ARVC單形性室速導管消融還是ICD課件

1、 ARVC單形性室速：導管消融還是ICD?南京醫(yī)科大學第一附屬醫(yī)院鄒建剛5th VAS-CHINA第1頁，共50頁。ARVC：并不罕見的心肌病第2頁，共50頁。ARVC診斷標準20101. 心臟整體和/或局部運動障礙和結(jié)構(gòu)改變2.室壁病理組織學特征3.復極障礙4.除極或傳導異常5.心律失常6.家族史 Circulation. 2010;121:1533-1541第3頁，共50頁。ARVC室速第4頁，共50頁。ARVC室性心律失常主要條件持續(xù)性或非持續(xù)性左束支傳導阻滯型室性心動過速, 伴電軸向上( II、III、aVF QRS 負向或不確定, aVL 正向)次要條件持續(xù)性或非持續(xù)性右室流出道型室

2、性心動過速, LBBB 型室性心動過速, 伴電軸向下( II、III、aVF QRS 正向或不確定, aVL 負向), 或電軸不明確Holter顯示室性早搏24 h 500個第5頁，共50頁。ARVC：ICD植入指證-ARVC-SCD的一級、二級預(yù)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年指南關(guān)于ARVC猝死二級預(yù)防未作調(diào)整 第6頁，共50頁。指南關(guān)于ARVC猝死的一級預(yù)防SCD危險因素：有1個以上者植入ICD 作為SCD的一級預(yù)防 電生理檢查誘發(fā)室性心動過速( VT) 心電監(jiān)護的非持續(xù)性VT 男性 嚴重右室擴大, 廣泛右室受累發(fā)病很早( 5 歲) 累及左室心臟驟停史不能解釋的暈厥第7頁，共50頁。ARVC-VT/SCD：ICD植入的循證證據(jù)第8頁，共50頁。

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頁，共50頁。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頁，共50頁。第11頁，共50頁。第12頁，共50頁。84 pts ARVC ： ICD for SCD一級預(yù)防FU: 4.7+/3.4y： 48% ICD interve

14、ntion 19%：VF5年生存率：伴1、2、3、4危險因子的為100%、83%、21%、15%EP誘發(fā)VT/VF、NSVT是獨立預(yù)測因子第13頁，共50頁。首次放電時間和放電次數(shù)第14頁，共50頁。第15頁，共50頁。ICD電治療的影響因子第16頁，共50頁。危險因子對生存率的影響第17頁，共50頁。結(jié)論： ARVC患者植入ICD作為SCD一級預(yù)防措施：接近一半患者可有效預(yù)防SCD第18頁，共50頁。ARVC室速：導管消融需要考慮的幾個問題ARVC室速的機制：疤痕折返，局灶導管消融的成功率遠期復發(fā)率第19頁，共50頁。J Am Coll Cardiol 2007;50:4324024例患者

15、48次消融 隨訪3236months (range 1 day to 12 years)第20頁，共50頁。10次為三維電解剖標測，38次為常規(guī)方法標測術(shù)后室速復發(fā)率高達85%，隨訪14個月無發(fā)作的比例僅為15%，且不同的標測方法之間未見顯著性差異，即使術(shù)中消除所有誘發(fā)出來的室速，仍然有極高的復發(fā)率第21頁，共50頁。南京醫(yī)科大學心臟科動態(tài)基質(zhì)標測指導ARVC-VT消融病例1病例2病例3APEX第22頁，共50頁。心動過速的標測病例1：誘發(fā)一種類型室速，最早激動點和出口靠近基質(zhì)邊緣，無完整折返環(huán)，無舒張中期電位，無峽部。病例2：有2種類型室速，其中一例有完整的折返環(huán)路和舒張中期電位，兩種室速形

16、態(tài)不同、激動傳導方向相反，但有共同的傳導通道位于三尖瓣環(huán)與基質(zhì)邊緣；一種室速的出口位于基質(zhì)邊緣，另一種室速出口遠離基質(zhì)。病例3：誘發(fā)兩種不同形態(tài)室速，無舒張中期電位，亦無峽部存在；一種室速起源于基質(zhì)內(nèi)并通過基質(zhì)傳導，出口位于基質(zhì)邊緣，另一種室速起源稍遠離基質(zhì)邊緣，而出口遠離基質(zhì)。第23頁，共50頁。VT1VT2病例2第24頁，共50頁。 病例3第25頁，共50頁。12 Lead ECG (slower VT) 第26頁，共50頁。Pacing at site APacing at site B第27頁，共50頁。 結(jié)果病例1、2的三種臨床室速消融全部成功，但病例2仍可誘發(fā)一種新的非臨床類型室速

17、，室速頻率快，電轉(zhuǎn)復后未再行標測，后選用可達龍治療。 病例3在完成兩條線性消融后誘發(fā)出一種頻率較慢的室速，經(jīng)非接觸球囊標測此慢頻率室速通過兩條消融線之間的間隙傳導，消融此間隙后室速不再誘發(fā)。平均放電次數(shù)17次，每條消融線達到雙向傳導阻滯。無手術(shù)并發(fā)癥。平均隨訪20月，無心動過速發(fā)生。 第28頁，共50頁。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），心內(nèi)膜消融失敗20 VTs 誘發(fā)（2個大折返，18個局灶）16例（94.1%）即刻成功隨訪26 15 (range 6 to 42)月12人（70.6%）無室速發(fā)作Heart Rhythm.2010 Oct;7(10):1406-10第29頁，共50頁。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%）心內(nèi)膜不能完全成功，需要行心外膜消融13例心外膜消融后隨訪18+/-13月10/13（77%）無VT發(fā)作Garcia FC， Circulation.2009 Aug 4;120(5):366-75第30頁，共50頁。ARVC-VT：消融的長期療效 Outcomes ofcatheter ablationofventricular tachycardiainarrhythmogenicrightventriculardysplasia/cardiomyopathy 87例患者，175次消融平均隨訪88.

20、366 月1年，5年，10年無室速發(fā)作比例分別為47%，21%，15%心外膜消融后1年，5年無室速發(fā)作比例64%，45%Circ Arrhythm Electrophysiol.2012 Jun 1;5(3):499-505ARVC-VT消融：心內(nèi)或和心外仍有較高復發(fā)率，但能顯著減少VT負荷第31頁，共50頁。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頁，共50頁。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頁，共50頁。第34頁，共50頁。第35頁，共50頁。ARVC-VT：消融的現(xiàn)狀與再認識即刻成功率高遠期復發(fā)率也較高三維標測結(jié)合心外膜消融明顯提高成功率即使完全消融成功，考慮VT復發(fā)，仍不能動搖ICD作為二級預(yù)防的適應(yīng)證第36頁，共50頁。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頁，共50頁。ARVC-VT：消融的時機？植入ICD之后？ 植入后VT反復發(fā)作，藥物效果欠佳， ATP成功率低，反復shock 但費用？植入ICD

24、之前？ 預(yù)防性消融 減少發(fā)作，提高生活質(zhì)量 如不植入ICD，有較大風險第38頁，共50頁。病例：男性，33歲，ARVC+SMVT 2010年3月15日植入ICDDFT測試：首次18J，失敗；第二次，22J成功第39頁，共50頁。植入時的參數(shù)設(shè)置倍他樂克、可達龍 第40頁，共50頁。 植入后3周：Electric storm第41頁，共50頁。第42頁，共50頁。問題？哪些患者需要早期，或先行消融后植入ICD，或ICD植入后盡早消融?術(shù)前室速發(fā)作對AADs不敏感，藥物不能終止或減少發(fā)作，預(yù)計植入后仍有較高的發(fā)生率術(shù)中發(fā)現(xiàn)高DFT或術(shù)后住院期間觀察到ATP效果欠佳電風暴高危第43頁，共50頁。AR

25、VC植入ICD后電治療的高危因素History of cardiac arrestVentriculartachycardia with hemodynamic compromiseYounger ageLeftventricularinvolvement Independent predictors ofVF/ V Flutter 這些人是否應(yīng)當早期行導管消融？Circulation.2003 Dec 23;108(25):3084-91第44頁，共50頁。導管消融治療ICD電風暴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. 消融可有效治療急性