医学交流课件：器质性心肌病室速的导管消融

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1、心内科心内科 在在LVEF 25%LVEF 25%的患者导管消融可降低的患者导管消融可降低ESES的风险的风险Europace.2012;14(12):1734-9.心功能情况心功能情况在在LVEFLVEF30%的器质性心脏病患者器质性心脏病患者导管消融可以作为血流动力学稳定单形性室速的首选治疗Maury P,et al.Eur Heart J.2014 Feb 28.Pts with well-tolerated SMVT,SHD,and LVEF 30%undergoing primary VT ablation without a back-up ICD had a very low r

2、ate of arrhythmic death and recurrences were generally non-fatal.Sustained STe-Q and LVEF30%were independent a risk factors of recurrent VT/VF and ES in pts with structural heart diseasesEuropace.2012;14(5):675-81n=156心功能情况心功能情况ICDICD放电后行室速消融的患者与单纯药物放电后行室速消融的患者与单纯药物治疗相比有更低的长期死亡率和心衰住院治疗相比有更低的长期死亡率和心衰

3、住院Bunch TJ,et al.Heart Rhythm.2014 Apr;11(4):533-40.Shock,ablation n=102No shock,n=2088Shock,No ablationn=817Survival after shock therapy in ICD and CRT-D recipients according to rhythm shocked-The ALTITUDE survival by rhythm study MVT=monomorphic VT;NSVT=nonsustained VT;PMVT=polymorphic VT;SVT=supr

4、aventricular tachycardia;Powell BD,et al.J Am Coll Cardiol 2013;62:1674-1679.在在ICDICD患者预防性消融诱发的单形性室速患者预防性消融诱发的单形性室速(A)3D voltage mapping during sinus rhythm shows extending the low-voltage area and the scar in patient with prior inferior MI.(B)Induced VT was haemodynamically intolerated.Paced QRS mo

5、rphology at site with fragmented potential during sinus rhythm was similar to the VT QRS morphology.The intracardiac electrogram of the ablation catheter positioned at this area showed mid-diastolic potential during the induced VT.Substrate ablation was performed around this area.Hayashi T,et al.Eur

6、opace.2013;15(10):1507-15.Activation Sequence mappingEntrainment mappingPace mappingVoltage Mapping Delayed potential mapping 器质性心脏病室速的导管消融治疗器质性心脏病室速的导管消融治疗Isthmus identification by mechanisms Substrate Ablation Isolated Diastolic potentialsStable VTPre-systolic potentialIsolated Diastolic potential

7、Entrainment mapping导管消融治疗瘢痕相关性室速导管消融治疗瘢痕相关性室速Characterization of Endocardial EP Substrate in Pts With Nonischemic Cardiomyopathy&MVTHsia HH,et al.Circulation.2003;108(6):704-10.MVMVMVElectroanatomic substrate for VT in setting of RV CardiomyopathyMarchlinski FE,et al.Circulation.2004;110(16):2293-8.

8、Peritricuspid Peripulmonic Both valvular Usefulness of the contact force sensing catheter to assess the areas of myocardial scar in pts with VTMIZUNO H,et al.J Cardiovasc Electrophysiol.2013;24:519-524.APAPThe frequency of late potentials in poor contact group was significantly lower com-pared to go

9、od contact group(11.9 vs 23.2%;P200 ms,-Shotest RS complex(SRS)121 ms -V2导联本位转折时间(IDT)85ms -Maximum deflection index（MDI）最大转折指数，MDI0.55-特发性VT Berruezo A,et al.Circulation.2004;109:1842 Daniels DV,et al.Circulation.2006,113:1659 在有经验的消融中心，VT经心内膜途径消融失败后，行心外膜标测，而不管VT时QRS波群的形态 Tedrow.J Cardiovasc Electr

10、ophysiol.2009;20:710-713器质性心外膜VT体表ECG特征Berruezo A,et al.Circulation.2004;109:1842l体表体表ECGECG特征特征 假性假性波波34ms34ms QRSQRS起点至起点至V2V2最大最大转折顶点转折顶点85ms85ms 胸导最短胸导最短RSRS120ms120msl机制：机制：心外膜远离心外膜远离PurkinjePurkinje纤维纤维l意义意义 疤痕范围和部位有疤痕范围和部位有一定影响一定影响 提示提示VTVT出口在心外出口在心外膜，缓慢传导区未必膜，缓慢传导区未必 意义不如特发性？意义不如特发性？Endocard

11、ial or epicardial VT in NICMRole of 12-lead ECG criteria in clinical practice?IIIIIIaVRaVLaVFV1V2V3V4V5V6Piers SR,et al.Heart Rhythm.2014 Mar 4.IDT:intrinsicoid deflection time to R wave in V2;MDI:maximum deflection indexPDW:pseudo delta wave;Q-I:Q wave in lead I;SoO:site of origin;SRS:shortest RS c

12、omplexEndocardial or epicardial VT in NICMRole of 12-lead ECG criteria in clinical practice?Piers SR,et al.Heart Rhythm.2014 Mar 4.When applied to 25 mm/s ECGs of clinically documented VTs,none of the ECG criteria could differentiate between pts with and those without epicardial VTs.These data sugge

13、st that the ECG criteria do not allow identification of pts who are likely to benefit from a primary epicardial ablation approach.心外膜标测和消融的时机与基础心脏病的关系1717名特发性名特发性VAVA中只有中只有2 2人成功从心外膜消融人成功从心外膜消融Epicardial ablation of VT:an institutional experience of safety and efficacy.Tung R,et al.Heart Rhythm.2013

14、;10(4):490-8.心外膜标测和消融的时机与基础心脏病的关系Bai R,et al.Circ Arrhythm Electrophysiol.2011;(4):478-85.Substrate-based Ablation of VAs in ARVD/C心外膜标测和消融的时机心外膜标测和消融的时机Indications of Epicardial Ablation and Procedure ApproachesIndications of Epicardial Catheter Ablation Among CentersEpicardial ablation for VT:a Eu

15、ropean multicenter studyDella Bella P,et al.Circ Arrhythm Electrophysiol.2011;(5):653-9Dukkipati SR,et al.Circ Arrhythm Electrophysiol.2011;(2):185-94.In highly selected pts with HCM,combined epi-and endocardial mapping and ablation is a feasible and reasonably efficacious option for MMVT if refract

16、ory to aggressive trials of AADs and antitachycardia pacingLong-term outcomes of combined epi-and endocardial ablation of MMVT related to HCMKOMATSU Y,et al.J Cardiovasc Electrophysiol.2013;24:1426-1427,Multimodality Imaging to Improve the Safety and Efficacy of Epicardial Ablation of Scar-Related V

17、TSinus rhythm detection of conducting channels and VT isthmus in ARVCPosterior view of an endocardial bipolar electroanatomic map merged with CT.Fernndez-Armenta J,et al.Heart Rhythm.2014;11(5):747-54.心外膜标测和消融的时机80名非特发性 VT患者消融前行CE-CMR检查，77例成功导管消融患者(96.3%)在CE-CMR上均有局部心肌过度增强(hyper-enhancement,HE)。在VT成

18、功消融部位，3名患者无HE(3.9%)，19名(24.7%)在心内膜，36名为透壁性(46.7%)，8名在中层(10.4%)，心外膜下为11名(14.3%)。VT需行心外膜消融的ICM患者为3例(6.1%)、NICM12例(42.9%)。心外膜下HE预测心外膜起源VT的敏感性为84.6%、特异性为100%。Andreu D,et al.Eur Heart J.2014;35(20):1316-26Usefulness of contrast-enhanced cardiac magnetic resonance(CE-CMR)in identifying the VT substrate 心外

19、膜标测和消融的时机Andreu D,et al.Eur Heart J.2014;35(20):1316-26Endocardial HETransmural HEMid-myocardia HEEpicardial HECMR and CARTO map of two pts with mid-myocardial HEA/B:Endocardial ablation of PVCs originated from the RV.The distance to theboundary of the HE region was shorter from the RV than from the

20、 LV.C/D:Endocardial ablation from the LV.The distance to the boundary of the HE region was shorter from the LV than from the RV.A previous unsuccessful RF ablation was attempted from the RV.Andreu D,et al.Eur Heart J.2014;35(20):1316-26Nademanee K,et al.Circulation.2011;123(12):1270-1279.Prevention

21、of VF in BrS by ablation over the anterior RVOT epicardium 46名VT患者(18 ICM,13 NICM,15 ARVC)先行针对Endo-和Epi-LAVA（local abnormal ventricular activities）的心内膜消融。173次面对Epi-LAVA的心内膜消融中，48 次(28%)成功消除Epi-LAVA(ICM:20/71 28%,NICM:3/39 8%,ARVC:25/63 40%)，伴有Endo-LAVA、心内膜面单极电图幅度低、明显延迟和双极电图幅度低的Epi-LAVA以及Epi-LAVA处在CT

22、扫描上室壁较薄者成功率较高。在4名ICM和2名ARVC患者，心内膜面消融可消除全部Epi-LAVA，而NICM患者均需心外膜消融。在15名ICM(83%)、2名NICM(13%)和11名ARVC患者(73%)中，心内膜消融可部分消除Epi-LAVA。Komatsu Y,and Hassaguerre M,et al.J Am Coll Cardiol.2014;63(14):1416-2 Endocardial Ablation to Eliminate Epicardial Arrhythmia Substrate in Scar-Related VT心外膜标测和消融的时机Character

23、ization of contact force during Endocardial and Epicardial ventricular mappingJesel L,et al.Circ Arrhythm Electrophysiol.2014;7(6):1168-73.Inadequate epicardial point with VO pointing outward the myocardiumAdequate endocardial point with VO pointing outward the myocardiumVector Orientation:VOSacher

24、F,et al.Circ Arrhythm Electrophysiol.2013;6:144-150.Characterization of contact force during Endocardial and Epicardial ventricular mappingCharacterization of contact force during Epicardial ventricular mappingJesel L,et al.Circ Arrhythm Electrophysiol.2014;7(6):1168-73.A,CF in the epicardium when V

25、O is adequate.B,Percentage of adequate vectors.u导管消融适合于多种器质性心脏病室速；导管消融适合于多种器质性心脏病室速；u非缺血性心肌病室速的解剖基础多在左右心室基底部围非缺血性心肌病室速的解剖基础多在左右心室基底部围绕二、三尖瓣瓣环处，或右室流出道附近；绕二、三尖瓣瓣环处，或右室流出道附近；u通过激动标测和拖带识别室速的关键通过激动标测和拖带识别室速的关键“部位部位”是传统的是传统的消融方法，基质改良与传统标测、消融方法结合在合适消融方法，基质改良与传统标测、消融方法结合在合适的人群可提高手术成功率；的人群可提高手术成功率；u心外膜消融的时机：心外膜消融的时机：VTVT时时ECGECG特征、心内膜标测未见明特征、心内膜标测未见明显瘢痕区、心内膜消融失败、显瘢痕区、心内膜消融失败、ec-CMRec-CMR提示提示HEHE在心外膜；在心外膜；uLVEFLVEF影响非缺血性心肌病室速导管消融的疗效和预后，影响非缺血性心肌病室速导管消融的疗效和预后，猝死高危室速患者应植入猝死高危室速患者应植入ICDICD，植入，植入ICDICD后行导管消融可后行导管消融可减少减少ICDICD的治疗和住院率，改善患者预后。的治疗和住院率，改善患者预后。器质性心脏病室速的导管消融器质性心脏病室速的导管消融