器质性心脏病完美版课件.ppt

1、器质性心脏病室性心律失常的分类室性心律失常的分类2006 ACC/AHA/ESC Guideline根据临床表现分类根据临床表现分类 血流动力学稳定血流动力学稳定无症状无症状症状轻微症状轻微心悸心悸 血流动力学不稳定血流动力学不稳定晕厥先兆晕厥先兆晕厥晕厥SCD心脏骤停心脏骤停根据心电图分类根据心电图分类 非持续性非持续性VT单形性单形性多形性多形性 持续性持续性VT单形性单形性多形性多形性 BBRT 双向性双向性VT和和TdP 心室扑动和颤动心室扑动和颤动室性心律失常的分类室性心律失常的分类2006 ACC/AHA/ESC Guideline根据基础疾病分类根据基础疾病分类 慢性冠状动脉性心

2、脏病慢性冠状动脉性心脏病 心力衰竭心力衰竭 先天性心脏病先天性心脏病 神经症神经症 非器质性心脏病非器质性心脏病 婴儿猝死综合征婴儿猝死综合征 心肌病心肌病DCMHCMARVCICD应用于应用于器质性心脏病器质性心脏病SCD的的二级预防二级预防 (临床研究临床研究AVID/CIDS/CASH 荟萃分析荟萃分析)2年内事件年内事件 ICD 可达龙可达龙 P 值值 (N=934)总死亡数总死亡数 200 255 P0.001 心律失常死亡数心律失常死亡数 61 117 P0.001 非心律失常死亡数非心律失常死亡数 139 138 ICD二级预防临床研究的提示二级预防临床研究的提示采用采用ICD治

3、疗有明确室性心律失常病史的治疗有明确室性心律失常病史的患者，每年可以挽救患者，每年可以挽救500条生命，而这仅条生命，而这仅占占SCD受害者总人数的受害者总人数的0.1%ICD的的一级预防研究一级预防研究 MADIT 96 196 EF 35%/ICD vs med ther 54%reduction in mortality with ICDMUSTT 99 704 EF 40%/ICD vs med ther 54%reduction in (EP guided)mortality with ICDMADIT II 02 1232 EF 35%ICD vs med ther 31%redu

4、ction in mortality with ICDDEFINITE 04 229 EF 36%ICD and med ther ICD reduced rate of vs med ther death-7.9%vs 14%COMPANION 04 1520 NYHA III-IV CRT or CRTD and CRT/CRTD was med ther vs med ther associated with a 36%reduct.of risk of deathSCD-HeFT 05 2521 EF 35%ICD+med ther vs med ther 23%reduction o

5、f +placebo vs med ther+Amio mortality with ICD Santini M,et al.Heart 2007;93:1479-1483研究资料来自一些病例报告与小样本研究总死亡数 200 255 P=120ms)主要终点：死亡或全因住院率主要终点：死亡或全因住院率二级终点：全因死亡率二级终点：全因死亡率COMPANION评价评价CRT或或CRT-D对心衰患者临床终点事件影响，结果显示对心衰患者临床终点事件影响，结果显示CRT-D 降低全因死亡率降低全因死亡率36%60%MUSTT55 years54%MADIT42 years20%CIDS33 years

6、37%CASH22 years31%AVID13 yearsICD与抗心律失常药物治疗与抗心律失常药物治疗在降低总死亡率方面的比较在降低总死亡率方面的比较0%10%20%30%40%50%60%Mortality Reduction1 The AVID Investigators.N Engl J Med.1997;337:1576-1583.2 Kuck,et al.Circulation.2000;102:748-754.3 Connolly,et al.Circulation.2000;101:1247-1302.4 Moss AJ.N Engl J Med.1996;335:1933-

7、1940.5 Buxton AE.N Engl J Med.1999;341:1882-1890.6 Moss.Investor Conference Call.November 27,2001.30%MADIT II62 yearsCost-Benefit Analysis of preventing Sudden Cardiac Deaths with an ICD versus AmiodaroneStudy in European(UK and France)ICDs decreased deaths during the 5 years from 37.0%to 29.7%at a

8、net cost of 26.222 to 20.008 per patient,cost-benefit rations of 0.17(UK)and 0.14(France)-more than a 5 to 1 return on investmentConclusion In these European countries where society values a life at more than 2 million.ICDs are a worthwhile investment compared with amiodarone for primary prevention

9、of SCD in pts with heart failure2007 International SPOR,1098-30Tolerated VT signals a risk of life-threatening arrhythmias期待VTACH II 的研究结果(both are 210 ms).DEFINITE 04 229 EF 36%ICD and med ther ICD reduced rate of2000;101:1247-1302.右束支是消融靶点，成功率100%mortality with ICD2002;346:877-83Follow up of 24 mo

10、nts,all successful cases free from VAs14(France)-more than a 5 to 1 return on investmentThe electrogram-QRS interval matches the stimulus-QRS intervalKaplan-Meier curves for the secondary endpoint of hospital admissionStevenson WG,et al.49%患者所有室速均成功Shown are the clinical slow VTat 585 ms(A),81%患者至少一

11、种室速消融成功总死亡数 200 255 P0.心肌梗死后室速的导管消融Number at risk2007 International SPOR,1098-30随防6个月，51%复发Jess Almendral and Mark E.ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of CRA ICD治疗适应证治疗适应证I 类类室颤或室颤或血流动力学不稳定的持续性室速血流动力学不稳定的持续性室速的心脏骤停的心脏骤停幸存者，病因明确且完全排除可逆因素幸存者，病因明确且完全排除可逆因素(证据等级：证据等级：C)器质性心脏病患者器质性心脏病患

12、者合合并自发并自发的的持续性室速持续性室速，不不论血论血流动力学是否稳定流动力学是否稳定(证据等级：证据等级：C)ICD治疗的相关问题治疗的相关问题 ICD本身可增加心律失常事件发生率本身可增加心律失常事件发生率 ICD的误放电问题的误放电问题 ICD的治疗费用较高的治疗费用较高 ICD反复更换所导致的感染问题反复更换所导致的感染问题 频繁电休克导致患者的生活质量下降以及心理问题频繁电休克导致患者的生活质量下降以及心理问题 ICD植入手术死亡率植入手术死亡率1%，严重并发症，严重并发症3%ICD治疗的相关问题治疗的相关问题MADIT II 研究中，根据死亡数绝对值下降推算，每预防研究中，根据死

13、亡数绝对值下降推算，每预防1次次SCD需要植入需要植入16台台ICD即使如此，仍然有未被识别的患者处于危险之中即使如此，仍然有未被识别的患者处于危险之中 N Engl J Med.2002;346:877-83Am Heart J.2007;153:951-9 J Cardiovasc Electrophysiol.2005;16 Suppl 1:S25-7J Cardiovasc Electrophysiol.2001;12:369-81ICD临床试验显示临床试验显示ICD植入增加心律失常事件植入增加心律失常事件ICD植入后事件显著增加植入后事件显著增加458例非缺血性心肌病患者随例非缺血性

14、心肌病患者随机分为标准药物组机分为标准药物组（STD）及标准药物及标准药物+ICD组组（ICD）STD组组15例猝死，例猝死，ICD组组3例例猝死猝死ICD组心律失常事件组心律失常事件（ICD放电放电+猝死猝死）显著多于显著多于STD组组DEFINITE Investigators.Circulation 2006;113:776-782单导联心电图连续记录显示了一例因多次单导联心电图连续记录显示了一例因多次ICD电击而致室颤晕厥的就诊患者，该患者自发电击而致室颤晕厥的就诊患者，该患者自发单形性室速时并无晕厥症状，单形性室速时并无晕厥症状，ICD第一次电击后将单形性室速转为室颤，之后第二次电击

15、第一次电击后将单形性室速转为室颤，之后第二次电击又将室颤转为另一种形态的室速，第三次电击再次转为室颤，由于又将室颤转为另一种形态的室速，第三次电击再次转为室颤，由于ICD最后一次电击，该最后一次电击，该患者发生了晕厥直到体外除颤。该患者之前除发作过数次单形性室速外从未有过晕厥以及患者发生了晕厥直到体外除颤。该患者之前除发作过数次单形性室速外从未有过晕厥以及心脏骤停。如果未置入心脏骤停。如果未置入ICD，该患者可能不会经历这次晕厥。，该患者可能不会经历这次晕厥。Almendral J et al.Circulation 2007;116:1204-1212 MADIT-II:ICD对对VT/VF

16、一次或一次以上准确治疗一次或一次以上准确治疗 36%年年电击复律的比例电击复律的比例SCD HeFT:从植入至从植入至VT/VF电击复律时间电击复律时间0.000.050.100.150.200.250.3001234581170740162223679Number at risk器质性心脏病器质性心脏病室速的导管消融室速的导管消融虽然虽然ICD是器质性心脏病室速的一线治疗手段，但是导管是器质性心脏病室速的一线治疗手段，但是导管消融及抗心律失常药物消融及抗心律失常药物(可达龙和可达龙和 受体阻滞剂受体阻滞剂)是其不可忽是其不可忽视的辅助治疗措施视的辅助治疗措施Catheter ablation

17、 is an important therapeutic option for controlling recurrent VAs in patients with heart diseaseZeppenfeld K and Stevenson WG.PACE 2008;31:358374器质性心脏病器质性心脏病室速的室速的导管消融导管消融下列室速推荐导管消融治疗下列室速推荐导管消融治疗 症状性症状性持续性单形性室速持续性单形性室速(SMVT),包括包括ICD终止的室速终止的室速,抗抗心律失常药物治疗后复发或抗心律失常药物不能耐受或不心律失常药物治疗后复发或抗心律失常药物不能耐受或不愿服用药物

18、的室速愿服用药物的室速 非可逆因素所致的非可逆因素所致的无休止性无休止性VT或室速风暴或室速风暴 束支折返性室速或分支型室速束支折返性室速或分支型室速 抗心律失常药物治疗无效的反复发生的抗心律失常药物治疗无效的反复发生的持续性多形性室速持续性多形性室速和室颤，如为触发灶引起者则可行消融治疗和室颤，如为触发灶引起者则可行消融治疗2009年年EHRA/HRS/ESC/ACC/AHA室速导管消融专家共识解读室速导管消融专家共识解读器质性心脏病器质性心脏病室速的导管消融室速的导管消融下列情况应当下列情况应当考虑考虑导管消融导管消融 尽管使用了一种或多种尽管使用了一种或多种类或类或类抗心律失常药物，但患

19、类抗心律失常药物，但患者仍有一次或多次者仍有一次或多次SMVT发作发作 陈旧性心肌梗死伴反复发生的陈旧性心肌梗死伴反复发生的SMVT患者、其患者、其LVEF30%且预计生存期且预计生存期1年，导管消融作为胺碘酮治疗外的年，导管消融作为胺碘酮治疗外的可以接受的选择性治疗措施可以接受的选择性治疗措施 陈旧性心肌梗死伴陈旧性心肌梗死伴LVEF35%，且且SMVT发作时血流动发作时血流动力学尚稳定者，力学尚稳定者，即使抗心律失常药物治疗可能有效，仍可即使抗心律失常药物治疗可能有效，仍可考虑导管消融考虑导管消融2009年年EHRA/HRS/ESC/ACC/AHA室速导管消融专家共识解读室速导管消融专家共

20、识解读of risk of deathSantini M,et al.Circulation 2006;113:776-7826%,FU:9.This likely reflects the fact that ARVC is a diffuse CM with progressively evolving electrical substrate2007;115:2697-2704心肌梗死后室速的导管消融Prophylactic Catheter Ablation for the Prevention of Defibrillator Therapy(SMASH)Kuck KH,et al.

21、下列情况应当考虑导管消融The benefit of secondary-prevention ICD therapy is difficult to challenge2002;346:877-83616 month follow-upForty(85%)procedure were followed by recurrenceForty(85%)procedure were followed by recurrenceThis likely reflects the fact that ARVC is a diffuse CM with progressively evolving ele

22、ctrical substrateSTD组15例猝死，ICD组3例猝死Kuck KH,et al.64 Pts with ICD/RFCA随访12月，死亡率为8%DEFINITE 04 229 EF 36%ICD and med ther ICD reduced rate ofHeart Rhythm 2011;8:968-974Scar-Related Reentrant VT心肌梗死后室速心肌梗死后室速的导管消融的导管消融 临床研究结果临床研究结果 19个中心共报导个中心共报导802例患者例患者 7296%患者至少成功消融一种室速患者至少成功消融一种室速 3072%患者成功消融所有诱发的室

23、速患者成功消融所有诱发的室速 手术相关的致死并发症为手术相关的致死并发症为0.5%13个研究平均随访个研究平均随访12个月以上，个月以上，5088%无复发无复发2009年年EHRA/HRS/ESC/ACC/AHA室速导管消融专家共识解读室速导管消融专家共识解读心肌梗死后室速心肌梗死后室速的导管消融的导管消融The Multicenter Thermocool Ventricular Tachycardia Ablation TrialThermocool 反复发作的室速患者反复发作的室速患者231例例(过去过去6个月发作平均个月发作平均11次次)采用拖带和采用拖带和/或电解剖基质标测技术或电解

24、剖基质标测技术 81%患者至少一种室速消融成功患者至少一种室速消融成功 49%患者所有室速均成功患者所有室速均成功 随防随防6个月，个月，51%复发复发Stevenson WG,et al.Circulation 2008;118:277382 心肌梗死后室速心肌梗死后室速的导管消融的导管消融The Euro-VT-Study 8个中心，入选个中心，入选63例，平均年龄例，平均年龄63岁，平均岁，平均LVEF28%平均可诱发平均可诱发3种室速，种室速，67%植入植入ICD 81%患者至少患者至少1种室速消融成功种室速消融成功 50%患者所有室速均成功消融患者所有室速均成功消融随访结果随访结果

25、随访随访6月，月，51%患者无复发患者无复发 随访随访12月，死亡率为月，死亡率为8%束支折返性室速束支折返性室速导管消融策略及处理导管消融策略及处理 多伴发于冠心病、瓣膜性心脏病或心肌病引起的心功能不全多伴发于冠心病、瓣膜性心脏病或心肌病引起的心功能不全 折返环由右束支折返环由右束支-心室肌心室肌-左束支左束支-希氏束希氏束-右束支构成右束支构成 右束支是消融靶点，成功率右束支是消融靶点，成功率100%即使窦律时呈即使窦律时呈LBBB，右束支消融后一般不会出现心脏传导阻滞，右束支消融后一般不会出现心脏传导阻滞，但术后但术后30%患者因心动过缓需要起搏治疗患者因心动过缓需要起搏治疗非缺血性心肌

26、病非缺血性心肌病BBRT的导管消融的导管消融 非缺血性扩张型心肌病合并室速的导管消融非缺血性扩张型心肌病合并室速的导管消融 19例例DCM合并合并SM室速，室速，14例经心内膜途径成功例经心内膜途径成功，随访，随访22个月，个月，5例患者无再发例患者无再发 另一项研究入选另一项研究入选22例患者，消融策略是如例患者，消融策略是如果心内膜消融失果心内膜消融失败则改为心外膜途径标测及消融败则改为心外膜途径标测及消融；术后随访；术后随访334天，天，46%患者室速再发，其中患者室速再发，其中1例患者死于心衰，例患者死于心衰，2例患者接受心脏例患者接受心脏移植移植非缺血性心肌病非缺血性心肌病室速的导管

27、消融室速的导管消融 Nazarian S,et al.Circulation 2005;112:28215 Soejima K,et al.J Am CollCardiol 2004;43:183442 Ablation of Ventricular Tachycardia in Patientswith Nonischemic CardiomyopathyAn effective ablation site in a patient with nonischemic cardiomyopathy.There is concealed entrainmentand a diastolic po

28、tential during VT.The electrogram-QRS interval matches the stimulus-QRS interval(both are 210 ms).Shown are leads I,II,III,V1,and V6 and the intracardiac tracings from the mappingcatheter(Map).Pacing cycle length is 450 ms and the VT cycle length is 490 ms.Epicardial and endocardial mapping data fro

29、m a patient with nonischemic cardiomyopathy心包穿刺心外膜标测消融示意图心包穿刺心外膜标测消融示意图Catheter Ablation of Multiple VT After MI Guided by Combined Contact and Noncontact MappingCirculation.2007;115:2697-2704(both are 210 ms).Dont offer complete protection against death from arrthymias64 Pts with ICD alone消融成功率 79.

30、17(UK)and 0.Lancet 2010;375-31-40CRT-D 降低全因死亡率36%心肌梗死后室速的导管消融Whether prophylactic RFCA of arrhymogenic ventricular tissue would reduce the incidence of ICD therapyCirculation 2007;116:224152Circulation 2008;118:2773822007;115:2697-2704患者 75岁,n=72 75岁,n=213 p值陈旧性心肌梗死伴LVEF35%，且SMVT发作时血流动力学尚稳定者，即使抗心律失常

31、药物治疗可能有效，仍可考虑导管消融This likely reflects the fact that ARVC is a diffuse CM with progressively evolving electrical substrateShown are the clinical slow VTat 585 ms(A),束支折返性室速或分支型室速束支折返性室速或分支型室速Although recurrence of a tolerated VT is not so rare,the SCD rate in these patients is extremely lowKuck KH,et

32、 al.vs med ther death-7.49%患者所有室速均成功Remote Magnetic Navigation to Guide Endocardial and Epicardial Catheter Mapping of Scar-Related Ventricular TachycardiaRemote map.and abl.of stable VTShown are the clinical slow VTat 585 ms(A),inferior views of the electroanatomicalactivation(B)and voltage(C)maps

33、during VT,and acardiac computed tomography scan Showing a calcified LV inferobasal scar(D)from a patient with post-MI VT(#1).E,At thestart of an attempt at entrainment from an inferior wall site deep within the scar(denotedby the black arrow in panel B),the first paced beat terminated the VT without

34、 manifest global ventricular capture.F,Just apical to this site(denoted by the red arrow in panel B),stable Diastolic potentials are seen during VT;entrainment with concealed fusion and a post-pacing interval equal to 585 ms were observed at this location.G,During remote RFCA at this site,the VTwas

35、eliminated in 4 s of commencing energy delivery研究资料来自一些病例报告与小样本研究研究资料来自一些病例报告与小样本研究 一项研究入选一项研究入选11例患者，例患者，诱发出的诱发出的15种室速均成功消融种室速均成功消融，随，随访访30个月，个月，91%患者无复发患者无复发 另一项研究入选另一项研究入选10例患者，均为法四矫正术后，采用非接触例患者，均为法四矫正术后，采用非接触标测系统成功标测标测系统成功标测13种诱发的室速，种诱发的室速，11种室速是大折返，种室速是大折返，8例例消融成功，随访期间消融成功，随访期间6例无复发例无复发先心脏病外科矫正

36、术后室速的导管消融先心脏病外科矫正术后室速的导管消融 Kriebel T,et al.J Am Coll Cardiol 2007;50:21628Zeppenfeld K,et al.Circulation 2007;116:224152ARVC室速的发生机理示意图室速的发生机理示意图Catheter Ablation for ARVC-VTVT in 32 ARVC-pts induced Mapping earliest VT activation using Non-Contact Mapping System Acute ablation success rate was 84.4%

37、(27/32)81.3%of the pts were free of VT without medication during the 28.616 month follow-upConclusion ARVC-VT can be abolished or improved significantly by Regional ablation under the guidance of Non-contact mapping Yan Yao et al.PACE 2007;30:526-533Long-Term Efficacy of Catheter Ablation of VT in p

38、ts with ARVC24 pts in the Johns Hospitals ARVD registry,who underwent 1 or more than RFA procedures for VT Follow-up for 3236 months A total of 48 RFCA procedure performed using Carto(n=10)or conventional(n=38)mapping Forty(85%)procedure were followed by recurrenceConclusion:A high rate of recurrenc

39、e in ARVC pts undergoing RFCA This likely reflects the fact that ARVC is a diffuse CM with progressively evolving electrical substrateDalal D,et al.JACC 2007;50:432-440ARRAY 非接触接触标测非接触接触标测 系统系统方方 法法 基质改良基质改良消融策略消融策略CARTO 基质起博标测基质起博标测 基质改良出口消融基质改良出口消融第一次成功率：第一次成功率：61.5%第二次成功率：第二次成功率：84.6%,FU:9.07.0(3

40、24)月月ARVC室速的导管消融室速的导管消融(南京医科大学第一附属医院南京医科大学第一附属医院)*导管消融导管消融21/44例例ARVC患者患者随访6月，51%患者无复发An aortic dissection occurred in aortic cuspCRT-D 降低全因死亡率36%from a patient with post-MI VT(#1).24 pts in the Johns Hospitals ARVD registry,who underwent 1 or more than RFA procedures for VTinferior wall site deep w

41、ithin the scar(denotedIn these European countries where society values a life at more than 2 million.N Engl J Med 2007;357:2657-2665Biase LD,et al.老年冠心病患者室速导管消融的安全性Circulation 2007;116:224152There is concealed entrainmentICD植入手术死亡率1%，严重并发症3%患者 75岁,n=72 75岁,n=213 p值ConclussionRFCA performed with use

42、of a substrate-based approach先心脏病外科矫正术后室速的导管消融非心律失常死亡数 139 13849%患者所有室速均成功start of an attempt at entrainment from anof stable VT49%患者所有室速均成功Safety and Outcomes of Cryoablation for VAs Results from a multicenter experienceStudy population:33 pts,mean age 54 8 years 15 pts endocardial ablation 13 pts

43、epicardial ablation 5 pts aortic cusp ablationAblation was successful in 15(45%)pts and unsuccessful in 18(55%)pts Cryoablation was successful in all parahisian case(100%)An aortic dissection occurred in aortic cusp Follow up of 24 monts,all successful cases free from VAsBiase LD,et al.Heart Rhythm

44、2011;8:968-974Safety and Outcomes of Cryoablation for VAs Results from a multicenter experienceConclussion Use of cryoablation for VAs has excellent success for arrhythmias near the His bundle Success rate at other sites appear less favorable Cryoablation may be considered as an alternative approach

45、 for reducing complication during ablation of VAs originating from sites close to other relevant cardiac structures(e.g.conduction system,coronary arteries)Biase LD,et al.Heart Rhythm 2011;8:968-974老年冠心病患者室速导管消融的安全性老年冠心病患者室速导管消融的安全性 患者患者 75岁岁,n=72 75岁岁,n=213 p值值消融成功率消融成功率 79.2%87.8%主要并发症主要并发症 5.6%2.

46、3%围手术期死亡率围手术期死亡率 2/72 9/213 0.74随访期死亡随访期死亡 50.0%35.2%0.08无无VT发生发生 63.9%60.1%0.80 K Inada,et al.Heart Rhythm 2010;7:740-744血流动力学稳定血流动力学稳定器质性心脏病室速治疗选择器质性心脏病室速治疗选择All Pats With Hemodynamically Tolerated Postinfarction VT:Do Not Require an ICD Catheter ablation confers both qualitative and quantitative

47、protection against VT recurrence and SCDAlthough recurrence of a tolerated VT is not so rare,the SCD rate in these patients is extremely lowCatheter ablation can be considered a therapeutic alternative for those patients with post-MI tolerated VT in whom the procedure produces a satisfactory short-t

48、erm result Jess Almendral and Mark E.Josephson,Circulation 2007;116;1204-1212血流动力学稳定血流动力学稳定器质性心脏病室速治疗选择器质性心脏病室速治疗选择Patients With Hemodynamically Tolerated VT Require ICDTolerated VT signals a risk of life-threatening arrhythmiasThe benefit of secondary-prevention ICD therapy is difficult to challeng

49、eSuccessful catheter ablation does not sufficiently reduce residual riskCallans DJ.Circulation 2007;116;1196-1203Prophylactic Catheter Ablation for the Prevention of Defibrillator Therapy(SMASH)Background ICD shocks Painfulness clinical depressionDont offer complete protection against death from arr

50、thymiasObjectiveRandomised trial to exam.Whether prophylactic RFCA of arrhymogenic ventricular tissue would reduce the incidence of ICD therapyReddy VY,et al.N Engl J Med 2007;357:2657-2665 Prophylactic Catheter Ablation for the Prevention of Defibrillator Therapy(SMASH)Methods Pts with a MI-history