器质性心脏病VTRFCAICD

器质性心脏病VTRFCAICD器质性心脏病VTRFCAICD第1页室性心律失常分类

ACC/AHA/ESCGuideline依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心脏骤停依据心电图分类非连续性VT单形性多形性连续性VT单形性多形性BBRT双向性VT和TdP心室扑动和颤动器质性心脏病VTRFCAICD第2页室性心律失常分类

ACC/AHA/ESCGuideline依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器质性心脏病VTRFCAICD第3页ICD应用于器质性心脏病SCD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器质性心脏病VTRFCAICD第4页ICD二级预防临床研究提醒采取ICD治疗有明确室性心律失常病史患者，每年能够挽救500条生命，而这仅占SCD受害者总人数0.1%器质性心脏病VTRFCAICD第5页ICD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.Heart;93:1479-1483器质性心脏病VTRFCAICD第6页器质性心脏病VTRFCAICD第7页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%器质性心脏病VTRFCAICD第8页60%MUSTT5

5years54%MADIT42years20%CIDS33years37%CASH22years31%AVID13yearsICD与抗心律失常药品治疗

在降低总死亡率方面比较0%10%20%30%40%50%60%%MortalityReduction1TheAVIDInvestigators.NEnglJMed.1997;337:1576-1583.2Kuck,etal.Circulation.;102:748-754.3Connolly,etal.Circulation.;101:1247-1302.4MossAJ.NEnglJMed.1996;335:1933-1940.5BuxtonAE.NEnglJMed.1999;341:1882-1890.6Moss.InvestorConferenceCall.November27,.30%MADITII62years器质性心脏病VTRFCAICD第9页Cost-BenefitAnalysisofpreventingSuddenCardiacDeathswithanICDversusAmiodaroneStudyinEuropean(UKandFrance)ICDsdecreaseddeathsduringthe5yearsfrom37.0%to29.7%atanetcostof£26.222to£20.008perpatient,cost-benefitrationsof0.17(UK)and0.14(France)-morethana5to1returnoninvestmentConclusionIntheseEuropeancountrieswheresocietyvaluesalifeatmorethan£2million.ICDsareaworthwhileinvestmentcomparedwithamiodaroneforprimarypreventionofSCDinptswithheartfailureInternationalSPOR,1098-30器质性心脏病VTRFCAICD第10页ACC/AHA/HRSGuidelinesforDevice-BasedTherapyofCRA

ICD治疗适应证I

类室颤或血流动力学不稳定连续性室速心脏骤停幸存者，病因明确且完全排除可逆原因(证据等级：C)器质性心脏病患者合并自发连续性室速，不论血流动力学是否稳定

(证据等级：C)器质性心脏病VTRFCAICD第11页ICD治疗相关问题ICD本身可增加心律失常事件发生率ICD误放电问题ICD治疗费用较高ICD重复更换所造成感染问题频繁电休克造成患者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%器质性心脏病VTRFCAICD第12页ICD治疗相关问题MADITII研究中，依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，依然有未被识别患者处于危险之中

NEnglJMed.;346:877-83AmHeartJ.;153:951-9JCardiovascElectrophysiol.;16Suppl1:S25-7JCardiovascElectrophysiol.;12:369-81器质性心脏病VTRFCAICD第13页ICD临床试验显示ICD植入增加心律失常事件器质性心脏病VTRFCAICD第14页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品组（STD）及标准药品+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.Circulation;113:776-782器质性心脏病VTRFCAICD第15页单导联心电图连续统计显示了一例因屡次ICD电击而致室颤晕厥就诊患者，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个形态室速，第三次电击再次转为室颤，因为ICD最终一次电击，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。假如未置入ICD，该患者可能不会经历这次晕厥。AlmendralJetal.Circulation;116:1204-1212器质性心脏病VTRFCAICD第16页MADIT-II:ICD对VT/VF一次或一次以上准确治疗

36%器质性心脏病VTRFCAICD第17页年电击复律百分比SCDHeFT:从植入至VT/VF电击复律时间0.000.050.100.150.200.250.3001234581170740162223679Numberatrisk器质性心脏病VTRFCAICD第18页器质性心脏病室速导管消融即使ICD是器质性心脏病室速一线治疗伎俩，不过导管消融及抗心律失常药品(可达龙和受体阻滞剂)是其不可忽略辅助治疗办法CatheterablationisanimportanttherapeuticoptionforcontrollingrecurrentVAsinpatientswithheartdiseaseZeppenfeldKandStevensonWG.PACE;31:358–374器质性心脏病VTRFCAICD第19页器质性心脏病室速导管消融以下室速推荐导管消融治疗症状性连续性单形性室速(SMVT),包含ICD终止室速,抗心律失常药品治疗后复发或抗心律失常药品不能耐受或不愿服用药品室速非可逆原因所致无休止性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品治疗无效重复发生连续性多形性室速和室颤，如为触发灶引发者则可行消融治疗年EHRA/HRS/ESC/ACC/AHA

室速导管消融教授共识解读器质性心脏病VTRFCAICD第20页器质性心脏病室速导管消融以下情况应该考虑导管消融尽管使用了一个或各种Ⅰ类或Ⅲ类抗心律失常药品，但患者仍有一次或屡次SMVT发作陈旧性心肌梗死伴重复发生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能够接收选择性治疗办法陈旧性心肌梗死伴LVEF＞35%，且SMVT发作时血流动力学尚稳定者，即使抗心律失常药品治疗可能有效，仍可考虑导管消融年EHRA/HRS/ESC/ACC/AHA

室速导管消融教授共识解读器质性心脏病VTRFCAICD第21页Scar-RelatedReentrantVT器质性心脏病VTRFCAICD第22页心肌梗死后室速导管消融

临床研究结果19个中心共报导802例患者72～96%患者最少成功消融一个室速30～72%患者成功消融全部诱发室速手术相关致死并发症为0.5%13个研究平均随访12个月以上，50～88%无复发年EHRA/HRS/ESC/ACC/AHA

室速导管消融教授共识解读器质性心脏病VTRFCAICD第23页器质性心脏病VTRFCAICD第24页心肌梗死后室速导管消融TheMulticenterThermocoolVentricularTachycardiaAblationTrialThermocool重复发作室速患者231例(过去6个月发作平均11次)采取拖带和/或电解剖基质标测技术81%患者最少一个室速消融成功49%患者全部室速均成功随防6个月，51%复发StevensonWG,etal.Circulation;118:2773–82器质性心脏病VTRFCAICD第25页心肌梗死后室速导管消融TheEuro-VT-Study8个中心，入选63例，平均年纪63岁，平均LVEF28%平均可诱发3种室速，67%植入ICD81%患者最少1种室速消融成功50%患者全部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.JCardiovascElectrophysiol;publishedonlineJuly28.DOI:10.1111/j.1540-8167..01563.x.器质性心脏病VTRFCAICD第26页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发心功效不全

折返环由右束支-心室肌-左束支-希氏束-右束支组成右束支是消融靶点，成功率100%即使窦律时呈LBBB，右束支消融后普通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导管消融

器质性心脏病VTRFCAICD第27页器质性心脏病VTRFCAICD第28页非缺血性扩张型心肌病合并室速导管消融19例DCM合并SM室速，14例经心内膜路径成功，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路径标测及消融；术后随访334天，46%患者室速再发，其中1例患者死于心衰，2例患者接收心脏移植非缺血性心肌病室速导管消融NazarianS,etal.Circulation;112:2821–5SoejimaK,etal.JAmCollCardiol;43:1834–42器质性心脏病VTRFCAICD第29页AblationofVentricularTachycardiainPatients

withNonischemicCardiomyopathyAneffectiveablationsiteinapatientwithnonischemiccardiomyopathy.ThereisconcealedentrainmentandadiastolicpotentialduringVT.Theelectrogram-QRSintervalmatchesthestimulus-QRSinterval(bothare210ms).ShownareleadsI,II,III,V1,andV6andtheintracardiactracingsfromthemappingcatheter(Map).Pacingcyclelengthis450msandtheVTcyclelengthis490ms.器质性心脏病VTRFCAICD第30页Epicardialandendocardialmappingdatafromapatientwithnonischemiccardiomyopathy器质性心脏病VTRFCAICD第31页心包穿刺心外膜标测消融示意图器质性心脏病VTRFCAICD第32页CatheterAblationofMultipleVTAfterMIGuidedbyCombinedContactandNoncontactMappingCirculation.;115:2697-2704器质性心脏病VTRFCAICD第33页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器质性心脏病VTRFCAICD第34页器质性心脏病VTRFCAICD第35页研究资料来自一些病例汇报与小样本研究一项研究入选11例患者，诱发出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，采取非接触标测系统成功标测13种诱发室速，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导管消融

KriebelT,etal.JAmCollCardiol;50:2162–8ZeppenfeldK,etal.Circulation;116:2241–52器质性心脏病VTRFCAICD第36页ARVC室速发生机理示意图器质性心脏病VTRFCAICD第37页CatheterAblationforARVC-VTVTin32ARVC-ptsinducedMappingearliestVTactivationusingNon-ContactMappingSystemAcuteablationsuccessratewas84.4%(27/32)81.3%oftheptswerefreeofVTwithoutmedicationduringthe28.6±16monthfollow-upConclusionARVC-VTcanbeabolishedorimprovedsignificantlybyRegionalablationundertheguidanceofNon-contactmapping

YanYaoetal.PACE;30:526-533器质性心脏病VTRFCAICD第38页Long-TermEfficacyofCatheterAblation

ofVTinptswithARVC24ptsintheJohnsHospitalsARVDregistry,whounderwent1ormorethanRFAproceduresforVTFollow-upfor32±36monthsAtotalof48RFCAprocedureperformedusingCarto(n=10)orconventional(n=38)mappingForty(85%)procedurewerefollowedbyrecurrenceConclusion:AhighrateofrecurrenceinARVCptsundergoingRFCAThislikelyreflectsthefactthatARVCisadiffuseCMwithprogressivelyevolvingelectricalsubstrateDalalD,etal.JACC;50:432-440器质性心脏病VTRFCAICD第39页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室速导管消融

(南京医科大学第一从属医院)*导管消融21/44例ARVC患者器质性心脏病VTRFCAICD第40页SafetyandOutcomesofCryoablationforVAsResultsfromamulticenterexperienceStudypopulation:33pts,meanage54±8years15ptsendocardialablation13ptsepicardialablation5ptsaorticcuspablationAblationwassuccessfulin15(45%)ptsandunsuccessfulin18(55%)ptsCryoablationwassuccessfulinallparahisiancase(100%)AnaorticdissectionoccurredinaorticcuspFollowupof24monts,allsuccessfulcasesfreefromVAsBiaseLD,etal.HeartRhythm;8:968-974器质性心脏病VTRFCAICD第41页SafetyandOutcomesofCryoablationforVAsResultsfromamulticenterexperienceConclussionUseofcryoablationforVAshasexcellentsuccessforarrhythmiasneartheHisbundleSuccessrateatothersitesappearlessfavorableCryoablationmaybeconsideredasanalternativeapproachforreducingcomplicationduringablationofVAsoriginatingfromsitesclosetootherrelevantcardiacstructures(e.g.conductionsystem,coronaryarteries…)BiaseLD,etal.HeartRhythm;8:968-974器质性心脏病VTRFCAICD第42页老年冠心病患者室速导管消融安全性

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.HeartRhythm;7:740-744器质性心脏病VTRFCAICD第43页血流动力学稳定

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

CatheterablationconfersbothqualitativeandquantitativeprotectionagainstVTrecurrenceandSCDAlthoughrecurrenceofatoleratedVTisnotsorare,theSCDrateinthesepatientsisextremelylowCatheterablationcanbeconsideredatherapeuticalternativeforthosepatientswithpost-MItoleratedVTinwhomtheprocedureproducesasatisfactoryshort-termresultJesúsAlmendralandMarkE.Josephson,Circulation;116;1204-1212器质性心脏病VTRFCAICD第44页血流动力学稳定

器质性心脏病室速治疗选择PatientsWithHemodynamicallyToleratedVTRequireICDToleratedVTsignalsariskoflife-threateningarrhythmiasThebenefitofsecondary-preventionICDtherapyisdifficulttochallengeSuccessfulcatheterablationdoesnotsufficientlyreduceresidualriskCallansDJ.Circulation;116;1196-1203器质性心脏病VTRFCAICD第45页ProphylacticCatheterAblation

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

器质性心脏病VTRFCAICD第46页ProphylacticCatheterAblation

forthePreventionofDefibrillatorThera