植入型心律转复除颤器在心律失常治疗中的应用

自1996年1月以来,我们对7例心律失常患者于治疗过程中采用植入型心律转复除颠器（ICD）,获得满意疗效。现报告如下。     

植入型心律转复除颤器治疗快速心律失常

１９８０年２月，Ｍｉｒｏｗｓｋ首次为一位心脏骤停幸存者应用植入型心律转复除颤器（ＩＣＤ）的最早产品ＡＩＤ（植入型自动除颤器，ａｕｔｏｍａｔｉｃｉｍｐｌａｎｔａｂｌｅｄｅｆｉｂｒｉｌａｔｏｒ）治疗取得成功。１９年来，ＩＣＤ的设计不断完善，功能日益复杂精...     

植入型心律转复除颤器治疗恶性室性心律失常

目的 报道植入型心律转复除颤器治疗恶性室性心律失常５例次临床应用经验。方法 采用经静脉途径为４例恶性室性心律失常患者植入５台植入型心律转复除颤器,并随访３～６４个月。结果 随访期间１例患者发生１次室性心动过速并经低通量电击复律成功和１次误放电,余患者经抗心律失常药物治疗无症状发作。结论 植入型心律转复除颤器有效地治疗恶性室性心律失常,预防心脏性猝死的发生,适当的抗心律失常药物可减少植入型心律转复除     

植入型心律转复除颤器的临床应用

自从１９８０年问世以来,植入型心律转复除颤器（ＩＣＤ）已成为临床上治疗持续性或致命性室性心律失常的一个重要手段。ＩＣＤ的概念最早出现于６０年代,但对于其应用价值一直存在争议,直到１９８０年,Ｍｉｒｏｗｓｋｉ首先将其应用于人体,其有效性及临床应用价值才开始被承认。１９８５年,美国食品与药物管理局（ＦＤＡ）批准了ＣＰＩ公司的第一代ＩＣＤ（植入型心脏自动除颤器,ＡＩＣＤ）用于临床,自那时以来,ＩＣＤ的制造技术取得了较大突破,无论是在设计、功能及可靠性等方面均有了很大的改善。ＡＩＣＤ除了体积庞大、使用寿…     

植入型心律转复除颤器对缺血性心肌病患者病死率的影响

目的:缺血性心肌病伴左心室功能不全[射血分数(EF)<40%]和恶性室性心律失常的患者预后不良,研究比较植入型心律转复除颤器(ICD)和传统药物治疗对这组患者病死率的影响。方法:回顾性分析2002年1月至2006年3月明确诊断为缺血性心肌病伴左心室功能不全(EF<40%)及恶性室性心律失常的患者152例,其中男性97例,女性55例,平均年龄(58.2±23.4)岁,其中ICD植入患者15例(A组),传统药物治疗患者137例(B组),随访(14±3)个月,主要终点事件为任何原因的死亡。结果:A组患者只有1例(6.7%)死亡,但对其ICD事件进行回顾性分析证实死亡为非恶性室性心律失常所致。B组患者死亡19例(13.9%),其中6例患者死于恶性室性心律失常。2组患者的病死率差异无显著性(P>0.05)。但对ICD植入患者的程控发现ICD共成功纠正心室颤动(VF)发作21次,持续性室速(VT)发作65次。结论:本研究提示ICD可降低缺血性心肌病患者恶性室性心律失常导致的猝死。     

植入型心律转复除颤器的临床随访

目的观察植入型心律转复除颤器(ICD)植入术后的工作情况。方法对植入ICD患者进行临床随访，应用体外程控仪调出ICD存储资料进行分析。结果11例植入ICD患者随访1～31个月，无手术并发症发生。4例患者的ICD成功放电终止恶性室性心律失常。2例患者的ICD因阵发性心房颤动发生误识别和误放电，重新设置工作参数和加入抗心律失常药物治疗后未再出现误放电。7例患者出现轻度精神症状，经心理辅导治疗后症状消失。结论ICD能有效治疗恶性室性心律失常。但ICD可能发生误识别、误放电，定期随访和及时调整参数可避免或减少此类情况发生。ICD植入后心理辅导治疗是必要的。     

心律转复除颤器对室性心律失常的疗效评价

目的 评价80例植入型心律转复除颤器(ICD)的临床应用效果,分析植入ICD患者室性心律失常的发作情况以及ICD治疗恶性室性心律失常的疗效.方法 对本院1996年8月至2008年1月来本院就诊定期随访、资料完整的植入了ICD患者进行回顾性临床分析.结果 80例植入了ICD患者(其中11例为二次更换ICD),其中65例(81.25%)为各种器质性心脏病,以冠心病最为常见.随访4～62(26.96±18.97)个月中,72例患者(90%)发生室性心动过速和/或心室颤动,并成功接受ICD治疗,共发生心律失常事件1243次,启动治疗程序1854次,包括抗心动过速起搏成功治疗室速712次,低能量复律和高能量除颤转复治疗共266次.误识别治疗147次.68次心律失常事件在ICD启动治疗程序中自行终止,ICD未继续实施治疗.随访期间共有3例(3.75%)患者死亡.结论 ICD能够有效地治疗室性心律失常.植入术后需要密切随访,根据情况及时调整工作参数.     

植入型心律转复除颤器治疗冠心病伴室性心律失常疗效观察

目的 观察冠心病伴恶性室性心律失常患者植入心律转复除颤器(ICD)治疗后的长期预后.方法 23例冠心病患者,其中男性18例,女性15例,年龄(71.56±10.38)岁.心功能不良16例.22例行血运重建术(经皮冠状动脉介入术20例,冠状动脉搭桥术2例).术后发生晕厥9例,持续性室性心动过速(VT)发作22例,心室颤动(VF)发作5例.植入单腔ICD(VVI)15例,双腔ICD(DDDR)1例,三腔ICD(CRT-D)7例.随访时间平均为(33.37±25.39)个月.结果 (1)死亡2例,因急性心肌梗死和急性左心衰竭死亡各1例.(2)4例患者术后再次住院.原因:1例为心功能不良,3例为ICD多次放电住院.(3)13例(56.5%)发生持续性VT或VF事件.持续性VT发作434次,386次(98.6%)经抗心动过速起搏(ATP)治疗成功.FVT发作25次,ATP治疗FVT总的成功率为84.0%.(4)ICD电风暴3例.(5)ICD误识别及误治疗2例.结论 冠心病伴恶性室性心律失常患者血运重建后用ICD治疗,可防止由于心肌的慢性的瘢痕产生室性心律失常而导致猝死的风险.     

植入型心律转复除颤器的随访观察三例

临床资料　例 1男性 ,5 3岁 ,陈旧性前壁心肌梗死 6年 ,发作性头晕、心悸、气短 1年 ,每次发病血压 4 0～ 6 0 / 0ｍｍＨｇ ,心电图示单形持续性室性心动过速 (室速 ) ,室速呈两种频率 ,分别为 2 0 0次 /ｍｉｎ和 14 0～ 15 0次 /ｍｉｎ ,心脏超声心动图示左心室舒张末期内径 5 5ｍｍ ,左心室射血分数 (ＬＶＥＦ) 0 4。植入的植入型心律转复除颤器 (ＩＣＤ)为ＣＰＩＶＥＮＴＡＫＭＩＮＩ。例 2男性 ,5 5岁 ,陈旧性前壁心肌梗死 3年 ,突然意识丧失、抽搐 3次 ,心电监护和动态心电图示多形室速、心室扑动 ,心脏超声心动图示ＬＶＥＦ 0 35 ,…     

植入型自动心律转复除颤器临床应用

心脏性猝死严重威胁心脏病患者的生命 ,其最常见直接原因为 VT和 VF。ICD是预防心脏性猝死的最有效的治疗方法。 1 980年 2月在美国霍普金氏医院 (Johns Hopkins Hospital)安装了第一台自动除颤器 ,到目前为止 ,世界上十万例患者安装了除颤器 ,挽救了数以万计患者的生命。在近六年内 ,这种治疗方法已成为标准治疗方法。越来越多的患者 ,尤其心脏骤停幸存者非常愿意接受这种治疗。仅 1 993年一年 ,美国接受 ICD植入的患者已达 1万例 ,1 995年已达 3万例。我国从 1 991年开始将 ICD应用于临床 ,迄今约有 30例患者安装了 ICD。我院1 99…     

37例致心律失常性右心室心肌病患者PKP2基因检测

目的 调查单中心致心律失常性右心室心肌病(ARVC)患者PKP2突变发生率.方法 对50例考虑诊断为ARVC的患者采用2010年新诊断标准进行重新评估.采用聚合酶链式反应(PCR)扩增PKP2基因各外显子片段并测序,结果与200例正常对照组进行比对分析.结果 37例被确诊ARVC,9例为临界诊断,另4例为疑似诊断.确诊患者中有10例(27％)携带7个新突变和3个已报道突变,包括7个无义突变和3个错义突变,临界诊断及疑似诊断患者均未检测出PKP2基因突变.携带PKP2突变的患者与未携带突变的患者临床特征差异无统计学意义.结论 本组ARVC患者PKP2基因突变发生率与欧美国家相似,但突变谱存在差异.     

Long-term follow-up in patients with arrhythmogenic right ventricular cardiomyopathy

Long‐Term Prognosis in Patients with ARVC. Introduction: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a major cause of sudden cardiac death due to tachyarrhythmias. The purpose of this study was to investigate the long‐term prognosis in patients with ARVC and the incidence of rapid ventricular arrhythmias during follow‐up. Methods: Thirty ARVC patients (19 male, 63.3%, mean age 48 ± 15 years) fulfilling modified Task Force criteria 2010 were included. Of them, 13 patients (43.3%) received implantable cardioverter‐defibrillator (ICD) implantation. Rapid ventricular arrhythmia was defined as electrical storm or the occurrence of ventricular tachycardia (VT) or ventricular fibrillation (VF) with a cycle length of 240 ms or less that necessitate shock delivery to 2 or more times within a 24‐hour period. Results: With a mean follow‐up of 68 ± 10 months, 6 patients (20%) with ICD implantation had recurrent rapid VT/VF. One (3.3%) of them died of multiple shocks and SCD, and 5 (16.7%) had multiple ICD therapies due to VT/VF and electrical storm. The interval between the diagnosis of ARVC and occurrence of rapid VT/VF was 13.4 ± 4.9 months. Most (5/6, 83.3%) events of recurrent rapid VT/VF occurred within 2 years. Ablated patients who did not receive an ICD implant were totally free of rapid VT/VF. Conclusions: For patients with ARVC, long‐term prognosis is favorable. During a long‐term follow‐up, patients meeting the criteria for ICD implantation have a higher rate of rapid and potentially life‐threatening arrhythmias. However, early and clustered recurrence of rapid VT/VF in patients with an ICD is common, whereas late occurrence of rapid VT/VF is very rare. (J Cardiovasc Electrophysiol, Vol. 23, pp. 750‐756, July 2012)     

Implantable cardioverter defibrillator therapy in patients with cardiac sarcoidosis

ICD Shocks in Cardiac Sarcoidosis . Background: An implantable cardioverter defibrillator (ICD) is indicated for some patients with cardiac sarcoidosis (CS) for prevention of sudden death. However, there are little data regarding the event rates of ICD therapies in these patients. We sought to identify the incidence and characteristics of ICD therapies in this patient population. Methods: We performed a cohort study of patients with ICDs at 3 institutions. Cases were those patients with CS and an ICD implanted for primary or secondary prevention of sudden death. Additionally, we included a comparison with historical controls of ICD therapy rates reported in clinical trials evaluating the ICD for primary and secondary prevention of sudden death. Results: Of the 112 CS subjects identified, 36 (32.1%) received appropriate therapies for ventricular tachyarrhythmias (VT) over a mean follow‐up period of 29.2 months. VT storm (>3 episodes in 24 hours) occurred in 16 (14.2%) CS subjects. Inappropriate therapies occurred in 13 CS subjects (11.6%). Covariates associated with appropriate ICD therapies included left ventricular ejection fraction (LVEF) <55% (OR 6.52 [95% CI 2.43–17.5]), right ventricular dysfunction (OR 6.73 [95% CI 2.69–16.8]), and symptomatic heart failure (OR 4.33 [95% CI 1.86–10.1]). Conclusions: In our cohort of patients with CS and ICDs, almost one‐third receive appropriate therapies. This may be due to a myocardial inflammatory process leading to increased triggered activity and subsequent scarring leading to reentrant tachyarrhythmias. Adjusted predictors of ICD therapies in this population include left or right ventricular dysfunction. (J Cardiovasc Electrophysiol, Vol. 23, pp. 925‐929, September 2012)     

致心律失常性右心室心肌病的QRS及QT离散度研究

目的　探讨致心律失常性右心室心肌病 (arrhythmogenicrightventricularcardiomyopathy ,ARVC)危重患者、家系中无症状患者及家系中可疑患者的QRS及QT离散度的存在规律。方法　按欧洲心脏病学会 (ESC)的诊断标准 ,选择有室性心动过速、晕厥或心脏骤停 (cardiacarrest)史的ARVC患者 2 5例为危重组 ,家系调查发现的家系中无明显症状的ARVC患者 16例为无症状组 ,家系中高度怀疑为ARVC但尚未达到诊断标准的 18例为可疑组 ,正常对照组为 14例。同步记录标准 12导联心电图。测量每个导联QRS时限 ,记录 12导联中的QRS时限最大值 (QRSm ,最长的 1个QRS值 )、QRS离散度 (QRSd ,12导联中最长的 1个QRS值减最短的 1个QRS值 )及QRS时限平均值 (QRSa)。测量每个导联QT间期 ,记录 12导联中的QT最大值 (QTm ,最长的 1个QT间期 )、QT平均值 (QTa)、QT离散度 (QTd ,导联中最长的 1个QT值减最短的 1个QT值 )、校正QTd(QTcd)及校正QTm(QTcm)。比较各组各指标的差异。结果　可疑组的年龄低于对照组、危重组与无症状组。 4组之间QRSd差异无显著性。QTd在危重组为 (6 9 6± 4 1)ms,在无症状组为 (77 3± 5 7)ms均显著高于对照组 (5 5 4±6 3)ms(P均为 0 0 0 3) ;危重组与无症状组差异无显著性。QRSm、QRSa、QTa、QTcd、QT     

Ventricular tachycardia ablation in arrhythmogenic right ventricular cardiomyopathy patients with TMEM43 gene mutations

1 Introduction

Catheter ablation of VT in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) is often challenging, frequently requiring multiple or epicardial ablation procedures; TMEM43 gene mutations typically cause aggressive disease. We sought to compare VT ablation outcomes for ARVC patients with and without TMEM43 mutations.

2 Methods

Patients with prior ablation for ARVC‐related VT were reviewed. Demographic, procedural, and follow‐up data were reviewed retrospectively. Patients with confirmed TMEM43 gene mutations were compared to those with other known mutations or who had no known mutations.

3 Results

Thirteen patients (10 male, mean age 49 ± 14 years) underwent 29 ablation procedures (median 2 procedures/patient, range 1–6) with a median of 4 targeted VTs/patient (range 1–9). They were followed for a mean duration of 7.3 ± 4.2 years. Gene mutations included TMEM43 (n = 5), PKP2 (n = 2), DSG2 (n = 2), unidentifiable (n = 4). TMEM patients showed more biventricular involvement compared to non‐TMEM patients (80% vs. 12.5%, P = 0.032), more inducible VTs during their ablation procedures (mean VTs/patient: 5.8 ± 3 vs. 2.6 ± 1, P = 0.021). Acute and long‐term procedural outcomes did not show a significant difference between the two groups, however TMEM patients had worse composite endpoint of death or transplantation (60% vs. 0, P = 0.035; log‐rank P = 0.013).

4 Conclusions

TMEM43 mutation patients were more likely to have biventricular arrhythmogenic substrate and more inducible VTs at EP study. Despite comparable acute VT ablation outcomes, long‐term prognosis is unfavorable.     

Predictors of appropriate implantable defibrillator therapies in patients with arrhythmogenic right ventricular dysplasia

BACKGROUND: Arrhythmogenic right ventricular dysplasia (ARVD) is an inherited cardiomyopathy characterized by ventricular arrhythmias and sudden cardiac death. The risk factors for sudden death and indications for implantable cardioverter-defibrillator (ICD) placement in patients with ARVD are not well defined. OBJECTIVES: The purpose of this study was to determine which clinical and electrophysiologic variables best predict appropriate ICD therapies in patients with ARVD. Particular attention focused on whether the ICD was implanted for primary or second prevention. METHODS: We enrolled 67 patients (mean age 36 +/- 14 years) with definite or probable ARVD who had undergone ICD placement. Appropriate ICD therapies were recorded, and Kaplan-Meier analysis was used to compare the event-free survival time between patients based upon the indication for ICD placement (primary vs secondary prevention), results of electrophysiologic testing, and whether the patient had probable or definite ARVD. RESULTS: Over a mean follow-up of 4.4 +/- 2.9 years, 40 (73%) of 55 patients who met task force criteria for ARVD and 4 (33%) of 12 patients with probable ARVD had appropriate ICD therapies for ventricular tachycardia/ventricular fibrillation (VT/VF; P = .027). Mean time to ICD therapy was 1.1 +/- 1.4 years. Eleven of 28 patients who received an ICD for primary prevention (39%) and 33 of 35 patients who received an ICD for secondary prevention (85%) experienced appropriate ICD therapies (P = .001). Electrophysiologic testing did not predict appropriate ICD interventions in patients who received an ICD for primary prevention. Fourteen patients (21%) received ICD therapy for life-threatening (VT/VF >240 bpm) arrhythmias. There was no difference in the incidence of life-threatening arrhythmias in the primary and secondary prevention groups (P = .29). CONCLUSION: Patients who meet task force criteria for ARVD are at high risk for sudden cardiac death and should undergo ICD placement for primary and secondary prevention, regardless of electrophysiologic testing results. Further research is needed to confirm that a low-risk subset of patients who may not require ICD placement can be identified.