ARVC单形性室速导管消融还是ICD课件

1、 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第1页，共50页。ARVC：并不罕见的心肌病第2页，共50页。ARVC诊断标准20101. 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. 2010;121:1533-1541第3页，共50页。ARVC室速第4页，共50页。ARVC室性心律失常主要条件持续性或非持续性左束支传导阻滞型室性心动过速, 伴电轴向上( II、III、aVF QRS 负向或不确定, aVL 正向)次要条件持续性或非持续性右室流出道型室

2、性心动过速, LBBB 型室性心动过速, 伴电轴向下( II、III、aVF QRS 正向或不确定, aVL 负向), 或电轴不明确Holter显示室性早搏24 h 500个第5页，共50页。ARVC：ICD植入指证-ARVC-SCD的一级、二级预防ICD therapy is indicated in patients with structural heart disease and spontaneous sustained VT, whether hemodynamically stable or unstable. ICD implantation is reasonable for

3、 the prevention of SCD in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) who have 1 or more risk factors for SCD.IIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIIIaIIaIIaIIbIIbIIbIIIIIIIIIBIIIaIIbIII(Class ，Level of Evidence

4、: B)(Class a，Level of Evidence: C)IIaACC/AHA/HRS 2008guidelines for device-based therapy of cardiac rhythm2012年指南关于ARVC猝死二级预防未作调整 第6页，共50页。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第7页，共50页。ARVC-VT/SCD：ICD植入的循证证据第8页，共50页。

5、BACKGROUND:Arrhythmogenic right ventricular cardiomyopathy/dysplasia(ARVC/D) is a condition associated with the risk ofsudden death(SD).METHODS AND RESULTS:We conducted a multicenter study of the impact of theimplantable cardioverter-defibrillator(ICD) forpreventionof SD in 132patients(93 males and

6、39 females, age 40+/-15 years) with ARVC/D. Implant indications were a history of cardiac arrest in 13patients(10%), sustainedventriculartachycardia in 82 (62%), syncope in 21 (16%), and other in 16 (12%). During a mean follow-up of 39+/-25 months, 64patients(48%) had appropriate ICD interventions,

7、21 (16%) had inappropriate interventions, and 19 (14%) had ICD-related complications. Fifty-three (83%) of the 64patientswith appropriate interventions received antiarrhythmic drugtherapyat the time of first ICD discharge. Programmedventricularstimulation was of limited value in identifyingpatientsa

8、t risk of tachyarrhythmias during the follow-up (positive predictive value 49%, negative predictive value 54%). Fourpatients(3%) died, and 32 (24%) experiencedventricularfibrillation/flutter that in all likelihood would have been fatal in the absence of the device. At 36 months, the actual patient s

9、urvival rate was 96% compared with theventricularfibrillation/flutter-free survival rate of 72% (P0.001).Patientswho received implants because ofventriculartachycardia without hemodynamic compromise had a significantly lower incidence ofventricularfibrillation/flutter (log rank=0.01). History of car

10、diac arrest orventriculartachycardia with hemodynamic compromise, younger age, and leftventricularinvolvement were independent predictors ofventricularfibrillation/flutter.CONCLUSIONS:Inpatientswith ARVC/D, ICDtherapyprovided life-saving protection by effectively terminating life-threateningventricu

11、lararrhythmias.Patientswho were prone toventricularfibrillation/flutter could be identified on the basis of clinical presentation, irrespective of programmedventricularstimulation outcome.Circulation.2003 Dec 23;108(25):3084-91ICD Therapy for prevention of SCD in ARVC Patients第9页，共50页。132pts(93 m, a

12、ge 40+/-15 y) with ARVCICD indications:history of cardiac arrest in 13patients(10%) sustainedVT in 82 (62%) syncope in 21 (16%), and other in 16 (12%)FU:39+/-25 m: 64patients(48%) :appropriate ICD R 21 (16%) :inappropriate R 4(3%) died At 36 months, the actual patient survival rate was 96% theventri

13、cularfibrillation/flutter-free survival rate of 72% Inpatientswith ARVC/D, ICDtherapyprovided life-saving protection by effectively terminating life-threateningventricular Circulation.2003 Dec 23;108(25):3084-91第10页，共50页。第11页，共50页。第12页，共50页。84 pts ARVC ： ICD for SCD一级预防FU: 4.7+/3.4y： 48% ICD interve

14、ntion 19%：VF5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是独立预测因子第13页，共50页。首次放电时间和放电次数第14页，共50页。第15页，共50页。ICD电治疗的影响因子第16页，共50页。危险因子对生存率的影响第17页，共50页。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第18页，共50页。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第19页，共50页。J Am Coll Cardiol 2007;50:4324024例患者

15、48次消融 随访3236months (range 1 day to 12 years)第20页，共50页。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第21页，共50页。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第22页，共50页。心动过速的标测病例1：诱发一种类型室速，最早激动点和出口靠近基质边缘，无完整折返环，无舒张中期电位，无峡部。病例2：有2种类型室速，其中一例有完整的折返环路和舒张中期电位，两种室速形

16、态不同、激动传导方向相反，但有共同的传导通道位于三尖瓣环与基质边缘；一种室速的出口位于基质边缘，另一种室速出口远离基质。病例3：诱发两种不同形态室速，无舒张中期电位，亦无峡部存在；一种室速起源于基质内并通过基质传导，出口位于基质边缘，另一种室速起源稍远离基质边缘，而出口远离基质。第23页，共50页。VT1VT2病例2第24页，共50页。 病例3第25页，共50页。12 Lead ECG (slower VT) 第26页，共50页。Pacing at site APacing at site B第27页，共50页。 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

17、，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。 第28页，共50页。ARVC-VT：心外膜消融 Percutaneous epicardial ablation ofventriculartachycardia after failure of endocardial approach in the pediatric population witharrhy

18、thmogenic right ventriculardysplasia17例患者（14+/-4y），心内膜消融失败20 VTs 诱发（2个大折返，18个局灶）16例（94.1%）即刻成功随访26 15 (range 6 to 42)月12人（70.6%）无室速发作Heart Rhythm.2010 Oct;7(10):1406-10第29页，共50页。ARVC-VT：心外膜消融 Epicardial substrate and outcome with epicardialablationofventricular tachycardiainarrhythmogenicrightventri

19、cularcardiomyopathy/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.2009 Aug 4;120(5):366-75第30页，共50页。ARVC-VT：消融的长期疗效 Outcomes ofcatheter ablationofventricular tachycardiainarrhythmogenicrightventriculardysplasia/cardiomyopathy 87例患者，175次消融平均随访88.

20、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 Arrhythm Electrophysiol.2012 Jun 1;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负荷第31页，共50页。In reported series of RV scar-related VT, abolition of inducible VT is achieved in 41%88% of patientsDuring average follow-ups of 1124 months, V

21、T recurs in 11%83% of patients, with some series observing a significant incidence of late recurrences increasing with time第32页，共50页。Catheter ablation in ARVC/D can reduce frequent episodes of VT but long-term follow-up has demonstrated a continued risk of recurrence.Recommendations for ablation are

22、 as stated for ablation for VT associated with structural heart disease in the Indications section above第33页，共50页。第34页，共50页。第35页，共50页。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第36页，共50页。Most patients who have VT related to structural heart disease will contin

23、ue to have a standard indication for ICD therapy for primary prevention.Even when all VTs have been rendered non-inducible by ablation, the recurrence rate remains substantial so that secondary prophylaxis remains indicated.第37页，共50页。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

24、之前？ 预防性消融 减少发作，提高生活质量 如不植入ICD，有较大风险第38页，共50页。病例：男性，33岁，ARVC+SMVT 2010年3月15日植入ICDDFT测试：首次18J，失败；第二次，22J成功第39页，共50页。植入时的参数设置倍他乐克、可达龙 第40页，共50页。 植入后3周：Electric storm第41页，共50页。第42页，共50页。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第43页，共50页。AR

25、VC植入ICD后电治疗的高危因素History of cardiac arrestVentriculartachycardia with hemodynamic compromiseYounger ageLeftventricularinvolvement Independent predictors ofVF/ V Flutter 这些人是否应当早期行导管消融？Circulation.2003 Dec 23;108(25):3084-91第44页，共50页。导管消融治疗ICD电风暴Catheter ablationfor the treatment of electrical storm in patients with implantable cardioverter-defibrillators: short- and long-term outcomes in a prospective single-center study.95 pts (13 ARVC, 72 CAD, 10 DCM)85 pts (89%) succeeded after 1-3 proceduresFU:22 (1-43)m: 92% no ES,66% no VT; 11(12%) diedCirculation.2008 Jan 29;117(4):462-9. 消融可有效治疗急性