左心室起源室性心动过速的手术治疗：成功的危险因素及长期预后
Surgery for ventricular tachycardia of left ventricular origin: risk factors for success and long-term outcome.
作者信息
von Oppell Ulrich Otto, Milne Dave, Okreglicki Andrzej, Scott Millar Robert Norman
机构信息
Department of Cardiothoracic Surgery, Cardiac Directorate, University Hospital of Wales, Cardiff CF14 4XW, UK.
出版信息
Eur J Cardiothorac Surg. 2002 Nov;22(5):762-70. doi: 10.1016/s1010-7940(02)00487-6.
OBJECTIVES
To review 26 consecutive patients with sustained monomorphic ventricular tachycardia (VT) of left ventricular origin, who underwent direct VT surgery.
METHODS
Economic factors precluded the use of an implantable cardioverter defibrillator (ICD) in the majority of these patients, and the indication for surgery in 81% of patients was for failed medical drug therapy and 27% of patients had frequent or incessant life-threatening VT. The principles of direct VT surgery included intraoperative mapping, extended endocardial resection, cryoablation, left ventricular aneurysm repair by left ventricular remodelling and endoaneurysmorrhaphy, as well as coronary artery bypass grafting.
RESULTS
Two patients with non-ischaemic VT were significantly younger (37.7 +/- 19.4 years, P = 0.03), had lower preoperative New York Heart Association class (P = 0.03), and had better left ventricular ejection fractions of 59.5 +/- 2.1% (P = 0.001) than the 24 ischaemic patients. No operative mortality or recurrence of VT occurred in this group. Ischaemic VT patients had an operative mortality of 8.3%; risk factors were concomitant valve surgery (P = 0.02), and perioperative intra-aortic balloon pump (P = 0.02). Surgery improved the left ventricular ejection fraction from 28.4 +/- 9.8% to 43.2 +/- 8.2% (P = 0.0001). Freedom from recurrence or inducibility of VT in operative survivors was 78.8 +/- 9.6% at 10 years; risk factors were arrhythmic focus remote to the left ventricular aneurysm (P = 0.015), and simple cryoablation or endocardial resection alone and not in combination (P = 0.003). Survival was 54.1 +/- 11.6% and 43.3 +/- 13.4% at 5 and 10 years, respectively, and there were no arrhythmic or sudden cardiac deaths. Patients with immediately life-threatening VT unsuitable for ICD implantation requiring urgent or emergent VT surgery had a 10-year survival of 22.2 +/- 13.9% compared to the more elective surgical group with a rate of 73.3 +/- 13.9% (P = 0.08).
CONCLUSIONS
Direct VT surgery should remain an objective for symptomatic drug refractory VT of left ventricular origin.
目的
回顾连续26例接受直接室性心动过速（VT）手术的左心室起源持续性单形性室性心动过速患者。
方法
经济因素使得大多数此类患者无法使用植入式心脏复律除颤器（ICD），81%患者的手术指征是药物治疗失败，27%的患者有频繁或持续性危及生命的室性心动过速。直接室性心动过速手术的原则包括术中标测、扩大的心内膜切除术、冷冻消融、通过左心室重塑和心内膜动脉瘤缝合术修复左心室动脉瘤，以及冠状动脉旁路移植术。
结果
2例非缺血性室性心动过速患者明显更年轻（37.7±19.4岁，P = 0.03），术前纽约心脏协会分级更低（P = 0.03），左心室射血分数更好，为59.5±2.1%（P = 0.001），而24例缺血性患者则不然。该组无手术死亡或室性心动过速复发。缺血性室性心动过速患者的手术死亡率为8.3%；危险因素是同期瓣膜手术（P = 0.02）和围手术期主动脉内球囊泵（P = 0.02）。手术使左心室射血分数从28.4±9.8%提高到43.2±8.2%（P = 0.0001）。手术幸存者在10年时无室性心动过速复发或诱发性的比例为78.8±9.6%；危险因素是心律失常灶远离左心室动脉瘤（P = 0.015），以及单纯冷冻消融或心内膜切除术而非联合使用（P = 0.003）。5年和10年生存率分别为54.1±11.6%和43.3±13.4%，且无心律失常或心源性猝死。对于不适合植入ICD且需要紧急或急诊室性心动过速手术的立即危及生命的室性心动过速患者，其10年生存率为22.2±13.9%，而择期手术组的生存率为73.3±13.9%（P = 0.08）。
结论
直接室性心动过速手术应仍然是左心室起源有症状药物难治性室性心动过速的治疗目标。
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