9例11次埋藏式心脏转复除颤器电风暴的临床观察

目的总结埋藏式心脏转复除颤器(ICD)电风暴治疗的体会。方法与结果9例置入ICD后发生电风暴11次。均去除诱因,心电监测下静脉推注美托洛尔和/或胺碘酮,其中,2例加行室性心动过速(VT)射频消融,另1例加行经皮冠状动脉介入治疗。11次ICD电风暴均全部纠治。结论静脉推注美托洛尔和/或胺碘酮、适时VT射频消融和/或急诊冠状动脉血运重建等综合治疗能有效终止ICD电风暴。     

His-Purkinje system re-entry in patients with clustering ventricular tachycardia episodes

Aims: Multiple arrhythmia re-inductions were recently shown in His-Purkinjesystem (HPS) ventricular tachycardia (VT). We hypothesized thatHPS VT was a frequent mechanism of repetitive or incessant VTand assessed diagnostic criteria to select patients likely tohave HPS VT. Methods and results: Consecutive patients with clustering VT episodes (>3 sustainedmonomorphic VT within 2 weeks) were included in the analysis.HPS VT was considered plausible in patients with (i) impairedleft ventricular function associated with dilated cardiomyopathyor valvular heart disease; or (ii) ECG during VT similar tosinus rhythm QRS or to bundle-branch block QRS. HPS VT was plausiblein 12 of 48 patients and HPS VT was demonstrated in 6 of 12patients (50%, or 13% of the whole study group). Median VT cyclelength was 318 ms (250–550). Catheter ablation was successfulin all six patients. Conclusion: His-Purkinje system VT is found in a significant number of patientswith repetitive or incessant VT episodes, and in a large proportionof patients with predefined clinical or electrocardiographiccharacteristics. Since it is easily amenable to catheter ablation,our data support the screening of all patients with repetitiveVT in this regard and an invasive approach in a selected groupof patients.     

Electrical storm in systemic sclerosis: Inside the electroanatomic substrate

We report the case of a 63-year-old woman affected by a severe form of systemic scleroderma with pul-monary involvement(interstitial fibrosis diagnosed by biopsy and moderate pulmonary hypertension) and cardiac involvement(paroxysmal atrial fibrillation, right atrial flutter treated by catheter ablation, ventricular tachyarrhythmias, previous dual chamber implantable cardioverter defibrillator implant). Because of recurrent electrical storms refractory to iv antiarrhythmic drugs the patient was referred to our institution to undergo catheter ablation. During electrophysiological proce-dure a 3D shell of cardiac anatomy was created with intracardiac echocardiography pointing out a significant right ventricular dilatation with a complex aneurysmal lesion characterized by thin walls and irregular multiple trabeculae. A substrate-guided strategy of catheter ab-lation was accomplished leading to a complete electri-cal isolation of the aneurism and to the abolishment of all abnormal electrical activities. The use of advanced strategies of imaging together with electroanatomical mapping added important information to the complex arrhythmogenic substrate and improved efficacy and safety.     

埋藏式心脏转复除颤器安置后电风暴的处理与预后

目的通过分析埋藏式心脏转复除颤器(ICD)患者的长期随访资料,总结电风暴(ES)的诱发因素、临床处理及预后。方法48例患者共植入50台ICD,ES定义为24hICD正确检测到≥3次室性快速性心律失常,并促发ICD电治疗。结果随访时间中位数为16.9个月。共6例发生了8次ES。常见诱因为严重感染、心力衰竭和肾功能衰竭等。通过纠正诱因,使用抗心律失常药物,能有效减少和避免ICD电治疗。ES发生后,死亡率明显增高。结论ICD患者发生ES有比较明确的诱发因素,并且ES具有一定的预后判断价值。     

Potential proarrhythmic effect of biventricular pacing: Fact or myth?

BACKGROUND: Hemodynamic improvement from biventricular pacing is well documented; however, its electrophysiologic effects have not been systematically studied. Sporadic case reports suggest a proarrhythmic effect of biventricular pacing resulting primarily in polymorphic ventricular tachycardia/ventricular fibrillation (VT/VF). OBJECTIVES: The purpose of this study was to report a series of patients in whom implantation of a biventricular system resulted in VT/VF storm with predominance of monomorphic VT. METHODS: In a retrospective analysis of all biventricular implants over a 4-year period at a single medical center, we identified 5 of 145 patients (3.4%) who developed VT/VF after they were upgraded to a biventricular system. All patients were male, age 71 +/- 8 years, with ejection fraction of 0.25 +/- 0.1. Four of five patients had ischemic cardiomyopathy. RESULTS: All patients developed incessant VT/VF within 1 week of implantation. Monomorphic VT of single morphology was noted in 3 of 5 patients, monomorphic VT of multiple morphologies in 1, and polymorphic VT/VF in 1. VT was managed by temporary discontinuation of biventricular pacing in all patients, amiodarone in 3 of 5, sotalol in 1, and beta-blocker in 1. During 11 +/- 7 months of follow-up, 4 of 5 patients remain alive and are arrhythmia-free. CONCLUSION: Biventricular pacing may result in precipitation of VT/VF storm in a minority of patients with prior history of VT/VF. This may be the first case series reporting both monomorphic and polymorphic VT after an upgrade to a system with biventricular pacing capabilities. The arrhythmias can be managed by conventional therapy and may require temporary discontinuation of left ventricular pacing. This observation is relevant to patients receiving a biventricular pacemaker without an implantable cardioverter-defibrillator backup.     

Management of electrical storm of unstable ventricular tachycardia in post myocardial infarction patients: A single centre experience

ObjectiveThis is a case series of consecutive patients with past myocardial infarction presenting with Electrical Storm (ES) of unstable ventricular tachycardia (VT) treated by a protocol directed algorithm.MethodsManagement protocol involved treatment of reversible causes, ventilatory & hemodynamic support, administration of antiarrhythmic drugs (AAD) & maximally tolerated doses of beta-blockers, stellate ganglionectomy and Radiofrequency ablation (RFA) guided by Electro Anatomic Mapping (EAM). Patients were followed up periodically with review of device data logs.ResultsThere were 12 patients (mean age = 61.38 ± 6.48 years & mean LVEF = 31.92 ± 4.23%). Presentation was recurrent ICD shocks (n = 5) or VT (n = 7). All were mechanically ventilated. Reversible causes were identified in 4 patients and appropriately addressed. Totally 8 patients underwent endocardial substrate modification by EAM & RFA. Endocardial LV Voltage mapping demonstrated a mean scar area of 70.04 ± 17.63 sq.cm (27.04 ± 6.20% of mapped area). The electrograms targeted for ablation included late potentials, fractionated electrograms, double potentials and channels within the scar. Two patients had stellate ganglionectomy in addition. Ten patients (83.3%) survived to discharge, all of whom are alive at a follow up of 30.12 ± 19 months free of ES. VT free survival at end of follow up was 80%. No patient had hospitalization related to VT. Single episode of VT recurrence was seen in 2 patients at 7 months and 1 year of follow up respectively.ConclusionIn post myocardial infarction patients presenting with ES and unstable VT, a protocol driven approach involving substrate modification targeting abnormal electrograms improves outcomes.     

Coexistence of 2 types of atrial tachycardias and right ventricular outflow tract tachycardia

Double tachycardia is a relatively uncommon type of tachycardia. In this report, we discuss a 68-year-old woman with history of frequent palpitations. Electrophysiologic study revealed that narrow QRS tachycardias from 2 origins and 1 wide QRS tachycardia were induced and each of the tachycardias was induced by the other. We found that 2 focal atrial tachycardias and 1 ventricular tachycardia originated from right ventricular outflow tract. All of these tachycardias were successfully ablated during one session, and no recurrence appeared during 10 months of follow-up.     

异搏定治疗特殊类型室性心动过速的临床疗效与安全性研究

目的　探讨异搏定治疗特殊类型室性心动过速 (室速 )的临床疗效与安全性。方法　对 2 3例特发性单形性室速和短联律间距室性早搏 (室早 )诱发的多形性室速患者 ,使用异搏定每次 5～ 10mg稀释后缓慢静脉注射 ,监测注药前后的心电与血压改变。室速终止后口服该药 40～ 80mg ,每日 3次维持治疗。 结果　 1例患者死亡 ,余2 2例均予静注该药而及时终止了室速发作 ,部分静注总量超过 2 0mg的患者出现短时血压下降和窦房结功能抑制。 16例口服维持治疗并随访 8个月至 6年的患者 ,室速未再发作或发作次数明显减少。结论　异搏定对于这类特殊类型室速的疗效肯定 ,安全性较好 ,副作用少。不良反应发生与剂量有关。但异搏定不能防止短联律间距室早诱发的多形性室速患者猝死发生。     

Brugada法联合Steurer法在宽QRS波心动过速鉴别诊断中的价值

为评价Brugada法联合Steurer法在宽QRS波心动过速 (WRT)鉴别诊断中的应用价值及存在的缺陷。对 1 0 1例WRT[室性心动过速 (VT) 5 8例 ,室上性心动过速 (SVT) 43例 ]进行分析。结果 :Brugada法诊断VT灵敏度、特异度、准确性分别为 85 .7%、89.5 %、87.1 % ;联合Steurer法后灵敏度、特异度、准确性分别升至 91 .5 %、90 .5 %、91 .1 %。进一步分析显示 :Brugada法对器质性原因所致VT、右束支阻滞型 (RBBB)特发性VT(IVT)、SVT伴室内差异性传导 (AC)或原有单侧束支阻滞 (BBB)者诊断符合率高 ( 95 .8%～ 1 0 0 .0 % ) ;对左束支阻滞型 (LBBB)特发性VT、SVT伴原有双支阻滞、心肌坏死或心肌梗死伴宽QRS波SVT及预激综合征伴旁道前传型SVT(WPW SVT)诊断的符合率低 ( 0～ 5 0 .0 % )。联合Steurer法可使WPW伴旁道前传型SVT得以明确诊断 ,但对前三者无鉴别意义 ,故不适合在前三者中应用。结论 :Brugada法联合Steurer法能提高WPW伴旁道前传型SVT的鉴别能力 ,是目前鉴别WRT的重要方法。