器质性心脏病室性心动过速导管消融治疗进展

器质性心脏病瘢痕相关性室性心动过速（室速）的发生主要是折返机制,目前多采用心脏三维标测系统指引下对耐受性好、血流动力学稳定的室速激动标测消融,对于血流动力学不稳定的室速,窦性心律下基质标测、电压图判断室速的解剖基质,结合起搏标测和拖带标测技术识别室速的折返环,盐水灌注导管消融治疗;近年来不断积累有关临床循证证据、适应证进一步拓展、新的标测消融和辅助技术临床上应用,取得了新的进展。     

器质性心脏病室性心动过速的导管射频消融治疗

总结导管射频消融 (RFCA)治疗 5例器质性心脏病室性心动过速 (简称室速 )的体会。电生理检查与RFCA一次完成。激动或 (和 )起搏标测确定靶点后消融。结果 :1例致心律失常性右室心肌病室速在右室心底部标测到较体表心电图 (ECG)之QRS波群提前 34ms的起始碎裂电位 ,室速可被隐匿拖带。 1例肥厚型心肌病术中发作 4种形态室速 ,分别于右室游离壁 ,流出道后侧壁、间隔前下及间隔前上标测到较体表ECG的QRS波群提前 40ms以上的碎裂电位 ,分别以此为靶点消融成功。 1例陈旧性心肌梗死室速于左室游离壁标测到较体表QRS波群提前 46ms的局部碎裂电位 ,起搏标测 12导联QRS波群形态与室速时完全一致 ,以此靶点消融成功。 1例扩张型心肌病 ,诱发束支折返性室速 ,消融右束支。 4例均消融成功 ,随访 10个月至 7年无复发。 1例Fallot四联征矫正术后患者有右室流出道室速发作 ,术中未能诱发室速 ,在起搏标测下消融 ,1个月后复发。 5例患者共发作 10种形态室速 ,消融成功 9种 ,复发 1种。平均手术时间 144min ,X线曝光时间 6 5min。结论 :对器质性心脏病反复发作的持续性单形性室速 ,RFCA是可行的治疗方法     

器质性心脏病室性心动过速的导管消融进展

器质性室性心动过速绝大多数是折返性机制。激动顺序、拖带和舒张期电位仍然有价值,而非接触式标测等新技术提供了较强大的标测手段。然而,消融的能量和效能仍然是制约成功率的主要因素。心外膜标测、盐水冲洗大头和冷凝消融具有潜在的价值。     

器质性心脏病相关室性心律失常导管消融进展

<正>器质性心脏病相关室性心律失常,尤其是室性心动过速(室速)是临床上常见的恶性心律失常,是导致心源性猝死的主要原因。常见的基础心脏病有冠状动脉粥样硬化性心脏病(冠心病)、心肌梗死、致心律失常型右心室心肌病、扩张型心肌病、肥厚性心肌病、心肌炎等[1,2]。近年来,器质性心脏病相关室性心律失常的导管消融无论是在电生理标测及导管消融器械、消融途径还是消融策略方面都取得显著进展,现综述如下。1器质性心脏病相关室性心律失常导管消融的循证医学新证据     

器质性心脏病合并室上性心动过速的射频消融治疗

目的 探讨器质性心脏病合并阵发性室上性心动过速射频消融的疗效和安全性.方法 对11例器质性心脏病合并房室折返性或房室结折返性心动过速患者进行了射频消融治疗,并与80例无器质性心脏病患者进行对照.结果 射频消融治疗的首次成功率为90.9%,无严重并发症.与对照组比较,手术时间和X线爆光时间长.结论 器质性心脏病合并阵发性室上性心动过速射频消融治疗仍安全有效,术前明确其解剖学改变和心功能状态,对于选择射频消融途径、增加成功率、减少操作时间及减低并发症具有重要意义.     

器质性心脏病室速基于异常电位的基质标测及消融

<正>器质性心脏病的室性心动过速(室速)的射频导管消融治疗一直是消融治疗的难点,也是近年来研究的热点问题。这类室速的机制最常见的是瘢痕相关的折返机制,对于血流动力学稳定的室速,可采取激动标测和拖带标测相结合的策略来寻找消融靶点,但室速有时难以诱发,或诱发后血流动力学不稳定,不能可靠的诱发。非持续性室速自行终止,拖带标测时室速周长和/或形态不一致,均导致激动标测和拖带标测难以进行。研究显示进行室速消融的     

非器质性心脏病室速的临床意义

本文叙述了在非器质性心脏病人中，发生室性心动过速的临床意义，提出了该类型室速的发生机理，临床特征，诊断及治疗原则。     

射频导管消融器质性心脏病室性心动过速9例临床观察

目的评价射频导管消融器质性心脏病室性心动过速(室速)的疗效。方法总共9例器质性心脏病患者(男7例,女2例),接受射频导管消融手术,其中肥厚型心肌病4例,扩张性心肌病2例,冠状动脉粥样硬化性心脏病1例,先天性心脏病、室间隔缺损修补术后1例,致心律失常性右室心肌病1例。所有患者术前心电图和动态心电图均提示为单形性室速。9例患者均在窦性心律下行起搏标测室速折返环出口或病灶起源点,如果起搏QRS波形态至少有11导联与诱发室速QRS波形态相同,且S-QRS间期≤20ms,则判断为消融靶点,在此部位行多靶点消融。结果 9例患者中,4例为右室流入道室速,3例为右室流出道室速,1例为左室流入道室速,1例为左室流出道室速。其中1例致心律失常性右室心肌病患者术中出现三种室速形态而放弃手术。其余8例患者分别消融3~11个靶点,其中2例手术失败。1例患者1周后再次行射频消融手术失败。所有患者术中、术后均无并发症发生。随访20~42(30.65±8.72)月,其中6例患者(包括1例2次手术者)无室速复发。结论射频导管消融能有效治疗器质性心脏病单形性室速;起搏标测手段在器质性心脏病室速射频消融中有其应用价值。     

射频消融治疗老年伴有器质性心脏病患者快速性心律失常

59例住院行射频消融(RFCA)治疗的老年伴器质性心脏病的快速性心律失常患者,统计其成功率、复发率、并发症发生率等指标。结果:各种心律失常治疗总成功率为89.8%,总复发率3.8%,总并发症发生率11.9%,无严重并发症发生。结论:RFCA治疗老年伴有器质性心脏病的快速性心律失常患者安全有效。     

Catheter ablation of ventricular tachycardia using radiofrequency techniques in patients without structural heart disease.

It has been previously demonstrated that radiofrequency (RF) energy can be safely applied to successfully eliminate accessory pathways in patients with the Wolff-Parkinson-White syndrome. This technique may also be used to successfully eliminate atrioventricular (AV) nodal reentrant tachycardia by elimination of either the fast or slow AV nodal pathways. However, RF energy has achieved only limited success in eliminating ventricular tachycardia (VT) in patients with structural heart disease, such as coronary artery disease and dilated cardiomyopathy. Direct-current catheter techniques have successfully eliminated VT in patients with and without structural heart disease, but this technique is limited by the risk of barotrauma and proarrhythmia. We used RF catheter ablation techniques to eliminate VT in patients without structural heart disease. Our results from the basis of this report. 16 patients (nine women and seven men; mean age 38; range 18 to 55 years) who did not have any identifiable structural heart disease by echocardiography where included in this study. These patients underwent RF catheter ablation to eliminate VT. Two patients had presented with syncope, nine with presyncope and five with palpitations only. The mean duration of symptoms was 6.7 years (range 0.5 to 20 years). VT was successfully eliminated by RF catheter techniques in 15 of the 16 patients (a 94% success rate). Importantly, successful ablation sites included regions other than the right ventricular outflow tract. Areas of VT origin therefore included the high right ventricular outflow tract (twelve patients), right ventricular septum near the tricuspid valve (three patients), and the left ventricular septum (one patient). The only ablation failure was in a patient whose VT arose from a region near the His bundle. Successful ablation occurred in patients in whom an accurate pace map could be obtained and early local endocardial activation was obtainable. Further, firm catheter contact with endocardium was required for successful elimination of VT. RF ablation did not cause any identifiable arrhythmia and produced a minimal cardiac enzyme rise. It also resulted in no detectable change in cardiac function by Doppler echocardiography. Based on these findings, we conclude that RF catheter ablation of VT in patients without structural heart disease was highly effective and safe. It may therefore be considered as early therapy in these patients.     

Catheter ablation of ventricular tachycardia associated with structural heart disease: Current status and perspectives

Catheter ablation is an effective and safe treatment for ventricular tachycardia attributable to structural heart disease, reducing the risk of recurrent arrhythmias and defibrillator shock therapy. Advances in medical technology and an accumulation of data have led to the development of detailed guidelines. Successful ablation requires accurate identification of the arrhythmia substrate and effective delivery of radiofrequency energy to the target tissue. Modern practice requires use of traditional electrophysiological mapping processes such as entrainment mapping and three-dimensional activation sequence mapping in combination with newer functional mapping techniques for which there is growing support. Thorough non-invasive preoperative assessment is also necessary before an invasive procedure is undertaken. In this review, we summarize contemporary practice and recent randomized controlled trials underpinning the latest developments in mapping and ablation and discuss potential future developments in this field.     

Catheter ablation of ventricular tachycardia in patients with ischemic heart disease

Radiofrequency ablation is a valuable adjunctive therapy to implantable defibrillators in patients with recurrent monomorphic ventricular tachycardia (VT) after myocardial infarction. Episodes of VT are markedly reduced in most patients, and the major complications are less than 5%. Newer approaches allow successful ablation even when VT is unstable, and when multiple VTs are present. Epicardial mapping and ablation are needed in some patients. Continued advances in technology can be expected to further improve results.     

Catheter ablation for ventricular tachycardia

Sudden cardiac death due to ventricular arrhythmias remains the most common cause of death in developed nations. Implantable cardioverter defibrillators have been shown to improve mortality in high‐risk groups for ventricular tachyarrhythmias, but they are not curative, with the risk of arrhythmia recurrence remaining unaltered. It is also important to remember that ventricular tachycardia (VT) in the setting of a structurally normal heart is often not associated with an increased risk of sudden death and catheter ablation is a potentially curative procedure in this cohort. Recent advances in catheter ablation for VT have increased the efficacy in creating adequate lesions, accurate three‐dimensional maps and mapping haemodynamically unstable VT, all of which have increased the utility of this modality in the treatment of ventricular arrhythmias. In this article, we review the recent advances that have fuelled renewed interest in catheter ablation of VT, its clinical utility and who should be referred.     

Catheter ablation in ventricular tachycardia

The basis for management of ventricular tachycardia (VT) is pharmacologic treatment which is effective, however, in only about 20 to 30% of the patients. With respect to this problem, alternative therapeutic modes have been developed which include, in addition to antitachycardia stimulation, electrical, palliative therapy such as the implantable automatic defibrillator, definitive measures such as map-guided antitachycardia surgery and catheter ablation. The goal of catheter ablation is the selective destruction of heart structures which are the morphologic correlate for initiation of propagation of VT. Catheter ablation was discovered by chance by Fontaine after a defibrillation during an electrophysiologic study in which a defibrillating electrode in the proximity of a catheter at the His bundle induced complete AV-block. This effect of destruction in the AV-conduction system by direct current as a therapeutic measure was further developed by Gallagher and Scheinman. The mechanism held responsible is coagulation by the electrode of neighboring tissue and barotrauma. The technique, which was initially used for ablation of the His bundle in supraventricular tachycardia, can also be used for ablation of accessory pathways or the site of origin of VT which generally lies endocardially in marginal regions of myocardial infarctions. CATHETER MAPPING: In sinus rhythm and induced VT, endocavity catheter mapping is carried out after heparinization with electrocardiograms recorded from at least six to ten sites in the right and left ventricles. At the site of early activation, detailed mapping is used for identification of the site of earliest activation, then pace-mapping is performed during sinus rhythm and VT. The morphology of the stimulated QRS complexes is compared with that of the spontaneous VT. In patients in whom VT cannot be induced, localization is carried out by pace-mapping alone. CATHETER ABLATION: After localization, in intubation narcosis and with continuously monitored arterial blood pressure, the suspected site of origin of the VT is subjected to an initial shock during sinus rhythm by means of a distal electrode of a catheter in stable contact with the endocardium. For mapping and ablation, the same catheter is used. After each subsequent shock, assessment is performed to determine if the distal electrode pair still conducts local ventricular signals and if ventricular stimulation is possible. The shock energy delivered is 100, 200 or 400 Joules. At the time of shock discharge, the remaining electrodes or catheters are disconnected. In the case of bradycardia or tachycardia after the shock, immediate connection to an external stimulation generator is established. At the time of the shocks, relaxation is provided by succinylcholine. All shocks are delivered from the anode. The integrity of the catheter is tested after each shock, no catheter is used more than three or four times. At the earliest, ten minutes after shock delivery, induction of clinical VT is attempted with programmed stimulation and if induction is possible, at the same site a maximum of two more shocks are delivered or, after renewed mapping, another shock is delivered to a different site. Induced non-clinical VT is not subjected to ablation.(ABSTRACT TRUNCATED AT 400 WORDS)     

Catheter ablation of ventricular tachycardia

Opinion statement Most patients with ventricular tachycardia (VT) associated with structural heart disease should receive an implantable cardioverter-defibrillator as initial therapy. Patients with symptomatic recurrences of tachycardia, including those with multiple defibrillator shocks, are considered for ablation. The vigor with which antiarrhythmic drug therapy is pursued as antecedent therapy to ablation depends on patient factors (eg, medical comorbidity, type of heart disease, number and hemodynamic tolerance of tachycardias) and the previous history of antiarrhythmic drug exposure (eg, side effects, inefficacy). In patients with mild left ventricular dysfunction and well-tolerated tachycardia, ablation may be offered as primary definitive therapy in selected individuals. In patients without structural heart disease, ablation is usually offered as primary definitive therapy to highly symptomatic patients, and is strongly recommended for patients with recurrent tachycardia following initial attempts at drug suppression. Optimal outcome of VT ablation depends on the availability of an experienced team and sophisticated facilities to accommodate the technical challenges associated with the broad spectrum of clinical presentations and arrhythmia mechanisms. Historically, major complications have been reported in up to 10% of patients, including death, stroke, cardiac tamponade, complete heart block, and myocardial infarction. In our own experience with VT ablation over the past 10 years, major complications occurred in three (1.8%) of 168 patients with structural heart disease and one (0.7%) of 142 patients without structural heart disease.