the QT interval and increases the existing transmural dispersion of repolarization, creating the substrate and trigger for re-entrant arrhythmias under long QT conditions. A number of case reports of R-on-T extrasystoles and ventricular tachyarrhythmia induction as a result of biventricular pacing support this observation, and raise concern that biventricular pacing may be proarrhythmic in select cases, particularly when associated with a prolonged QT interval. Our focus in this review is on current understanding of transmural heterogeneity of repolarization that exists across the left ventricular wall, how this dispersion of repolarization is amplified as a consequence of reversal of the normal activation sequence, and how these basic experimental findings may apply to patients receiving cardiac re synchronization therapy.