Stevenson William G, Wilber David J, Natale Andrea, Jackman Warren M, Marchlinski Francis E, Talbert Timothy, Gonzalez Mario D, Worley Seth J, Daoud Emile G, Hwang Chun, Schuger Claudio, Bump Thomas E, Jazayeri Mohammad, Tomassoni Gery F, Kopelman Harry A, Soejima Kyoko, Nakagawa Hiroshi
Cardiovascular Division, Brigham and Women's Hospital, Boston, MA 02115, USA.
Circulation. 2008 Dec 16;118(25):2773-82. doi: 10.1161/CIRCULATIONAHA.108.788604. Epub 2008 Dec 8.
Recurrent ventricular tachycardia (VT) is an important cause of mortality and morbidity late after myocardial infarction. With frequent use of implantable cardioverter-defibrillators, these VTs are often poorly defined and not tolerated for mapping, factors previously viewed as relative contraindications to ablation. This observational multicenter study assessed the outcome of VT ablation with a saline-irrigated catheter combined with an electroanatomic mapping system.
Two hundred thirty-one patients (median LV ejection fraction, 0.25; heart failure in 62%) with recurrent episodes of monomorphic VT (median, 11 in the preceding 6 months) caused by prior myocardial infarction were enrolled. All inducible monomorphic VTs with a rate approximating or slower than any spontaneous VTs were targeted for ablation guided by electroanatomic mapping during sinus rhythm and/or VT. Patients were not excluded for multiple VTs (median, 3 per patient) or unmappable VT (present in 69% of patients). Ablation abolished all inducible VTs in 49% of patients. The primary end point of freedom from recurrent incessant VT or intermittent VT after 6 months of follow-up was achieved for 123 patients (53%). In 142 patients with implantable cardioverter-defibrillators before and after ablation for intermittent VT who survived 6 months, VT episodes were reduced from a median of 11.5 to 0 (P<0.0001). The 1-year mortality rate was 18%, with 72.5% of deaths attributed to ventricular arrhythmias or heart failure. The procedure mortality rate was 3%, with no strokes.
Catheter ablation is a reasonable option to reduce episodes of recurrent VT in patients with prior myocardial infarction, even when multiple and/or unmappable VTs are present. This population remains at high risk for death, warranting surveillance and further study.
复发性室性心动过速（VT）是心肌梗死后晚期死亡和发病的重要原因。随着植入式心脏复律除颤器的频繁使用，这些室性心动过速往往定义不明确且不耐受标测，这些因素以前被视为消融的相对禁忌证。这项观察性多中心研究评估了使用盐水灌注导管结合电解剖标测系统进行室性心动过速消融的结果。
纳入231例既往心肌梗死导致复发性单形性室性心动过速（中位数，前6个月发作11次）的患者（左心室射血分数中位数为0.25；62%有心力衰竭）。所有可诱发的、速率接近或慢于任何自发性室性心动过速的单形性室性心动过速均在窦性心律和/或室性心动过速期间通过电解剖标测指导进行消融。患者不因其有多发性室性心动过速（中位数，每位患者3次）或不可标测的室性心动过速（69%的患者存在）而被排除。49%的患者消融消除了所有可诱发的室性心动过速。123例患者（53%）在随访6个月后达到了无复发性持续性室性心动过速或间歇性室性心动过速的主要终点。在142例消融前后植入了植入式心脏复律除颤器且存活6个月的间歇性室性心动过速患者中，室性心动过速发作次数从中位数11.5次减少至0次（P<0.0001）。1年死亡率为18%，72.5%的死亡归因于室性心律失常或心力衰竭。手术死亡率为3%，无卒中发生。
导管消融是减少既往心肌梗死患者复发性室性心动过速发作次数的合理选择，即使存在多发性和/或不可标测性室性心动过速。该人群仍有较高的死亡风险，需要进行监测和进一步研究。
