室性心律失常的治療策略

ManagingStrategiesofVentricularArrhythmias

AnatomicalLayoutoftheHeart室性心律失?！猄CD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UnderlyingArrhythmiasofSuddenCardiacArrestTorsadesdePointes

13%VT

62%Bradycardia

17%PrimaryVF

8%

心臟猝死的危險因素發(fā)生過心臟猝死事件發(fā)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室性心律失常的治療措施抗心律失常藥物治療電復(fù)律和電除顫心律復(fù)律除顫器（ICD）射頻導(dǎo)管消融外科手術(shù)治療基因治療?室性心律失常的藥物治療藥物選擇依據(jù)基礎(chǔ)心臟病變心功能狀態(tài)藥物副作用總體死亡率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(qiáng)的負(fù)性肌力作用和致心律失常作用應(yīng)避免使用室性早搏的藥物治療原則無器質(zhì)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(zhì)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PharmacologicalTherapyofVentricularArrhythmiasforPrimaryandSecondaryPreventionofSCDSCD的一級/二級藥物預(yù)防Well-designedprospectivetrialsinptswithCHFhavemadeitclearthatsurvivalisunchangedwithuseofAADTreatmentwithAmio.InptswithCHFintheGESICAtrialresultedinatrendtowardreductioninCHFhospita-lizationSCDandtotalmortality,whichcouldnotbere-producedinCHF-STATSummaryEvidencesdonotsupporttheuseAADforprimarypre-ventionofSCDinpost-MIorCHF-patientsNewandinvestigationalantiarrhythmicagentsIonchannelinhibitorsAzimilide

TedisamilDronedaroneCelivarone(SSR149744C)ATI-2042PM101 JTV-519 Ranolazine

Arialrepolarization-delayingagentsVernakalant(RSD1235)AVE-0118 AZD7009KCB-328 Tertiapin-Q

具有抗VA作用的上游藥物Angiotensinconvertingenzymeinhibitors(ACEIs)AngiotensinreceptorBlocker(ARBs)AldosteronereceptorantagonistsAntiinflammatoryagentsStatinsOmega-3polyunsaturatedfattyacidsVitaminC反復(fù)發(fā)生在非缺血性DCM患者的室性心律失常

Evidence-basedpredictors

CurvesforsurvivalwithoutarrhythmiarecurrencesinpatientstreatedwithACEI(n=57)andwithoutACEI(n=28)60%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%%MortalityReduction30%MADITII62yearsCOMPANION

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(jié)果顯示CRT-D降低全因死亡率36%Kaplan-MeierestimatesoftheprobabilityofsurvivalfreeofheartfailureinMADIT-CRT僅有8%的臨床適應(yīng)證患者最終接受ICD治療Source:GuidantestimatesICD一級預(yù)防死亡率下降超過二級預(yù)防13,4576二級預(yù)防死亡率的降低比一級預(yù)防高嗎？54%75%55%76%31%61%27months39months20months31%56%28%59%20%33%%MortalityReductionw/ICDRx%MortalityReductionw/ICDRx3Years3Years3YearsICD治療的相關(guān)問題ICD本身可增加心律失常事件發(fā)生率ICD的誤放電問題ICD的治療費(fèi)用較高ICD反復(fù)更換所導(dǎo)致的感染問題頻繁電休克導(dǎo)致患者的生活質(zhì)量下降以及心理問題ICD植入手術(shù)死亡率1%，嚴(yán)重并發(fā)癥3%ICD臨床試驗顯示ICD植入增加心律失常事件單導(dǎo)聯(lián)心電圖連續(xù)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(fā)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(zhuǎn)為室顫，之后第二次電擊又將室顫轉(zhuǎn)為另一種形態(tài)的室速，第三次電擊再次轉(zhuǎn)為室顫，由于ICD最后一次電擊，該患者發(fā)生了暈厥直到體外除顫。該患者之前除發(fā)作過數(shù)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(jīng)歷這次暈厥。

MADIT-II:ICD對VT/VF一次或一次以上準(zhǔn)確治療

36%室性心律失常的導(dǎo)管射頻消融

(特發(fā)性室速)特發(fā)性左室室速的射頻消融成功率一般85%左右，甚至可達(dá)90%以上特發(fā)性右室流出道室速的射頻消融成功率高達(dá)95%以上，并發(fā)癥低雖然ICD是器質(zhì)性心臟病室速(冠心病室速，先心病室速，ARVC和擴(kuò)心病室速)的一線治療措施，但導(dǎo)管消融仍然是重要的手段，其與抗心律失常藥物和ICD聯(lián)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室性心律失常的導(dǎo)管射頻消融

(器質(zhì)性心臟病室速)心肌梗死后室速的導(dǎo)管消融TheMulticenter

ThermocoolVentricularTachycardiaAblationTrialThermocool反復(fù)發(fā)作的室速患者231例(過去6個月發(fā)作平均11次)采用拖帶和/或電解剖基質(zhì)標(biāo)測技術(shù)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(fù)發(fā)心肌梗死后室速的導(dǎo)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(fā)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(jié)果隨訪6月，51%患者無復(fù)發(fā)隨訪12月，死亡率為8%CatheterAblationofMultipleVentricularTachycardiasAfterMyocardialInfarctionGuidedbyCombinedContactandNoncontactMappingFramesofsequentialunipolar

isopo-tentialmapsareshownaftercreationofalinearablationlesionatacriticalborderofpatient10.Theactivationsequencewasobservedduringrein-ductionofVT.Exitsitesof2VTs(E1andE2)wereincludedintheline;exitE3isaremotesitediscon-tinuoustothecriticalborder.Frame1,diastolicVTisthmusactivationapproachestheablationline.Frame2,thepreviouspathwaythatexitedatE1isblocked.Frame3,theactivationtakesadetourwithashiftedexitclosertoE2andactivatestheleftventricle.Frame4,myocardiumdistaltotheablationlineisnowactivatedlateRemoteMagneticNavigationtoGuideEndo-andEpicardialCatheterMappingofScar-RelatedVT27procedureson24ptswithahistoryofVTrelatedtoMI,DCM,ARVC,HCM,orSarcoidosis

75of77VTs(97%)wereultimatelyablatedConclusionsSafetyandfeasibilityofremotecatheternavigationtoperformsubstratemappingofscar-relatedVTWithaminimalamountoffluoroscopyexposureRemoteMagneticNavigationtoGuideEndo-andEpicardialCatheterMappingofScar-RelatedVTBBRT的導(dǎo)管消融CatheterAblationforARVC-VTRFCAofARVC-VTusingNon-contactmappingVTin32ARVC-ptswasinducedRegionalablationwasappliedbytargetingtheearliestVTactivationsitesAcutesuccessratewas84.4%(27/32)81.3%oftheptswerefreeofVTwithoutmedicationduringthe28.6±16monthfollow-up

Long-TermEfficacyofCatheterAblationofVTinptswithARVC24ptsintheJohnsHospitalsARVDregistryFollow-upfor32±36monthsForty(85%)

procedurewerefollowed

byrecurrenceConclusion:AhighrateofrecurrenceofVTinARVCptsARVCisadiffuseCMwithprogressivelyevolvingelectricalsubstrateSafetyandOutcomesofCryoablationforVAs

ResultsfromamulticenterexperienceStudypopulation:33pts,meanage54±8years15ptsendocardialablation13ptsepicardialablation5ptsaorticcuspablationAblationwassuccessfulin15(45%)ptsandunsuccessfulin18(55%)ptsCryoablationwassuccessfulinallparahisiancase(100%)Followupof24monts,allsuccessfulcasesfreefromVAs多形性室速和室顫的導(dǎo)管消融

2009年EHRA/HRS/ESC/ACC/AHA室速導(dǎo)管消融專家共識PLVT和VF導(dǎo)管消融適應(yīng)癥消融針對觸發(fā)多形性室速和室顫的室早小樣本研究結(jié)果提示消融可行，但需更多臨床研究證據(jù)僅局限在有經(jīng)驗的中心遺傳性心律失常的治療藥物治療特發(fā)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(fēng)暴ARVC、HCM:AAD有效非藥物治療特發(fā)性室顫、BrugadaSyndrome、SQTs：ICD療效肯定ARVC、HCM:ICD療效肯定，導(dǎo)管消融ARVC有一定效果PreventionofVFEpisodesinBrSbyCatheterAblationOvertheAnteriorRVOTEpicardiumNinePatswithTypeIBrSECGpatternandVFElectroanatomicmappingofRV(endo/epicardially),andepicardialmappingofLVduringSRUniqueabnormallowvoltage,andfractionatedlatepotentialsclusteringexclusivelyintheanterioraspectoftheRVOTepicardiumNormalizationoftheBrugadaECGpatternin89%Long-termoutcomes(20months)wereexcellent,withnorecurrentVT/VFinallpatientsoffmedicationPreventionofVFEpisodesinBrSbyCatheterAblationOvertheAnteriorRVOTEpicardiumCT與Carto圖像融合技術(shù)顯示RV,LV,Aorta,PA和CA。RVOT前壁心外膜靶點標(biāo)測顯示局部低電位，碎裂電位和電位時間長PreventionofVFEpisodesinBrSbyCatheterAblationOvertheAnteriorRVOTEpicardiumCT與Carto圖像融合技術(shù)顯示RV,LV,Aorta,PA和CA。RVOT前壁心外膜靶點標(biāo)測顯示局部低電壓，碎裂電位，電位時間長和除極延遲

BeforeAblation1Mo.PostAblation3Mo.PostAblationProphylacticCatheterAblation

forthePreventionofDefibrillatorTherapy

CatheterAblationofStableVentricularTachycardiabeforeICDimplantationinPatswithCAD(VTACH)

Kaplan-MeiercurvesfortheprimaryendpointCatheterAblationofStableVentricularTachycardiabeforeICDimplantationinPatswithCAD(VTACH)

Meta-analysisofcatheterablationasanadjuncttomedicaltherapyfortreatmentofVTinpatientswithstructuralheartdisease血流動力學(xué)穩(wěn)定

器質(zhì)性心臟病室速治療選擇AllPatsWithHemodynamicallyToleratedPostinfarctionVT:DoNotRequireanICD

Catheterablation,ifsuccessfulintheshortterm,confersbothqualitativeandquantitativeprotectionagainstVTrecurrencea