器質(zhì)性心臟病VT：RFCAorICD課件

1、器質(zhì)性心臟病室速的治療 導(dǎo)管消融和/或 ICD?室性心律失常的分類2006 ACC/AHA/ESC Guideline根據(jù)臨床表現(xiàn)分類血流動(dòng)力學(xué)穩(wěn)定無癥狀癥狀輕微心悸血流動(dòng)力學(xué)不穩(wěn)定暈厥先兆暈厥SCD心臟驟停根據(jù)心電圖分類非持續(xù)性VT單形性多形性持續(xù)性VT單形性多形性BBRT雙向性VT和TdP心室撲動(dòng)和顫動(dòng)室性心律失常的分類2006 ACC/AHA/ESC Guideline根據(jù)基礎(chǔ)疾病分類慢性冠狀動(dòng)脈性心臟病心力衰竭先天性心臟病神經(jīng)癥非器質(zhì)性心臟病嬰兒猝死綜合征心肌病DCMHCMARVCICD應(yīng)用于器質(zhì)性心臟病SCD的二級(jí)預(yù)防 (臨床研究AVID/CIDS/CASH 薈萃分析)2年內(nèi)事件 I

2、CD 可達(dá)龍 P 值 (N=934) 總死亡數(shù) 200 255 P0.001 心律失常死亡數(shù) 61 117 P=120ms)主要終點(diǎn)：死亡或全因住院率二級(jí)終點(diǎn)：全因死亡率COMPANION評(píng)價(jià)CRT或CRT-D對(duì)心衰患者臨床終點(diǎn)事件影響，結(jié)果顯示CRT-D 降低全因死亡率36%60%MUSTT5 5 years54%MADIT42 years20%CIDS33 years37%CASH22 years31%AVID13 yearsICD與抗心律失常藥物治療在降低總死亡率方面的比較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治療適應(yīng)證I 類室顫或血流動(dòng)力學(xué)不穩(wěn)定的持續(xù)性室速的心臟驟停幸存者，病因明確且完全排除可逆因素 (證據(jù)等級(jí)：C)器質(zhì)性心臟病患者合并自發(fā)的持續(xù)性室速，不論血流動(dòng)力學(xué)是否穩(wěn)定 (證據(jù)等級(jí)：C)ICD治療的相關(guān)問題ICD本身可增加心律失常事件發(fā)生率ICD的誤放電問題ICD的治療費(fèi)用較高ICD反復(fù)更換所導(dǎo)致的感染問題頻繁電休克導(dǎo)致患者的生活質(zhì)量下降以及心理問題ICD植入手術(shù)死亡率1%，嚴(yán)重并發(fā)癥3%ICD治療的相關(guān)問題MADIT II 研究中，根據(jù)死亡數(shù)絕對(duì)值下降推算，每預(yù)防1次SCD需要植入16臺(tái)ICD即使如此，仍然有未被識(shí)別的患者處于危險(xiǎn)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臨床試驗(yàn)顯示ICD植入增加心律失常事件ICD植入后事件顯著增加458例非缺血性心肌病患者隨機(jī)分為標(biāo)準(zhǔn)藥物組（STD）及標(biāo)準(zhǔn)藥物+ICD組（ICD）STD組15例猝死，ICD組3例猝死ICD組心律失常事件（ICD放電+猝死）顯著多于STD組DEFINITE Investigators. Circulati

8、on 2006;113:776-782單導(dǎo)聯(lián)心電圖連續(xù)記錄顯示了一例因多次ICD電擊而致室顫暈厥的就診患者，該患者自發(fā)單形性室速時(shí)并無暈厥癥狀，ICD第一次電擊后將單形性室速轉(zhuǎn)為室顫，之后第二次電擊又將室顫轉(zhuǎn)為另一種形態(tài)的室速，第三次電擊再次轉(zhuǎn)為室顫，由于ICD最后一次電擊，該患者發(fā)生了暈厥直到體外除顫。該患者之前除發(fā)作過數(shù)次單形性室速外從未有過暈厥以及心臟驟停。如果未置入ICD，該患者可能不會(huì)經(jīng)歷這次暈厥。Almendral J et al. Circulation 2007;116:1204-1212 MADIT-II: ICD對(duì)VT/VF一次或一次以上準(zhǔn)確治療 36%年電擊復(fù)律的比例SC

9、D HeFT: 從植入至VT/VF電擊復(fù)律時(shí)間0.000.050.100.150.200.250.3001234581170740162223679Number at risk器質(zhì)性心臟病室速的導(dǎo)管消融雖然ICD是器質(zhì)性心臟病室速的一線治療手段，但是導(dǎo)管消融及抗心律失常藥物(可達(dá)龍和受體阻滯劑)是其不可忽視的輔助治療措施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器質(zhì)性心臟病室速的導(dǎo)管消融下列室速推薦導(dǎo)管消融治療癥狀性持續(xù)性單形性室速(SMVT), 包括ICD終止的室速,抗心律失常藥物治療后復(fù)發(fā)或抗心律失常藥物不能耐受或不愿服用藥物的室速非可逆因素所致的無休止性VT或室速風(fēng)暴 束支折返性室速或分支型室速 抗心律失常藥物治療無效的反復(fù)發(fā)生的持續(xù)性多形性室速和室顫，如為觸發(fā)灶引起者則可行消融治療2009年EHRA/HRS/ESC/ACC/AHA室速導(dǎo)管消融專家共識(shí)解讀器質(zhì)性心臟病室速的導(dǎo)管消融下列情況應(yīng)當(dāng)考慮導(dǎo)管消融盡管使用了一種或多種類或類抗心律失常藥物，但患者仍有一次或多次SMVT發(fā)作陳舊性心肌梗死伴反

11、復(fù)發(fā)生的SMVT患者、其LVEF30%且預(yù)計(jì)生存期1年，導(dǎo)管消融作為胺碘酮治療外的可以接受的選擇性治療措施陳舊性心肌梗死伴LVEF35%，且SMVT發(fā)作時(shí)血流動(dòng)力學(xué)尚穩(wěn)定者，即使抗心律失常藥物治療可能有效，仍可考慮導(dǎo)管消融2009年EHRA/HRS/ESC/ACC/AHA室速導(dǎo)管消融專家共識(shí)解讀Scar-Related Reentrant VT心肌梗死后室速的導(dǎo)管消融 臨床研究結(jié)果19個(gè)中心共報(bào)導(dǎo)802例患者7296%患者至少成功消融一種室速3072%患者成功消融所有誘發(fā)的室速手術(shù)相關(guān)的致死并發(fā)癥為0.5%13個(gè)研究平均隨訪12個(gè)月以上，5088%無復(fù)發(fā)2009年EHRA/HRS/ESC/AC

12、C/AHA室速導(dǎo)管消融專家共識(shí)解讀心肌梗死后室速的導(dǎo)管消融The Multicenter Thermocool Ventricular Tachycardia Ablation TrialThermocool反復(fù)發(fā)作的室速患者231例(過去6個(gè)月發(fā)作平均11次)采用拖帶和/或電解剖基質(zhì)標(biāo)測技術(shù)81%患者至少一種室速消融成功49%患者所有室速均成功隨防6個(gè)月，51%復(fù)發(fā)Stevenson WG, et al. Circulation 2008;118:277382 心肌梗死后室速的導(dǎo)管消融The Euro-VT-Study8個(gè)中心，入選63例，平均年齡63歲，平均LVEF28%平均可誘發(fā)3種室速

13、，67%植入ICD81%患者至少1種室速消融成功50%患者所有室速均成功消融隨訪結(jié)果隨訪6月，51%患者無復(fù)發(fā)隨訪12月，死亡率為8%Tanner H, et al. J Cardiovasc Electrophysiol 2009; published online July 28.DOI:10.1111/j.1540-8167.2009.01563.x.束支折返性室速導(dǎo)管消融策略及處理多伴發(fā)于冠心病、瓣膜性心臟病或心肌病引起的心功能不全 折返環(huán)由右束支-心室肌-左束支-希氏束-右束支構(gòu)成右束支是消融靶點(diǎn)，成功率100%即使竇律時(shí)呈LBBB，右束支消融后一般不會(huì)出現(xiàn)心臟傳導(dǎo)阻滯，但術(shù)后30%

14、患者因心動(dòng)過緩需要起搏治療非缺血性心肌病BBRT的導(dǎo)管消融 非缺血性擴(kuò)張型心肌病合并室速的導(dǎo)管消融19例DCM合并SM室速，14例經(jīng)心內(nèi)膜途徑成功，隨訪22個(gè)月，5例患者無再發(fā)另一項(xiàng)研究入選22例患者，消融策略是如果心內(nèi)膜消融失敗則改為心外膜途徑標(biāo)測及消融；術(shù)后隨訪334天，46%患者室速再發(fā)，其中1例患者死于心衰，2例患者接受心臟移植非缺血性心肌病室速的導(dǎo)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心包穿刺心外膜標(biāo)測消融示意圖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研究資料來自一些病例報(bào)告與小樣本研究 一項(xiàng)研究入選11例患者，誘發(fā)出的15種室速均成功消融，隨訪30個(gè)月，91%患者無復(fù)發(fā) 另一項(xiàng)研究入選10例患者，均為法四矯正術(shù)后，采用非接觸標(biāo)測系統(tǒng)成功標(biāo)測13種誘發(fā)的室速，11種室速是大折返，8例消融成功，隨訪期間6例無復(fù)發(fā)先心臟病外科矯正術(shù)后室速的導(dǎo)管消融 Kriebel T, et al. J Am Coll Cardiol 2007;50:216

21、28Zeppenfeld K, et al. Circulation 2007; 116: 224152ARVC室速的發(fā)生機(jī)理示意圖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 非接觸接觸標(biāo)測 系統(tǒng)方 法 基質(zhì)改良消融策略CARTO 基質(zhì)起博標(biāo)測 基質(zhì)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室速的導(dǎo)管消融 (南京醫(yī)科大學(xué)第一附屬醫(yī)院)*導(dǎo)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導(dǎo)管消融的安全性 患者 75歲, n=72 75歲, n=213 p值消融成功率 79.2% 87.8%主要并發(fā)癥 5.6% 2.3%圍手術(shù)期死亡率 2/72 9/213 0.74隨訪期死亡 50.0% 35.2% 0.08無VT發(fā)生 63.9% 60.1% 0.80 K Inada, et al. Heart Rhythm 2010; 7: 740-744血流動(dòng)力學(xué)穩(wěn)定器質(zhì)性心臟病室速治療選擇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血流動(dòng)力學(xué)穩(wěn)定器質(zhì)性心臟病室速治療選擇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