ARVC單形性室速導(dǎo)管消融ICD

1、 arvc單形性室速：?jiǎn)涡涡允宜伲簩?dǎo)管消融還是導(dǎo)管消融還是icd?南京醫(yī)科大學(xué)第一附屬醫(yī)院南京醫(yī)科大學(xué)第一附屬醫(yī)院鄒建剛鄒建剛5th vas-chinaarvc：并不罕見(jiàn)的心肌病：并不罕見(jiàn)的心肌病arvc診斷標(biāo)準(zhǔn)診斷標(biāo)準(zhǔn)20101. 心臟整體和心臟整體和/或局部運(yùn)動(dòng)障礙和結(jié)構(gòu)改變或局部運(yùn)動(dòng)障礙和結(jié)構(gòu)改變2.室壁病理組織學(xué)特征室壁病理組織學(xué)特征3.復(fù)極障礙復(fù)極障礙4.除極或傳導(dǎo)異常除極或傳導(dǎo)異常5.心律失常心律失常6.家族史家族史 circulation. 2010;121:1533-1541arvc室速室速arvc室性心律失常室性心律失常主要條件主要條件 持續(xù)性或非持續(xù)性左束支傳導(dǎo)阻滯型室性心

2、動(dòng)持續(xù)性或非持續(xù)性左束支傳導(dǎo)阻滯型室性心動(dòng)過(guò)速過(guò)速, 伴電軸向上伴電軸向上 ( ii、iii、avf qrs 負(fù)向或不確定負(fù)向或不確定, avl 正向正向)次要條件次要條件 持續(xù)性或非持續(xù)性右室流出道型室性心動(dòng)過(guò)速持續(xù)性或非持續(xù)性右室流出道型室性心動(dòng)過(guò)速, lbbb 型室性心動(dòng)過(guò)速型室性心動(dòng)過(guò)速, 伴電軸向下伴電軸向下( ii、iii、avf qrs 正向或不確定正向或不確定, avl 負(fù)向負(fù)向), 或電軸不明確或電軸不明確 holter顯示室性早搏顯示室性早搏24 h 500個(gè)個(gè)arvc：icd植入指證植入指證-arvc-scd的一級(jí)、二級(jí)預(yù)防的一級(jí)、二級(jí)預(yù)防icd therapy is i

3、ndicated in patients with structural heart disease and spontaneous sustained vt, whether hemodynamically stable or unstable. icd implantation is reasonable for the prevention of scd in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (arvd/c) who have 1 or more risk factors fo

4、r scd.i i iiiaiiaiiaiibiibiibiiiiiiiiii i iiiaiiaiiaiibiibiibiiiiiiiiii i iiiaiiaiiaiibiibiibiiiiiiiiiiiaiiaiiaiibiibiibiiiiiiiiiiiia iibiii(class ，level of evidence: b)(class a，level of evidence: c)iialacc/aha/hrs 2008guidelines for device-based therapy of cardiac rhythml2012年指南關(guān)于年指南關(guān)于arvc猝死二級(jí)預(yù)防未作調(diào)

5、整猝死二級(jí)預(yù)防未作調(diào)整 指南關(guān)于指南關(guān)于arvc猝死的一級(jí)預(yù)防猝死的一級(jí)預(yù)防scd危險(xiǎn)因素：危險(xiǎn)因素：有有1個(gè)以上者植入個(gè)以上者植入icd 作為作為scd的一級(jí)預(yù)防的一級(jí)預(yù)防 電生理檢查誘發(fā)室性心動(dòng)過(guò)速電生理檢查誘發(fā)室性心動(dòng)過(guò)速( vt) 心電監(jiān)護(hù)的非持續(xù)性心電監(jiān)護(hù)的非持續(xù)性vt 男性男性 嚴(yán)重右室擴(kuò)大嚴(yán)重右室擴(kuò)大, 廣泛右室受累廣泛右室受累 發(fā)病很早發(fā)病很早( 5 歲歲) 累及左室累及左室 心臟驟停史心臟驟停史 不能解釋的暈厥不能解釋的暈厥arvc-vt/scd：icd植入的循證證據(jù)植入的循證證據(jù)background:arrhythmogenic right ventricular card

6、iomyopathy/dysplasia (arvc/d) is a condition associated with the risk of sudden death (sd).methods and results:we conducted a multicenter study of the impact of the implantable cardioverter-defibrillator (icd) for prevention of sd in 132 patients (93 males and 39 females, age 40+/-15 years) with arv

7、c/d. implant indications were a history of cardiac arrest in 13 patients (10%), sustained ventricular tachycardia in 82 (62%), syncope in 21 (16%), and other in 16 (12%). during a mean follow-up of 39+/-25 months, 64 patients(48%) had appropriate icd interventions, 21 (16%) had inappropriate interve

8、ntions, and 19 (14%) had icd-related complications. fifty-three (83%) of the 64 patients with appropriate interventions received antiarrhythmic drug therapy at the time of first icd discharge. programmed ventricularstimulation was of limited value in identifying patients at risk of tachyarrhythmias

9、during the follow-up (positive predictive value 49%, negative predictive value 54%). four patients (3%) died, and 32 (24%) experienced ventricular fibrillation/flutter that in all likelihood would have been fatal in the absence of the device. at 36 months, the actual patient survival rate was 96% co

10、mpared with the ventricular fibrillation/flutter-free survival rate of 72% (p0.001). patients who received implants because of ventricular tachycardia without hemodynamic compromise had a significantly lower incidence of ventricular fibrillation/flutter (log rank=0.01). history of cardiac arrest or

11、ventricular tachycardia with hemodynamic compromise, younger age, and left ventricular involvement were independent predictors of ventricular fibrillation/flutter.conclusions:in patients with arvc/d, icd therapy provided life-saving protection by effectively terminating life-threatening ventricular

12、arrhythmias.patients who were prone to ventricular fibrillation/flutter could be identified on the basis of clinical presentation, irrespective of programmed ventricularstimulation outcome.circulation. 2003 dec 23;108(25):3084-91icd therapy for prevention of scd in arvc patientsu132 pts (93 m, age 4

13、0+/-15 y) with arvcuicd indications:history of cardiac arrest in 13 patients (10%) sustained vt in 82 (62%) syncope in 21 (16%), and other in 16 (12%)ufu:39+/-25 m: 64 patients(48%) :appropriate icd r 21 (16%) :inappropriate r 4 (3%) died at 36 months, the actual patient survival rate was 96% the ve

14、ntricular fibrillation/flutter-free survival rate of 72% uin patients with arvc/d, icd therapy provided life-saving protection by effectively terminating life-threatening ventricular circulation. 2003 dec 23;108(25):3084-91 84 pts arvc ： icd for scd一級(jí)預(yù)防一級(jí)預(yù)防 fu: 4.7+/3.4y： 48% icd intervention 19%：vf

15、 5年生存率：伴年生存率：伴1、2、3、4危險(xiǎn)因子的危險(xiǎn)因子的為為100%、83%、21%、15% ep誘發(fā)誘發(fā)vt/vf、nsvt是獨(dú)立預(yù)測(cè)因子是獨(dú)立預(yù)測(cè)因子首次放電時(shí)間和放電次數(shù)首次放電時(shí)間和放電次數(shù)icd電治療的影響因子電治療的影響因子危險(xiǎn)因子對(duì)生存率的影響危險(xiǎn)因子對(duì)生存率的影響結(jié)論：結(jié)論： arvc患者植入患者植入icd作為作為scd一級(jí)預(yù)防措施：一級(jí)預(yù)防措施：接近一半患者可有效預(yù)防接近一半患者可有效預(yù)防scdarvc室速：導(dǎo)管消融室速：導(dǎo)管消融需要考慮的幾個(gè)問(wèn)題需要考慮的幾個(gè)問(wèn)題 arvc室速的機(jī)制：疤痕折返，局灶室速的機(jī)制：疤痕折返，局灶 導(dǎo)管消融的成功率導(dǎo)管消融的成功率 遠(yuǎn)期復(fù)發(fā)

16、率遠(yuǎn)期復(fù)發(fā)率j am coll cardiol 2007;50:43240 24例患者例患者 48次消融次消融 隨訪隨訪3236months (range 1 day to 12 years)10次為三維電解剖標(biāo)測(cè)，次為三維電解剖標(biāo)測(cè)，38次為常規(guī)方法標(biāo)測(cè)次為常規(guī)方法標(biāo)測(cè)術(shù)后室速?gòu)?fù)發(fā)率高達(dá)術(shù)后室速?gòu)?fù)發(fā)率高達(dá)85%，隨訪，隨訪14個(gè)月無(wú)發(fā)作的比例僅為個(gè)月無(wú)發(fā)作的比例僅為15%，且不同的標(biāo)測(cè)方法，且不同的標(biāo)測(cè)方法之間未見(jiàn)顯著性差異，即使術(shù)中消除所有誘發(fā)出來(lái)的室速，仍然有極高的復(fù)發(fā)率之間未見(jiàn)顯著性差異，即使術(shù)中消除所有誘發(fā)出來(lái)的室速，仍然有極高的復(fù)發(fā)率南京醫(yī)科大學(xué)心臟科南京醫(yī)科大學(xué)心臟科動(dòng)動(dòng)態(tài)基質(zhì)標(biāo)

17、態(tài)基質(zhì)標(biāo)測(cè)指導(dǎo)測(cè)指導(dǎo)arvc-vt消融消融病例病例1病例病例2病例病例3apex心動(dòng)過(guò)速的標(biāo)測(cè)心動(dòng)過(guò)速的標(biāo)測(cè)v病例病例1：誘發(fā)一種類型室速，最早激動(dòng)點(diǎn)和出口靠近基質(zhì)邊：誘發(fā)一種類型室速，最早激動(dòng)點(diǎn)和出口靠近基質(zhì)邊緣，無(wú)完整折返環(huán)，無(wú)舒張中期電位，無(wú)峽部。緣，無(wú)完整折返環(huán)，無(wú)舒張中期電位，無(wú)峽部。v病例病例2：有：有2種類型室速，其中一例有完整的折返環(huán)路和舒種類型室速，其中一例有完整的折返環(huán)路和舒張中期電位，兩種室速形態(tài)不同、激動(dòng)傳導(dǎo)方向相反，但張中期電位，兩種室速形態(tài)不同、激動(dòng)傳導(dǎo)方向相反，但有共同的傳導(dǎo)通道位于三尖瓣環(huán)與基質(zhì)邊緣；一種室速的有共同的傳導(dǎo)通道位于三尖瓣環(huán)與基質(zhì)邊緣；一種室速的出

18、口位于基質(zhì)邊緣，另一種室速出口遠(yuǎn)離基質(zhì)。出口位于基質(zhì)邊緣，另一種室速出口遠(yuǎn)離基質(zhì)。v病例病例3：誘發(fā)兩種不同形態(tài)室速，無(wú)舒張中期電位，亦無(wú)峽：誘發(fā)兩種不同形態(tài)室速，無(wú)舒張中期電位，亦無(wú)峽部存在；一種室速起源于基質(zhì)內(nèi)并通過(guò)基質(zhì)傳導(dǎo)，出口位部存在；一種室速起源于基質(zhì)內(nèi)并通過(guò)基質(zhì)傳導(dǎo)，出口位于基質(zhì)邊緣，另一種室速起源稍遠(yuǎn)離基質(zhì)邊緣，而出口遠(yuǎn)于基質(zhì)邊緣，另一種室速起源稍遠(yuǎn)離基質(zhì)邊緣，而出口遠(yuǎn)離基質(zhì)。離基質(zhì)。vt1vt2病例病例2 病例病例312 lead ecg (slower vt) pacing at site apacing at site b 結(jié)果結(jié)果v病例病例1、2的三種臨床室速消融全部成功

19、，但病例的三種臨床室速消融全部成功，但病例2仍可仍可誘發(fā)一種新的非臨床類型室速，室速頻率快，電轉(zhuǎn)復(fù)誘發(fā)一種新的非臨床類型室速，室速頻率快，電轉(zhuǎn)復(fù)后未再行標(biāo)測(cè)，后選用可達(dá)龍治療。后未再行標(biāo)測(cè)，后選用可達(dá)龍治療。 v病例病例3在完成兩條線性消融后誘發(fā)出一種頻率較慢的室在完成兩條線性消融后誘發(fā)出一種頻率較慢的室速，經(jīng)非接觸球囊標(biāo)測(cè)此慢頻率室速通過(guò)兩條消融線速，經(jīng)非接觸球囊標(biāo)測(cè)此慢頻率室速通過(guò)兩條消融線之間的間隙傳導(dǎo)，消融此間隙后室速不再誘發(fā)。之間的間隙傳導(dǎo)，消融此間隙后室速不再誘發(fā)。v平均放電次數(shù)平均放電次數(shù)17次，每條消融線達(dá)到雙向傳導(dǎo)阻滯。次，每條消融線達(dá)到雙向傳導(dǎo)阻滯。無(wú)手術(shù)并發(fā)癥。平均隨訪無(wú)

20、手術(shù)并發(fā)癥。平均隨訪20月，無(wú)心動(dòng)過(guò)速發(fā)生。月，無(wú)心動(dòng)過(guò)速發(fā)生。 arvc-vt：心外膜消融：心外膜消融 percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia 17例患者（例患者（14+/-4y），心內(nèi)膜消融失?。膬?nèi)膜消融失敗 20 vts 誘發(fā)（誘發(fā)（2個(gè)大折返，個(gè)大折返，18個(gè)局灶）個(gè)局灶） 16

21、例（例（94.1%）即刻成功）即刻成功 隨訪隨訪 26 15 (range 6 to 42)月月 12人（人（70.6%）無(wú)室速發(fā)作）無(wú)室速發(fā)作heart rhythm. 2010 oct;7(10):1406-10arvc-vt：心外膜消融：心外膜消融 epicardial substrate and outcome with epicardial ablation of ventricular tachycardia in arrhythmogenic rightventricular cardiomyopathy/dysplasia. 33例患者中例患者中13例例（39.4%）心內(nèi)膜不能

22、完全成功，心內(nèi)膜不能完全成功，需要行心外膜消融需要行心外膜消融 13例心外膜消融后隨訪例心外膜消融后隨訪18+/-13 月月 10/13（77%）無(wú)）無(wú)vt發(fā)作發(fā)作garcia fc， circulation. 2009 aug 4;120(5):366-75arvc-vt：消融的長(zhǎng)期療效：消融的長(zhǎng)期療效 outcomes of catheter ablation of ventricular tachycardia in arrhythmogenic right ventriculardysplasia/cardiomyopathy 87例患者，例患者，175次消融次消融 平均隨訪平均隨訪8

23、8.366 月月 1年，年，5年，年，10年無(wú)室速發(fā)作比例分別為年無(wú)室速發(fā)作比例分別為47%，21%，15% 心外膜消融后心外膜消融后1年，年，5年無(wú)室速發(fā)作比例年無(wú)室速發(fā)作比例64%，45%circ arrhythm electrophysiol. 2012 jun 1;5(3):499-505arvc-vt消融：心內(nèi)或和心外仍有較高復(fù)發(fā)率，但能顯著減少消融：心內(nèi)或和心外仍有較高復(fù)發(fā)率，但能顯著減少vt負(fù)荷負(fù)荷 in reported series of rv scar-related vt, abolition of inducible vt is achieved in 41%88% o

24、f patients during average follow-ups of 1124 months, vt recurs in 11%83% of patients, with some series observing a significant incidence of late recurrences increasing with time catheter ablation in arvc/d can reduce frequent episodes of vt but long-term follow-up has demonstrated a continued risk o

25、f recurrence. recommendations for ablation are as stated for ablation for vt associated with structural heart disease in the indications section abovearvc-vt：消融的現(xiàn)狀與再認(rèn)識(shí)：消融的現(xiàn)狀與再認(rèn)識(shí) 即刻成功率高即刻成功率高 遠(yuǎn)期復(fù)發(fā)率也較高遠(yuǎn)期復(fù)發(fā)率也較高 三維標(biāo)測(cè)結(jié)合心外膜消融明顯提高成功率三維標(biāo)測(cè)結(jié)合心外膜消融明顯提高成功率 即使完全消融成功，考慮即使完全消融成功，考慮vt復(fù)發(fā)，仍不能復(fù)發(fā)，仍不能動(dòng)搖動(dòng)搖icd作為二級(jí)預(yù)防的適應(yīng)證作為

26、二級(jí)預(yù)防的適應(yīng)證 most patients who have vt related to structural heart disease will continue to have a standard indication for icd therapy for primary prevention. even when all vts have been rendered non-inducible by ablation, the recurrence rate remains substantial so that secondary prophylaxis remains ind

27、icated.arvc-vt：消融的時(shí)機(jī)？：消融的時(shí)機(jī)？ 植入植入icd之后？之后？ 植入后植入后vt反復(fù)發(fā)作，藥物效果欠佳，反復(fù)發(fā)作，藥物效果欠佳， atp成功率低，反復(fù)成功率低，反復(fù)shock 但費(fèi)用？但費(fèi)用？ 植入植入icd之前？之前？ 預(yù)防性消融預(yù)防性消融 減少發(fā)作，提高生活質(zhì)量減少發(fā)作，提高生活質(zhì)量 如不植入如不植入icd，有較大風(fēng)險(xiǎn)，有較大風(fēng)險(xiǎn)病例：男性，病例：男性，33歲，歲，arvc+smvt 2010年年3月月15日植入日植入icddft測(cè)試：首次測(cè)試：首次18j，失敗；第二次，失?。坏诙?，22j成功成功植入時(shí)的參數(shù)設(shè)置植入時(shí)的參數(shù)設(shè)置倍他樂(lè)克、可達(dá)龍倍他樂(lè)克、可達(dá)龍 植入

28、后植入后3周：周：electric storm問(wèn)題？問(wèn)題？哪些患者需要早期，或先行消融后植入哪些患者需要早期，或先行消融后植入icd，或，或icd植入后盡早消融植入后盡早消融? 術(shù)前室速發(fā)作對(duì)術(shù)前室速發(fā)作對(duì)aads不敏感，藥物不能終止不敏感，藥物不能終止或減少發(fā)作，預(yù)計(jì)植入后仍有較高的發(fā)生率或減少發(fā)作，預(yù)計(jì)植入后仍有較高的發(fā)生率 術(shù)中發(fā)現(xiàn)高術(shù)中發(fā)現(xiàn)高dft或術(shù)后住院期間觀察到或術(shù)后住院期間觀察到atp效效果欠佳果欠佳 電風(fēng)暴高危電風(fēng)暴高危arvc植入植入icd后電治療的高危因素后電治療的高危因素 history of cardiac arrest ventricular tachycardia

29、 with hemodynamic compromise younger age left ventricular involvement independent predictors of vf/ v flutter 這些人是否應(yīng)當(dāng)早期行導(dǎo)管消融？這些人是否應(yīng)當(dāng)早期行導(dǎo)管消融？circulation. 2003 dec 23;108(25):3084-91導(dǎo)管消融治療導(dǎo)管消融治療icd電風(fēng)暴電風(fēng)暴 catheter ablation for the treatment of electrical storm in patients with implantable cardioverter-

30、defibrillators: short- and long-term outcomes in a prospective single-center study. 95 pts (13 arvc, 72 cad, 10 dcm) 85 pts (89%) succeeded after 1-3 procedures fu:22 (1-43)m: 92% no es,66% no vt; 11(12%) diedcirculation. 2008 jan 29;117(4):462-9. 消融可有效治療急性期消融可有效治療急性期es，聯(lián)合，聯(lián)合aad可發(fā)揮長(zhǎng)期保護(hù)作用可發(fā)揮長(zhǎng)期保護(hù)作用prophylactic catheter ablation for the preventio