Rolf Sascha, Haverkamp Wilhelm
Medizinische Klinik mit Schwerpunkt Kardiologie, Charité - Campus Virchow-Klinikum, Berlin, Germany.
Herz. 2009 Nov;34(7):528-38. doi: 10.1007/s00059-009-3294-6.
Patients with ischemic heart disease and left ventricular systolic dysfunction (ICM), dilated (DCM), hypertrophic (HCM), or arrhythmogenic right ventricular cardiomyopathy (ARVCM) carry a high risk of sudden cardiac death (SCD). Ventricular tachyarrhythmias are most often the cause of SCD, which can be treated with internal cardioverter defibrillators (ICDs). However, a great proportion of these high-risk patients will never experience potentially lethal ventricular arrhythmias, and as such will never be in need of these devices. Given the risks, inconvenience, and costs of ICDs, markers that adequately stratify patients according to their risk of SCD are needed. Programmed ventricular stimulation (PVS) has long been used to identify the patients' risk of SCD. However, the prognostic ability of PVS is only modest and the negative predictive value is poor. As far as patients with ICM are concerned, recent data from the MUSTT and MADIT II trials demonstrate that in patients with a left ventricular ejection fraction between 30% and 40%, inducibility by PVS can help to identify patients who are at particularly increased risk of SCD. The value of PVS in patients with DCM, HCM, and ARVCM for risk stratification of SCD is less clear and the available data even more limited. In these patients, the inducibility of ventricular tachyarrhythmias does not clearly correlate with VT/VF (ventricular tachycardia/ventricular fibrillation) risk, and more importantly, noninducibility does not portend good prognosis. The current German guidelines appreciate these uncertainties of PVS for risk stratification with class IIb recommendations in certain patients with ICM, HCM or ARVCM. In the future, combining the results of invasive PVS with other noninvasive parameters may improve its prognostic value. Furthermore, expanding the role of PVS to guiding therapeutic ablation of ventricular arrhythmias may influence patient's future risk of SCD.
患有缺血性心脏病和左心室收缩功能障碍（缺血性心肌病）、扩张型心肌病（DCM）、肥厚型心肌病（HCM）或致心律失常性右心室心肌病（ARVCM）的患者发生心脏性猝死（SCD）的风险很高。室性快速心律失常通常是SCD的原因，可通过植入式心律转复除颤器（ICD）进行治疗。然而，这些高危患者中有很大一部分人永远不会发生潜在致命性室性心律失常，因此也永远不需要这些设备。鉴于ICD存在风险、不便之处及成本，需要有能够根据患者SCD风险进行充分分层的标志物。程控心室刺激（PVS）长期以来一直用于识别患者的SCD风险。然而，PVS的预后能力一般，阴性预测价值较差。就缺血性心肌病患者而言，MUSTT和MADIT II试验的最新数据表明，对于左心室射血分数在30%至40%之间的患者，PVS可诱导性有助于识别SCD风险特别增加的患者。PVS在DCM、HCM和ARVCM患者中对SCD进行风险分层的价值尚不清楚，现有数据甚至更为有限。在这些患者中，室性快速心律失常的可诱导性与室性心动过速/心室颤动（VT/VF）风险并无明确关联，更重要的是，不可诱导性并不预示良好的预后。德国现行指南认识到PVS在某些缺血性心肌病、HCM或ARVCM患者风险分层方面存在这些不确定性，给出了IIb类推荐。未来，将有创PVS的结果与其他无创参数相结合可能会提高其预后价值。此外，扩大PVS在指导室性心律失常治疗性消融方面的作用可能会影响患者未来的SCD风险。
