室性心律失常射频消融优质课件

室性心律失常射频消融室性心律失常射频消融1心脏结构正常合并PVC----良性心律失常?AmJCardiol.2012Jan1;109(1):105–109.心脏结构正常合并PVC----良性心律失常?AmJCar2JAmCollCardiol.2015Jul14;66(2):101-9PVC越多死亡率越高心衰越重JAmCollCardiol.2015Jul143器质性心脏病PVC触发VF器质性心脏病PVC触发VF4器质性心脏病

PVC影响CRT疗效Inconclusion

AlittlebitofprematurebeatsandalittlebitofincompletebiventricularpacingcanmeanalottoCRTpatients.ThisreportreaffirmsthatnearlycontinuousCRTpacing(>97%)isnecessaryforoptimalCRTresponseandthatevenaverysmallpercentageofectopicbeats(>0.1%)isassociatedwithlessCRTpacingandworsepatientoutcomesafterCRT.器质性心脏病

PVC影响CRT疗效5AblationoffrequentPVCinpatientsmeetingcriteriaforprimarypreventionICDimplant:SafetyofwithholdingtheimplantHeartRhythm2015;0:-1–9ConclusionInpatientswithfrequentPVCandPP-ICDindication,ablationimprovesLVEFand,inmostcases,allowsremovaloftheindication.WithholdingtheICDandreevaluatingwithin6monthsofablationseemstobeasafeandappropriatestrategy.AblationoffrequentPVCinpa6抗心律失常问题I类抗心律失常：风险CASTII类使用广泛，特殊情况无法使用III类胺碘酮:心外副作用超过心脏

使用半年以上1/3出现甲状腺问题索他洛尔：LQTIV类非广谱，增加心动过缓、AVB风险抗心律失常问题I类抗心律失常：风险CAST7ConclusionsCatheterablationismoreefficaciousthanAADsforpreventingVPBrecurrenceinpatientswithfrequentVPBsoriginatingfromtheRVOT.QSmorphologyinleadIwasassociatedwithbetteroutcomeafterablation.Circulation:ArrhythmiaandElectrophysiology.2014;7:237-243ConclusionsCirculation:Arrhyt8PVC消融适应症PVC消融适应症9PVC消融适应症非器质性心脏病I类适应症PVC消融适应症非器质性心脏病I类适应症10PVC消融适应症器质性心脏病：触发VT/VFI类适应症左室功能障碍PVC消融适应症左室功能障碍11心脏结构正常VT消融适应症心脏结构正常VT消融适应症12器质性VT消融适应症持续性单形性室速导管消融器质性VT消融适应症持续性单形性室速导管消13器质性室速消融适应症器质性室速消融适应症14室性心律失常机制

非器质性心脏病流出道VA触发腺苷分支性VA折返异搏定瓣环乳头肌调节束折返触发自律性器质性心脏病疤痕折返相关VT

触发自律性室性心律失常机制非器质性15分支性VT折返机制/show/81655.shtm分支性VT折返机制http://www.365heart16分支性VT折返机制/show/81655.shtml分支性VT折返机制http://www.365heart17VA标测和消融起搏：部分流出道VA激动:大多数VA拖带、重整:主要应用于折返性VA基质标测：双极电压标测疤痕低电压正常心肌血液动力学支持下消融器质性VTLAVA电位消融：窦律下消融血液动力学不稳定的器质性VT

VA标测和消融起搏：部分流出道VA18起搏标测起搏标测19激动标测激动标测20拖带-重整拖带-重整21VT基质标测VT基质标测22LAVA电位标测和消融

LocalabnormalventricularactivitiesCirculation.2012;125:2184-2196LAVA电位标测和消融

Localabnormalven23LAVA电位标测和消融

LocalabnormalventricularactivitiesCirculation.2012;125:2184-2196LAVA电位标测和消融

Localabnormalven24血液动力学支持的VT消融TheJournalofInnovationsinCardiacRhythmManagement,3(2012),959–967血液动力学支持的VT消融TheJournalofInn25非器质性VA消融疗效PVC

Thisstudyincluded1185patients

即刻成功率84%随访71%无需抗心律失常药1.9年后成功率85%RVOT-PVC成功率高PVC-诱发心肌病心衰改善：EF38%to50%

死亡率：0%

并发症：5.2%严重并发症2.4%，血管入路并发症2.8%JACCCEP.2015;1(3):116-123非器质性VA消融疗效PVC26非器质性VA消融疗效VTLong-TermFollow-UpAfterRadiofrequencyCatheterAblationofVentricularTachycardia:ASuccessfulApproach?成功率93%复发率19%(含部分器质性室速)

JCardiovascElectrophysiol.2002May;13(5):417-23非器质性VA消融疗效VTLong-TermFollow-27器质性心脏病PVC消融疗效CRTnonresponderswith>10,000PVCin24h即刻成功率91%，远期成功率88%LVEF26.2%32.7%LVED6.83cm6.51cm

心功能（NYHA)

3.0级2.0级AblationoffrequentPVCinpatientsmeetingcriteriaforprimarypreventionICDimplant

减少ICD放电去除ICD适应症(26%)JAmCollCardiol.2012Oct16;60(16):1531-9HeartRhythm2015;0:-1–9器质性心脏病PVC消融疗效CRTnonresponder28器质性VA消融疗效BBRT消融根治，无需ICD,IA指征Thelong-termoutcomes

ARVC-VT＞RemoteMI-VT＞NIDCMJArrhythm.2015Feb;31(1):22-8器质性VA消融疗效BBRT消融根治，无需ICD,IA指征29荟萃分析

Meta-analysisofcatheterablationasanadjuncttomedicaltherapyfortreatmentofventriculartachycardiainpatientswithstructuralheartdisease.Results457患者并发症：死亡1%，卒中1%，

穿孔1%,AVB1.6%。与单纯药物相比，减少VT复发35%。死亡率无差异。

5年复发率:

25-50%结论：与药物相比，导管消融减少VT复发，对死亡率无影响。HeartRhythm.2011Apr;8(4):503-10荟萃分析

Meta-analysisofcatheter30心外膜联合消融结果消融疗效ICM心内膜心外膜联合消融结果12月无VT事件联合组85%，单纯心内膜消融56%InvasiveElectrophysiologyAndPacing,2012,Vol14,p577-583心外膜联合消融结果消融疗效ICM心内膜心外膜联合消融结果I31器质性心脏病VT处理大部分器质性心脏病室速首选ICD但ICD不能预防VA复发。预防VA发作

药物：

Beta-blocker+amiodarone

导管消融：

减少ICD放电，预防VA复发

控制无休止VT和电风暴。器质性心脏病VT处理大部分器质性心脏病室速首选ICD32病例分享

Case1流出道室速/PVC病例分享Case1流出道室速/PVC33病例分享Case2高位间隔分支型室速

病例分享Case2高位间隔分支型室速34病例分享Case2高位间隔分支型室速

病例分享Case2高位间隔分支型室速35病例分享

Case2高位间隔分支型室速

his病例分享Case2高位间隔分支型室速his36病例分享Case3左后分支型室速

病例分享Case3左后分支型室速37病例分享Case3左后分支型室速病例分享Case3左后分支型室速38病例分享Case3左后分支型室速病例分享Case3左后分支型室速39标测消融靶点20-30ms标测消融靶点20-30ms40心电图变化

左前分支阻滞心电图变化左前分支阻滞41病例分享Case4His束旁室速病例分享Case4His束旁室速42病例分享Case5乳头肌室早病例分享Case5乳头肌室早43文献病例器质性室速ARVC文献病例器质性室速ARVC44文献病例器质性室速BRS消融Circulation.2011;123:1270-1279文献病例器质性室速BRS消融Circulatio45室性心律失常射频消融优质课件46室性心律失常射频消融室性心律失常射频消融47心脏结构正常合并PVC----良性心律失常?AmJCardiol.2012Jan1;109(1):105–109.心脏结构正常合并PVC----良性心律失常?AmJCar48JAmCollCardiol.2015Jul14;66(2):101-9PVC越多死亡率越高心衰越重JAmCollCardiol.2015Jul1449器质性心脏病PVC触发VF器质性心脏病PVC触发VF50器质性心脏病

PVC影响CRT疗效Inconclusion

AlittlebitofprematurebeatsandalittlebitofincompletebiventricularpacingcanmeanalottoCRTpatients.ThisreportreaffirmsthatnearlycontinuousCRTpacing(>97%)isnecessaryforoptimalCRTresponseandthatevenaverysmallpercentageofectopicbeats(>0.1%)isassociatedwithlessCRTpacingandworsepatientoutcomesafterCRT.器质性心脏病

PVC影响CRT疗效51AblationoffrequentPVCinpatientsmeetingcriteriaforprimarypreventionICDimplant:SafetyofwithholdingtheimplantHeartRhythm2015;0:-1–9ConclusionInpatientswithfrequentPVCandPP-ICDindication,ablationimprovesLVEFand,inmostcases,allowsremovaloftheindication.WithholdingtheICDandreevaluatingwithin6monthsofablationseemstobeasafeandappropriatestrategy.AblationoffrequentPVCinpa52抗心律失常问题I类抗心律失常：风险CASTII类使用广泛，特殊情况无法使用III类胺碘酮:心外副作用超过心脏

使用半年以上1/3出现甲状腺问题索他洛尔：LQTIV类非广谱，增加心动过缓、AVB风险抗心律失常问题I类抗心律失常：风险CAST53ConclusionsCatheterablationismoreefficaciousthanAADsforpreventingVPBrecurrenceinpatientswithfrequentVPBsoriginatingfromtheRVOT.QSmorphologyinleadIwasassociatedwithbetteroutcomeafterablation.Circulation:ArrhythmiaandElectrophysiology.2014;7:237-243ConclusionsCirculation:Arrhyt54PVC消融适应症PVC消融适应症55PVC消融适应症非器质性心脏病I类适应症PVC消融适应症非器质性心脏病I类适应症56PVC消融适应症器质性心脏病：触发VT/VFI类适应症左室功能障碍PVC消融适应症左室功能障碍57心脏结构正常VT消融适应症心脏结构正常VT消融适应症58器质性VT消融适应症持续性单形性室速导管消融器质性VT消融适应症持续性单形性室速导管消59器质性室速消融适应症器质性室速消融适应症60室性心律失常机制

非器质性心脏病流出道VA触发腺苷分支性VA折返异搏定瓣环乳头肌调节束折返触发自律性器质性心脏病疤痕折返相关VT

触发自律性室性心律失常机制非器质性61分支性VT折返机制/show/81655.shtm分支性VT折返机制http://www.365heart62分支性VT折返机制/show/81655.shtml分支性VT折返机制http://www.365heart63VA标测和消融起搏：部分流出道VA激动:大多数VA拖带、重整:主要应用于折返性VA基质标测：双极电压标测疤痕低电压正常心肌血液动力学支持下消融器质性VTLAVA电位消融：窦律下消融血液动力学不稳定的器质性VT

VA标测和消融起搏：部分流出道VA64起搏标测起搏标测65激动标测激动标测66拖带-重整拖带-重整67VT基质标测VT基质标测68LAVA电位标测和消融

LocalabnormalventricularactivitiesCirculation.2012;125:2184-2196LAVA电位标测和消融

Localabnormalven69LAVA电位标测和消融

LocalabnormalventricularactivitiesCirculation.2012;125:2184-2196LAVA电位标测和消融

Localabnormalven70血液动力学支持的VT消融TheJournalofInnovationsinCardiacRhythmManagement,3(2012),959–967血液动力学支持的VT消融TheJournalofInn71非器质性VA消融疗效PVC

Thisstudyincluded1185patients

即刻成功率84%随访71%无需抗心律失常药1.9年后成功率85%RVOT-PVC成功率高PVC-诱发心肌病心衰改善：EF38%to50%

死亡率：0%

并发症：5.2%严重并发症2.4%，血管入路并发症2.8%JACCCEP.2015;1(3):116-123非器质性VA消融疗效PVC72非器质性VA消融疗效VTLong-TermFollow-UpAfterRadiofrequencyCatheterAblationofVentricularTachycardia:ASuccessfulApproach?成功率93%复发率19%(含部分器质性室速)

JCardiovascElectrophysiol.2002May;13(5):417-23非器质性VA消融疗效VTLong-TermFollow-73器质性心脏病PVC消融疗效CRTnonresponderswith>10,000PVCin24h即刻成功率91%，远期成功率88%LVEF26.2%32.7%LVED6.83cm6.51cm

心功能（NYHA)

3.0级2.0级AblationoffrequentPVCinpatientsmeetingcriteriaforprimarypreventionICDimplant

减少ICD放电去除ICD适应症(26%)JAmCollCardiol.2012Oct16;60(16):1531-9HeartRhythm2015;0:-1–9器质性心脏病PVC消融疗效CRTnonresponder74器质性VA消融疗效BBRT消融根治，无需ICD,IA指征Thelong-termoutcomes

ARVC-VT＞RemoteMI-VT＞NIDCMJArrhythm.2015Feb;31(1):22-8器质性VA消融疗效BBRT消融根治，无需ICD,IA指征75荟萃分析

Meta-analysisofcatheterablationasanadjuncttomedicaltherapyfortreatmentofventriculartachycardiainpatientswithstructuralheartdisease.Results457患者并发症：死亡1%，卒中1%，

穿孔1%,AVB1.6%。与单纯药物相比，减少VT复发35%。死亡率无差异。

5年复发率:

25-50%结论：与药物相比，导管消融减少VT复发，对死亡率无影响。HeartRhythm.2011Apr;8(4):503-10荟萃分析

Meta-analysisofcatheter76心外膜联合消融结果消融疗效ICM心内膜