室性心律失常的治疗策略课件.ppt

1、南京医科大学第一附属医院南京医科大学第一附属医院江苏省心肺疾病研究所江苏省心肺疾病研究所曹克将曹克将室性心律失常的治疗策略室性心律失常的治疗策略 Managing Strategies of Ventricular Arrhythmias Anatomical Layout of the Heart室性心律失常室性心律失常SCD的主要原因的主要原因全球全球：9,000,000/年；平均生还率小于年；平均生还率小于1西欧：西欧：300,000/年年；平均生还率；平均生还率2-3%美国：美国：250,000-350,000/年年中国：心血管疾病致死中国：心血管疾病致死54万万/年年Underlyi

2、ng Arrhythmias of Sudden Cardiac ArrestTorsades de Pointes13%VT62%Bradycardia17%Primary VF8%Bays de Luna A.Am Heart J 1989,117:151-159.心脏猝死的危险因素心脏猝死的危险因素发生过心脏猝死事件发生过心脏猝死事件发生过室性心动过速发生过室性心动过速(VT)心肌梗塞后的患者心肌梗塞后的患者(MI)冠状动脉疾病冠状动脉疾病(CAD)心衰患者心衰患者肥厚性心肌病肥厚性心肌病(HCM)LQTS、AQTS、BrS、CPVTEarly Repolarization室性心律失常的

3、治疗措施室性心律失常的治疗措施抗心律失常药物治疗抗心律失常药物治疗电复律和电除颤电复律和电除颤心律复律除颤器心律复律除颤器（ICDICD）射频导管消融射频导管消融外科手术治疗外科手术治疗基因治疗基因治疗?室性心律失常的药物治疗室性心律失常的药物治疗药物选择依据药物选择依据基础心脏病变基础心脏病变心功能状态心功能状态药物副作用药物副作用总体死亡率总体死亡率室性心律失常的药物治疗室性心律失常的药物治疗抗心律失常药物抗心律失常药物Ib,IC类药物类药物Beta BlockersAmiodarone and Sotalol钙拮抗剂钙拮抗剂合并心功能不全时的药物选择合并心功能不全时的药物选择胺碘酮是较为

4、理想的药物胺碘酮是较为理想的药物索他洛尔不适用于心衰合并索他洛尔不适用于心衰合并VT -阻滞剂可减低心梗后心衰并阻滞剂可减低心梗后心衰并VT猝死率猝死率I类药物因其较强的负性肌力作用和致心律失类药物因其较强的负性肌力作用和致心律失常作用应避免使用常作用应避免使用室性早搏的药物治疗原则室性早搏的药物治疗原则无器质性心脏病也无症状的室早，一般不需要无器质性心脏病也无症状的室早，一般不需要治疗，如果症状明显者可考虑药物治疗：治疗，如果症状明显者可考虑药物治疗：-阻滞剂阻滞剂 I类抗心律失常药物类抗心律失常药物 钙拮抗剂钙拮抗剂器质性心脏病室早并不一定要用药物治疗，如器质性心脏病室早并不一定要用药物治

5、疗，如果症状明显、果症状明显、AMI、左心功能差时者药物治疗、左心功能差时者药物治疗Pharmacological Therapy of Ventricular Arrhythmias for Primary and Secondary Prevention of SCDRev Esp Cardiol 2004;57:768-82SCD的一级的一级/二级药物预防二级药物预防Well-designed prospective trials in pts with CHF have made it clear that survival is unchanged with use of AADTr

6、eatment with Amio.In pts with CHF in the GESICA trial resulted in a trend toward reduction in CHF hospita-lization SCD and total mortality,which could not be re-produced in CHF-STATSummary Evidences do not support the use AAD for primary pre-vention of SCD in post-MI or CHF-patientsNew and investiga

7、tional antiarrhythmic agentsIon channel inhibitors Azimilide Tedisamil Dronedarone Celivarone(SSR149744C)ATI-2042 PM101 JTV-519 RanolazineArial repolarization-delaying agents Vernakalant(RSD1235)AVE-0118 AZD7009 KCB-328 Tertiapin-Q具有抗具有抗VA作用作用的的上游药物上游药物Angiotensin converting enzyme inhibitors(ACEIs)

8、Angiotensin receptor Blocker(ARBs)Aldosterone receptor antagonistsAntiinflammatory agentsStatinsOmega-3 polyunsaturated fatty acidsVitamin CMurray KT,et al.Heart Rhythm 2007;4:S88 S90反复发生在非缺血性反复发生在非缺血性DCM患者的室性心律失常患者的室性心律失常 Evidence-based predictors Curves for survival without arrhythmia recurrences

9、in patients treated with ACEI(n=57)and without ACEI(n=28)60%MUSTT5 5 years54%MADIT42 years20%CIDS33 years37%CASH22 years31%AVID13 years室性心律失常的非药物治疗室性心律失常的非药物治疗(ICD vs AAD)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

10、:748-754.3 Connolly,et al.Circulation.2000;101:1247-1302.4 Moss AJ.N Engl J Med.1996;335:1933-1940.5 Buxton AE.N Engl J Med.1999;341:1882-1890.6 Moss.Investor Conference Call.November 27,2001.30%MADIT II62 yearsCOMPANION QRS=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

11、心衰患者临床终点事件影响。对心衰患者临床终点事件影响。结果显示结果显示CRT-D 降低全因死亡率降低全因死亡率36%Kaplan-Meier estimates of the probability of survival free of heart failure in MADIT-CRT Moss AJ.Circ J 2010;74:1038 1041仅有仅有8%的临床适应证患者最终接受的临床适应证患者最终接受ICD治疗治疗Source:Guidant estimates Guidant Services Europe 20051 Moss AJ.N Engl J Med.1996;335

12、:1933-40.2 Buxton AE.N Engl J Med.1999;341:1882-90.3 Moss AJ.N Engl J Med.2002;346:877-834 Moss AJ.Presented before ACC 51st Annual Scientific Sessions,Late Breaking Clinical Trials,March 19,2002.5 The AVID Investigators.N Engl J Med.1997;337:1576-83.6 Kuck K.Circ.2000;102:748-54.7 Connolly S.Circ.2

13、000:101:1297-1302.ICD一级预防死亡率下一级预防死亡率下降超过二级预防降超过二级预防13,4576二级预防死亡率的降低比一级预防高吗？二级预防死亡率的降低比一级预防高吗？54%75%55%76%31%61%27 months39 months20 months31%56%28%59%20%33%Mortality Reduction w/ICD Rx%Mortality Reduction w/ICD Rx3 Years3 Years3 YearsICD治疗的相关问题治疗的相关问题n 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n ICD的误放电问题的误放电

14、问题n ICD的治疗费用较高的治疗费用较高n 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n 频繁电休克导致患者的生活质量下降以及心理频繁电休克导致患者的生活质量下降以及心理问题问题n 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，之后第二次电击第

15、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一

16、次或一次以上准确治疗一次或一次以上准确治疗 36%室性心律失常的导管射频消融室性心律失常的导管射频消融(特发性室速特发性室速)特发性左室室速的射频消融特发性左室室速的射频消融成功率一般成功率一般85%左右，甚至可达左右，甚至可达90%以上以上特发性右室流出道室速的射频消融特发性右室流出道室速的射频消融成功率高达成功率高达95%以上，并发症低以上，并发症低 虽然虽然ICD是器质性心脏病室速是器质性心脏病室速(冠心病室速，先冠心病室速，先心病室速，心病室速，ARVC和扩心病室速和扩心病室速)的一线治疗措的一线治疗措施，但导管消融仍然是重要的手段，其与抗心施，但导管消融仍然是重要的手段，其与抗心律失

17、常药物和律失常药物和ICD联合治疗，形成的所谓联合治疗，形成的所谓”杂交杂交”治疗措施，是目前临床上通常采用的治疗方治疗措施，是目前临床上通常采用的治疗方法法Zeppenfeld K and Stevenson WG.PACE 2008;31:358374室性心律失常的导管射频消融室性心律失常的导管射频消融(器质性心脏病室速器质性心脏病室速)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

18、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

19、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 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%Tanner H,et al.J Cardiovasc Electrophysiol 2009;published online July 28.DOI:10.1111/j.1540-8167.2009.01563.x.Catheter Ablation of Multiple Ventricular Tachycardias After Myocardial Infarction Guided by Combined Con

20、tact and Noncontact MappingFrames of sequential unipolar isopo-tential maps are shown after creation of a linear ablation lesion at a critical border of patient 10.The activation sequence was observed during rein-duction of VT.Exit sites of 2 VTs(E1 and E2)were included in the line;exit E3 is a remo

21、te site discon-tinuous to the critical border.Frame 1,diastolic VT isthmus activation approaches the ablation line.Frame 2,the previous pathway that exited at E1 is blocked.Frame 3,the activation takes a detour with a shifted exit closer to E2 and activates the left ventricle.Frame 4,myocardium dist

22、al to the ablation line is now activated lateRemote Magnetic Navigation to Guide Endo-and Epicardial Catheter Mapping of Scar-Related VT27 procedures on 24 pts with a history of VT related to MI,DCM,ARVC,HCM,or Sarcoidosis 75 of 77 VTs(97%)were ultimately ablatedConclusions Safety and feasibility of

23、 remote catheter navigation to perform substrate mapping of scar-related VT With a minimal amount of fluoroscopy exposure Aryana A,et al.,Circulation.2007;115:1191-1200Remote Magnetic Navigation to Guide Endo-and Epicardial Catheter Mapping of Scar-Related VTBBRT的导管消融的导管消融Catheter Ablation for ARVC-

24、VTRFCA of ARVC-VT using Non-contact mapping VT in 32 ARVC-pts was induced Regional ablation was applied by targeting the earliest VT activation sites Acute success rate was 84.4%(27/32)81.3%of the pts were free of VT without medication during the 28.616 month follow-up Yan Yao et al.PACE 2007;30:526

25、-533Long-Term Efficacy of Catheter Ablation of VT in pts with ARVC24 pts in the Johns Hospitals ARVD registry Follow-up for 3236 months Forty(85%)procedure were followed by recurrenceConclusion:A high rate of recurrence of VT in ARVC pts ARVC is a diffuse CM with progressively evolving electrical su

26、bstrateDalal D,et al.JACC 2007;50:432-440Safety 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 epicardial ablation 5 pts aortic cusp ablationAblation was successful in 15(45%)pts and unsuccessfu

27、l in 18(55%)pts Cryoablation was successful in all parahisian case(100%)Follow up of 24 monts,all successful cases free from VAsBiase LD,et al.Heart Rhythm 2011;8:968-974多形性室速和室颤的导管消融多形性室速和室颤的导管消融 2009年年EHRA/HRS/ESC/ACC/AHA室速导管消融专家共识室速导管消融专家共识PLVT和和VF导管消融适应症导管消融适应症消融针对触发多形性室速和室颤的室早消融针对触发多形性室速和室颤的室早小

28、样本研究结果提示消融可行，但小样本研究结果提示消融可行，但需更多临床研需更多临床研究证据究证据仅局限在仅局限在有经验的中心有经验的中心遗传性心律失常的治疗遗传性心律失常的治疗药物治疗药物治疗 特发性室颤、特发性室颤、SQTs：AAD药物治疗效果？药物治疗效果？LQTs:-阻滞剂有效阻滞剂有效 Brugada Syndrome：奎尼丁至少减少电风暴：奎尼丁至少减少电风暴 ARVC、HCM:AAD有效有效非药物治疗非药物治疗 特发性室颤、特发性室颤、Brugada Syndrome、SQTs：ICD疗效肯定疗效肯定 ARVC、HCM:ICD疗效肯定，导管消融疗效肯定，导管消融ARVC有一定效果有一

29、定效果Prevention of VF Episodes in BrS by Catheter Ablation Over the Anterior RVOT EpicardiumNine Pats with Type I BrS ECG pattern and VF Electroanatomic mapping of RV(endo/epicardially),and epicardial mapping of LV during SRUnique abnormal low voltage,and fractionated late potentials clustering exclus

30、ively in the anterior aspect of the RVOT epicardiumNormalization of the Brugada ECG pattern in 89%Long-term outcomes(20 months)were excellent,with no recurrent VT/VF in all patients off medicationNodemanee K,et al.Circulation 2011,123:1270-1279Prevention of VF Episodes in BrS by Catheter Ablation Ov

31、er the Anterior RVOT EpicardiumCT与与Carto图像融合技术显示图像融合技术显示RV,LV,Aorta,PA和和CA。RVOT前壁前壁心外膜靶点标测显示局部低电位，碎裂电位和电位时间长心外膜靶点标测显示局部低电位，碎裂电位和电位时间长Prevention of VF Episodes in BrS by Catheter Ablation Over the Anterior RVOT EpicardiumCT与与Carto图像融合技术显示图像融合技术显示RV,LV,Aorta,PA和和CA。RVOT前壁前壁心外膜靶点标测显示局部低电压，碎裂电位，电位时间长和除极

32、延迟心外膜靶点标测显示局部低电压，碎裂电位，电位时间长和除极延迟 Before Ablation 1 Mo.Post Ablation 3 Mo.Post Ablation Nodemanee K,et al.Circulation 2011,123:1270-1279Prophylactic Catheter Ablation for the Prevention of Defibrillator TherapyReddy VY,et al New Engl J Med 2007;357:2657-65Kuck KH,et al.Lancet 2010;375-31-40 Catheter

33、Ablation of Stable Ventricular Tachycardia before ICD implantation in Pats with CAD(VTACH)Kaplan-Meier curves for the primary endpointCatheter Ablation of Stable Ventricular Tachycardia before ICD implantation in Pats with CAD(VTACH)Kuck KH,et al.Lancet 2010;375-31-40 Mallidi J,et al.Heart Rhythm 20

34、11;8:503-510Meta-analysis of catheter ablation as an adjunct to medical therapy for treatment of VT in patients with structural heart disease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,if successful in the sh

35、ort term,confers both qualitative and quantitative protection against VT recurrence and SCDOf note,although 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 tolerat

36、ed VT in whom the procedure produces a satisfactory short-term 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 o

37、f secondary-prevention ICD therapy is difficult to challengeSuccessful catheter ablation does not sufficiently reduce residual riskCallans DJ.Circulation 2007;116;1196-1203器质性心脏病室速治疗器质性心脏病室速治疗:ICD/RFCA?血流动力学不稳定血流动力学不稳定VTICDICD+RFCA+MedICDRFCAICD+RFCA+MedICD频繁放电频繁放电杂交治疗杂交治疗杂交治疗杂交治疗选择选择血流动力学稳定血流动力学稳定VT期期 待待.SMASH：ICD RFCAVTACH:RFCA ICD VTACH II:RFCA no ICD?期待期待VTACH II 的研究结果的研究结果 期待更理想的导管消融技术：期待更理想的导管消融技术：更精确的标测技术更精确的标测技术更满意的消融导管更满意的消融导管更好的消融能量更好的消融能量 Thank You