器质性心脏病VT：RFCAorICD课件

1、器质性心脏病室速的治疗 导管消融和/或 ICD?室性心律失常的分类2006 ACC/AHA/ESC Guideline根据临床表现分类血流动力学稳定无症状症状轻微心悸血流动力学不稳定晕厥先兆晕厥SCD心脏骤停根据心电图分类非持续性VT单形性多形性持续性VT单形性多形性BBRT双向性VT和TdP心室扑动和颤动室性心律失常的分类2006 ACC/AHA/ESC Guideline根据基础疾病分类慢性冠状动脉性心脏病心力衰竭先天性心脏病神经症非器质性心脏病婴儿猝死综合征心肌病DCMHCMARVCICD应用于器质性心脏病SCD的二级预防 (临床研究AVID/CIDS/CASH 荟萃分析)2年内事件 I

2、CD 可达龙 P 值 (N=934) 总死亡数 200 255 P0.001 心律失常死亡数 61 117 P=120ms)主要终点：死亡或全因住院率二级终点：全因死亡率COMPANION评价CRT或CRT-D对心衰患者临床终点事件影响，结果显示CRT-D 降低全因死亡率36%60%MUSTT5 5 years54%MADIT42 years20%CIDS33 years37%CASH22 years31%AVID13 yearsICD与抗心律失常药物治疗在降低总死亡率方面的比较0%10%20%30%40%50%60% Mortality Reduction1 The AVID Investi

3、gators. N Engl J Med. 1997;337:1576-1583.2 Kuck, et al. Circulation. 2000; 102:748-754.3 Connolly, et al. Circulation. 2000; 101:1247-1302. 4 Moss AJ. N Engl J Med. 1996;335:1933-1940.5 Buxton AE. N Engl J Med. 1999;341:1882-1890.6 Moss. Investor Conference Call. November 27, 2001.30%MADIT II62 year

4、sCost-Benefit Analysis of preventing Sudden Cardiac Deaths with an ICD versus AmiodaroneStudy in European (UK and France) ICDs decreased deaths during the 5 years from 37.0% to 29.7% at a net cost of 26.222 to 20.008 per patient, cost-benefit rations of 0.17(UK) and 0.14(France)-more than a 5 to 1 r

5、eturn on investmentConclusionIn these European countries where society values a life at more than 2 million. ICDs are a worthwhile investment compared with amiodarone for primary prevention of SCD in pts with heart failure2007 International SPOR, 1098-30ACC/AHA/HRS 2008 Guidelines for Device-Based T

6、herapy of CRA ICD治疗适应证I 类室颤或血流动力学不稳定的持续性室速的心脏骤停幸存者，病因明确且完全排除可逆因素 (证据等级：C)器质性心脏病患者合并自发的持续性室速，不论血流动力学是否稳定 (证据等级：C)ICD治疗的相关问题ICD本身可增加心律失常事件发生率ICD的误放电问题ICD的治疗费用较高ICD反复更换所导致的感染问题频繁电休克导致患者的生活质量下降以及心理问题ICD植入手术死亡率1%，严重并发症3%ICD治疗的相关问题MADIT II 研究中，根据死亡数绝对值下降推算，每预防1次SCD需要植入16台ICD即使如此，仍然有未被识别的患者处于危险之中 N Engl J

7、Med. 2002; 346:877-83Am Heart J. 2007; 153: 951-9 J Cardiovasc Electrophysiol. 2005;16 Suppl 1:S25-7J Cardiovasc Electrophysiol. 2001 ; 12:369-81ICD临床试验显示ICD植入增加心律失常事件ICD植入后事件显著增加458例非缺血性心肌病患者随机分为标准药物组（STD）及标准药物+ICD组（ICD）STD组15例猝死，ICD组3例猝死ICD组心律失常事件（ICD放电+猝死）显著多于STD组DEFINITE Investigators. Circulati

8、on 2006;113:776-782单导联心电图连续记录显示了一例因多次ICD电击而致室颤晕厥的就诊患者，该患者自发单形性室速时并无晕厥症状，ICD第一次电击后将单形性室速转为室颤，之后第二次电击又将室颤转为另一种形态的室速，第三次电击再次转为室颤，由于ICD最后一次电击，该患者发生了晕厥直到体外除颤。该患者之前除发作过数次单形性室速外从未有过晕厥以及心脏骤停。如果未置入ICD，该患者可能不会经历这次晕厥。Almendral J et al. Circulation 2007;116:1204-1212 MADIT-II: ICD对VT/VF一次或一次以上准确治疗 36%年电击复律的比例SC

9、D HeFT: 从植入至VT/VF电击复律时间0.000.050.100.150.200.250.3001234581170740162223679Number at risk器质性心脏病室速的导管消融虽然ICD是器质性心脏病室速的一线治疗手段，但是导管消融及抗心律失常药物(可达龙和受体阻滞剂)是其不可忽视的辅助治疗措施Catheter ablation is an important therapeutic option for controlling recurrent VAs in patients with heart diseaseZeppenfeld K and Stevenson

10、 WG. PACE 2008; 31:358374器质性心脏病室速的导管消融下列室速推荐导管消融治疗症状性持续性单形性室速(SMVT), 包括ICD终止的室速,抗心律失常药物治疗后复发或抗心律失常药物不能耐受或不愿服用药物的室速非可逆因素所致的无休止性VT或室速风暴 束支折返性室速或分支型室速 抗心律失常药物治疗无效的反复发生的持续性多形性室速和室颤，如为触发灶引起者则可行消融治疗2009年EHRA/HRS/ESC/ACC/AHA室速导管消融专家共识解读器质性心脏病室速的导管消融下列情况应当考虑导管消融尽管使用了一种或多种类或类抗心律失常药物，但患者仍有一次或多次SMVT发作陈旧性心肌梗死伴反

11、复发生的SMVT患者、其LVEF30%且预计生存期1年，导管消融作为胺碘酮治疗外的可以接受的选择性治疗措施陈旧性心肌梗死伴LVEF35%，且SMVT发作时血流动力学尚稳定者，即使抗心律失常药物治疗可能有效，仍可考虑导管消融2009年EHRA/HRS/ESC/ACC/AHA室速导管消融专家共识解读Scar-Related Reentrant VT心肌梗死后室速的导管消融 临床研究结果19个中心共报导802例患者7296%患者至少成功消融一种室速3072%患者成功消融所有诱发的室速手术相关的致死并发症为0.5%13个研究平均随访12个月以上，5088%无复发2009年EHRA/HRS/ESC/AC

12、C/AHA室速导管消融专家共识解读心肌梗死后室速的导管消融The Multicenter Thermocool Ventricular Tachycardia Ablation TrialThermocool反复发作的室速患者231例(过去6个月发作平均11次)采用拖带和/或电解剖基质标测技术81%患者至少一种室速消融成功49%患者所有室速均成功随防6个月，51%复发Stevenson WG, et al. Circulation 2008;118:277382 心肌梗死后室速的导管消融The Euro-VT-Study8个中心，入选63例，平均年龄63岁，平均LVEF28%平均可诱发3种室速

13、，67%植入ICD81%患者至少1种室速消融成功50%患者所有室速均成功消融随访结果随访6月，51%患者无复发随访12月，死亡率为8%Tanner H, et al. J Cardiovasc Electrophysiol 2009; published online July 28.DOI:10.1111/j.1540-8167.2009.01563.x.束支折返性室速导管消融策略及处理多伴发于冠心病、瓣膜性心脏病或心肌病引起的心功能不全 折返环由右束支-心室肌-左束支-希氏束-右束支构成右束支是消融靶点，成功率100%即使窦律时呈LBBB，右束支消融后一般不会出现心脏传导阻滞，但术后30%

14、患者因心动过缓需要起搏治疗非缺血性心肌病BBRT的导管消融 非缺血性扩张型心肌病合并室速的导管消融19例DCM合并SM室速，14例经心内膜途径成功，随访22个月，5例患者无再发另一项研究入选22例患者，消融策略是如果心内膜消融失败则改为心外膜途径标测及消融；术后随访334天，46%患者室速再发，其中1例患者死于心衰，2例患者接受心脏移植非缺血性心肌病室速的导管消融 Nazarian S, et al. Circulation 2005;112:28215 Soejima K, et al. J Am CollCardiol 2004;43:183442 Ablation of Ventricu

15、lar Tachycardia in Patientswith Nonischemic CardiomyopathyAn effective ablation site in a patient with nonischemic cardiomyopathy. There is concealed entrainmentand a diastolic potential during VT. The electrogram-QRS interval matches the stimulus-QRS interval (both are 210 ms). Shown are leads I, I

16、I, III, V1, and V6 and the intracardiac tracings from the mappingcatheter (Map). Pacing cycle length is 450 ms and the VT cycle length is 490 ms.Epicardial and endocardial mapping data from a patient with nonischemic cardiomyopathy心包穿刺心外膜标测消融示意图Catheter Ablation of Multiple VT After MI Guided by Com

17、bined Contact and Noncontact MappingCirculation. 2007; 115: 2697-2704Remote Magnetic Navigation to Guide Endocardial and Epicardial Catheter Mapping of Scar-Related Ventricular TachycardiaRemote map. and abl. of stable VTShown are the clinical slow VTat 585 ms (A), inferior views of the electroanato

18、micalactivation (B) and voltage (C) maps during VT, and acardiac computed tomography scan Showing a calcified LV inferobasal scar (D) from a patient with post-MI VT (#1). E, At thestart of an attempt at entrainment from an inferior wall site deep within the scar (denotedby the black arrow in panel B

19、), the first paced beat terminated the VT without manifest global ventricular capture. F, Just apical to this site(denoted by the red arrow in panel B), stable Diastolic potentials are seen during VT; entrainment with concealed fusion and a post-pacing interval equal to 585 ms were observed at this

20、location. G, During remote RFCA at this site, the VTwas eliminated in 4 s of commencing energy delivery研究资料来自一些病例报告与小样本研究 一项研究入选11例患者，诱发出的15种室速均成功消融，随访30个月，91%患者无复发 另一项研究入选10例患者，均为法四矫正术后，采用非接触标测系统成功标测13种诱发的室速，11种室速是大折返，8例消融成功，随访期间6例无复发先心脏病外科矫正术后室速的导管消融 Kriebel T, et al. J Am Coll Cardiol 2007;50:216

21、28Zeppenfeld K, et al. Circulation 2007; 116: 224152ARVC室速的发生机理示意图Catheter Ablation for ARVC-VTVT in 32 ARVC-pts induced Mapping earliest VT activation using Non-Contact Mapping SystemAcute ablation success rate was 84.4%(27/32) 81.3% of the pts were free of VT without medication during the 28.616 m

22、onth follow-upConclusionARVC-VT can be abolished or improved significantly by Regional ablation under the guidance of Non-contact mapping Yan Yao et al. PACE 2007;30:526-533Long-Term Efficacy of Catheter Ablation of VT in pts with ARVC24 pts in the Johns Hospitals ARVD registry, who underwent 1 or m

23、ore than RFA procedures for VTFollow-up for 3236 monthsA total of 48 RFCA procedure performed using Carto (n=10) or conventional (n=38) mappingForty (85%) procedure were followed by recurrenceConclusion: A high rate of recurrence in ARVC pts undergoing RFCAThis likely reflects the fact that ARVC is

24、a diffuse CM with progressively evolving electrical substrateDalal D, et al. JACC 2007; 50: 432-440ARRAY 非接触接触标测 系统方 法 基质改良消融策略CARTO 基质起博标测 基质改良出口消融第一次成功率：61.5%第二次成功率：84.6% , FU: 9.07.0 (324)月ARVC室速的导管消融 (南京医科大学第一附属医院)*导管消融21/44例ARVC患者Safety and Outcomes of Cryoablation for VAs Results from a multic

25、enter experienceStudy population: 33 pts, mean age 54 8 years15 pts endocardial ablation13 pts epicardial ablation5 pts aortic cusp ablationAblation was successful in 15 (45%) pts and unsuccessful in 18 (55%) ptsCryoablation was successful in all parahisian case (100%)An aortic dissection occurred i

26、n aortic cuspFollow up of 24 monts, all successful cases free from VAsBiase LD, et al. Heart Rhythm 2011; 8: 968-974Safety and Outcomes of Cryoablation for VAs Results from a multicenter experienceConclussionUse of cryoablation for VAs has excellent success for arrhythmias near the His bundleSuccess

27、 rate at other sites appear less favorableCryoablation may be considered as an alternative approach for reducing complication during ablation of VAs originating from sites close to other relevant cardiac structures (e.g. conduction system, coronary arteries) Biase LD, et al. Heart Rhythm 2011; 8: 96

28、8-974老年冠心病患者室速导管消融的安全性 患者 75岁, n=72 75岁, n=213 p值消融成功率 79.2% 87.8%主要并发症 5.6% 2.3%围手术期死亡率 2/72 9/213 0.74随访期死亡 50.0% 35.2% 0.08无VT发生 63.9% 60.1% 0.80 K Inada, et al. Heart Rhythm 2010; 7: 740-744血流动力学稳定器质性心脏病室速治疗选择All Pats With Hemodynamically Tolerated Postinfarction VT: Do Not Require an ICD Cathet

29、er ablation confers both qualitative and quantitative protection against VT recurrence and SCDAlthough recurrence of a tolerated VT is not so rare, the SCD rate in these patients is extremely lowCatheter ablation can be considered a therapeutic alternative for those patients with post-MI tolerated V

30、T in whom the procedure produces a satisfactory short-term result Jess Almendral and Mark E. Josephson, Circulation 2007; 116; 1204-1212血流动力学稳定器质性心脏病室速治疗选择Patients With Hemodynamically Tolerated VT Require ICDTolerated VT signals a risk of life-threatening arrhythmiasThe benefit of secondary-prevent

31、ion ICD therapy is difficult to challengeSuccessful catheter ablation does not sufficiently reduce residual riskCallans DJ. Circulation 2007; 116; 1196-1203Prophylactic Catheter Ablation for the Prevention of Defibrillator Therapy (SMASH)BackgroundICD shocks Painfulness clinical depressionDont offer

32、 complete protection against death from arrthymiasObjectiveRandomised trial to exam. Whether prophylactic RFCA of arrhymogenic ventricular tissue would reduce the incidence of ICD therapyReddy VY, et al. N Engl J Med 2007; 357: 2657-2665 Prophylactic Catheter Ablation for the Prevention of Defibrillator Therapy (SMASH)Methods Pts with a MI-history/no antiarrhythmic drugs64 Pts with ICD alone64 Pts with ICD/RFCARFCA performed with use of a substrate-based