心内膜消融失败后的心室内折返性心动过速的导管消融：心外膜基质还是不合适的心内膜消融？
Catheter ablation for ventricular tachycardia after failed endocardial ablation: epicardial substrate or inappropriate endocardial ablation?
机构信息
Asklepios Klinik St. Georg, Department of Cardiology, Hamburg, Germany.
出版信息
Heart Rhythm. 2010 Dec;7(12):1746-52. doi: 10.1016/j.hrthm.2010.08.010. Epub 2010 Aug 13.
BACKGROUND
The substrate of myocardial ventricular tachycardia (VT) may involve the subepicardial myocardium.
OBJECTIVE
The purpose of this study was to assess the incidence of epicardial substrates in patients with a previously failed endocardial ablation attempt for VT as well as the safety and effectiveness of epicardial ablation.
METHODS
Using an electroanatomic mapping system, endocardial and epicardial maps were acquired. Irrigated radiofrequency current ablations of all inducible VTs were performed.
RESULTS
Between 2005 and 2009, 59 patients with or without structural heart disease underwent epicardial VT ablation. Pericardial access failed in 3 (5%) of these patients. Of the remaining 56 patients, an epicardial substrate was found in 41 (73%). Overall, acute success was achieved in 46 (78%) of 59 patients, with complete VT abolition in 27 (46%) and partial abolition in 19 (32%). Successful outcomes were the result of endocardial ablation only in 14 (24%) patients, epicardial ablation in 21 (36%), and endocardial/epicardial in 11 (19%). Ablation failed to prevent reinduction in 8 (13%) patients, and VTs were noninducible prior to ablation in 5 (8%). Two periprocedural deaths occurred, one after right ventricular perforation and one due to electromechanical dissociation. Hepatic bleeding occurred in two patients. Recurrence of any VT occurred in 27 (47%) of 57 surviving patients during median follow-up of 362 days (q1-q3; 180-468 days). Repeat epicardial mapping was not feasible due to adhesions in 3 (25%) of 12 patients.
CONCLUSION
In patients with a previously failed endocardial VT ablation, epicardial mapping reveals a VT substrate in nearly three fourths of all patients, and epicardial ablation is required for successful VT abolition in more than half of patients. However, life-threatening complications may occur. Repeat epicardial access was not possible in 25% due to local pericardial adhesions.
背景
心肌室性心动过速（VT）的底物可能涉及心外膜心肌。
目的
本研究旨在评估先前因 VT 而失败的心内膜消融尝试后患者心外膜底物的发生率以及心外膜消融的安全性和有效性。
方法
使用电解剖标测系统获取心内膜和心外膜图。对所有可诱发性 VT 进行灌流射频电流消融。
结果
2005 年至 2009 年间，59 例有或无结构性心脏病的患者接受了心外膜 VT 消融。其中 3 例（5%）患者心包入路失败。在其余 56 例患者中，41 例（73%）发现心外膜底物。总体而言，59 例患者中有 46 例（78%）获得急性成功，其中 27 例（46%）完全消除 VT，19 例（32%）部分消除 VT。仅通过心内膜消融获得成功的有 14 例（24%），心外膜消融 21 例（36%），心内膜/心外膜消融 11 例（19%）。8 例（13%）患者消融未能预防再诱发，5 例（8%）患者消融前 VT 不可诱导。2 例患者发生围手术期死亡，1 例为右心室穿孔，1 例为电机械分离。2 例患者发生肝出血。57 例存活患者的中位随访 362 天（180-468 天）期间，27 例（47%）患者出现任何 VT 复发。由于 12 例患者中的 3 例（25%）存在局部心包粘连，无法进行重复心外膜标测。
结论
在先前因 VT 而失败的心内膜消融的患者中，近四分之三的患者心外膜标测显示 VT 底物，超过一半的患者需要心外膜消融才能成功消除 VT。然而，可能会发生危及生命的并发症。由于局部心包粘连，25%的患者无法进行重复心外膜入路。
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