室性心律失常的治療策略

ManagingStrategiesofVentricularArrhythmias

室性心律失常的治療策略

ManagingStrategiAnatomicalLayoutoftheHeartAnatomicalLayoutoftheHeart室性心律失常—SCD的主要原因全球：9,000,000/年；平均生還率小于1％西歐：300,000/年；平均生還率2-3%美國：250,000-350,000/年中國：心血管疾病致死54萬/年室性心律失常—SCD的主要原因全球：9,000,000/UnderlyingArrhythmiasofSuddenCardiacArrestTorsadesdePointes

13%VT

62%Bradycardia

17%PrimaryVF

8%BayésdeLunaA.AmHeartJ

1989,117:151-159.UnderlyingArrhythmiasofSudd

心臟猝死的危險因素發生過心臟猝死事件發生過室性心動過速(VT)心肌梗塞后的患者(MI)冠狀動脈疾病(CAD)心衰患者肥厚性心肌病(HCM)LQTS、AQTS、BrS、CPVTEarlyRepolarization心臟猝死的危險因素發生過心臟猝死事件室性心律失常的治療措施抗心律失常藥物治療電復律和電除顫心律復律除顫器（ICD）射頻導管消融外科手術治療基因治療?室性心律失常的治療措施抗心律失常藥物治療室性心律失常的藥物治療藥物選擇依據基礎心臟病變心功能狀態藥物副作用總體死亡率室性心律失常的藥物治療藥物選擇依據室性心律失常的藥物治療抗心律失常藥物Ib,IC類藥物BetaBlockersAmiodaroneandSotalol鈣拮抗劑室性心律失常的藥物治療抗心律失常藥物合并心功能不全時的藥物選擇胺碘酮是較為理想的藥物索他洛爾不適用于心衰合并VT-阻滯劑可減低心梗后心衰并VT猝死率I類藥物因其較強的負性肌力作用和致心律失常作用應避免使用合并心功能不全時的藥物選擇胺碘酮是較為理想的藥物室性早搏的藥物治療原則無器質性心臟病也無癥狀的室早，一般不需要治療，如果癥狀明顯者可考慮藥物治療：-阻滯劑I類抗心律失常藥物鈣拮抗劑器質性心臟病室早并不一定要用藥物治療，如果癥狀明顯、AMI、左心功能差時者藥物治療室性早搏的藥物治療原則無器質性心臟病也無癥狀的室早，一般不需PharmacologicalTherapyofVentricularArrhythmiasforPrimaryandSecondaryPreventionofSCDRevEspCardiol2004;57:768-82PharmacologicalTherapyofVen室性心律失常的治療策略課件SCD的一級/二級藥物預防Well-designedprospectivetrialsinptswithCHFhavemadeitclearthatsurvivalisunchangedwithuseofAADTreatmentwithAmio.InptswithCHFintheGESICAtrialresultedinatrendtowardreductioninCHFhospita-lizationSCDandtotalmortality,whichcouldnotbere-producedinCHF-STATSummaryEvidencesdonotsupporttheuseAADforprimarypre-ventionofSCDinpost-MIorCHF-patientsSCD的一級/二級藥物預防Well-designedproNewandinvestigationalantiarrhythmicagentsIonchannelinhibitorsAzimilide TedisamilDronedaroneCelivarone(SSR149744C)ATI-2042PM101 JTV-519 Ranolazine Arialrepolarization-delayingagentsVernakalant(RSD1235)AVE-0118 AZD7009KCB-328 Tertiapin-Q

Newandinvestigationalantiar具有抗VA作用的上游藥物Angiotensinconvertingenzymeinhibitors(ACEIs)AngiotensinreceptorBlocker(ARBs)AldosteronereceptorantagonistsAntiinflammatoryagentsStatinsOmega-3polyunsaturatedfattyacidsVitaminCMurrayKT,etal.HeartRhythm2007;4:S88–S90具有抗VA作用的上游藥物Angiotensinconver反復發生在非缺血性DCM患者的室性心律失常Evidence-basedpredictors

CurvesforsurvivalwithoutarrhythmiarecurrencesinpatientstreatedwithACEI(n=57)andwithoutACEI(n=28)反復發生在非缺血性DCM患者的室性心律失常Evidence60%MUSTT55years54%MADIT42years20%CIDS33years37%CASH22years31%AVID13years室性心律失常的非藥物治療

(ICDvsAAD)0%10%20%30%40%50%60%%MortalityReduction1TheAVIDInvestigators.NEnglJMed.1997;337:1576-1583.2Kuck,etal.Circulation.2000;102:748-754.3Connolly,etal.Circulation.2000;101:1247-1302.4MossAJ.NEnglJMed.1996;335:1933-1940.5BuxtonAE.NEnglJMed.1999;341:1882-1890.6Moss.InvestorConferenceCall.November27,2001.30%MADITII62years60%MUSTT554%MADIT420%CIDS337%CCOMPANION

QRS>=120ms主要終點：死亡或全因住院率二級終點：全因死亡率COMPANION評價CRT或CRT-D對心衰患者臨床終點事件影響。結果顯示CRT-D降低全因死亡率36%COMPANIONQRS>=120ms主要終點：Kaplan-MeierestimatesoftheprobabilityofsurvivalfreeofheartfailureinMADIT-CRTMossAJ.CircJ2010;74:1038–1041Kaplan-Meierestimatesofthe僅有8%的臨床適應證患者最終接受ICD治療Source:Guidantestimates?GuidantServicesEurope2005僅有8%的臨床適應證患者最終接受ICD治療Source:1MossAJ.NEnglJMed.1996;335:1933-40.2BuxtonAE.NEnglJMed.1999;341:1882-90.3MossAJ.NEnglJMed.2002;346:877-834MossAJ.PresentedbeforeACC51stAnnualScientificSessions,LateBreakingClinicalTrials,March19,2002.5TheAVIDInvestigators.NEnglJMed.1997;337:1576-83.6KuckK.Circ.2000;102:748-54.7ConnollyS.Circ.2000:101:1297-1302.ICD一級預防死亡率下降超過二級預防13,4576二級預防死亡率的降低比一級預防高嗎？54%75%55%76%31%61%27months39months20months31%56%28%59%20%33%%MortalityReductionw/ICDRx%MortalityReductionw/ICDRx3Years3Years3Years1MossAJ.NEnglJMed.1996;ICD治療的相關問題ICD本身可增加心律失常事件發生率ICD的誤放電問題ICD的治療費用較高ICD反復更換所導致的感染問題頻繁電休克導致患者的生活質量下降以及心理問題ICD植入手術死亡率1%，嚴重并發癥3%ICD治療的相關問題ICD本身可增加心律失常事件發生率ICD臨床試驗顯示ICD植入增加心律失常事件ICD臨床試驗顯示ICD植入增加心律失常事件單導聯心電圖連續記錄顯示了一例因多次ICD電擊而致室顫暈厥的就診患者，該患者自發單形性室速時并無暈厥癥狀，ICD第一次電擊后將單形性室速轉為室顫，之后第二次電擊又將室顫轉為另一種形態的室速，第三次電擊再次轉為室顫，由于ICD最后一次電擊，該患者發生了暈厥直到體外除顫。該患者之前除發作過數次單形性室速外從未有過暈厥以及心臟驟停。如果未置入ICD，該患者可能不會經歷這次暈厥。AlmendralJetal.Circulation2007;116:1204-1212單導聯心電圖連續記錄顯示了一例因多次ICD電擊而致室顫暈厥的

MADIT-II:ICD對VT/VF一次或一次以上準確治療

36%MADIT-II:ICD對VT/VF一次或一次以上準確室性心律失常的導管射頻消融

(特發性室速)特發性左室室速的射頻消融成功率一般85%左右，甚至可達90%以上特發性右室流出道室速的射頻消融成功率高達95%以上，并發癥低室性心律失常的導管射頻消融

(特發性室速)特發性左室室速的射雖然ICD是器質性心臟病室速(冠心病室速，先心病室速，ARVC和擴心病室速)的一線治療措施，但導管消融仍然是重要的手段，其與抗心律失常藥物和ICD聯合治療，形成的所謂”雜交”治療措施，是目前臨床上通常采用的治療方法ZeppenfeldKandStevensonWG.PACE2008;31:358–374室性心律失常的導管射頻消融

(器質性心臟病室速)雖然ICD是器質性心臟病室速(冠心病室速，先心病室速，ARV心肌梗死后室速的導管消融TheMulticenterThermocoolVentricularTachycardiaAblationTrialThermocool反復發作的室速患者231例(過去6個月發作平均11次)采用拖帶和/或電解剖基質標測技術81%患者至少一種室速消融成功49%患者所有室速均成功隨防6個月，51%復發StevensonWG,etal.Circulation2008;118:2773–82心肌梗死后室速的導管消融TheMulticenterTh心肌梗死后室速的導管消融TheEuro-VT-Study8個中心，入選63例，平均年齡63歲，平均LVEF28%平均可誘發3種室速，67%植入ICD81%患者至少1種室速消融成功50%患者所有室速均成功消融隨訪結果隨訪6月，51%患者無復發隨訪12月，死亡率為8%TannerH,etal.JCardiovascElectrophysiol2009;publishedonlineJuly28.DOI:10.1111/j.1540-8167.2009.01563.x.心肌梗死后室速的導管消融TheEuro-VT-StudyTCatheterAblationofMultipleVentricularTachycardiasAfterMyocardialInfarctionGuidedbyCombinedContactandNoncontactMappingFramesofsequentialunipolarisopo-tentialmapsareshownaftercreationofalinearablationlesionatacriticalborderofpatient10.Theactivationsequencewasobservedduringrein-ductionofVT.Exitsitesof2VTs(E1andE2)wereincludedintheline;exitE3isaremotesitediscon-tinuoustothecriticalborder.Frame1,diastolicVTisthmusactivationapproachestheablationline.Frame2,thepreviouspathwaythatexitedatE1isblocked.Frame3,theactivationtakesadetourwithashiftedexitclosertoE2andactivatestheleftventricle.Frame4,myocardiumdistaltotheablationlineisnowactivatedlateCatheterAblationofMultipleRemoteMagneticNavigationtoGuideEndo-andEpicardialCatheterMappingofScar-RelatedVT27procedureson24ptswithahistoryofVTrelatedtoMI,DCM,ARVC,HCM,orSarcoidosis75of77VTs(97%)wereultimatelyablatedConclusionsSafetyandfeasibilityofremotecatheternavigationtoperformsubstratemappingofscar-relatedVTWithaminimalamountoffluoroscopyexposure

AryanaA,etal.,Circulation.2007;115:1191-1200RemoteMagneticNavigationtoRemoteMagneticNavigationtoGuideEndo-andEpicardialCatheterMappingofScar-RelatedVTRemoteMagneticNavigationtoBBRT的導管消融BBRT的導管消融CatheterAblationforARVC-VTRFCAofARVC-VTusingNon-contactmappingVTin32ARVC-ptswasinducedRegionalablationwasappliedbytargetingtheearliestVTactivationsitesAcutesuccessratewas84.4%(27/32)81.3%oftheptswerefreeofVTwithoutmedicationduringthe28.6±16monthfollow-up

YanYaoetal.PACE2007;30:526-533CatheterAblationforARVC-VTRLong-TermEfficacyofCatheterAblationofVTinptswithARVC24ptsintheJohnsHospitalsARVDregistryFollow-upfor32±36monthsForty(85%)

procedurewerefollowed

byrecurrenceConclusion:AhighrateofrecurrenceofVTinARVCptsARVCisadiffuseCMwithprogressivelyevolvingelectricalsubstrateDalalD,etal.JACC2007;50:432-440Long-TermEfficacyofCatheterSafetyandOutcomesofCryoablationforVAsResultsfromamulticenterexperienceStudypopulation:33pts,meanage54±8years15ptsendocardialablation13ptsepicardialablation5ptsaorticcuspablationAblationwassuccessfulin15(45%)ptsandunsuccessfulin18(55%)ptsCryoablationwassuccessfulinallparahisiancase(100%)Followupof24monts,allsuccessfulcasesfreefromVAsBiaseLD,etal.HeartRhythm2011;8:968-974SafetyandOutcomesofCryoabl多形性室速和室顫的導管消融

2009年EHRA/HRS/ESC/ACC/AHA室速導管消融專家共識PLVT和VF導管消融適應癥消融針對觸發多形性室速和室顫的室早小樣本研究結果提示消融可行，但需更多臨床研究證據僅局限在有經驗的中心多形性室速和室顫的導管消融

2009年EHRA/HRS/E遺傳性心律失常的治療藥物治療特發性室顫、SQTs：AAD藥物治療效果？LQTs:-阻滯劑有效BrugadaSyndrome：奎尼丁至少減少電風暴ARVC、HCM:AAD有效非藥物治療特發性室顫、BrugadaSyndrome、SQTs：ICD療效肯定ARVC、HCM:ICD療效肯定，導管消融ARVC有一定效果遺傳性心律失常的治療藥物治療PreventionofVFEpisodesinBrSbyCatheterAblationOvertheAnteriorRVOTEpicardiumNinePatswithTypeIBrSECGpatternandVFElectroanatomicmappingofRV(endo/epicardially),andepicardialmappingofLVduringSRUniqueabnormallowvoltage,andfractionatedlatepotentialsclusteringexclusivelyintheanterioraspectoftheRVOTepicardiumNormalizationoftheBrugadaECGpatternin89%Long-termoutcomes(20months)wereexcellent,withnorecurrentVT/VFinallpatientsoffmedicationNodemaneeK,etal.Circulation2011,123:1270-1279PreventionofVFEpisodesinBPreventionofVFEpisodesinBrSbyCatheterAblationOvertheAnteriorRVOTEpicardiumCT與Carto圖像融合技術顯示RV,LV,Aorta,PA和CA。RVOT前壁心外膜靶點標測顯示局部低電位，碎裂電位和電位時間長PreventionofVFEpisodesinBPreventionofVFEpisodesinBrSbyCatheterAblationOvertheAnteriorRVOTEpicardiumCT與Carto圖像融合技術顯示RV,LV,Aorta,PA和CA。RVOT前壁心外膜靶點標測顯示局部低電壓，碎裂電位，電位時間長和除極延遲PreventionofVFEpisodesinB

BeforeAblation1Mo.PostAblation3Mo.PostAblationNodemaneeK,etal.Circulation2011,123:1270-1279BeforeAblationProphylacticCatheterAblation

forthePreventionofDefibrillatorTherapyReddyVY,etalNewEnglJMed2007;357:2657-65ProphylacticCatheterAblationKuckKH,etal.Lancet2010;375-31-40

CatheterAblationofStableVentricularTachycardiabeforeICDimplantationinPatswithCAD(VTACH)

Kaplan-MeiercurvesfortheprimaryendpointKuckKH,etal.Lancet2010;CatheterAblationofStableVentricularTachycardiabeforeICDimplantationinPatswithCAD(VTACH)KuckKH,etal.Lancet2010;375-31-40CatheterAblationofStableVe

MallidiJ,etal.HeartRhythm2011;8:503-510Meta-analysisofcatheterablationasanadjuncttomedicaltherapyfortreatmentofVTinpatientswithstructuralheartdiseaseMallidiJ,etal.HeartRhyt血流動力學穩定

器質性心臟病室速治療選擇AllPatsWithHemodynamicallyToleratedPostinfarctionVT:DoNotRequireanICD

Catheterablation,ifsuccessfulintheshortterm,confersbothqualitativeandquantitativeprotectionagainstVTrecurrenceandSCDOfnote,althoughrecurrenceofatoleratedVTisnotsorare,theSCDrateinthesepatientsisextremelylowCatheterablationcanbeconsideredatherapeuticalternativeforthosepatientswithpost-MItoleratedVTinwhomtheprocedureproducesasatisfactoryshort-termresultJesúsAlmendralandMarkE.Josephson,Circulation2007;116;1204-1212血流動力學穩定

器質性心臟病室速治療選擇AllPatsW血流動力學穩定

器質性心臟病室速治療選擇PatientsWithHemodynamicallyToleratedVTRequireICDToleratedVTsignalsariskoflife-threateningarrhythmiasThebenefitofsecondary-preventionICDtherapyisdifficulttochallengeSuccessfulcatheterablationdoesnotsufficientlyreduceresidualriskCallansDJ.Circulation2007;116;1196-1203血流動力學穩定

器質性心臟病室速治療選擇PatientsW器質性心臟病室速治療:ICD/RFCA?

血流動力學不穩定VTICDICD

+RFCA

+MedICDRFCAICD

+

RFCA

+MedICD頻繁放電雜交治療雜交治療選擇血流動力學穩定VT器質性心臟病室速治療:ICD/RFCA?期待…….SMASH：ICD→RFCAVTACH:RFCA→ICDVTACHII:RFCA→noICD?期待VTACHII的研究結果期待更理想的導管消融技術：更精確的標測技術更滿意的消融導管更好的消融能量期待…….SMASH：ICD→RFCA

ThankYou

Tha室性心律失常的治療策略

ManagingStrategiesofVentricularArrhythmias

室性心律失常的治療策略

ManagingStrategiAnatomicalLayoutoftheHeartAnatomicalLayoutoftheHeart室性心律失常—SCD的主要原因全球：9,000,000/年；平均生還率小于1％西歐：300,000/年；平均生還率2-3%美國：250,000-350,000/年中國：心血管疾病致死54萬/年室性心律失常—SCD的主要原因全球：9,000,000/UnderlyingArrhythmiasofSuddenCardiacArrestTorsadesdePointes

13%VT

62%Bradycardia

17%PrimaryVF

8%BayésdeLunaA.AmHeartJ

1989,117:151-159.UnderlyingArrhythmiasofSudd

心臟猝死的危險因素發生過心臟猝死事件發生過室性心動過速(VT)心肌梗塞后的患者(MI)冠狀動脈疾病(CAD)心衰患者肥厚性心肌病(HCM)LQTS、AQTS、BrS、CPVTEarlyRepolarization心臟猝死的危險因素發生過心臟猝死事件室性心律失常的治療措施抗心律失常藥物治療電復律和電除顫心律復律除顫器（ICD）射頻導管消融外科手術治療基因治療?室性心律失常的治療措施抗心律失常藥物治療室性心律失常的藥物治療藥物選擇依據基礎心臟病變心功能狀態藥物副作用總體死亡率室性心律失常的藥物治療藥物選擇依據室性心律失常的藥物治療抗心律失常藥物Ib,IC類藥物BetaBlockersAmiodaroneandSotalol鈣拮抗劑室性心律失常的藥物治療抗心律失常藥物合并心功能不全時的藥物選擇胺碘酮是較為理想的藥物索他洛爾不適用于心衰合并VT-阻滯劑可減低心梗后心衰并VT猝死率I類藥物因其較強的負性肌力作用和致心律失常作用應避免使用合并心功能不全時的藥物選擇胺碘酮是較為理想的藥物室性早搏的藥物治療原則無器質性心臟病也無癥狀的室早，一般不需要治療，如果癥狀明顯者可考慮藥物治療：-阻滯劑I類抗心律失常藥物鈣拮抗劑器質性心臟病室早并不一定要用藥物治療，如果癥狀明顯、AMI、左心功能差時者藥物治療室性早搏的藥物治療原則無器質性心臟病也無癥狀的室早，一般不需PharmacologicalTherapyofVentricularArrhythmiasforPrimaryandSecondaryPreventionofSCDRevEspCardiol2004;57:768-82PharmacologicalTherapyofVen室性心律失常的治療策略課件SCD的一級/二級藥物預防Well-designedprospectivetrialsinptswithCHFhavemadeitclearthatsurvivalisunchangedwithuseofAADTreatmentwithAmio.InptswithCHFintheGESICAtrialresultedinatrendtowardreductioninCHFhospita-lizationSCDandtotalmortality,whichcouldnotbere-producedinCHF-STATSummaryEvidencesdonotsupporttheuseAADforprimarypre-ventionofSCDinpost-MIorCHF-patientsSCD的一級/二級藥物預防Well-designedproNewandinvestigationalantiarrhythmicagentsIonchannelinhibitorsAzimilide TedisamilDronedaroneCelivarone(SSR149744C)ATI-2042PM101 JTV-519 Ranolazine Arialrepolarization-delayingagentsVernakalant(RSD1235)AVE-0118 AZD7009KCB-328 Tertiapin-Q

Newandinvestigationalantiar具有抗VA作用的上游藥物Angiotensinconvertingenzymeinhibitors(ACEIs)AngiotensinreceptorBlocker(ARBs)AldosteronereceptorantagonistsAntiinflammatoryagentsStatinsOmega-3polyunsaturatedfattyacidsVitaminCMurrayKT,etal.HeartRhythm2007;4:S88–S90具有抗VA作用的上游藥物Angiotensinconver反復發生在非缺血性DCM患者的室性心律失常Evidence-basedpredictors

CurvesforsurvivalwithoutarrhythmiarecurrencesinpatientstreatedwithACEI(n=57)andwithoutACEI(n=28)反復發生在非缺血性DCM患者的室性心律失常Evidence60%MUSTT55years54%MADIT42years20%CIDS33years37%CASH22years31%AVID13years室性心律失常的非藥物治療

(ICDvsAAD)0%10%20%30%40%50%60%%MortalityReduction1TheAVIDInvestigators.NEnglJMed.1997;337:1576-1583.2Kuck,etal.Circulation.2000;102:748-754.3Connolly,etal.Circulation.2000;101:1247-1302.4MossAJ.NEnglJMed.1996;335:1933-1940.5BuxtonAE.NEnglJMed.1999;341:1882-1890.6Moss.InvestorConferenceCall.November27,2001.30%MADITII62years60%MUSTT554%MADIT420%CIDS337%CCOMPANION

QRS>=120ms主要終點：死亡或全因住院率二級終點：全因死亡率COMPANION評價CRT或CRT-D對心衰患者臨床終點事件影響。結果顯示CRT-D降低全因死亡率36%COMPANIONQRS>=120ms主要終點：Kaplan-MeierestimatesoftheprobabilityofsurvivalfreeofheartfailureinMADIT-CRTMossAJ.CircJ2010;74:1038–1041Kaplan-Meierestimatesofthe僅有8%的臨床適應證患者最終接受ICD治療Source:Guidantestimates?GuidantServicesEurope2005僅有8%的臨床適應證患者最終接受ICD治療Source:1MossAJ.NEnglJMed.1996;335:1933-40.2BuxtonAE.NEnglJMed.1999;341:1882-90.3MossAJ.NEnglJMed.2002;346:877-834MossAJ.PresentedbeforeACC51stAnnualScientificSessions,LateBreakingClinicalTrials,March19,2002.5TheAVIDInvestigators.NEnglJMed.1997;337:1576-83.6KuckK.Circ.2000;102:748-54.7ConnollyS.Circ.2000:101:1297-1302.ICD一級預防死亡率下降超過二級預防13,4576二級預防死亡率的降低比一級預防高嗎？54%75%55%76%31%61%27months39months20months31%56%28%59%20%33%%MortalityReductionw/ICDRx%MortalityReductionw/ICDRx3Years3Years3Years1MossAJ.NEnglJMed.1996;ICD治療的相關問題ICD本身可增加心律失常事件發生率ICD的誤放電問題ICD的治療費用較高ICD反復更換所導致的感染問題頻繁電休克導致患者的生活質量下降以及心理問題ICD植入手術死亡率1%，嚴重并發癥3%ICD治療的相關問題ICD本身可增加心律失常事件發生率ICD臨床試驗顯示ICD植入增加心律失常事件ICD臨床試驗顯示ICD植入增加心律失常事件單導聯心電圖連續記錄顯示了一例因多次ICD電擊而致室顫暈厥的就診患者，該患者自發單形性室速時并無暈厥癥狀，ICD第一次電擊后將單形性室速轉為室顫，之后第二次電擊又將室顫轉為另一種形態的室速，第三次電擊再次轉為室顫，由于ICD最后一次電擊，該患者發生了暈厥直到體外除顫。該患者之前除發作過數次單形性室速外從未有過暈厥以及心臟驟停。如果未置入ICD，該患者可能不會經歷這次暈厥。AlmendralJetal.Circulation2007;116:1204-1212單導聯心電圖連續記錄顯示了一例因多次ICD電擊而致室顫暈厥的

MADIT-II:ICD對VT/VF一次或一次以上準確治療

36%MADIT-II:ICD對VT/VF一次或一次以上準確室性心律失常的導管射頻消融

(特發性室速)特發性左室室速的射頻消融成功率一般85%左右，甚至可達90%以上特發性右室流出道室速的射頻消融成功率高達95%以上，并發癥低室性心律失常的導管射頻消融

(特發性室速)特發性左室室速的射雖然ICD是器質性心臟病室速(冠心病室速，先心病室速，ARVC和擴心病室速)的一線治療措施，但導管消融仍然是重要的手段，其與抗心律失常藥物和ICD聯合治療，形成的所謂”雜交”治療措施，是目前臨床上通常采用的治療方法ZeppenfeldKandStevensonWG.PACE2008;31:358–374室性心律失常的導管射頻消融

(器質性心臟病室速)雖然ICD是器質性心臟病室速(冠心病室速，先心病室速，ARV心肌梗死后室速的導管消融TheMulticenterThermocoolVentricularTachycardiaAblationTrialThermocool反復發作的室速患者231例(過去6個月發作平均11次)采用拖帶和/或電解剖基質標測技術81%患者至少一種室速消融成功49%患者所有室速均成功隨防6個月，51%復發StevensonWG,etal.Circulation2008;118:2773–82心肌梗死后室速的導管消融TheMulticenterTh心肌梗死后室速的導管消融TheEuro-VT-Study8個中心，入選63例，平均年齡63歲，平均LVEF28%平均可誘發3種室速，67%植入ICD81%患者至少1種室速消融成功50%患者所有室速均成功消融隨訪結果隨訪6月，51%患者無復發隨訪12月，死亡率為8%TannerH,etal.JCardiovascElectrophysiol2009;publishedonlineJuly28.DOI:10.1111/j.1540-8167.2009.01563.x.心肌梗死后室速的導管消融TheEuro-VT-StudyTCatheterAblationofMultipleVentricularTachycardiasAfterMyocardialInfarctionGuidedbyCombinedContactandNoncontactMappingFramesofsequentialunipolarisopo-tentialmapsareshownaftercreationofalinearablationlesionatacriticalborderofpatient10.Theactivationsequencewasobservedduringrein-ductionofVT.Exitsitesof2VTs(E1andE2)wereincludedintheline;exitE3isaremotesitediscon-tinuoustothecriticalborder.Frame1,diastolicVTisthmusactivationapproachestheablationline.Frame2,thepreviouspathwaythatexitedatE1isblocked.Frame3,theactivationtakesadetourwithashiftedexitclosertoE2andactivatestheleftventricle.Frame4,myocardiumdistaltotheablationlineisnowactivatedlateCatheterAblationofMultipleRemoteMagneticNavigationtoGuideEndo-andEpicardialCatheterMappingofScar-RelatedVT27procedureson24ptswithahistoryofVTrelatedtoMI,DCM,ARVC,HCM,orSarcoidosis75of77VTs(97%)wereultimatelyablatedConclusionsSafetyandfeasibilityofremotecatheternavigationtoperformsubstratemappingofscar-relatedVTWithaminimalamountoffluoroscopyexposure

AryanaA,etal.,Circulation.2007;115:1191-1200RemoteMagneticNavigationtoRemoteMagneticNavigationtoGuideEndo-andEpicardialCatheterMappingofScar-RelatedVTRemoteMagneticNavigationtoBBRT的導管消融BBRT的導管消融CatheterAblationforARVC-VTRFCAofARVC-VTusingNon-contactmappingVTin32ARVC-ptswasinducedRegionalablationwasappliedbytargetingtheearliestVTactivationsitesAcutesuccessratewas84.4%(27/32)81.3%oftheptswerefreeofVTwithoutmedicationduringthe28.6±16monthfollow-up

YanYaoetal.PACE2007;30:526-533CatheterAblationforARVC-VTRLong-TermEfficacyofCatheterAblationofVTinptswithARVC24ptsintheJohnsHospitalsARVDregistryFollow-upfor32±36monthsForty(85%)

procedurewerefollowed

byrecurrenceConclusion:AhighrateofrecurrenceofVTinARVCptsARVCisadiffuseCMwithprogressivelyevolvingelectricalsubstrateDalalD,etal.JACC2007;50:432-440Long-TermEfficacyofCatheterSafetyandOutcomesofCryoablationforVAsResultsfromamulticenterexperienceStudypopulation:33pts,meanage54±8years15ptsendocardialablation13ptsepicardialablation5ptsaorticcuspablationAblationwassuccessfulin15(45%)ptsandunsuccessfulin18(55%)ptsCryoablationwassuccessfulinallparahisiancase(100%)Followupof24monts,allsuccessfulcasesfreefromVAsBiaseLD,etal.HeartRhythm2011;8:968-974SafetyandOutcomesofCryoabl多形性室速和室顫的導管消融

2009年EHRA/HRS/ESC/ACC/AHA室速導管消融專家共識PLVT和VF導管消融適應癥消融針對觸發多形性室速和室顫的室早小樣本研究結果提示消融可行，但需更多臨床研究證據僅局限在有經驗的中心多形性室速和室顫的導管消融

2009年EHRA/HRS/E遺傳性心律失常的治療藥物治療特發性室顫、SQTs：AAD藥物治療效果？LQTs:-阻滯劑有效BrugadaSyndrome：奎尼丁至少減少電風暴ARVC、HCM:AAD有效非藥物治療特發性室顫、BrugadaSyndrome、SQTs：ICD療效肯定ARVC、HCM:ICD療效肯定，導管消融ARVC有一定效果遺傳性心律失常的治療藥物治療PreventionofVFEpisodesinBrSbyCatheterAblationOvertheAnteriorRVOTEpicardiumNinePatswithTypeIBrSECGpatternandVFElectroanatomicmappingofRV(endo/epicardially),andepicardialmappingofLVduringSRUniqueabnormallowvoltage,andfractionatedlatepotentialsclusteringexclusivelyintheanterioraspectoftheRVOTepicardiumNormalizationoftheBrugadaECGpatternin89%Long-termoutcomes(20months)wereexcellent,withnorecurrentVT/VFinallpatientsoffmedicationNodemaneeK,etal.Circulation2011,123:1270-1279PreventionofVFEpisodesinBPreventionofVFEpisodesinBrSbyCatheterAblationOvertheAnteriorRVOTEpicardiumCT與Carto圖像融合技術顯示RV,LV,Aorta,PA和CA。RVOT前壁心外膜靶點標測顯示局部低電位，碎裂電位和電位時間長PreventionofVFEpisodesinBPreventionofVFEpisodesinBrSbyCatheterAblationOvertheAnteriorRVOTEpicardiumCT與Carto圖像融合技術顯示RV,LV