缺血性心脏病血流动力学稳定的单形性室速首选导管消融还课件

缺血性心脏病血流动力学稳 定的单形性室速：首选导管 消融还是ICD? 中国医科大学第一医院 于 波 持续性单形性室性心动过速 （Sustained monomorphic ventricular tachycardia （SMVT） uA regular wide QRS complex tachycardia at a rate of 100 bpm uThe consecutive beats have a uniform and stable QRS morphology uThe arrhythmia lasts 30 sec or causes hemodynamic collapse uStable SMVT was defined as a VT not leading to cardiac arrest or syncope and SBP 90 mmHg Primary VT 占猝死病人约8.3% Incidence of SMVT after infarction 3% 2008年ACC/AHA/HRS心脏节律异常 器械治疗指南-ICD的I类适应症 u 非可逆性原因导致的 VF或血流动力学不稳定的VT引起的心脏骤停 u伴有器质性心脏病的自发性持续性 VT，无 论血流动力学是否稳定 u 原因不明的晕厥，在电生理检查时能诱发有血液动力学异常的持续性 室速或室颤 u 心肌梗死所致LVEF35%，心肌梗死后40天、NYHA II或III级 u NYHA II或III级LVEF35%，非缺血性心肌病患者 u 心肌梗死所致LVEF30%，心肌梗死后40天、NYHA 级 u 心肌梗死所致非持续性VT，LVEF40%且电生理检查能够诱发出VF 或持续性VT 0.6 0.8 1.01.2 1.4 MADIT-I AVID 1.6 0.4 CABG-Patch MADIT-II 1996 1997 1997 2002 Aborted cardiac arrest N = 196 N = 1016 N = 900 N = 1232 0.46 0.62 1.07 0.69 Hazard ratio ICD better SCD-HeFT N = 1676 2005 0.77 1.8 LVEF, other features 0.35 or less, NSVT, EP positive 0.30 or less, prior MI 0.35 or less, LVD due to prior MI and NICM 0.35 or less, abnormal SAECG and scheduled for CABG CASH* 2000 N = 191 Aborted cardiac arrest DEFINITE 2004 N = 458 0.65 0.35 or less, NICM and PVCs or NSVT CIDS 2000 N = 659 0.82 Aborted cardiac arrest or syncope DINAMIT 2004 N = 674 1.08 0.35 or less, MI within 6 to 40 days and impaired cardiac autonomic function Trial Name, Pub Year 0.83 ICDs: Results from Primary and Secondary Prevention Trials Primary Prevention of SCD in Absence of Ventricular Arrhythmias Primary Prevention of SCD in Ventricular Arrhythmias a prior MI, dec EF and NSVT -ICD provides the lowest mortalitya prior MI, dec EF and NSVT -ICD provides the lowest mortality uICD并非治愈心律失常，术后1年内发生ICD治疗比例二级预防 约40%，一级预防约5-18% uICD虽可挽救生命，反复放电却显著增加心理疾病（发生率 50%），明显降低生活质量，ICD术后同样可以晕厥 u每年5次电击（尤其是电风暴，10-25%）死亡率明显增加 uICD并不能提供由于心律失常原因所致死亡的绝对保护 ，荟萃 分析显示ICD无反应率5%，猝死率30%，这些病人大多死于ICD 放电后的心电机械分离或因为ICD未能终止的VT/VF而致死 u合并器质性心脏病的血流动力学稳定VT病人在植入ICD的随机 研究中未见预后获益 u对所有适应症患者植入ICD因为太贵而不能广泛应用：中国每 年约54万人猝死，年植入不足1500余台，包括CRTD,累计近3300 台，美国每年约45人猝死，年安装ICD也只有近26万台 ICD预防SCD的局限性 预防ICD放电的最好方法是不植入ICD！ Ablation is indicated in pts who are otherwise at low risk for SCD and have sustained predominantly monomorphic VT that is drug resistant or intolerant, or who do not wish long-term drug therapy Ablation is indicated in patients with bundle-branch reentrant VT Ablation is indicated as adjunctive therapy in pts with an ICD who are receiving multiple shocks as a result of sustained VT that is not manageable by reprogramming or changing drug therapy or who do not wish long-term drug therapy Ablation is indicated in patients with WPW syndrome resuscitated from sudden cardiac arrest due to AF and rapid conduction over the accessory pathway causing VF I I I IIaIIa IIa IIb IIb IIb III IIIIII I I I IIaIIa IIa IIb IIb IIb III IIIIII I I I IIaIIa IIa IIb IIb IIb III IIIIIIIIaIIa IIbIIa IIb IIIIIb IIIIII 2006 ACC/AHA/ESC Ventricular Arrhythmia 11:771-817 MI Scar-Related SMVT CircuitTheoretical reentry circuits related to an inferior wall infarct scar Role of the 12-lead ECG in Localizing Site of Origin in Sustained VT: -not precisely identify the site of origin MARK E. JOSEPHSON, et al. Circulation 1981 MARK E. JOSEPHSON, et al. Circulation 1981 LOCUSFINDINGS APICALQ in L 1, V2 11:771-817 (A) Electrograms types recorded from 2 mm bipolar electrodes with a 510 mm interelectrode distance filtered at 30500 Hz. Normal signals are bi- or triphasic with an amplitude of 3 mV, duration 1.5 mV) uorange and red being low voltage or scarred regions (35% and 50% did not show any recurrent VT uThis study confirm the role of RFCA in reducing ICD therapies and also place RFCA in the overall clinical management of recurrent post infarction VT according to the LV function J Interv Card Electrophysiol, 2009 Sep;25(3):229-34 VT inducibility after radiofrequency ablation affects the outcomes in patients with CAD and ICD: The role of LV function The frequency of VT during 6 months before and after ablation for 142 pts with ICDs Aliot E M et al. Europace 2009;11:771-817 Presented at HRS 2006 ggPrimary Endpoint: Appropriate ICD therapies, Primary Endpoint: Appropriate ICD therapies, mean follow-up 2 years ICD implantation with ICD implantation with substrate-based catheter substrate-based catheter ablation ablation n=62n=62 ICD aloneICD alone n=64n=64 126 pts not using AAD, prior MI, and either 18% VF arrest, 52% unstable VT, 21% had syncope and inducible VT and 9% prior ICD and single appropriate shock, Randomized. 13% female, mean age 66 yrs, 71% NYHA Class ll, 18% NYHA Class lll, Mean EF 31.7% 96% beta-blockers and 91%ACEI, MI was anterior in 41% of pts and 67% prior revascularization gAblation was performed with electroanatomic mapping to delineate the endocardial infarct margins in sinus rhythm gThe radiofrequency ablation catheter used either a standard 4mm (n=10) or an irrigated 3.5 mm tip (n=52) Substrate Mapping and Ablation in Sinus Rhythm to Halt VT (SMASH-VT) trial To evaluate treatment with ICD + catheter ablation compared with To evaluate treatment with ICD + catheter ablation compared with ICD among post MI pts with sustained VT/VFICD among post MI pts with sustained VT/VF Vivek Y. Reddy, N Engl J Med. 2007 December 27; 357(26): 26572665. Primary End Point： Survival Free from ICD Therapy Vivek Y. Reddy, N Engl J Med. 2007 December 27; 357(26): 26572665. SMASH-VT Trial: Primary Endpoint Presented at HRS 2006 appropriate ICD therapy (%) p30%)分层 u消融组，7例 (13%)没有进行消融，因此消融组45例，对照62 例病人进行分析 u平均随访 22.5 9 月 Catheter Ablation of Stable Ventricular Tachycardia Before Defibrillator Implantation in Patients with CAD (VTACH) The Lancet 2010 ；375（9708）： 31 - 40 VTACH The primary endpoint (first recurrence of any documented VT or VF) was reached after a median of 19.5 mon in the ablation group and 5.9 mon in the ICD only group (P = 0.01) u22例消融病人每年累计发生 685.5 VT/VF事件，43例对照组发 现4,985.8次事件(P = 0.024) u12个月，62%消融病人和40%对 照病人无任何VT或VF事件 u24个月时，分别为48%和29% u当仅考虑有EGM事件时 u12M（ 62% 和40%, P = 0.01） u24M（ 48% vs 29%, P = 0.01） u抗心律失常药在消融组29%（45 人中13例），对照组50%（62人中 31人），(P = 0.021) The Lancet 2010 ；375（9708）： 31 - 40 Primary endpoint by LV function Graphs show estimates for survival free from VT or VF in patients with different LVEF VTACH uVT/VF比例：消融组较对照 组少21%，每年平均ICD治疗 次数对照组明显高于消融组 u至少1次电击：消融组29% ，对照组53%(P = 0.017) u24月无ICD电击存活：消融 组和ICD组分别77%和 48%(HR 0.4, 95% CI 0.2 0.8, P = 0.008) u不恰当电击数量两组相似 The Lancet 2010 ；375（9708）： 31 - 40 VTACH Secondary endpoint of hospital admission Estimates of survival free from hospital admission for cardiac reasons u二级终点：VT风暴 ，晕厥或死亡两组无 区别 u无因为心脏原因住 院的生存在消融组高 于对照组 (12月为 78%和62%， 24个月 73%和44%) Complications related to the ablation ccurred in 2 pts; no deaths within 30 days 15 device-related complications requiring surgical intervention in 13 pts 9 pts died during the study (ablation group, 5; control group, 4) The Lancet 2010 ；375（9708）： 31 - 40 uVT ablation before ICD in pts after 1st hemodynamically stable VT significantly prolonged the median time to first VT/VF from 5.9 mons to 18.6 mons. The benefit was more pronounced in pts with LVEF30% uVT ablation reduced the overall incidence of appropriate ICD interventions by 28% and ICD shocks by 43% uVT ablation reduced the median number of appropriate ICD interventions per patient and year of follow-up by 93% uVT ablation reduced the rate of hospitalizations for cardiac reasons uVT ablation clearly prolonged time to recurrence of VT/VF episodes and markedly decreased VT/VF burden VTACH study summary The Lancet 2010 ；375（9708）： 31 - 40 小 结 u目前虽不清楚也未证明导管消融VT可以取代ICD，彻底改善病人预后，但是 ，消融治疗确实给这些病人的治疗带来了新的希望 u对多次ICD放电病人预防性导管消融减少VT/VF复发和ICD治疗达43-73% u导管消融是终止和消除无休止VT和ICD电风暴的唯一方法 u这些病人VT消融目的不是治愈所有异常传导通路，而是治疗临床相关的VT u消融失败多由于心脏结构问题，VT可能起源于心外膜或心肌内 uVT复发多由于以往消融折返环路复发，但更多是由于缺血心脏病进展 u消融手术相关死亡率为0，主要并发症3.8- 4.7%，相对安全 u更好理解VT机制，如何制造损伤径线，更好标测工具，新型能源，新型消融 导管（磁导航）可以提高手术成功率，使更多医生接受和推广该治疗手段 u消融治疗目前作为ICD的辅助治疗，随经验增加，对室速机制的理解，大样 本研究的进展，未来这一观点有可能改变 u目前许多ICD病人很晚才被推荐导管消融，常常已经发生ICD多 次放电的不良后果，强烈建议对于缺血性心脏病合并血流动力学缺血性心脏病合并血流动力学 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