器质性心脏病vt：rfcaoricd

器质性心脏病室速的治疗

导管消融和/或

ICD?精选课件室性心律失常的分类

2006ACC/AHA/ESCGuideline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心室扑动和颤动精选课件室性心律失常的分类

2006ACC/AHA/ESCGuideline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DCMHCMARVC精选课件ICD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ICD可达龙P值

(N=934)

总死亡数200255P<0.001心律失常死亡数61117P<0.001非心律失常死亡数139138精选课件ICD二级预防临床研究的提示采用ICD治疗有明确室性心律失常病史的患者，每年可以挽救500条生命，而这仅占SCD受害者总人数的0.1%精选课件ICD的一级预防研究

MADIT96196EF≤35%/ICDvsmedther54%reductioninmortalitywithICDMUSTT99704EF≤40%/ICDvsmedther54%reductionin(EPguided)mortalitywithICDMADITII021232EF≤35%ICDvsmedther31%reductioninmortalitywithICDDEFINITE04229EF≤36%ICDandmedtherICDreducedrateofvsmedtherdeath-7.9%vs14%COMPANION041520NYHAIII-IVCRTorCRTDandCRT/CRTDwasmedthervsmedtherassociatedwitha36%reduct.ofriskofdeathSCD-HeFT052521EF≤35%ICD+medthervsmedther23%reductionof+placebovsmedther+AmiomortalitywithICD

SantiniM,etal.Heart2007;93:1479-1483精选课件精选课件COMPANION研究(QRS>=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%精选课件60%MUSTT5

5years54%MADIT42years20%CIDS33years37%CASH22years31%AVID13yearsICD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%%MortalityReduction1TheAVIDInvestigators.NEnglJMed.1997;337:1576-1583.2Kuck,etal.Circulation.2000;102:748-754.3Connolly,etal.Circulation.2000;101:1247-1302.4MossAJ.NEnglJMed.1996;335:1933-1940.5BuxtonAE.NEnglJMed.1999;341:1882-1890.6Moss.InvestorConferenceCall.November27,2001.30%MADITII62years精选课件Cost-BenefitAnalysisofpreventingSuddenCardiacDeathswithanICDversusAmiodaroneStudyinEuropean(UKandFrance)ICDsdecreaseddeathsduringthe5yearsfrom37.0%to29.7%atanetcostof£26.222to£20.008perpatient,cost-benefitrationsof0.17(UK)and0.14(France)-morethana5to1returnoninvestmentConclusionIntheseEuropeancountrieswheresocietyvaluesalifeatmorethan£2million.ICDsareaworthwhileinvestmentcomparedwithamiodaroneforprimarypreventionofSCDinptswithheartfailure2007InternationalSPOR,1098-30精选课件ACC/AHA/HRS2008GuidelinesforDevice-BasedTherapyofCRA

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)精选课件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%精选课件ICD治疗的相关问题MADITII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

NEnglJMed.2002;346:877-83AmHeartJ.2007;153:951-9JCardiovascElectrophysiol.2005;16Suppl1:S25-7JCardiovascElectrophysiol.2001;12:369-81精选课件ICD临床试验显示ICD植入增加心律失常事件精选课件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DEFINITEInvestigators.Circulation2006;113:776-782精选课件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。AlmendralJetal.Circulation2007;116:1204-1212精选课件MADIT-II:ICD对VT/VF一次或一次以上准确治疗36%精选课件年电击复律的比例SCDHeFT:从植入至VT/VF电击复律时间0.000.050.100.150.200.250.3001234581170740162223679Numberatrisk精选课件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CatheterablationisanimportanttherapeuticoptionforcontrollingrecurrentVAsinpatientswithheartdiseaseZeppenfeldKandStevensonWG.PACE2008;31:358–374精选课件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精选课件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Ⅰ类或Ⅲ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复发生的SMVT患者、其LVEF＞30%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LVEF＞35%，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精选课件Scar-RelatedReentrantVT精选课件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72～96%患者至少成功消融一种室速30～72%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，50～88%无复发2009年EHRA/HRS/ESC/ACC/AHA

室速导管消融专家共识解读精选课件精选课件心肌梗死后室速的导管消融TheMulticenterThermocoolVentricularTachycardiaAblationTrialThermocool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StevensonWG,etal.Circulation2008;118:2773–82精选课件心肌梗死后室速的导管消融TheEuro-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，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%TannerH,etal.JCardiovascElectrophysiol2009;publishedonlineJuly28.DOI:10.1111/j.1540-8167.2009.01563.x.精选课件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%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

精选课件精选课件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NazarianS,etal.Circulation2005;112:2821–5SoejimaK,etal.JAmCollCardiol2004;43:1834–42精选课件AblationofVentricularTachycardiainPatients

withNonischemicCardiomyopathyAneffectiveablationsiteinapatientwithnonischemiccardiomyopathy.ThereisconcealedentrainmentandadiastolicpotentialduringVT.Theelectrogram-QRSintervalmatchesthestimulus-QRSinterval(bothare210ms).ShownareleadsI,II,III,V1,andV6andtheintracardiactracingsfromthemappingcatheter(Map).Pacingcyclelengthis450msandtheVTcyclelengthis490ms.精选课件Epicardialandendocardialmappingdatafromapatientwithnonischemiccardiomyopathy精选课件心包穿刺心外膜标测消融示意图精选课件CatheterAblationofMultipleVTAfterMIGuidedbyCombinedContactandNoncontactMappingCirculation.2007;115:2697-2704精选课件RemoteMagneticNavigationtoGuideEndocardialandEpicardialCatheterMappingofScar-Related

VentricularTachycardiaRemotemap.andabl.ofstableVTShownaretheclinicalslowVTat585ms(A),inferiorviewsoftheelectroanatomicalactivation(B)andvoltage(C)mapsduringVT,andacardiaccomputedtomographyscanShowingacalcifiedLVinferobasalscar(D)fromapatientwithpost-MIVT(#1).E,Atthestartofanattemptatentrainmentfromaninferiorwallsitedeepwithinthescar(denotedbytheblackarrowinpanelB),thefirstpacedbeatterminatedtheVTwithoutmanifestglobalventricularcapture.F,Justapicaltothissite(denotedbytheredarrowinpanelB),stableDiastolicpotentialsareseenduringVT;entrainmentwithconcealedfusionandapost-pacingintervalequalto585mswereobservedatthislocation.G,DuringremoteRFCAatthissite,theVTwaseliminatedin4sofcommencingenergydelivery精选课件精选课件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

KriebelT,etal.JAmCollCardiol2007;50:2162–8ZeppenfeldK,etal.Circulation2007;116:2241–52精选课件ARVC室速的发生机理示意图精选课件CatheterAblationforARVC-VTVTin32ARVC-ptsinducedMappingearliestVTactivationusingNon-ContactMappingSystemAcuteablationsuccessratewas84.4%(27/32)81.3%oftheptswerefreeofVTwithoutmedicationduringthe28.6±16monthfollow-upConclusionARVC-VTcanbeabolishedorimprovedsignificantlybyRegionalablationundertheguidanceofNon-contactmapping

YanYaoetal.PACE2007;30:526-533精选课件Long-TermEfficacyofCatheterAblation

ofVTinptswithARVC24ptsintheJohnsHospitalsARVDregistry,whounderwent1ormorethanRFAproceduresforVTFollow-upfor32±36monthsAtotalof48RFCAprocedureperformedusingCarto(n=10)orconventional(n=38)mappingForty(85%)procedurewerefollowedbyrecurrenceConclusion:AhighrateofrecurrenceinARVCptsundergoingRFCAThislikelyreflectsthefactthatARVCisadiffuseCMwithprogressivelyevolvingelectricalsubstrateDalalD,etal.JACC2007;50:432-440精选课件ARRAY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:9.0±7.0(3~24)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患者精选课件SafetyandOutcomesofCryoablationforVAsResultsfromamulticenterexperienceStudypopulation:33pts,meanage54±8years15ptsendocardialablation13ptsepicardialablation5ptsaorticcuspablationAblationwassuccessfulin15(45%)ptsandunsuccessfulin18(55%)ptsCryoablationwassuccessfulinallparahisiancase(100%)AnaorticdissectionoccurredinaorticcuspFollowupof24monts,allsuccessfulcasesfreefromVAsBiaseLD,etal.HeartRhythm2011;8:968-974精选课件SafetyandOutcomesofCryoablationforVAsResultsfromamulticenterexperienceConclussionUseofcryoablationforVAshasexcellentsuccessforarrhythmiasneartheHisbundleSuccessrateatothersitesappearlessfavorableCryoablationmaybeconsideredasanalternativeapproachforreducingcomplicationduringablationofVAsoriginatingfromsitesclosetootherrelevantcardiacstructures(e.g.conductionsystem,coronaryarteries…)BiaseLD,etal.HeartRhythm2011;8:968-974精选课件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=213p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2/729/2130.74随访期死亡50.0%35.2%0.08无VT发生63.9%60.1%0.80KInada,etal.HeartRhythm2010;7:740-744精选课件血流动力学稳定

器质性心脏病室速治疗选择AllPatsWithHemodynamicallyToleratedPostinfarctionVT:DoNotRequireanICD

CatheterablationconfersbothqualitativeandquantitativeprotectionagainstVTrecurrenceandSCDAlthoughrecurrenceofatoleratedVTisnotsorare,theSCDrateinthesepatientsisextremelylowCatheterablationcanbeconsideredatherapeuticalternativeforthosepatientswithpost-MItoleratedVTinwhomtheprocedureproducesasatisfactoryshort-termresultJesúsAlmendralandMarkE.Josephson,Circulation2007;116;1204-1212精选课件血流动力学稳定

器质性心脏病室速治疗选择PatientsWithHemodynamicallyToleratedVTRequireICDToleratedVTsignalsariskoflife-threateningarrhythmiasThebenefitofsecondary-preventionICDtherapyisdifficulttochallengeSuccessfulcatheterablationdoesnotsufficientlyreduceresidualriskCallansDJ.Circulation2007;116;1196-1203精选课件ProphylacticCatheterAblation

forthePreventionofDefibrillatorTherapy(SMASH)BackgroundICDshocksPainfulness–clinicaldepressionDon´toffercompleteprotectionagainstdeathfromarrthymiasObjectiveRandomisedtrialtoexam.WhetherprophylacticRFCAofarrhymogenicventriculartissuewouldreducetheincidenceofICDtherapyReddyVY,etal.NEnglJMed2007;357:2657-2665

精选课件ProphylacticCathe