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 2
17、002 124 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%,ODonnell Furniss Eur Heart J 2002 112 84-38% 6% 23% 61 mos 22% 11.6% 1.7%,No. patients Age (years SD) Sex (M) Site of MI (%a/i/m) No. VT morphol.s/pt Mean VT cl (ms) Pts with EF 30% Pt
18、s with ICD Acute success No. RF pulses Fluoro time Procedure dur. Postablation ICD,pVT 97 628 94% 29/60/11 1.9 407 81 23% 16% 72% 108 4025 19153 6.1%,iVT 27 6311 96% 25/40/35 1.7 412 83 62% 22% 78% 86 3424 18851 7.4%,p n.s. n.s. n.s. 0.05 n.s. n.s. 0.01 n.s. 0.63 0.35 0.41 0.82 0.73,Incessant vs par
19、oxysmal VT,Techniques for Ablation of VT-Carto mapping,Activation map/Propagation map/Voltage map Advantages: 3-D re-construction of activation wave-front (VT, SR)precision Identification of scar tissue, scar border zones and foci of VT ；areas w/ low voltage；areas w/ slow conduction enable real-time
20、 localization of the catheter allows the operator to return to previously ablated sites, facilitating the creation of contiguous lesions, necessary for linear ablation,purple being healthy tissue (1.5 mV) orange and red being low voltage or scarred regions (0.5 mV) green and blue being the scar bord
21、erzone (0.51.5 mV) the anterior wall and apex are scarred because of anterior MI,Internal Medicine Journal Volume 40, Issue 10, pages 673-681, 2010,Mapping of VT. A 3D real-time map of the ventricle (created during the procedure) merged with CT,Tung R et al. Circulation 2010;122:e389-e391,A 12-lead
22、ECG of clinical VT with a perfect pace map of the VT from the epicardium,Tung R et al. Circulation 2011;123:2284-2288,220,Techniques for Ablation of VT-EnSite mapping,非接触式标测：64多极网篮导管放在心室腔内，同时不同方向的监测6000个电图，能够根据单个心室激动构建3D心内膜电压和激动电图Advantage： 3-D re-construction of activation wave-front (VT, SR),retro
23、spectively studied 66 pts with previous MI and with ICD who also underwent RFCA for recurrent refractory VT During the follow-up only 19 pts (29%) showed VTs Pts with EF35% and 50% did not show any recurrent VT This study confirm the role of RFCA in reducing ICD therapies and also place RFCA in the
24、overall clinical management of recurrent post infarction VT according to the LV function,J Interv Card Electrophysiol, 2009 Sep;25(3):229-34,VT inducibility after radiofrequency ablation affects the outcomes in patients with CAD and ICD: The role of LV function,The frequency of VT during 6 months be
25、fore and after ablation for 142 pts with ICDs,Aliot E M et al. Europace 2009;11:771-817,Presented at HRS 2006,Primary Endpoint: Appropriate ICD therapies, mean follow-up 2 years,ICD implantation with substrate-based catheter ablation n=62,ICD alonen=64,126 pts not using AAD, prior MI, and either 18%
26、 VF arrest, 52% unstable VT, 21% had syncope and inducible VT and 9% prior ICD and single appropriate shock, Randomized. 13% female, mean age 66 yrs, 71% NYHA Class ll, 18% NYHA Class lll, Mean EF 31.7% 96% beta-blockers and 91%ACEI, MI was anterior in 41% of pts and 67% prior revascularization,Abla
27、tion was performed with electroanatomic mapping to delineate the endocardial infarct margins in sinus rhythm The radiofrequency ablation catheter used either a standard 4mm (n=10) or an irrigated 3.5 mm tip (n=52),Substrate Mapping and Ablation in Sinus Rhythm to Halt VT (SMASH-VT) trial,To evaluate
28、 treatment with ICD + catheter ablation compared with ICD among post MI pts with sustained VT/VF,Vivek Y. Reddy, N Engl J Med. 2007 December 27; 357(26): 26572665.,Primary End Point： Survival Free from ICD Therapy,Vivek Y. Reddy, N Engl J Med. 2007 December 27; 357(26): 26572665.,SMASH-VT Trial: Pri
29、mary Endpoint,Presented at HRS 2006,appropriate ICD therapy (%) p0.05,Incidence of appropriate ICD shock (%) p0.05,73%,Vivek Y. Reddy, N Engl J Med. 2007 December 27; 357(26): 26572665.,SMASH-VT Trial: Adverse Events,Presented at HRS 2006,In the ablation group, there was 1 pericardial effusion w/o t
30、amponade, 1 deep vein thrombosis, and 1 CHF exacerbation,Mortality among both patient groups (%) p=0.073,Vivek Y. Reddy, N Engl J Med. 2007 December 27; 357(26): 26572665.,Figure 3,Vivek Y. Reddy, N Engl J Med. 2007 December 27; 357(26): 26572665.,Secondary End Points,21 pts in ICD group(33%) and 8
31、pts in ICD+ ablation (12%) received appropriate ICD therapy (ATP or shocks) (HR 0.15 to 0.78, P = 0.007),20 in control group (31%) and 6 in ablation group (9%) received shocks,Vivek Y. Reddy, N Engl J Med. 2007 December 27; 357(26): 26572665.,Effect of Substrate Ablation on Ventricular Function: no
32、significant changes,SMASH-VT Trial: Summary,Among post-MI pts with sustained VT/VF, ICD with Substrate Mapping and catheter ablation in Sinus Rhythm was associated with a 73% reduction in appropriate ICD therapy through 2 years compared with ICD therapy alone,Presented at HRS 2006,Vivek Y. Reddy, N
33、Engl J Med. 2007 December 27; 357(26): 26572665.,Catheter Ablation of Recurrent Scar Related VT Using Electroanatomical Mapping and Irrigated Ablation Technology: Results of the Prospective Multicenter （EuroVT Study）,study was to assess the efficacy and safety of electroanatomical mapping in combina
34、tion with open-saline irrigated ablation technology for ablation of chronic recurrent mappable and unmappable VT in remote MI,J Cardiovasc Electrophysiol 2010 Jan;21(1):47-53,EuroVT Study study design,In 8 European center, 63 pts remote MI and presented with a median number of 17 (range 1-380) VTs i
35、n the preceding 6 months(89% males) enrolled 42 pts (66.7%) had an ICD before ablation, and another 9 pts (14.3%) received an ICD thereafter Incessant VT was in 14 pts (22%)，LVEF 30 +/- 13% A total of 164 VTs were targeted during ablation，mean of 3 VTs were targeted per patient and 22% of all pts ha
36、d only unmappable VT The mean follow-up period was 12 +/- 3 months,J Cardiovasc Electrophysiol 2010 Jan;21(1):47-53,Acutely successful in 51 pts (81%)， no death occurred in the trial 19 initially successful ablated pts (37%) developed VT recurrence In pts with VT recurrences, 79% had a significant r
37、eduction of ICD therapies. The mean number of ICD therapies was decreased significantly from 6070 before ablation to 1415 (23%) in the same period of time (6 months) after ablation This study demonstrate the high acute success rate and a low complication rate of irrigated tip catheter ablation of al
38、l clinical relevant VTs in remote MI,J Cardiovasc Electrophysiol 2010 Jan;21(1):47-53,EuroVT Study Conclusion,前瞻性，开放，随机，对照，16个欧洲中心进行的比较ICD同时进行和不进行VT消融治疗陈旧性MI，LVEF降低合并血流动力学稳定VT病人预后的影响研究 EP检查可以诱发临床意义的VT患者110例（1880岁），随机1：1分为ICD加消融组54例，和单纯ICD的对照组56例，随机按照中心和EF (30% or 30%)分层 消融组，7例 (13%)没有进行消融，因此消融组45例，对
39、照62例病人进行分析 平均随访 22.5 9 月,Catheter Ablation of Stable Ventricular Tachycardia Before Defibrillator Implantation in Patients with CAD (VTACH),The Lancet 2010 ；375（9708）： 31 - 40,VTACH,The primary endpoint (first recurrence of any documented VT or VF) was reached after a median of 19.5 mon in the ablat
40、ion group and 5.9 mon in the ICD only group (P = 0.01),22例消融病人每年累计发生685.5 VT/VF事件，43例对照组发现4,985.8次事件(P = 0.024)12个月，62%消融病人和40%对照病人无任何VT或VF事件 24个月时，分别为48%和29% 当仅考虑有EGM事件时 12M（ 62% 和40%, P = 0.01） 24M（ 48% vs 29%, P = 0.01） 抗心律失常药在消融组29%（45人中13例），对照组50%（62人中31人），(P = 0.021),The Lancet 2010 ；375（9708）
41、： 31 - 40,Primary endpoint by LV function Graphs show estimates for survival free from VT or VF in patients with different LVEF,VTACH,VT/VF比例：消融组较对照组少21%，每年平均ICD治疗次数对照组明显高于消融组 至少1次电击：消融组29%，对照组53%(P = 0.017) 24月无ICD电击存活：消融组和ICD组分别77%和48%(HR 0.4, 95% CI 0.20.8, P = 0.008) 不恰当电击数量两组相似,The Lancet 2010
42、；375（9708）： 31 - 40,VTACH,Secondary endpoint of hospital admission Estimates of survival free from hospital admission for cardiac reasons,二级终点：VT风暴，晕厥或死亡两组无区别 无因为心脏原因住院的生存在消融组高于对照组 (12月为78%和62%， 24个月73%和44%),Complications related to the ablation ccurred in 2 pts; no deaths within 30 days 15 device-r
43、elated complications requiring surgical intervention in 13 pts 9 pts died during the study (ablation group, 5; control group, 4),The Lancet 2010 ；375（9708）： 31 - 40,VT ablation before ICD in pts after 1st hemodynamically stable VT significantly prolonged the median time to first VT/VF from 5.9 mons
44、to 18.6 mons. The benefit was more pronounced in pts with LVEF30% VT ablation reduced the overall incidence of appropriate ICD interventions by 28% and ICD shocks by 43% VT ablation reduced the median number of appropriate ICD interventions per patient and year of follow-up by 93% VT ablation reduce
45、d the rate of hospitalizations for cardiac reasons VT ablation clearly prolonged time to recurrence of VT/VF episodes and markedly decreased VT/VF burden,VTACH study summary,The Lancet 2010 ；375（9708）： 31 - 40,小 结,目前虽不清楚也未证明导管消融VT可以取代ICD，彻底改善病人预后，但是，消融治疗确实给这些病人的治疗带来了新的希望 对多次ICD放电病人预防性导管消融减少VT/VF复发和I
46、CD治疗达43-73% 导管消融是终止和消除无休止VT和ICD电风暴的唯一方法 这些病人VT消融目的不是治愈所有异常传导通路，而是治疗临床相关的VT 消融失败多由于心脏结构问题，VT可能起源于心外膜或心肌内 VT复发多由于以往消融折返环路复发，但更多是由于缺血心脏病进展 消融手术相关死亡率为0，主要并发症3.8- 4.7%，相对安全 更好理解VT机制，如何制造损伤径线，更好标测工具，新型能源，新型消融导管（磁导航）可以提高手术成功率，使更多医生接受和推广该治疗手段 消融治疗目前作为ICD的辅助治疗，随经验增加，对室速机制的理解，大样本研究的进展，未来这一观点有可能改变 目前许多ICD病人很晚才被推荐导管消融，常常已经发生ICD多次放电的不良后果，强烈建议对于缺血性心脏病合并血流动力学稳定的单形性室速病人尽早尝试消融治疗，对于不源或无条件接受ICD治疗的病人应该首选,
