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1、室性心律失常射频消融室性心律失常射频消融心脏结构正常合并PVC-良性心律失常?Am J Cardiol. 2012 Jan 1; 109(1): 105109. J Am Coll Cardiol. 2015 Jul 14;66(2):101-9PVC越多 死亡率越高 心衰越重器质性心脏病 PVC触发VF器质性心脏病PVC 影响CRT疗效 In conclusion A little bit of premature beats and a little bit of incomplete biventricular pacing can mean a lot to CRT patients.
2、 This report reaffirms that nearly continuous CRT pacing (97%) is necessary for optimal CRT response and that even a very small percentage of ectopic beats (0.1%) is associated with less CRT pacing and worse patient outcomes after CRT. Ablation of frequent PVC in patients meeting criteria for primar
3、y prevention ICD implant: Safety of withholding the implantHeart Rhythm 2015;0:-19 ConclusionIn patients with frequent PVC and PP-ICD indication, ablation improves LVEF and, in most cases, allows removal of the indication. Withholding the ICD and reevaluating within 6 months of ablation seems to be
4、a safe and appropriate strategy.抗心律失常问题I I类抗心律失常：风险类抗心律失常：风险 CASTCASTIIII类类 使用广泛，使用广泛，特殊情况无法使用特殊情况无法使用IIIIII类类 胺碘酮胺碘酮 : :心外副作用超过心脏心外副作用超过心脏 使用半年以上使用半年以上1/31/3出现甲状腺问出现甲状腺问题题 索他洛尔：索他洛尔：LQTLQTIVIV类类 非广谱，增加心动过缓、非广谱，增加心动过缓、AVBAVB风险风险ConclusionsCatheter ablation is more efficacious than AADs for preventin
5、g VPB recurrence in patients with frequent VPBs originating from the RVOT. QS morphology in lead I was associated with better outcome after ablation.Circulation: Arrhythmia and Electrophysiology.2014; 7: 237-243 PVC消融适应症PVC消融适应症非器质性心脏病 I类适应症PVC消融适应症 器质性心脏病：触发VT/VF I类适应症左室功能障碍左室功能障碍心脏结构正常 VT消融适应症 器质性
6、VT消融适应症持续性单形性室速导管消融持续性单形性室速导管消融器质性室速消融适应症室性心律失常机制 非器质性心脏病非器质性心脏病流出道流出道VA VA 触发触发 腺苷腺苷分支性分支性VA VA 折返折返 异搏定异搏定瓣环瓣环 乳头肌乳头肌 调节束调节束 折返折返 触发触发 自律性自律性 器质性心脏病器质性心脏病疤痕折返相关疤痕折返相关VTVT 触发触发 自律性自律性分支性VT 折返机制http:/ 折返机制http:/ 部分流出道VA激动: 大多数VA拖带、重整: 主要应用于折返性VA基质标测：双极电压标测疤痕 低电压 正常心肌 血液动力学支持下消融器质性VTLAVA电位消融： 窦律下消融血液
7、动力学不稳定的器质性VT 起搏标测激动标测拖带-重整VT基质标测LAVA电位标测和消融Local abnormal ventricular activitiesCirculation. 2012;125:2184-2196LAVA电位标测和消融Local abnormal ventricular activitiesCirculation. 2012;125:2184-2196血液动力学支持的VT消融The Journal of Innovations in Cardiac Rhythm Management, 3 (2012), 959967非器质性VA消融疗效 PVC This study
8、 included 1185 patients 即刻成功率84% 随访71%无需抗心律失常药1.9年后成功率85% RVOT- PVC 成功率高PVC-诱发心肌病心衰改善：EF 38% to 50% 死亡率：0% 并发症： 5.2% 严重并发症2.4% ，血管入路并发症2.8%JACCCEP. 2015;1(3):116-123非器质性VA消融疗效 VTLong-Term Follow-Up After Radiofrequency Catheter Ablation of Ventricular Tachycardia: A Successful Approach?成功率成功率 93%复复发
9、率率19%(含部分器含部分器质性室速性室速) J Cardiovasc Electrophysiol. 2002 May;13(5):417-23器质性心脏病PVC消融疗效 CRT nonresponders with 10,000 PVC in 24 h即刻成功率91% ，远期成功率88% LVEF 26.2% 32.7% LVED 6.83 cm 6.51cm 心功能（NYHA) 3.0级 2.0级Ablation of frequent PVC in patients meeting criteria for primary prevention ICD implant 减少ICD放电
10、去除ICD适应症(26%)J Am Coll Cardiol. 2012 Oct 16;60(16):1531-9Heart Rhythm 2015;0:-19 器质性VA消融疗效 BBRTBBRT消融根治，无需消融根治，无需ICD, IAICD, IA指征指征The long-term outcomes ARVC-VT Remote MI-VT NIDCM J Arrhythm. 2015 Feb;31(1):22-8荟萃分析萃分析Meta-analysis of catheter ablation as an adjunct to medical therapy for treatment
11、 of ventricular tachycardia in patients with structural heart disease.Results457 患者并发症：死亡1%，卒中1%， 穿孔1%, AVB 1.6% 。与单纯药物相比，减少VT复发 35% 。死亡率无差异。 5年复发率: 25-50%结论：与：与药物相比，物相比，导管消融减少管消融减少VT复复发，对死亡率无影死亡率无影响。响。Heart Rhythm. 2011 Apr;8(4):503-10心外膜联合消融结果消融疗效ICM 心内膜心外膜联合消融结果12 月无VT事件联合组 85% ，单纯心内膜消融 56%Invasi
12、ve Electrophysiology And Pacing,2012, Vol14, p 577-583器器质性心性心脏病病VT处理理大部分大部分器器质性心性心脏病室速病室速首首选ICD但ICD不能预防VA复发。预防防VA发作作 药物：物： Beta-blocker +amiodarone 导管消融：管消融： 减少ICD放电，预防VA复发 控制无休止VT和电风暴。病例分享 Case1 流出道室速/PVC病例分享 Case2 高位间隔分支型室速 病例分享 Case2 高位间隔分支型室速 病例分享 Case2 高位间隔分支型室速 his病例分享 Case3左后分支型室速 病例分享 Case3 左后分支型室速 病例分享 Case3 左后分支型室速 标测 消融靶点20-30ms心电图变化 左前分支阻滞病例分享 Case4 His束旁室速病例分享 Case5 乳头肌室早文献病例 器质性室速 ARVC文献病例 器质性室速 BRS 消融Circulation. 2011;123:1270-1279
