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
2、Stable 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
3、LVEF 35%，心肌梗死后 40天、 NYHA II或 III级 NYHA II或 III级 LVEF 35%，非缺血性心肌病患者 心肌梗死所致 LVEF 30%，心肌梗死后 40天、 NYHA 级 心肌梗死所致非持续性 VT， LVEF 40%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.
4、69 Hazard ratio ICD better 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
5、.35 or less, NICM and PVCs 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 o
6、f SCD in Absence of Ventricular 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
7、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
8、 are otherwise at low risk for SCD and have sustained predominantly monomorphic VT that is drug resistant or intolerant, or who do not wish long-term drug therapy Ablation is indicated in patients with bundle-branch reentrant VT Ablation is indicated as adjunctive therapy in pts with an ICD who are
9、receiving multiple shocks as a result of sustained VT that is not manageable by reprogramming or changing drug therapy or who do not wish long-term drug therapy Ablation is indicated in patients with WPW syndrome resuscitated from sudden cardiac arrest due to AF and rapid conduction over the accesso
10、ry pathway causing VF I IIa IIb III II IIa IIb IIIIIIII IIa IIb IIIIIIII IIa IIb IIIIII2006 ACC/AHA/ESC Ventricular Arrhythmia 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 Sustain
11、ed VT: -not precisely identify the site of origin MARK E. JOSEPHSON, et al. Circulation 1981 LOCUS FINDINGS APICAL Q in L 1, V2 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
12、 an amplitude of 3 mV, duration 1.5 mV) orange and red being low voltage or scarred regions (35% 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 overall clinical management of recurrent post infarction VT according to the
13、 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 before and after ablation for 142 pts with ICDs Aliot E M et al. Europace 2009
14、;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 alone n=64 126 pts not using AAD, prior MI, and either 18% VF arrest, 52% unstable VT, 21% had syncope and inducible VT and 9% prior
15、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 Ablation was performed with electroanatomic mapping to delineate the endocardia
16、l 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 treatment with ICD + catheter ablation compared with ICD among post MI pts
17、 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: Primary Endpoint Presented at HRS 2006 15%33%0%10%20%30%A b l a t i o n G r o
18、u p C o n t r o l G r o u pappropriate ICD therapy (%) p0.05 Incidence of appropriate ICD shock (%) p0.05 10%31%0%10%20%30%A b l a t i o n G r o u p C o n t r o l G r o u p73% Vivek Y. Reddy, N Engl J Med. 2007 December 27; 357(26): 26572665. SMASH-VT Trial: Adverse Events Presented at HRS 2006 In t
19、he ablation group, there was 1 pericardial effusion w/o tamponade, 1 deep vein thrombosis, and 1 CHF exacerbation 7%17%0%5%10%15%20%A b l a t i o nG r o u pCo n t r o lG r o u pMortality among both patient groups (%) p=0.073 Vivek Y. Reddy, N Engl J Med. 2007 December 27; 357(26): 26572665. Figure 3
20、 Vivek Y. Reddy, N Engl J Med. 2007 December 27; 357(26): 26572665. Secondary End Points 21 pts in ICD group(33%) and 8 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 significant changes
