Belhassen Bernard, Ohayon-Tsioni Tamar, Glick Aharon, Viskin Sami
Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
Isr Med Assoc J. 2009 Sep;11(9):520-4, 526, 528.
The predictive value of electrophysiologic studies depends on the aggressiveness of the programmed ventricular stimulation protocol.
To assess if non-inducibility with an "aggressive" protocol of PVS identifies post-infarction patients with low ejection fraction (EF < or = 30%) who may safely be treated without implantable cardioverter defibrillator.
We studied 154 patients during a 9 year period. Our aggressive PVS protocol included: a) stimulus current five times the diastolic threshold (< or = 3 mA) and b) repetition of double and triple extrastimulation at the shortest coupling intervals that capture the ventricle.
Sustained ventricular tachyarrhythmias were induced in 116 patients (75.4%) and 112 (97%) of them received an ICD (EPS+/ICD+ group). Of the 38 non-inducible patients, 34 (89.5%) did not receive an ICD (EPS-/ICD-group). In comparison to the EPS+/ICD+ group, EPS-/ICD-group patients were older (69 +/- 10 vs. 65 +/- 10 years, P < 0.05), had a lower EF (23 +/- 5% vs. 25 +/- 5%, P < 0.05) and a higher prevalence of left bundle branch block (45.5% vs. 20.2%, P < 0.005). Follow-up was longer for EPS+/ICD+ patients (40 +/- 26 months) than for EPS-/ICD- patients (27 +/- 22 months) (P = 0.011). Twelve EPS+/ICD+ patients (10.7%) and 5 EPS-/ICD-patients (14.7%) died during follow-up (P = 0.525). Kaplan-Meier survival curves did not show a significant difference between the two groups (P = 0.18).
The mortality rate in patients without inducible VTAs using an aggressive PVS protocol and who did not undergo subsequent ICD implantation is not different from that of patients with inducible arrhythmias who received an ICD. Using this protocol, as many as one-fourth of primary prevention ICD implants could be spared without compromising patient prognosis.
电生理研究的预测价值取决于程控心室刺激方案的激进程度。
评估采用“激进”的程控心室刺激（PVS）方案未能诱发出心律失常，是否可识别出射血分数低（EF≤30%）的心肌梗死后患者，这些患者无需植入式心脏复律除颤器即可安全治疗。
我们在9年期间研究了154例患者。我们激进的PVS方案包括：a）刺激电流为舒张期阈值的5倍（≤3 mA），b）以能夺获心室的最短联律间期重复进行双次和三次额外刺激。
116例患者（75.4%）诱发出持续性室性快速心律失常，其中112例（97%）接受了植入式心脏复律除颤器（EPS+/ICD+组）。在38例未诱发出心律失常的患者中，34例（89.5%）未接受植入式心脏复律除颤器（EPS-/ICD-组）。与EPS+/ICD+组相比，EPS-/ICD-组患者年龄更大（69±10岁对65±10岁，P<0.05），EF更低（23±5%对25±5%，P<0.05），左束支传导阻滞患病率更高（45.5%对20.2%，P<0.005）。EPS+/ICD+组患者的随访时间（40±26个月）比EPS-/ICD-组患者更长（27±22个月）（P = 0.011）。12例EPS+/ICD+患者（10.7%）和5例EPS-/ICD-患者（14.7%）在随访期间死亡（P = 0.525）。Kaplan-Meier生存曲线显示两组之间无显著差异（P = 0.18）。
采用激进的PVS方案且未诱发出室性快速心律失常且未接受后续植入式心脏复律除颤器植入的患者的死亡率，与诱发出心律失常并接受植入式心脏复律除颤器的患者的死亡率无差异。使用该方案，在不影响患者预后的情况下，多达四分之一的一级预防植入式心脏复律除颤器可不必植入。
