器質(zhì)性心臟病室速的導(dǎo)管消融課件

1、器質(zhì)性心肌病室速的導(dǎo)管消融 在LVEF 25%的患者導(dǎo)管消融可降低ES的風(fēng)險(xiǎn)Europace. 2012;14(12):1734-9.心功能情況在LVEF30%的器質(zhì)性心臟病患者導(dǎo)管消融可以作為血流動(dòng)力學(xué)穩(wěn)定單形性室速的首選治療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 rate of arrhythmic death and

2、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心功能情況ICD放電后行室速消融的患者與單純藥物治療相比有更低的長期死亡率和心衰住院Bunch TJ, et al. Heart Rhythm. 2014 Apr;11(4):533-40.Shock, abl

3、ation 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 = supraventricular tachycardia;Powell BD, et al. J Am

4、Coll Cardiol 2013;62:1674-1679.在ICD患者預(yù)防性消融誘發(fā)的單形性室速(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 morphology at site with fragmented potential during sinus rhyth

5、m 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. Europace. 2013;15(10):1507-15. Activation Sequence mappingEn

6、trainment mappingPace mappingVoltage Mapping Delayed potential mapping 器質(zhì)性心臟病室速的導(dǎo)管消融治療Isthmus identification by mechanisms Substrate Ablation Isolated Diastolic potentialsStable VTPre-systolic potentialIsolated Diastolic potentialEntrainment mapping導(dǎo)管消融治療瘢痕相關(guān)性室速Characterization of Endocardial EP Sub

7、strate in Pts With Nonischemic Cardiomyopathy & MVTHsiaHH, et al. Circulation.2003;108(6):704-10.MVMVMVElectroanatomic substrate for VT in setting of RV CardiomyopathyMarchlinskiFE, et al. Circulation.2004;110(16):2293-8. Peritricuspid Peripulmonic Both valvular Usefulness of thecontactforcesensing

8、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 good contact group (11.9 vs 23.2%; P200 ms, - Shotest RS complex (SRS) 121 ms -

9、V2導(dǎo)聯(lián)本位轉(zhuǎn)折時(shí)間(IDT) 85ms - Maximum deflection index（MDI）最大轉(zhuǎn)折指數(shù)， MDI0.55-特發(fā)性VT Berruezo A, et al. Circulation. 2004;109:1842 Daniels DV, et al. Circulation. 2006,113:1659在有經(jīng)驗(yàn)的消融中心，VT經(jīng)心內(nèi)膜途徑消融失敗后，行心外膜標(biāo)測，而不管VT時(shí)QRS波群的形態(tài) Tedrow. J Cardiovasc Electrophysiol. 2009;20:710-713器質(zhì)性心外膜VT體表ECG特征Berruezo A, et al. Cir

10、culation. 2004;109:1842體表ECG特征 假性波34ms QRS起點(diǎn)至V2最大轉(zhuǎn)折頂點(diǎn)85ms 胸導(dǎo)最短RS120ms機(jī)制：心外膜遠(yuǎn)離Purkinje纖維意義 疤痕范圍和部位有一定影響 提示VT出口在心外膜，緩慢傳導(dǎo)區(qū)未必 意義不如特發(fā)性？Endocardial or epicardial VT in NICMRole of 12-lead ECG criteria in clinical practice?IIIIIIaVRaVLaVFV1V2V3V4V5V6Piers SR, et al. Heart Rhythm. 2014 Mar 4. IDT: intrinsic

11、oid 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 complexEndocardial 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

12、 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 suggest that the ECG criteria do not allow identification of pts who are likely to benefit from a primary epicardial ablation approach. 心外膜標(biāo)測和消融的時(shí)機(jī)與基

13、礎(chǔ)心臟病的關(guān)系17名特發(fā)性VA中只有2人成功從心外膜消融Epicardial ablation of VT: an institutional experience of safety and efficacy.Tung R, et al. Heart Rhythm. 2013;10(4):490-8. 心外膜標(biāo)測和消融的時(shí)機(jī)與基礎(chǔ)心臟病的關(guān)系Bai R, et al. Circ Arrhythm Electrophysiol. 2011;(4):478-85. Substrate-based Ablation of VAs in ARVD/C心外膜標(biāo)測和消融的時(shí)機(jī)心外膜標(biāo)測和消融的時(shí)機(jī)Ind

14、ications of Epicardial Ablation and Procedure ApproachesIndications of Epicardial Catheter Ablation Among CentersEpicardial ablation for VT: a European multicenter studyDella Bella P, et al. Circ Arrhythm Electrophysiol. 2011;(5):653-9Dukkipati SR, et al. Circ Arrhythm Electrophysiol. 2011;(2):185-9

15、4. In highly selected pts with HCM, combined epi- and endocardial mapping and ablation is a feasible and reasonably efficacious option for MMVT if refractory to aggressive trials of AADs and antitachycardia pacingLong-term outcomes of combined epi- and endocardial ablation of MMVT related to HCMKOMA

16、TSU Y, et al. J Cardiovasc Electrophysiol. 2013;24:1426-1427,Multimodality Imaging to Improve the Safety and Efficacy of Epicardial Ablation of Scar-Related VTSinus rhythm detection of conducting channels andVTisthmus in ARVCPosterior view of an endocardial bipolar electroanatomic map merged with CT

17、.Fernndez-Armenta J, et al. Heart Rhythm.2014;11(5):747-54.心外膜標(biāo)測和消融的時(shí)機(jī)80名非特發(fā)性 VT患者消融前行CE-CMR檢查，77例成功導(dǎo)管消融患者(96.3%)在CE-CMR上均有局部心肌過度增強(qiáng)(hyper-enhancement, HE)。在VT成功消融部位，3名患者無HE(3.9%)，19名(24.7%)在心內(nèi)膜，36名為透壁性(46.7%)，8名在中層(10.4%)，心外膜下為11名(14.3%)。VT需行心外膜消融的ICM患者為3例(6.1%)、NICM12例(42.9%)。心外膜下HE預(yù)測心外膜起源VT的敏感性為84

18、.6%、特異性為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 心外膜標(biāo)測和消融的時(shí)機(jī)Andreu D, et al. Eur Heart J. 2014;35(20):1316-26Endocardial HETransmural HEMid-myocardia HEEpicardial HECMR and CARTO map of t

19、wo 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 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.

20、 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 of VF in BrS by ablation over the anterior RVOT epicardium 46名VT患者(18 ICM, 13 NICM, 15 ARVC)先行針對(duì)Endo-和Epi-LAVA（local abn

21、ormal ventricular activities）的心內(nèi)膜消融。173次面對(duì)Epi-LAVA的心內(nèi)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、心內(nèi)膜面單極電圖幅度低、明顯延遲和雙極電圖幅度低的Epi-LAVA以及Epi-LAVA處在CT掃描上室壁較薄者成功率較高。在4名ICM和2名ARVC患者，心內(nèi)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，心內(nèi)膜消融可

22、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心外膜標(biāo)測和消融的時(shí)機(jī)Characterization ofcontactforceduring Endocardial and Epicardial ventricular mappingJesel L, et al. Circ Arrhythm Electrophysiol.2014;7(6):1168-73. Inadequate epicardial point with V