ARVC 单形性室速导管消融还是 ICD

南京医科大学第一附属医院

邹建刚

5th VAS-CHINA

ARVC 并不罕见的心肌病

ARVC 诊断标准 2010

1 心脏整体和 或局部运动障碍和结构改变

2 室壁病理组织学特征

3 复极障碍

4 除极或传导异常

5 心律失常

6 家族史

Circulation 20101211533-1541

ARVC 室速

ARVC 室性心律失常主要条件bull 持续性或非持续性左束支传导阻滞型室性心动过

速 伴电轴向上bull ( II III aVF QRS 负向或不确定 aVL 正向 )

次要条件bull 持续性或非持续性右室流出道型室性心动过速

LBBB 型室性心动过速 伴电轴向下( II III aVF QRS 正向或不确定 aVL 负向 ) 或电轴不明确

bull Holter 显示室性早搏 24 h gt 500 个

ARVC ICD 植入指证----ARVC-SCD 的一级二级预防

ICD therapy is indicated in patients with structural heart disease and spontaneous sustained VT whether hemodynamically stable or unstable

ICD implantation is reasonable for the prevention of SCD in patients with arrhythmogenic right ventricular dysplasiacardiomyopathy (ARVDC) who have 1 or more risk factors for SCD

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

I IIa IIb III

(Class Ⅰ Level of Evidence B)

(Class aⅡ Level of Evidence C)

IIa

ACCAHAHRS 2008guidelines for device-based therapy of cardiac rhythm2012 年指南关于 ARVC 猝死二级预防未作调整

指南关于 ARVC 猝死的一级预防SCD 危险因素有 1 个以上者植入 ICD 作为 SCD 的一级预防

bull 电生理检查诱发室性心动过速 ( VT) bull 心电监护的非持续性 VTbull 男性bull 严重右室扩大 广泛右室受累bull 发病很早 ( lt 5 岁 ) bull 累及左室bull 心脏骤停史bull 不能解释的晕厥

ARVC-VTSCD ICD 植入的循证证据

bull BACKGROUNDbull Arrhythmogenic right ventricular cardiomyopathydysplasia (ARVCD) is a condition associated

with the risk of sudden death (SD)bull METHODS AND RESULTSbull We conducted a multicenter study of the impact of the implantable cardioverter-defibrillator (ICD)

for prevention of SD in 132 patients (93 males and 39 females age 40+-15 years) with ARVCD Implant indications were a history of cardiac arrest in 13 patients (10) sustained ventricular tachycardia in 82 (62) syncope in 21 (16) and other in 16 (12) During a mean follow-up of 39+-25 months 64 patients(48) had appropriate ICD interventions 21 (16) had inappropriate interventions and 19 (14) had ICD-related complications Fifty-three (83) of the 64 patients with appropriate interventions received antiarrhythmic drug therapy at the time of first ICD discharge Programmed ventricularstimulation was of limited value in identifying patients at risk of tachyarrhythmias during the follow-up (positive predictive value 49 negative predictive value 54) Four patients (3) died and 32 (24) experienced ventricular fibrillationflutter that in all likelihood would have been fatal in the absence of the device At 36 months the actual patient survival rate was 96 compared with the ventricular fibrillationflutter-free survival rate of 72 (Plt0001) Patients who received implants because of ventricular tachycardia without hemodynamic compromise had a significantly lower incidence of ventricular fibrillationflutter (log rank=001) History of cardiac arrest or ventricular tachycardia with hemodynamic compromise younger age and left ventricular involvement were independent predictors of ventricular fibrillationflutter

bull CONCLUSIONSbull In patients with ARVCD ICD therapy provided life-saving protection by effectively terminating life-

threatening ventricular arrhythmiasPatients who were prone to ventricular fibrillationflutter could be identified on the basis of clinical presentation irrespective of programmed ventricularstimulation outcome

Circulation 2003 Dec 23108(25)3084-91

ICD Therapy for prevention of SCD in ARVC Patients

ARVC 并不罕见的心肌病

ARVC 诊断标准 2010

1 心脏整体和 或局部运动障碍和结构改变

2 室壁病理组织学特征

3 复极障碍

4 除极或传导异常

5 心律失常

6 家族史

Circulation 20101211533-1541

ARVC 室速

ARVC 室性心律失常主要条件bull 持续性或非持续性左束支传导阻滞型室性心动过

速 伴电轴向上bull ( II III aVF QRS 负向或不确定 aVL 正向 )

次要条件bull 持续性或非持续性右室流出道型室性心动过速

LBBB 型室性心动过速 伴电轴向下( II III aVF QRS 正向或不确定 aVL 负向 ) 或电轴不明确

bull Holter 显示室性早搏 24 h gt 500 个

ARVC ICD 植入指证----ARVC-SCD 的一级二级预防

ICD therapy is indicated in patients with structural heart disease and spontaneous sustained VT whether hemodynamically stable or unstable

ICD implantation is reasonable for the prevention of SCD in patients with arrhythmogenic right ventricular dysplasiacardiomyopathy (ARVDC) who have 1 or more risk factors for SCD

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

I IIa IIb III

(Class Ⅰ Level of Evidence B)

(Class aⅡ Level of Evidence C)

IIa

ACCAHAHRS 2008guidelines for device-based therapy of cardiac rhythm2012 年指南关于 ARVC 猝死二级预防未作调整

指南关于 ARVC 猝死的一级预防SCD 危险因素有 1 个以上者植入 ICD 作为 SCD 的一级预防

bull 电生理检查诱发室性心动过速 ( VT) bull 心电监护的非持续性 VTbull 男性bull 严重右室扩大 广泛右室受累bull 发病很早 ( lt 5 岁 ) bull 累及左室bull 心脏骤停史bull 不能解释的晕厥

ARVC-VTSCD ICD 植入的循证证据

bull BACKGROUNDbull Arrhythmogenic right ventricular cardiomyopathydysplasia (ARVCD) is a condition associated

with the risk of sudden death (SD)bull METHODS AND RESULTSbull We conducted a multicenter study of the impact of the implantable cardioverter-defibrillator (ICD)

for prevention of SD in 132 patients (93 males and 39 females age 40+-15 years) with ARVCD Implant indications were a history of cardiac arrest in 13 patients (10) sustained ventricular tachycardia in 82 (62) syncope in 21 (16) and other in 16 (12) During a mean follow-up of 39+-25 months 64 patients(48) had appropriate ICD interventions 21 (16) had inappropriate interventions and 19 (14) had ICD-related complications Fifty-three (83) of the 64 patients with appropriate interventions received antiarrhythmic drug therapy at the time of first ICD discharge Programmed ventricularstimulation was of limited value in identifying patients at risk of tachyarrhythmias during the follow-up (positive predictive value 49 negative predictive value 54) Four patients (3) died and 32 (24) experienced ventricular fibrillationflutter that in all likelihood would have been fatal in the absence of the device At 36 months the actual patient survival rate was 96 compared with the ventricular fibrillationflutter-free survival rate of 72 (Plt0001) Patients who received implants because of ventricular tachycardia without hemodynamic compromise had a significantly lower incidence of ventricular fibrillationflutter (log rank=001) History of cardiac arrest or ventricular tachycardia with hemodynamic compromise younger age and left ventricular involvement were independent predictors of ventricular fibrillationflutter

bull CONCLUSIONSbull In patients with ARVCD ICD therapy provided life-saving protection by effectively terminating life-

threatening ventricular arrhythmiasPatients who were prone to ventricular fibrillationflutter could be identified on the basis of clinical presentation irrespective of programmed ventricularstimulation outcome

Circulation 2003 Dec 23108(25)3084-91

ICD Therapy for prevention of SCD in ARVC Patients

ARVC 诊断标准 2010

1 心脏整体和 或局部运动障碍和结构改变

2 室壁病理组织学特征

3 复极障碍

4 除极或传导异常

5 心律失常

6 家族史

Circulation 20101211533-1541

ARVC 室速

ARVC 室性心律失常主要条件bull 持续性或非持续性左束支传导阻滞型室性心动过

速 伴电轴向上bull ( II III aVF QRS 负向或不确定 aVL 正向 )

次要条件bull 持续性或非持续性右室流出道型室性心动过速

LBBB 型室性心动过速 伴电轴向下( II III aVF QRS 正向或不确定 aVL 负向 ) 或电轴不明确

bull Holter 显示室性早搏 24 h gt 500 个

ARVC ICD 植入指证----ARVC-SCD 的一级二级预防

ICD therapy is indicated in patients with structural heart disease and spontaneous sustained VT whether hemodynamically stable or unstable

ICD implantation is reasonable for the prevention of SCD in patients with arrhythmogenic right ventricular dysplasiacardiomyopathy (ARVDC) who have 1 or more risk factors for SCD

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

I IIa IIb III

(Class Ⅰ Level of Evidence B)

(Class aⅡ Level of Evidence C)

IIa

ACCAHAHRS 2008guidelines for device-based therapy of cardiac rhythm2012 年指南关于 ARVC 猝死二级预防未作调整

指南关于 ARVC 猝死的一级预防SCD 危险因素有 1 个以上者植入 ICD 作为 SCD 的一级预防

bull 电生理检查诱发室性心动过速 ( VT) bull 心电监护的非持续性 VTbull 男性bull 严重右室扩大 广泛右室受累bull 发病很早 ( lt 5 岁 ) bull 累及左室bull 心脏骤停史bull 不能解释的晕厥

ARVC-VTSCD ICD 植入的循证证据

bull BACKGROUNDbull Arrhythmogenic right ventricular cardiomyopathydysplasia (ARVCD) is a condition associated

with the risk of sudden death (SD)bull METHODS AND RESULTSbull We conducted a multicenter study of the impact of the implantable cardioverter-defibrillator (ICD)

for prevention of SD in 132 patients (93 males and 39 females age 40+-15 years) with ARVCD Implant indications were a history of cardiac arrest in 13 patients (10) sustained ventricular tachycardia in 82 (62) syncope in 21 (16) and other in 16 (12) During a mean follow-up of 39+-25 months 64 patients(48) had appropriate ICD interventions 21 (16) had inappropriate interventions and 19 (14) had ICD-related complications Fifty-three (83) of the 64 patients with appropriate interventions received antiarrhythmic drug therapy at the time of first ICD discharge Programmed ventricularstimulation was of limited value in identifying patients at risk of tachyarrhythmias during the follow-up (positive predictive value 49 negative predictive value 54) Four patients (3) died and 32 (24) experienced ventricular fibrillationflutter that in all likelihood would have been fatal in the absence of the device At 36 months the actual patient survival rate was 96 compared with the ventricular fibrillationflutter-free survival rate of 72 (Plt0001) Patients who received implants because of ventricular tachycardia without hemodynamic compromise had a significantly lower incidence of ventricular fibrillationflutter (log rank=001) History of cardiac arrest or ventricular tachycardia with hemodynamic compromise younger age and left ventricular involvement were independent predictors of ventricular fibrillationflutter

bull CONCLUSIONSbull In patients with ARVCD ICD therapy provided life-saving protection by effectively terminating life-

threatening ventricular arrhythmiasPatients who were prone to ventricular fibrillationflutter could be identified on the basis of clinical presentation irrespective of programmed ventricularstimulation outcome

Circulation 2003 Dec 23108(25)3084-91

ICD Therapy for prevention of SCD in ARVC Patients

ARVC 室速

ARVC 室性心律失常主要条件bull 持续性或非持续性左束支传导阻滞型室性心动过

速 伴电轴向上bull ( II III aVF QRS 负向或不确定 aVL 正向 )

次要条件bull 持续性或非持续性右室流出道型室性心动过速

LBBB 型室性心动过速 伴电轴向下( II III aVF QRS 正向或不确定 aVL 负向 ) 或电轴不明确

bull Holter 显示室性早搏 24 h gt 500 个

ARVC ICD 植入指证----ARVC-SCD 的一级二级预防

ICD therapy is indicated in patients with structural heart disease and spontaneous sustained VT whether hemodynamically stable or unstable

ICD implantation is reasonable for the prevention of SCD in patients with arrhythmogenic right ventricular dysplasiacardiomyopathy (ARVDC) who have 1 or more risk factors for SCD

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

I IIa IIb III

(Class Ⅰ Level of Evidence B)

(Class aⅡ Level of Evidence C)

IIa

ACCAHAHRS 2008guidelines for device-based therapy of cardiac rhythm2012 年指南关于 ARVC 猝死二级预防未作调整

指南关于 ARVC 猝死的一级预防SCD 危险因素有 1 个以上者植入 ICD 作为 SCD 的一级预防

bull 电生理检查诱发室性心动过速 ( VT) bull 心电监护的非持续性 VTbull 男性bull 严重右室扩大 广泛右室受累bull 发病很早 ( lt 5 岁 ) bull 累及左室bull 心脏骤停史bull 不能解释的晕厥

ARVC-VTSCD ICD 植入的循证证据

bull BACKGROUNDbull Arrhythmogenic right ventricular cardiomyopathydysplasia (ARVCD) is a condition associated

with the risk of sudden death (SD)bull METHODS AND RESULTSbull We conducted a multicenter study of the impact of the implantable cardioverter-defibrillator (ICD)

for prevention of SD in 132 patients (93 males and 39 females age 40+-15 years) with ARVCD Implant indications were a history of cardiac arrest in 13 patients (10) sustained ventricular tachycardia in 82 (62) syncope in 21 (16) and other in 16 (12) During a mean follow-up of 39+-25 months 64 patients(48) had appropriate ICD interventions 21 (16) had inappropriate interventions and 19 (14) had ICD-related complications Fifty-three (83) of the 64 patients with appropriate interventions received antiarrhythmic drug therapy at the time of first ICD discharge Programmed ventricularstimulation was of limited value in identifying patients at risk of tachyarrhythmias during the follow-up (positive predictive value 49 negative predictive value 54) Four patients (3) died and 32 (24) experienced ventricular fibrillationflutter that in all likelihood would have been fatal in the absence of the device At 36 months the actual patient survival rate was 96 compared with the ventricular fibrillationflutter-free survival rate of 72 (Plt0001) Patients who received implants because of ventricular tachycardia without hemodynamic compromise had a significantly lower incidence of ventricular fibrillationflutter (log rank=001) History of cardiac arrest or ventricular tachycardia with hemodynamic compromise younger age and left ventricular involvement were independent predictors of ventricular fibrillationflutter

bull CONCLUSIONSbull In patients with ARVCD ICD therapy provided life-saving protection by effectively terminating life-

threatening ventricular arrhythmiasPatients who were prone to ventricular fibrillationflutter could be identified on the basis of clinical presentation irrespective of programmed ventricularstimulation outcome

Circulation 2003 Dec 23108(25)3084-91

ICD Therapy for prevention of SCD in ARVC Patients

ARVC 室性心律失常主要条件bull 持续性或非持续性左束支传导阻滞型室性心动过

速 伴电轴向上bull ( II III aVF QRS 负向或不确定 aVL 正向 )

次要条件bull 持续性或非持续性右室流出道型室性心动过速

LBBB 型室性心动过速 伴电轴向下( II III aVF QRS 正向或不确定 aVL 负向 ) 或电轴不明确

bull Holter 显示室性早搏 24 h gt 500 个

ARVC ICD 植入指证----ARVC-SCD 的一级二级预防

ICD therapy is indicated in patients with structural heart disease and spontaneous sustained VT whether hemodynamically stable or unstable

ICD implantation is reasonable for the prevention of SCD in patients with arrhythmogenic right ventricular dysplasiacardiomyopathy (ARVDC) who have 1 or more risk factors for SCD

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

I IIa IIb III

(Class Ⅰ Level of Evidence B)

(Class aⅡ Level of Evidence C)

IIa

ACCAHAHRS 2008guidelines for device-based therapy of cardiac rhythm2012 年指南关于 ARVC 猝死二级预防未作调整

指南关于 ARVC 猝死的一级预防SCD 危险因素有 1 个以上者植入 ICD 作为 SCD 的一级预防

bull 电生理检查诱发室性心动过速 ( VT) bull 心电监护的非持续性 VTbull 男性bull 严重右室扩大 广泛右室受累bull 发病很早 ( lt 5 岁 ) bull 累及左室bull 心脏骤停史bull 不能解释的晕厥

ARVC-VTSCD ICD 植入的循证证据

bull BACKGROUNDbull Arrhythmogenic right ventricular cardiomyopathydysplasia (ARVCD) is a condition associated

with the risk of sudden death (SD)bull METHODS AND RESULTSbull We conducted a multicenter study of the impact of the implantable cardioverter-defibrillator (ICD)

for prevention of SD in 132 patients (93 males and 39 females age 40+-15 years) with ARVCD Implant indications were a history of cardiac arrest in 13 patients (10) sustained ventricular tachycardia in 82 (62) syncope in 21 (16) and other in 16 (12) During a mean follow-up of 39+-25 months 64 patients(48) had appropriate ICD interventions 21 (16) had inappropriate interventions and 19 (14) had ICD-related complications Fifty-three (83) of the 64 patients with appropriate interventions received antiarrhythmic drug therapy at the time of first ICD discharge Programmed ventricularstimulation was of limited value in identifying patients at risk of tachyarrhythmias during the follow-up (positive predictive value 49 negative predictive value 54) Four patients (3) died and 32 (24) experienced ventricular fibrillationflutter that in all likelihood would have been fatal in the absence of the device At 36 months the actual patient survival rate was 96 compared with the ventricular fibrillationflutter-free survival rate of 72 (Plt0001) Patients who received implants because of ventricular tachycardia without hemodynamic compromise had a significantly lower incidence of ventricular fibrillationflutter (log rank=001) History of cardiac arrest or ventricular tachycardia with hemodynamic compromise younger age and left ventricular involvement were independent predictors of ventricular fibrillationflutter

bull CONCLUSIONSbull In patients with ARVCD ICD therapy provided life-saving protection by effectively terminating life-

threatening ventricular arrhythmiasPatients who were prone to ventricular fibrillationflutter could be identified on the basis of clinical presentation irrespective of programmed ventricularstimulation outcome

Circulation 2003 Dec 23108(25)3084-91

ICD Therapy for prevention of SCD in ARVC Patients

ARVC ICD 植入指证----ARVC-SCD 的一级二级预防

ICD therapy is indicated in patients with structural heart disease and spontaneous sustained VT whether hemodynamically stable or unstable

ICD implantation is reasonable for the prevention of SCD in patients with arrhythmogenic right ventricular dysplasiacardiomyopathy (ARVDC) who have 1 or more risk factors for SCD

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

I IIa IIb III

(Class Ⅰ Level of Evidence B)

(Class aⅡ Level of Evidence C)

IIa

ACCAHAHRS 2008guidelines for device-based therapy of cardiac rhythm2012 年指南关于 ARVC 猝死二级预防未作调整

指南关于 ARVC 猝死的一级预防SCD 危险因素有 1 个以上者植入 ICD 作为 SCD 的一级预防

bull 电生理检查诱发室性心动过速 ( VT) bull 心电监护的非持续性 VTbull 男性bull 严重右室扩大 广泛右室受累bull 发病很早 ( lt 5 岁 ) bull 累及左室bull 心脏骤停史bull 不能解释的晕厥

ARVC-VTSCD ICD 植入的循证证据

bull BACKGROUNDbull Arrhythmogenic right ventricular cardiomyopathydysplasia (ARVCD) is a condition associated

with the risk of sudden death (SD)bull METHODS AND RESULTSbull We conducted a multicenter study of the impact of the implantable cardioverter-defibrillator (ICD)

for prevention of SD in 132 patients (93 males and 39 females age 40+-15 years) with ARVCD Implant indications were a history of cardiac arrest in 13 patients (10) sustained ventricular tachycardia in 82 (62) syncope in 21 (16) and other in 16 (12) During a mean follow-up of 39+-25 months 64 patients(48) had appropriate ICD interventions 21 (16) had inappropriate interventions and 19 (14) had ICD-related complications Fifty-three (83) of the 64 patients with appropriate interventions received antiarrhythmic drug therapy at the time of first ICD discharge Programmed ventricularstimulation was of limited value in identifying patients at risk of tachyarrhythmias during the follow-up (positive predictive value 49 negative predictive value 54) Four patients (3) died and 32 (24) experienced ventricular fibrillationflutter that in all likelihood would have been fatal in the absence of the device At 36 months the actual patient survival rate was 96 compared with the ventricular fibrillationflutter-free survival rate of 72 (Plt0001) Patients who received implants because of ventricular tachycardia without hemodynamic compromise had a significantly lower incidence of ventricular fibrillationflutter (log rank=001) History of cardiac arrest or ventricular tachycardia with hemodynamic compromise younger age and left ventricular involvement were independent predictors of ventricular fibrillationflutter

bull CONCLUSIONSbull In patients with ARVCD ICD therapy provided life-saving protection by effectively terminating life-

threatening ventricular arrhythmiasPatients who were prone to ventricular fibrillationflutter could be identified on the basis of clinical presentation irrespective of programmed ventricularstimulation outcome

Circulation 2003 Dec 23108(25)3084-91

ICD Therapy for prevention of SCD in ARVC Patients

指南关于 ARVC 猝死的一级预防SCD 危险因素有 1 个以上者植入 ICD 作为 SCD 的一级预防

bull 电生理检查诱发室性心动过速 ( VT) bull 心电监护的非持续性 VTbull 男性bull 严重右室扩大 广泛右室受累bull 发病很早 ( lt 5 岁 ) bull 累及左室bull 心脏骤停史bull 不能解释的晕厥

ARVC-VTSCD ICD 植入的循证证据

bull BACKGROUNDbull Arrhythmogenic right ventricular cardiomyopathydysplasia (ARVCD) is a condition associated

with the risk of sudden death (SD)bull METHODS AND RESULTSbull We conducted a multicenter study of the impact of the implantable cardioverter-defibrillator (ICD)

for prevention of SD in 132 patients (93 males and 39 females age 40+-15 years) with ARVCD Implant indications were a history of cardiac arrest in 13 patients (10) sustained ventricular tachycardia in 82 (62) syncope in 21 (16) and other in 16 (12) During a mean follow-up of 39+-25 months 64 patients(48) had appropriate ICD interventions 21 (16) had inappropriate interventions and 19 (14) had ICD-related complications Fifty-three (83) of the 64 patients with appropriate interventions received antiarrhythmic drug therapy at the time of first ICD discharge Programmed ventricularstimulation was of limited value in identifying patients at risk of tachyarrhythmias during the follow-up (positive predictive value 49 negative predictive value 54) Four patients (3) died and 32 (24) experienced ventricular fibrillationflutter that in all likelihood would have been fatal in the absence of the device At 36 months the actual patient survival rate was 96 compared with the ventricular fibrillationflutter-free survival rate of 72 (Plt0001) Patients who received implants because of ventricular tachycardia without hemodynamic compromise had a significantly lower incidence of ventricular fibrillationflutter (log rank=001) History of cardiac arrest or ventricular tachycardia with hemodynamic compromise younger age and left ventricular involvement were independent predictors of ventricular fibrillationflutter

bull CONCLUSIONSbull In patients with ARVCD ICD therapy provided life-saving protection by effectively terminating life-

threatening ventricular arrhythmiasPatients who were prone to ventricular fibrillationflutter could be identified on the basis of clinical presentation irrespective of programmed ventricularstimulation outcome

Circulation 2003 Dec 23108(25)3084-91

ICD Therapy for prevention of SCD in ARVC Patients

ARVC-VTSCD ICD 植入的循证证据

bull BACKGROUNDbull Arrhythmogenic right ventricular cardiomyopathydysplasia (ARVCD) is a condition associated

with the risk of sudden death (SD)bull METHODS AND RESULTSbull We conducted a multicenter study of the impact of the implantable cardioverter-defibrillator (ICD)

for prevention of SD in 132 patients (93 males and 39 females age 40+-15 years) with ARVCD Implant indications were a history of cardiac arrest in 13 patients (10) sustained ventricular tachycardia in 82 (62) syncope in 21 (16) and other in 16 (12) During a mean follow-up of 39+-25 months 64 patients(48) had appropriate ICD interventions 21 (16) had inappropriate interventions and 19 (14) had ICD-related complications Fifty-three (83) of the 64 patients with appropriate interventions received antiarrhythmic drug therapy at the time of first ICD discharge Programmed ventricularstimulation was of limited value in identifying patients at risk of tachyarrhythmias during the follow-up (positive predictive value 49 negative predictive value 54) Four patients (3) died and 32 (24) experienced ventricular fibrillationflutter that in all likelihood would have been fatal in the absence of the device At 36 months the actual patient survival rate was 96 compared with the ventricular fibrillationflutter-free survival rate of 72 (Plt0001) Patients who received implants because of ventricular tachycardia without hemodynamic compromise had a significantly lower incidence of ventricular fibrillationflutter (log rank=001) History of cardiac arrest or ventricular tachycardia with hemodynamic compromise younger age and left ventricular involvement were independent predictors of ventricular fibrillationflutter

bull CONCLUSIONSbull In patients with ARVCD ICD therapy provided life-saving protection by effectively terminating life-

threatening ventricular arrhythmiasPatients who were prone to ventricular fibrillationflutter could be identified on the basis of clinical presentation irrespective of programmed ventricularstimulation outcome

Circulation 2003 Dec 23108(25)3084-91

ICD Therapy for prevention of SCD in ARVC Patients

bull BACKGROUNDbull Arrhythmogenic right ventricular cardiomyopathydysplasia (ARVCD) is a condition associated

with the risk of sudden death (SD)bull METHODS AND RESULTSbull We conducted a multicenter study of the impact of the implantable cardioverter-defibrillator (ICD)

for prevention of SD in 132 patients (93 males and 39 females age 40+-15 years) with ARVCD Implant indications were a history of cardiac arrest in 13 patients (10) sustained ventricular tachycardia in 82 (62) syncope in 21 (16) and other in 16 (12) During a mean follow-up of 39+-25 months 64 patients(48) had appropriate ICD interventions 21 (16) had inappropriate interventions and 19 (14) had ICD-related complications Fifty-three (83) of the 64 patients with appropriate interventions received antiarrhythmic drug therapy at the time of first ICD discharge Programmed ventricularstimulation was of limited value in identifying patients at risk of tachyarrhythmias during the follow-up (positive predictive value 49 negative predictive value 54) Four patients (3) died and 32 (24) experienced ventricular fibrillationflutter that in all likelihood would have been fatal in the absence of the device At 36 months the actual patient survival rate was 96 compared with the ventricular fibrillationflutter-free survival rate of 72 (Plt0001) Patients who received implants because of ventricular tachycardia without hemodynamic compromise had a significantly lower incidence of ventricular fibrillationflutter (log rank=001) History of cardiac arrest or ventricular tachycardia with hemodynamic compromise younger age and left ventricular involvement were independent predictors of ventricular fibrillationflutter

bull CONCLUSIONSbull In patients with ARVCD ICD therapy provided life-saving protection by effectively terminating life-

threatening ventricular arrhythmiasPatients who were prone to ventricular fibrillationflutter could be identified on the basis of clinical presentation irrespective of programmed ventricularstimulation outcome

Circulation 2003 Dec 23108(25)3084-91

ICD Therapy for prevention of SCD in ARVC Patients

132 pts (93 m age 40+-15 y) with ARVC ICD indicationshistory of cardiac arrest in 13 patients (10) sustained VT in 82 (62) syncope in 21 (16) and other in 16 (12)FU39+-25 m 64 patients(48) appropriate ICD R 21 (16) inappropriate R 4 (3) died At 36 months the actual patient survival rate was 96

the ventricular fibrillationflutter-free survival rate of 72

In patients with ARVCD ICD therapy provided life-saving protection by effectively terminating life-threatening ventricular

Circulation 2003 Dec 23108(25)3084-91

bull 84 pts ARVC ICD for SCD 一级预防bull FU 47+34y 48 ICD intervention 19 VFbull 5 年生存率伴 1 2 3 4 危险因

子的为 100 83 21 15bull EP 诱发 VTVF NSVT 是独立预测因子

首次放电时间和放电次数

ICD 电治疗的影响因子

危险因子对生存率的影响

结论

ARVC 患者植入 ICD 作为 SCD 一级预防措施

接近一半患者可有效预防 SCD

ARVC 室速导管消融需要考虑的几个问题

bull ARVC 室速的机制疤痕折返局灶

bull 导管消融的成功率

bull 远期复发率

J Am Coll Cardiol 200750432ndash40

bull 24 例患者 bull 48 次消融 bull 随访 32plusmn36months (range 1 day to 12 years)

10 次为三维电解剖标测 38 次为常规方法标测术后室速复发率高达 85 随访 14 个月无发作的比例仅为 15 且不同的标测方法之间未见显著性差异即使术中消除所有诱发出来的室速仍然有极高的复发率

南京医科大学心脏科动态基质标测指导 ARVC-VT 消融

病例 1 病例 2 病例 3

APEX

VT1

VT2

病例 2

病例 3

12 Lead ECG (slower VT)

Pacing at site A

Pacing at site B

结果

病例 1 2 的三种临床室速消融全部成功但病例 2仍可诱发一种新的非临床类型室速室速频率快电转复后未再行标测后选用可达龙治疗

病例 3 在完成两条线性消融后诱发出一种频率较慢的室速经非接触球囊标测此慢频率室速通过两条消融线之间的间隙传导消融此间隙后室速不再诱发

平均放电次数 17 次每条消融线达到双向传导阻滞无手术并发症平均随访 20 月无心动过速发生

ARVC-VT 心外膜消融

bull Percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia

bull 17 例患者（ 14+-4y）心内膜消融失败bull 20 VTs 诱发（ 2 个大折返 18 个局灶）bull 16 例（ 941）即刻成功bull 随访 26 plusmn 15 (range 6 to 42) 月bull 12人（ 706）无室速发作

Heart Rhythm 2010 Oct7(10)1406-10

首次放电时间和放电次数

ICD 电治疗的影响因子

危险因子对生存率的影响

结论

ARVC 患者植入 ICD 作为 SCD 一级预防措施

接近一半患者可有效预防 SCD

ARVC 室速导管消融需要考虑的几个问题

bull ARVC 室速的机制疤痕折返局灶

bull 导管消融的成功率

bull 远期复发率

J Am Coll Cardiol 200750432ndash40

bull 24 例患者 bull 48 次消融 bull 随访 32plusmn36months (range 1 day to 12 years)

10 次为三维电解剖标测 38 次为常规方法标测术后室速复发率高达 85 随访 14 个月无发作的比例仅为 15 且不同的标测方法之间未见显著性差异即使术中消除所有诱发出来的室速仍然有极高的复发率

南京医科大学心脏科动态基质标测指导 ARVC-VT 消融

病例 1 病例 2 病例 3

APEX

VT1

VT2

病例 2

病例 3

12 Lead ECG (slower VT)

Pacing at site A

Pacing at site B

结果

病例 1 2 的三种临床室速消融全部成功但病例 2仍可诱发一种新的非临床类型室速室速频率快电转复后未再行标测后选用可达龙治疗

病例 3 在完成两条线性消融后诱发出一种频率较慢的室速经非接触球囊标测此慢频率室速通过两条消融线之间的间隙传导消融此间隙后室速不再诱发

平均放电次数 17 次每条消融线达到双向传导阻滞无手术并发症平均随访 20 月无心动过速发生

ARVC-VT 心外膜消融

bull Percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia

bull 17 例患者（ 14+-4y）心内膜消融失败bull 20 VTs 诱发（ 2 个大折返 18 个局灶）bull 16 例（ 941）即刻成功bull 随访 26 plusmn 15 (range 6 to 42) 月bull 12人（ 706）无室速发作

Heart Rhythm 2010 Oct7(10)1406-10

ICD 电治疗的影响因子

危险因子对生存率的影响

结论

ARVC 患者植入 ICD 作为 SCD 一级预防措施

接近一半患者可有效预防 SCD

ARVC 室速导管消融需要考虑的几个问题

bull ARVC 室速的机制疤痕折返局灶

bull 导管消融的成功率

bull 远期复发率

J Am Coll Cardiol 200750432ndash40

bull 24 例患者 bull 48 次消融 bull 随访 32plusmn36months (range 1 day to 12 years)

10 次为三维电解剖标测 38 次为常规方法标测术后室速复发率高达 85 随访 14 个月无发作的比例仅为 15 且不同的标测方法之间未见显著性差异即使术中消除所有诱发出来的室速仍然有极高的复发率

南京医科大学心脏科动态基质标测指导 ARVC-VT 消融

病例 1 病例 2 病例 3

APEX

VT1

VT2

病例 2

病例 3

12 Lead ECG (slower VT)

Pacing at site A

Pacing at site B

结果

病例 1 2 的三种临床室速消融全部成功但病例 2仍可诱发一种新的非临床类型室速室速频率快电转复后未再行标测后选用可达龙治疗

病例 3 在完成两条线性消融后诱发出一种频率较慢的室速经非接触球囊标测此慢频率室速通过两条消融线之间的间隙传导消融此间隙后室速不再诱发

平均放电次数 17 次每条消融线达到双向传导阻滞无手术并发症平均随访 20 月无心动过速发生

ARVC-VT 心外膜消融

bull Percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia

bull 17 例患者（ 14+-4y）心内膜消融失败bull 20 VTs 诱发（ 2 个大折返 18 个局灶）bull 16 例（ 941）即刻成功bull 随访 26 plusmn 15 (range 6 to 42) 月bull 12人（ 706）无室速发作

Heart Rhythm 2010 Oct7(10)1406-10

危险因子对生存率的影响

结论

ARVC 患者植入 ICD 作为 SCD 一级预防措施

接近一半患者可有效预防 SCD

ARVC 室速导管消融需要考虑的几个问题

bull ARVC 室速的机制疤痕折返局灶

bull 导管消融的成功率

bull 远期复发率

J Am Coll Cardiol 200750432ndash40

bull 24 例患者 bull 48 次消融 bull 随访 32plusmn36months (range 1 day to 12 years)

10 次为三维电解剖标测 38 次为常规方法标测术后室速复发率高达 85 随访 14 个月无发作的比例仅为 15 且不同的标测方法之间未见显著性差异即使术中消除所有诱发出来的室速仍然有极高的复发率

南京医科大学心脏科动态基质标测指导 ARVC-VT 消融

病例 1 病例 2 病例 3

APEX

VT1

VT2

病例 2

病例 3

12 Lead ECG (slower VT)

Pacing at site A

Pacing at site B

结果

病例 1 2 的三种临床室速消融全部成功但病例 2仍可诱发一种新的非临床类型室速室速频率快电转复后未再行标测后选用可达龙治疗

病例 3 在完成两条线性消融后诱发出一种频率较慢的室速经非接触球囊标测此慢频率室速通过两条消融线之间的间隙传导消融此间隙后室速不再诱发

平均放电次数 17 次每条消融线达到双向传导阻滞无手术并发症平均随访 20 月无心动过速发生

ARVC-VT 心外膜消融

bull Percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia

bull 17 例患者（ 14+-4y）心内膜消融失败bull 20 VTs 诱发（ 2 个大折返 18 个局灶）bull 16 例（ 941）即刻成功bull 随访 26 plusmn 15 (range 6 to 42) 月bull 12人（ 706）无室速发作

Heart Rhythm 2010 Oct7(10)1406-10

结论

ARVC 患者植入 ICD 作为 SCD 一级预防措施

接近一半患者可有效预防 SCD

ARVC 室速导管消融需要考虑的几个问题

bull ARVC 室速的机制疤痕折返局灶

bull 导管消融的成功率

bull 远期复发率

J Am Coll Cardiol 200750432ndash40

bull 24 例患者 bull 48 次消融 bull 随访 32plusmn36months (range 1 day to 12 years)

10 次为三维电解剖标测 38 次为常规方法标测术后室速复发率高达 85 随访 14 个月无发作的比例仅为 15 且不同的标测方法之间未见显著性差异即使术中消除所有诱发出来的室速仍然有极高的复发率

南京医科大学心脏科动态基质标测指导 ARVC-VT 消融

病例 1 病例 2 病例 3

APEX

VT1

VT2

病例 2

病例 3

12 Lead ECG (slower VT)

Pacing at site A

Pacing at site B

结果

病例 1 2 的三种临床室速消融全部成功但病例 2仍可诱发一种新的非临床类型室速室速频率快电转复后未再行标测后选用可达龙治疗

病例 3 在完成两条线性消融后诱发出一种频率较慢的室速经非接触球囊标测此慢频率室速通过两条消融线之间的间隙传导消融此间隙后室速不再诱发

平均放电次数 17 次每条消融线达到双向传导阻滞无手术并发症平均随访 20 月无心动过速发生

ARVC-VT 心外膜消融

bull Percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia

bull 17 例患者（ 14+-4y）心内膜消融失败bull 20 VTs 诱发（ 2 个大折返 18 个局灶）bull 16 例（ 941）即刻成功bull 随访 26 plusmn 15 (range 6 to 42) 月bull 12人（ 706）无室速发作

Heart Rhythm 2010 Oct7(10)1406-10

ARVC 室速导管消融需要考虑的几个问题

bull ARVC 室速的机制疤痕折返局灶

bull 导管消融的成功率

bull 远期复发率

J Am Coll Cardiol 200750432ndash40

bull 24 例患者 bull 48 次消融 bull 随访 32plusmn36months (range 1 day to 12 years)

10 次为三维电解剖标测 38 次为常规方法标测术后室速复发率高达 85 随访 14 个月无发作的比例仅为 15 且不同的标测方法之间未见显著性差异即使术中消除所有诱发出来的室速仍然有极高的复发率

南京医科大学心脏科动态基质标测指导 ARVC-VT 消融

病例 1 病例 2 病例 3

APEX

VT1

VT2

病例 2

病例 3

12 Lead ECG (slower VT)

Pacing at site A

Pacing at site B

结果

病例 1 2 的三种临床室速消融全部成功但病例 2仍可诱发一种新的非临床类型室速室速频率快电转复后未再行标测后选用可达龙治疗

病例 3 在完成两条线性消融后诱发出一种频率较慢的室速经非接触球囊标测此慢频率室速通过两条消融线之间的间隙传导消融此间隙后室速不再诱发

平均放电次数 17 次每条消融线达到双向传导阻滞无手术并发症平均随访 20 月无心动过速发生

ARVC-VT 心外膜消融

bull Percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia

bull 17 例患者（ 14+-4y）心内膜消融失败bull 20 VTs 诱发（ 2 个大折返 18 个局灶）bull 16 例（ 941）即刻成功bull 随访 26 plusmn 15 (range 6 to 42) 月bull 12人（ 706）无室速发作

Heart Rhythm 2010 Oct7(10)1406-10

J Am Coll Cardiol 200750432ndash40

bull 24 例患者 bull 48 次消融 bull 随访 32plusmn36months (range 1 day to 12 years)

10 次为三维电解剖标测 38 次为常规方法标测术后室速复发率高达 85 随访 14 个月无发作的比例仅为 15 且不同的标测方法之间未见显著性差异即使术中消除所有诱发出来的室速仍然有极高的复发率

南京医科大学心脏科动态基质标测指导 ARVC-VT 消融

病例 1 病例 2 病例 3

APEX

VT1

VT2

病例 2

病例 3

12 Lead ECG (slower VT)

Pacing at site A

Pacing at site B

结果

病例 1 2 的三种临床室速消融全部成功但病例 2仍可诱发一种新的非临床类型室速室速频率快电转复后未再行标测后选用可达龙治疗

病例 3 在完成两条线性消融后诱发出一种频率较慢的室速经非接触球囊标测此慢频率室速通过两条消融线之间的间隙传导消融此间隙后室速不再诱发

平均放电次数 17 次每条消融线达到双向传导阻滞无手术并发症平均随访 20 月无心动过速发生

ARVC-VT 心外膜消融

bull Percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia

bull 17 例患者（ 14+-4y）心内膜消融失败bull 20 VTs 诱发（ 2 个大折返 18 个局灶）bull 16 例（ 941）即刻成功bull 随访 26 plusmn 15 (range 6 to 42) 月bull 12人（ 706）无室速发作

Heart Rhythm 2010 Oct7(10)1406-10

10 次为三维电解剖标测 38 次为常规方法标测术后室速复发率高达 85 随访 14 个月无发作的比例仅为 15 且不同的标测方法之间未见显著性差异即使术中消除所有诱发出来的室速仍然有极高的复发率

南京医科大学心脏科动态基质标测指导 ARVC-VT 消融

病例 1 病例 2 病例 3

APEX

VT1

VT2

病例 2

病例 3

12 Lead ECG (slower VT)

Pacing at site A

Pacing at site B

结果

病例 1 2 的三种临床室速消融全部成功但病例 2仍可诱发一种新的非临床类型室速室速频率快电转复后未再行标测后选用可达龙治疗

病例 3 在完成两条线性消融后诱发出一种频率较慢的室速经非接触球囊标测此慢频率室速通过两条消融线之间的间隙传导消融此间隙后室速不再诱发

平均放电次数 17 次每条消融线达到双向传导阻滞无手术并发症平均随访 20 月无心动过速发生

ARVC-VT 心外膜消融

bull Percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia

bull 17 例患者（ 14+-4y）心内膜消融失败bull 20 VTs 诱发（ 2 个大折返 18 个局灶）bull 16 例（ 941）即刻成功bull 随访 26 plusmn 15 (range 6 to 42) 月bull 12人（ 706）无室速发作

Heart Rhythm 2010 Oct7(10)1406-10

南京医科大学心脏科动态基质标测指导 ARVC-VT 消融

病例 1 病例 2 病例 3

APEX

VT1

VT2

病例 2

病例 3

12 Lead ECG (slower VT)

Pacing at site A

Pacing at site B

结果

病例 1 2 的三种临床室速消融全部成功但病例 2仍可诱发一种新的非临床类型室速室速频率快电转复后未再行标测后选用可达龙治疗

病例 3 在完成两条线性消融后诱发出一种频率较慢的室速经非接触球囊标测此慢频率室速通过两条消融线之间的间隙传导消融此间隙后室速不再诱发

平均放电次数 17 次每条消融线达到双向传导阻滞无手术并发症平均随访 20 月无心动过速发生

ARVC-VT 心外膜消融

bull Percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia

bull 17 例患者（ 14+-4y）心内膜消融失败bull 20 VTs 诱发（ 2 个大折返 18 个局灶）bull 16 例（ 941）即刻成功bull 随访 26 plusmn 15 (range 6 to 42) 月bull 12人（ 706）无室速发作

Heart Rhythm 2010 Oct7(10)1406-10

VT1

VT2

病例 2

病例 3

12 Lead ECG (slower VT)

Pacing at site A

Pacing at site B

结果

病例 1 2 的三种临床室速消融全部成功但病例 2仍可诱发一种新的非临床类型室速室速频率快电转复后未再行标测后选用可达龙治疗

病例 3 在完成两条线性消融后诱发出一种频率较慢的室速经非接触球囊标测此慢频率室速通过两条消融线之间的间隙传导消融此间隙后室速不再诱发

平均放电次数 17 次每条消融线达到双向传导阻滞无手术并发症平均随访 20 月无心动过速发生

ARVC-VT 心外膜消融

bull Percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia

bull 17 例患者（ 14+-4y）心内膜消融失败bull 20 VTs 诱发（ 2 个大折返 18 个局灶）bull 16 例（ 941）即刻成功bull 随访 26 plusmn 15 (range 6 to 42) 月bull 12人（ 706）无室速发作

Heart Rhythm 2010 Oct7(10)1406-10

病例 3

12 Lead ECG (slower VT)

Pacing at site A

Pacing at site B

结果

病例 1 2 的三种临床室速消融全部成功但病例 2仍可诱发一种新的非临床类型室速室速频率快电转复后未再行标测后选用可达龙治疗

病例 3 在完成两条线性消融后诱发出一种频率较慢的室速经非接触球囊标测此慢频率室速通过两条消融线之间的间隙传导消融此间隙后室速不再诱发

平均放电次数 17 次每条消融线达到双向传导阻滞无手术并发症平均随访 20 月无心动过速发生

ARVC-VT 心外膜消融

bull Percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia

bull 17 例患者（ 14+-4y）心内膜消融失败bull 20 VTs 诱发（ 2 个大折返 18 个局灶）bull 16 例（ 941）即刻成功bull 随访 26 plusmn 15 (range 6 to 42) 月bull 12人（ 706）无室速发作

Heart Rhythm 2010 Oct7(10)1406-10

12 Lead ECG (slower VT)

Pacing at site A

Pacing at site B

结果

病例 1 2 的三种临床室速消融全部成功但病例 2仍可诱发一种新的非临床类型室速室速频率快电转复后未再行标测后选用可达龙治疗

病例 3 在完成两条线性消融后诱发出一种频率较慢的室速经非接触球囊标测此慢频率室速通过两条消融线之间的间隙传导消融此间隙后室速不再诱发

平均放电次数 17 次每条消融线达到双向传导阻滞无手术并发症平均随访 20 月无心动过速发生

ARVC-VT 心外膜消融

bull Percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia

bull 17 例患者（ 14+-4y）心内膜消融失败bull 20 VTs 诱发（ 2 个大折返 18 个局灶）bull 16 例（ 941）即刻成功bull 随访 26 plusmn 15 (range 6 to 42) 月bull 12人（ 706）无室速发作

Heart Rhythm 2010 Oct7(10)1406-10

Pacing at site A

Pacing at site B

结果

病例 1 2 的三种临床室速消融全部成功但病例 2仍可诱发一种新的非临床类型室速室速频率快电转复后未再行标测后选用可达龙治疗

病例 3 在完成两条线性消融后诱发出一种频率较慢的室速经非接触球囊标测此慢频率室速通过两条消融线之间的间隙传导消融此间隙后室速不再诱发

平均放电次数 17 次每条消融线达到双向传导阻滞无手术并发症平均随访 20 月无心动过速发生

ARVC-VT 心外膜消融

bull Percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia

bull 17 例患者（ 14+-4y）心内膜消融失败bull 20 VTs 诱发（ 2 个大折返 18 个局灶）bull 16 例（ 941）即刻成功bull 随访 26 plusmn 15 (range 6 to 42) 月bull 12人（ 706）无室速发作

Heart Rhythm 2010 Oct7(10)1406-10

结果

病例 1 2 的三种临床室速消融全部成功但病例 2仍可诱发一种新的非临床类型室速室速频率快电转复后未再行标测后选用可达龙治疗

病例 3 在完成两条线性消融后诱发出一种频率较慢的室速经非接触球囊标测此慢频率室速通过两条消融线之间的间隙传导消融此间隙后室速不再诱发

平均放电次数 17 次每条消融线达到双向传导阻滞无手术并发症平均随访 20 月无心动过速发生

ARVC-VT 心外膜消融

bull Percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia

bull 17 例患者（ 14+-4y）心内膜消融失败bull 20 VTs 诱发（ 2 个大折返 18 个局灶）bull 16 例（ 941）即刻成功bull 随访 26 plusmn 15 (range 6 to 42) 月bull 12人（ 706）无室速发作

Heart Rhythm 2010 Oct7(10)1406-10

ARVC-VT 心外膜消融

bull Percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia

bull 17 例患者（ 14+-4y）心内膜消融失败bull 20 VTs 诱发（ 2 个大折返 18 个局灶）bull 16 例（ 941）即刻成功bull 随访 26 plusmn 15 (range 6 to 42) 月bull 12人（ 706）无室速发作

Heart Rhythm 2010 Oct7(10)1406-10

ARVC-VT 心外膜消融

bull Epicardial substrate and outcome with epicardial ablation of ventricular tachycardia in arrhythmogenic rightventricular cardiomyopathydysplasia

bull 33 例患者中 13 例（ 394）心内膜不能完全成功需要行心外膜消融

bull 13 例心外膜消融后随访 18+-13 月bull 1013 （ 77）无 VT 发作

Garcia FC Circulation 2009 Aug 4120(5)366-75

ARVC-VT 消融的长期疗效 Outcomes of catheter ablation of ventricular

tachycardia in arrhythmogenic right ventriculardysplasiacardiomyopathy

bull 87 例患者 175 次消融

bull 平均随访 883plusmn66 月

bull 1 年 5 年 10 年无室速发作比例分别为47 21 15

bull 心外膜消融后 1 年 5 年无室速发作比例 64 45

Circ Arrhythm Electrophysiol 2012 Jun 15(3)499-505

ARVC-VT 消融心内或和心外仍有较高复发率但能显著减少 VT 负荷

bull In reported series of RV scar-related VT abolition of inducible VT is achieved in 41ndash88 of patients

bull During average follow-ups of 11ndash24 months VT recurs in 11ndash83 of patients with some series observing a significant incidence of late recurrences increasing with time

ARVC-VT 消融的现状与再认识

bull 即刻成功率高

bull 远期复发率也较高

bull 三维标测结合心外膜消融明显提高成功率

bull 即使完全消融成功考虑 VT 复发仍不能动摇 ICD 作为二级预防的适应证

ARVC-VT 消融的时机

bull 植入 ICD 之后 植入后 VT反复发作药物效

果欠佳 ATP 成功率低反复 shock 但费用bull 植入 ICD 之前 预防性消融 减少发作提高生活质量 如不植入 ICD 有较大风险

病例男性 33岁 ARVC+SMVT 2010 年 3 月 15日植入 ICD

DFT 测试首次 18J 失败第二次 22J 成功

植入时的参数设置

倍他乐克可达龙

植入后 3周 Electric storm

问题哪些患者需要早期或先行消融后植入

ICD 或 ICD 植入后尽早消融

bull 术前室速发作对 AADs 不敏感药物不能终止或减少发作预计植入后仍有较高的发生率

bull 术中发现高 DFT 或术后住院期间观察到 ATP

效果欠佳

bull 电风暴高危

ARVC 植入 ICD 后电治疗的高危因素bull History of cardiac arrestbull Ventricular tachycardia with hemodynamic

compromisebull Younger agebull Left ventricular involvement Independent predictors of VF V Flutter

这些人是否应当早期行导管消融Circulation 2003 Dec 23108(25)3084-91

ARVC-VT 消融的现状与再认识

bull 即刻成功率高

bull 远期复发率也较高

bull 三维标测结合心外膜消融明显提高成功率

bull 即使完全消融成功考虑 VT 复发仍不能动摇 ICD 作为二级预防的适应证

ARVC-VT 消融的时机

bull 植入 ICD 之后 植入后 VT反复发作药物效

果欠佳 ATP 成功率低反复 shock 但费用bull 植入 ICD 之前 预防性消融 减少发作提高生活质量 如不植入 ICD 有较大风险

病例男性 33岁 ARVC+SMVT 2010 年 3 月 15日植入 ICD

DFT 测试首次 18J 失败第二次 22J 成功

植入时的参数设置

倍他乐克可达龙

植入后 3周 Electric storm

问题哪些患者需要早期或先行消融后植入

ICD 或 ICD 植入后尽早消融

bull 术前室速发作对 AADs 不敏感药物不能终止或减少发作预计植入后仍有较高的发生率

bull 术中发现高 DFT 或术后住院期间观察到 ATP

效果欠佳

bull 电风暴高危

ARVC 植入 ICD 后电治疗的高危因素bull History of cardiac arrestbull Ventricular tachycardia with hemodynamic

compromisebull Younger agebull Left ventricular involvement Independent predictors of VF V Flutter

这些人是否应当早期行导管消融Circulation 2003 Dec 23108(25)3084-91

ARVC-VT 消融的时机

bull 植入 ICD 之后 植入后 VT反复发作药物效

果欠佳 ATP 成功率低反复 shock 但费用bull 植入 ICD 之前 预防性消融 减少发作提高生活质量 如不植入 ICD 有较大风险

病例男性 33岁 ARVC+SMVT 2010 年 3 月 15日植入 ICD

DFT 测试首次 18J 失败第二次 22J 成功

植入时的参数设置

倍他乐克可达龙

植入后 3周 Electric storm

问题哪些患者需要早期或先行消融后植入

ICD 或 ICD 植入后尽早消融

bull 术前室速发作对 AADs 不敏感药物不能终止或减少发作预计植入后仍有较高的发生率

bull 术中发现高 DFT 或术后住院期间观察到 ATP

效果欠佳

bull 电风暴高危

ARVC 植入 ICD 后电治疗的高危因素bull History of cardiac arrestbull Ventricular tachycardia with hemodynamic

compromisebull Younger agebull Left ventricular involvement Independent predictors of VF V Flutter

这些人是否应当早期行导管消融Circulation 2003 Dec 23108(25)3084-91

病例男性 33岁 ARVC+SMVT 2010 年 3 月 15日植入 ICD

DFT 测试首次 18J 失败第二次 22J 成功

植入时的参数设置

倍他乐克可达龙

植入后 3周 Electric storm

问题哪些患者需要早期或先行消融后植入

ICD 或 ICD 植入后尽早消融

bull 术前室速发作对 AADs 不敏感药物不能终止或减少发作预计植入后仍有较高的发生率

bull 术中发现高 DFT 或术后住院期间观察到 ATP

效果欠佳

bull 电风暴高危

ARVC 植入 ICD 后电治疗的高危因素bull History of cardiac arrestbull Ventricular tachycardia with hemodynamic

compromisebull Younger agebull Left ventricular involvement Independent predictors of VF V Flutter

这些人是否应当早期行导管消融Circulation 2003 Dec 23108(25)3084-91

植入时的参数设置

倍他乐克可达龙

植入后 3周 Electric storm

问题哪些患者需要早期或先行消融后植入

ICD 或 ICD 植入后尽早消融

bull 术前室速发作对 AADs 不敏感药物不能终止或减少发作预计植入后仍有较高的发生率

bull 术中发现高 DFT 或术后住院期间观察到 ATP

效果欠佳

bull 电风暴高危

ARVC 植入 ICD 后电治疗的高危因素bull History of cardiac arrestbull Ventricular tachycardia with hemodynamic

compromisebull Younger agebull Left ventricular involvement Independent predictors of VF V Flutter

这些人是否应当早期行导管消融Circulation 2003 Dec 23108(25)3084-91

植入后 3周 Electric storm

问题哪些患者需要早期或先行消融后植入

ICD 或 ICD 植入后尽早消融

bull 术前室速发作对 AADs 不敏感药物不能终止或减少发作预计植入后仍有较高的发生率

bull 术中发现高 DFT 或术后住院期间观察到 ATP

效果欠佳

bull 电风暴高危

ARVC 植入 ICD 后电治疗的高危因素bull History of cardiac arrestbull Ventricular tachycardia with hemodynamic

compromisebull Younger agebull Left ventricular involvement Independent predictors of VF V Flutter

这些人是否应当早期行导管消融Circulation 2003 Dec 23108(25)3084-91

问题哪些患者需要早期或先行消融后植入

ICD 或 ICD 植入后尽早消融

bull 术前室速发作对 AADs 不敏感药物不能终止或减少发作预计植入后仍有较高的发生率

bull 术中发现高 DFT 或术后住院期间观察到 ATP

效果欠佳

bull 电风暴高危

ARVC 植入 ICD 后电治疗的高危因素bull History of cardiac arrestbull Ventricular tachycardia with hemodynamic

compromisebull Younger agebull Left ventricular involvement Independent predictors of VF V Flutter

这些人是否应当早期行导管消融Circulation 2003 Dec 23108(25)3084-91

ARVC 植入 ICD 后电治疗的高危因素bull History of cardiac arrestbull Ventricular tachycardia with hemodynamic

compromisebull Younger agebull Left ventricular involvement Independent predictors of VF V Flutter

这些人是否应当早期行导管消融Circulation 2003 Dec 23108(25)3084-91

导管消融治疗 ICD 电风暴bull Catheter ablation for the treatment of

electrical storm in patients with implantable cardioverter-defibrillators short- and long-term outcomes in a prospective single-center study

bull 95 pts (13 ARVC 72 CAD 10 DCM)bull 85 pts (89) succeeded after 1-3 proceduresbull FU22 (1-43)m 92 no ES66 no VT 11(12)

died

Circulation 2008 Jan 29117(4)462-9 消融可有效治疗急性期 ES 联合 AAD 可发挥长期保护作用

Prophylactic catheter ablation for the prevention of defibrillator therapy

bull ICD 组和 ICD+RFCA 组各 64人

bull 随访 225+-55 月

bull ICD 组 21人（ 33）消融组 8人（ 12）发生正确 ICD 治疗事件（ P=0007） SHOCK 比例分别为 31 和 9 （ P=0003）

bull 结论预防性导管消融减少 ICD 治疗

ICD 术前预防性导管消融的研究

N Engl J Med 2007 Dec 27357(26)2657-65

ICD 术前预防性导管消融的研究Catheter Ablation of Stable Ventricular Tachycardia Before

Defibrillator Implantation in Patients with Coronary Heart Disease (VTACH) An On-Treatment Analysis

bull 结论预防性导管消融可以显著延长首次发作室速前的时间显著降低室速室颤负荷

J Cardiovasc Electrophysiol 2012 Dec 17 doi 101111jce12073 [Epub ahead of print]

结论bull ARVC 单形性室速 ICD 植入是必须的bull ARVC 室速导管消融的成功率较高长期随

访的复发率也较高bull ARVC 室速患者植入 ICD 后再发室速的风险

远高于无发作史的患者这类患者应当在植入前或植入同时积极考虑行导管消融

bull 药物或 ATP 不敏感年轻累及左心室 DFT

高的患者应早期消融

谢谢

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谢谢

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