Eckardt Lars, Breithardt Günter
Medizinischen Klinik und Poliklinik C, Universitätsklinikum Münster, Albert-Schweitzer-Strasse 33, 48149 Münster, Germany.
Herz. 2009 May;34(3):187-96. doi: 10.1007/s00059-009-3247-0.
The majority of ventricular tachycardias (VTs) occurs in patients with structural heart disease, predominantly coronary heart disease. Implantable cardioverter defibrillators (ICDs) are first-line therapy in patients with VT and structural heart disease. In patients who receive an ICD after a spontaneous sustained VT, recurrent VT episodes or an electrical storm are major problems. In addition, in patients with an ICD implanted for primary prevention of sudden cardiac death, 20% will experience at least one VT episode within 3-5 years after ICD implantation. Catheter ablation has a high acute success rate in eliminating clinical VT. However, several factors make catheter ablation of VT more difficult than ablation of supraventricular tachyarrhythmias. (1) The infarct region is often large. (2) The induced VT can be unstable or hemodynamically only poorly tolerated and therefore "unmappable". (3) Though most commonly located in the subendocardium, the critical VT zone can occasionally be epicardial or intramural in location. (4) In many cases, several reentrant circuits may coexist making ablation of a single form of VT a palliative procedure which does not obviate the risk of sudden death. Thus, catheter ablation of sustained VT in the setting of structural heart disease can only be considered an adjunctive therapy which, in general, will require ICD therapy. Numerous "modern" mapping technologies have been developed, which have increased success rates of catheter ablation of VT in patients with and without structural heart disease. The aim of the present article is to review current three-dimensional mapping systems in comparison to conventional mapping and to describe a reasonable, tailored approach for the individual patient with VT.
大多数室性心动过速（VT）发生于有结构性心脏病的患者，主要是冠心病。植入式心脏复律除颤器（ICD）是VT和结构性心脏病患者的一线治疗方法。在自发性持续性VT后接受ICD治疗的患者中，VT复发或电风暴是主要问题。此外，在植入ICD用于心脏性猝死一级预防的患者中，20%会在ICD植入后3至5年内经历至少一次VT发作。导管消融在消除临床VT方面有较高的急性成功率。然而，有几个因素使得VT的导管消融比室上性快速心律失常的消融更困难。（1）梗死区域通常较大。（2）诱发的VT可能不稳定或血流动力学耐受性差，因此“无法标测”。（3）尽管关键VT区域最常见于心内膜下，但偶尔也可能位于心外膜或心肌内。（4）在许多情况下，可能并存多个折返环，使得消融单一形式的VT成为一种姑息性手术，不能消除猝死风险。因此，在结构性心脏病背景下，持续性VT的导管消融只能被视为一种辅助治疗，一般而言，这需要ICD治疗。已经开发了许多“现代”标测技术，这些技术提高了有或无结构性心脏病患者VT导管消融的成功率。本文的目的是与传统标测相比，综述当前的三维标测系统，并描述针对个体VT患者的合理、个性化方法。
