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1、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）,A regular wide QRS complex tachycardia at a rate of 100 bpm The consecutive beats have a uniform and stable QRS morphology The arrhythmia lasts 30 sec or causes hemodynamic collapse Sta
2、ble 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,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 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 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 心肌梗死所致LVEF35%，心
3、肌梗死后40天、NYHA II或III级 NYHA II或III级LVEF35%，非缺血性心肌病患者 心肌梗死所致LVEF30%，心肌梗死后40天、NYHA 级 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,0.6,0.8,1.0,1.2,1.4,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 bett
4、er,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 PV
5、Cs 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 Vent
6、ricular Arrhythmias,Primary Prevention of SCD in Ventricular Arrhythmias,a prior MI, dec EF and NSVT -ICD provides the lowest mortality,ICD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% ICD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 每年5次电击（尤其是电风暴，10-25%）死亡率明显增加 ICD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
7、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 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 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 susta
8、ined predominantly monomorphic VT that is drug resistant or intolerant, or who do not wish long-term drug therapyAblation is indicated in patients with bundle-branch reentrant VTAblation is indicated as adjunctive therapy in pts with an ICD who are receiving multiple shocks as a result of sustained
9、VT that is not manageable by reprogramming or changing drug therapy or who do not wish long-term drug therapyAblation is indicated in patients with WPW syndrome resuscitated from sudden cardiac arrest due to AF and rapid conduction over the accessory pathway causing VF,2006 ACC/AHA/ESC Ventricular A
10、rrhythmia & SCD Guidelines Therapies for VA-Ablation-Class I indication,Catheter ablation can be useful for pts with implanted ICDs who experience incessant or frequently recurring VTIn pts experiencing inappropriate ICD therapy, EP evaluation can be useful for diagnostic and therapeutic purposes,20
11、06 ACC/AHA/ESC Ventricular Arrhythmia & SCD Guidelines Therapies for VA-Ablation- Related to Pts with ICDs,2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias,Europace (2009) 11 (6): 771-817,2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias,Eur
12、opace (2009) 11 (6): 771-817,EP substrate - develops in the first 2 weeks after MI Inducible VT signifies the presence of an VT anatomic substrate (islands of relatively viable muscle alternating with areas of necrosis and later fibrosis，scar-related）,Mechanisms of VT with Ischemic Heart Disease,Ali
13、ot E M et al. Europace 2009;11:771-817,MI Scar-Related SMVT Circuit,Theoretical 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,ECG Du
14、ring VT with LBBB Morphology,ECG During VT with RBBB Morphology,RBBB & LBBB VT- ANTERIOR,RBBB & LBBB VT -POSTERIOR,EP-Mapping Techniques for Catheter Ablation of Hemodynamically stable VT,Areas of slow conduction -substrate for re-entry，result in fragmentation of the propagating electromotive forces
15、,Aliot E M et al. Europace 2009;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 70 ms, and amplitude/duration ratio of 0.046 mV/ms.,基质消融（substra
16、te-based）：通过了解VT基质，标测和消融可以在窦律下进行，方法是心内膜电压标测瘢痕的电压“通道”,在瘢痕之间的缓慢传导区还可以观察窦律时的舒张晚期电位来确定，一旦电压通路确定，诱发通过心电图确认的是临床相关的VT，在缓慢传导区消融,Conventional RFCA for VT based on VT mapping,Journal Year No. Pts. Success Complication Use of ICD FU duration Recurrences Non SCD SCD-FU,Della Bella De Ponti Salerno Eur Heart J 2002 124 73% 7.2% 19% 41.5 mos 21% 9.6% 2.4%,BorgerVanDerBurg - Schalij JCE 2002 151 83% 7% 22% 34 mos 26% 7.2% 0.6%,
