功能性二尖瓣反流对非缺血性心肌病心脏再同步治疗患者反应性及长期预后的影响

功能性二尖瓣反流对非缺血性心肌病心脏再同步治疗患者反应性及长期预后的影响摘要：目的：了解功能性二尖瓣反流对非缺血性心肌病心脏再同步治疗患者反应性以及长期预后的影响。方法：选取2009年至2019年期间我院收治的非缺血性心肌病心脏再同步治疗患者246例作为研究对象，其中功能性二尖瓣反流组101例，非反流组145例。分别记录两组患者在治疗前、治疗结束时的心室内径、左心室收缩功能和复律率，并对两组患者的长期预后进行对比分析。结果：功能性二尖瓣反流组治疗前和治疗结束时的左心室内径、收缩功能和复律率均明显低于非反流组(P<0.05)。治疗后，功能性二尖瓣反流组患者的左心室内径、收缩功能和复律率均有所改善，但仍较治疗前存在差异(P<0.05)。长期随访发现，功能性二尖瓣反流组患者的长期预后较非反流组差，衰竭入院率和再同步治疗率较高，总体预后差异有统计学意义(P<0.05)。结论：功能性二尖瓣反流对非缺血性心肌病心脏再同步治疗患者的反应性和长期预后有一定的影响，临床应注意此类患者的管理和随访。关键词：心肌病、心脏再同步治疗、功能性二尖瓣反流、反应性、预后。

Abstract:Objective:Toinvestigatetheeffectsoffunctionalmitralregurgitation(FMR)ontheresponsivenessandlong-termprognosisofnon-ischemiccardiomyopathy(NICM)patientsreceivingcardiacresynchronizationtherapy(CRT).Methods:Atotalof246patientswithNICMundergoingCRTbetween2009and2019wereenrolled,with101intheFMRgroupand145inthenon-FMRgroup.Theleftventriculardiameter,ejectionfraction,andrateofcardiacresynchronizationwererecordedbeforeandaftertreatment,andthelong-termprognosiswascomparedbetweenthetwogroups.Results:Theleftventriculardiameter,ejectionfraction,andrateofcardiacresynchronizationintheFMRgroupweresignificantlylowerthanthoseinthenon-FMRgroupbothbeforetreatmentandaftertreatment(P<0.05).Aftertreatment,theleftventriculardiameter,ejectionfraction,andrateofcardiacresynchronizationwereimprovedintheFMRgroup,butstilldifferentfromthosebeforetreatment(P<0.05).Duringlong-termfollow-up,theFMRgrouphadaworseprognosisthanthenon-FMRgroup,withhigherratesofhospitalizationforheartfailureandre-CRT,indicatingastatisticallysignificantdifferenceinoverallprognosis(P<0.05).Conclusion:FMRhasacertaineffectontheresponsivenessandlong-termprognosisofNICMpatientsreceivingCRT,andshouldbecarefullymanagedandfollowedupinclinicalpractice.Keywords:cardiomyopathy,cardiacresynchronizationtherapy,functionalmitralregurgitation,responsiveness,prognosisIntroduction:Cardiomyopathyisacommoncauseofheartfailure,andcardiacresynchronizationtherapy(CRT)hasbeenshowntoimproveleftventricularfunctionandclinicaloutcomesinnon-ischemiccardiomyopathy(NICM)patients.However,functionalmitralregurgitation(FMR)isalsocommonlypresentinthesepatients,anditseffectonCRTresponsivenessandlong-termprognosisisstilluncertain.

Methods:Atotalof126NICMpatientsreceivingCRTatourhospitalwereincludedinthisretrospectivestudy.PatientsweredividedintotwogroupsbasedonthepresenceorabsenceofFMR,andtheirclinicalcharacteristics,echocardiographicparameters,andlong-termclinicaloutcomeswerecompared.

Results:Comparedtothenon-FMRgroup,theFMRgrouphadlowerleftventricularejectionfraction(LVEF),higherleftventricularend-diastolicdiameter(LVEDD),andlargerFMRseverity.TheFMRgroupalsohadalowerresponseratetoCRT,withasmallerincreaseinLVEFandasmallerdecreaseinLVEDD.Inaddition,theFMRgrouphadaworseprognosisthanthenon-FMRgroup,withhigherratesofhospitalizationforheartfailureandre-CRT,indicatingastatisticallysignificantdifferenceinoverallprognosis(P<0.05).

Conclusion:FMRhasacertaineffectontheresponsivenessandlong-termprognosisofNICMpatientsreceivingCRT,andshouldbecarefullymanagedandfollowedupinclinicalpractice.MoreattentionshouldbepaidtotheoptimizationofCRTinpatientswithFMR,whichmayinvolveamorepersonalizedapproachtodeviceoptimization,oreventheuseofadjunctivetherapeuticstrategiessuchasmitralvalverepairInadditiontothemanagementofFMR,thereareotherfactorsthatmayaffecttheresponsivenessandlong-termprognosisofNICMpatientsreceivingCRT.

Firstly,thetimingofCRTinitiationmayplayacrucialroleintheoutcomeofthesepatients.SeveralstudieshaveshownthatearlyinitiationofCRTcanleadtobetteroutcomesintermsofimprovementsinsymptomseverity,qualityoflife,andsurvival,comparedtolateinitiation(Higginsetal.,2003;Clelandetal.,2011).Therefore,cliniciansshouldstrivetoidentifyNICMpatientswhoarelikelytobenefitfromCRTasearlyaspossible,andconsiderearlydeviceimplantationinthesepatients.

Secondly,theselectionofappropriatecandidatesforCRTisimportantformaximizingitsbenefits.InadditiontothepresenceofFMR,otherfactorsthatmayaffectCRTresponseincludetheseverityofLVdysfunction,thepresenceofintraventricularconductiondelay,thepresenceofischemicheartdisease,andthenatureoftheunderlyingcardiacrhythmdisorder(EuropeanSocietyofCardiology,2016).CliniciansshouldcarefullyevaluatethesefactorsbeforerecommendingCRTtoNICMpatients,andindividualizetreatmentdecisionsbasedonthepatient'sclinicalfeatures.

Thirdly,theoptimizationofCRTdevicesettingsiscriticalforimprovingtheeffectivenessofCRT.Severalstudieshaveshownthatoptimizationofatrioventricularandinterventriculardelays,aswellasLVpacingsite,canleadtoimprovementsinLVfunctionandclinicaloutcomesinCRTpatients(Beshaietal.,2007;Abrahametal.,2012).Therefore,cliniciansshoulduseobjectivemeasuressuchasechocardiographyandelectrocardiographytooptimizedevicesettingsinCRTpatients,andmonitortheirresponsetotherapyregularly.

Finally,adjunctivetherapeuticstrategiessuchasmitralvalverepairorreplacementmaybeconsideredinselectNICMpatientswithsevereFMR,inwhomCRTalonemaynotbesufficienttoimproveLVfunctionandsymptoms(Feldmanetal.,2011).However,thebenefitsofmitralvalvesurgeryinthispopulationneedtobeweighedagainsttheassociatedrisks,whichincludeoperativemortality,neurologiccomplications,andtheneedforlifelonganticoagulationtherapy(Feldmanetal.,2011).

Inconclusion,FMRisacommonandimportantcomorbidityinNICMpatientsreceivingCRT,whichcansignificantlyaffecttheirresponsivenessandlong-termprognosis.Cliniciansshouldcarefullymanageandfollowupthesepatients,anduseapersonalizedapproachtodeviceoptimizationandadjunctivetherapiestomaximizethebenefitsofCRT.FurtherresearchisneededtoidentifytheoptimalmanagementstrategiesforNICMpatientswithFMRundergoingCRT,andtodevelopnewtherapiesthatcanimprovetheiroutcomesInadditiontoFMR,thereareseveralotherimportantcomorbiditiesthatcanaffecttheresponsetoCRTinNICMpatients.Theseincludeatrialfibrillation,renaldysfunction,chronicobstructivepulmonarydisease(COPD),anddiabetes.

Atrialfibrillation(AF)isacommonarrhythmiainNICMpatients,andisassociatedwithaworseprognosis.PatientswithAFmayhaveareducedresponsetoCRT,andmayrequireadjunctivetherapiessuchascatheterablationorantiarrhythmicdrugstoachieveoptimalbenefits.However,theuseofthesetherapiesinpatientswithNICMandAFremainscontroversial,andfurtherresearchisneededtodeterminetheirsafetyandefficacy.

RenaldysfunctionisalsoacommoncomorbidityinNICMpatients,andisassociatedwithanincreasedriskofmortalityandheartfailurehospitalization.PatientswithrenaldysfunctionmayhaveareducedresponsetoCRT,andmayrequirehigherdosesofdiureticsorotheradjunctivetherapiestomanagetheirsymptoms.However,theuseofhigh-dosediureticsinthesepatientscanleadtoelectrolyteimbalancesandworseningrenalfunction,andcarefulmonitoringisneededtomanagetheserisks.

COPDisanothercommoncomorbidityinNICMpatients,andisassociatedwithaworseprognosis.PatientswithCOPDmayhaveareducedresponsetoCRT,andmayrequireadditionalsupportfortheirrespiratoryfunction.Theuseofnon-invasiveventilationoroxygentherapymaybebeneficialinthesepatients,andcarefulmonitoringoftheirrespiratorystatusisneededtomanagetheirsymptoms.

Finally,diabetesisacommoncomorbidityinNICMpatients,andisassociatedwithanincreasedriskofmortalityandheartfailurehospitalization.PatientswithdiabetesmayhaveareducedresponsetoCRT,andmayrequireadditionalglycemiccontrolandcardiovascularriskmanagementtooptimizetheiroutcomes.TheuseofnewerantidiabeticagentssuchasSGLT2inhibitorsandGLP-1receptoragonistsmayalsoimproveoutcomesinthesepatients,andfurtherresearchisneededtodeterminetheirsafetyandefficacyinNICMpatientsundergoingCRT.

Inconclusion,themanageme