ARVC单形性室速导管消融还是ICD教案资料

ARVC单形性室速导管消融还是ICD教案资料 ARVC单形性室速导管消融还是ICD?南京医科大学第一附属医院邹建刚5th VAS-CHINA ARVC并不罕见的心肌病ARVC诊断标准xx1.心脏整体和/或局部运动障碍和结构改变2.室壁病理组织学特征3.复极障碍4.除极或传导异常5.心律失常6.家族史Circulation.xx;121:1533-1541ARVC室速ARVC ICD植入指证-ARVC-SCD的一级、二级预防ICD therapyis indicatedin patients with structuralheart diseaseand spontaneoussustained VT,whether hemodynamicallystable orunstable.ICD implantationis reasonablefor the prevention of SCD in patients witharrhythmogenic rightventricular dysplasia/cardiomyopathy(ARVD/C)who have1or morerisk factorsfor SCD.I IIa IIb III I IIa IIb IIII IIaIIb IIIIIaIIbIIIIIIaIIbIII(Class，Level ofEvidence:B)(Classa，Level ofEvidence:C)IIa?ACC/AHA/HRSxxguidelines fordevice-based therapyof cardiacrhythm?xx年指南关于ARVC猝死二级预防未作调整指南关于ARVC猝死的一级预防SCD危险因素有1个以上者植入ICD作为SCD的一级预防?电生理检查诱发室性心动过速(VT)?心电监护的非持续性VT?男性?严重右室扩大,广泛右室受累?发病很早(5岁)?累及左室?心脏骤停史?不能解释的晕厥ARVC-VT/SCD ICD植入的循证证据?BACKGROUND:?Arrhythmogenic rightventricular cardiomyopathy/dysplasia(ARVC/D)is acondition associatedwith therisk ofsudden death(SD).?METHODS ANDRESULTS:?We conducteda multicenter study of the impactof theimplantable cardioverter-defibrillator(ICD)for preventionof SDin132patients(93males and39females,age40+/-15years)with ARVC/D.Implant indicationswere ahistory ofcardiac arrestin13patients(10%),sustained ventricular tachycardia in82(62%),syncope in21(16%),and otherin16(12%).During amean follow-up of39+/-25months,64patients(48%)had appropriate ICD interventions,21(16%)had inappropriate interventions,and19(14%)had ICD-related plications.Fifty-three(83%)of the64patientswithappropriateinterventionsreceived antiarrhythmicdrug therapyat thetime offirst ICDdischarge.Programmed ventricularstimulationwas oflimited valuein identifyingpatients atrisk oftachyarrhythmias duringthe follow-up(positive predictivevalue49%,negative predictivevalue54%).Four patients(3%)died,and32(24%)experienced ventricular fibrillation/flutter thatin alllikelihood wouldhave beenfatal inthe absenceofthedevice.At36months,the actualpatient survivalrate was96%pared withthe ventricularfibrillation/flutter-free survivalrate of72%(P0.001).Patients whoreceived implantsbecause of ventricular tachycardia without hemodynamic promise hada significantlylower incidence of ventricularfibrillation/flutter(log rank=0.01).History ofcardiac arrestor ventricular tachycardiawith hemodynamiompromise,younger age,and leftventricular involvementwere independentpredictors ofventricularfibrillation/flutter.?CONCLUSIONS:?In patientswith ARVC/D,ICD therapyprovided life-saving protectionby effectivelyterminating life-threatening ventriculararrhythmias.Patients whowere proo ventricularfibrillation/flutter couldbe identifiedon thebasis ofclinical presentation,irrespective ofprogrammed ventricularstimulationoute.Circulation.xxDec23;108 (25):3084-91ICD Therapyfor preventionofSCDin ARVCPatients?132pts(93m,age40+/-15y)with ARVC?ICD indications:history ofcardiac arrestin13patients(10%)sustained VTin82(62%)syncope in21(16%),and otherin16(12%)?FU:39+/-25m:64patients(48%):appropriateICDR21(16%):inappropriate R4(3%)died At36months,the actualpatient survivalrate was96%the ventricularfibrillation/flutter-free survivalrate of72%?In patientswith ARVC/D,ICD therapyprovided life-saving protectionby effectivelyterminating life-threatening ventricularCirculation.xxDec23;108 (25):3084-91?84pts ARVCICD forSCD一级预防?FU:4.7+/3.4y48%ICD intervention19%VF?5年生存率伴 1、 2、 3、4危险因子的为100%、83%、21%、15%?EP诱发VT/VF、NSVT是独立预测因子首次放电时间和放电次数ICD电治疗的影响因子危险因子对生存率的影响结论ARVC患者植入ICD作为SCD一级预防措施接近一半患者可有效预防SCD ARVC室速导管消融需要考虑的几个问题?ARVC室速的机制疤痕折返，局灶?导管消融的成功率?远期复发率J AmColl Cardiolxx;50:43240?24例患者?48次消融?随访3236months(range1day to12years)10次为三维电解剖标测，38次为常规方法标测术后室速复发率高达85%，随访14个月无发作的比例仅为15%，且不同的标测方法之间未见显著性差异，即使术中消除所有诱发出来的室速，仍然有极高的复发率南京医科大学心脏科动态基质标测指导ARVC-VT消融病例1病例2病例3APEX VT1VT2病例2病例312Lead ECG(slower VT)Pacing atsite APacing atsite B结果?病例 1、2的三种临床室速消融全部成功，但病例2仍可诱发一种新的非临床类型室速，室速频率快，电转复后未再行标测，后选用可达龙治疗。 ?病例3在完成两条线性消融后诱发出一种频率较慢的室速，经非接触球囊标测此慢频率室速通过两条消融线之间的间隙传导，消融此间隙后室速不再诱发。 ?平均放电次数17次，每条消融线达到双向传导阻滞。 无手术并发症。 平均随访20月，无心动过速发生。 ARVC-VT心外膜消融?Percutaneous epicardialablation ofventriculartachycardiaafter failureof endocardialapproach inthe pediatricpopulation witharrhythmogenic rightventricular dysplasia?17例患者（14+/-4y），心内膜消融失败?20VTs诱发（2个大折返，18个局灶）?16例（94.1%）即刻成功?随访2615(range6to42)月?12人（70.6%）无室速发作Heart Rhythm.xxOct;7 (10):1406-10ARVC-VT心外膜消融?Epicardial substrateand outewith epicardialablation ofventriculartachycardia in arrhythmogenic rightventricular cardiomyopathy/dysplasia.?33例患者中13例（39.4%）心内膜不能完全成功，需要行心外膜消融?13例心外膜消融后随访18+/-13月?10/13（77%）无VT发作Garcia FC，Circulation.xxAug4;120 (5):366-75ARVC-VT消融的长期疗效Outes ofcatheter ablationofventriculartachycardiain arrhythmogenicrightventriculardysplasia/cardiomyopathy?87例患者，175次消融?平均随访88.366月?1年，5年，10年无室速发作比例分别为47%，21%，15%?心外膜消融后1年，5年无室速发作比例64%，45%Circ ArrhythmElectrophysiol.xxJun1;5 (3):499-505ARVC-VT消融心内或和心外仍有较高复发率，但能显著减少VT负荷?In reportedseries ofRV scar-related VT,abolition ofinducible VTis achievedin41%88%of patients?During averagefollow-ups of1124months,VT recursin11%83%of patients,with someseries observinga significantincidenceoflate recurrencesincreasing withtime ARVC-VT消融的现状与再认识?即刻成功率高?远期复发率也较高?三维标测结合心外膜消融明显提高成功率?即使完全消融成功，考虑VT复发，仍不能动摇ICD作为二级预防的适应证ARVC-VT消融的时机？?植入ICD之后？植入后VT反复发作，药物效果欠佳，ATP成功率低，反复shock但费用？?植入ICD之前？预防性消融减少发作，提高生活质量如不植入ICD，有较大风险病例男性，33岁，ARVC+SMVTxx年3月15日植入ICD DFT测试首次18J，失败；第二次，22J成功植入时的参数设置倍他乐克、可达龙植入后3周Electric storm问题？哪些患者需要早期，或先行消融后植入ICD，或ICD植入后尽早消融?术前室速发作对AADs不敏感，药物不能终止或减少发作，预计植入后仍有较高的发生率?术中发现高DFT或术后住院期间观察到ATP效果欠佳?电风暴高危ARVC植入ICD后电治疗的高危因素?History ofcardiac arrest?Ventricular tachycardiawithhemodynamiompromise?Younger age?Left ventricularinvolvement Independentpredictors ofVF/V Flutter这些人是否应当早期行导管消融？Circulation.xxDec23;108 (25):3084-91导管消融治疗ICD电风暴?Catheter ablation for thetreatment ofelectrical storminpatientswith implantablecardioverter-defibrillators:short-and long-term outesinaprospective single-centerstudy.?95pts(13ARVC,72CAD,10DCM)?85pts(89%)sueeded after1-3procedures?FU:22(1-43)m:92%no ES,66%no VT;11(12%)died Circulation.xxJan29;117 (4):462-9.消融可有效治疗急性期ES，联合AAD可发挥长期保护作用Pr