Peichl Petr, Wichterle Dan, Čihák Robert, Aldhoon Bashar, Kautzner Josef
Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
Pacing Clin Electrophysiol. 2016 Jun;39(6):581-7. doi: 10.1111/pace.12844. Epub 2016 Apr 13.
Catheter ablation of ventricular tachycardia (VT) in patients with structural heart disease (SHD) is effective in prevention of arrhythmia recurrences. However, endocardial ablation may be challenging in the presence of organized left ventricular (LV) endocavitary thrombus. Our goal was to analyze the results of VT ablation in patients with identified old thrombus.
We reviewed clinical and procedural data of 344 consecutive patients who underwent VT ablation for SHD. Old endocavitary thrombus was identified in four patients by preprocedural transthoracic echocardiography (TTE) and in four more patients by intracardiac echocardiography (ICE). All together, the case series of eight patients with detectable thrombus is reported. All patients (one woman, age: 67 ± 7 years) had postinfarction aneurysm (20 ± 8 years after the index myocardial infarction) and the thrombus was well organized without mobile structures. Arrhythmogenic substrate could not be obviously targeted beneath the base of thrombus; however, catheter ablation was successfully performed in the close vicinity. A total of 2.4 ± 1.2 procedures were necessary to abolish VT recurrences. Epicardial ablation was performed in three of eight (38%) patients as a second elective procedure. No procedural or periprocedural complications were observed. During the follow-up of 14 ± 15 months, two patients (25%) had sporadic VT recurrences.
ICE seems to be more sensitive for the detection of LV thrombi compared to TTE and is helpful in real-time navigation of mapping/ablation catheter. Besides potential thromboembolic risk, large thrombus may prevent accessibility to the "critical" portion of arrhythmia circuit and epicardial ablation is required in selected cases.
在患有结构性心脏病（SHD）的患者中，导管消融治疗室性心动过速（VT）对于预防心律失常复发是有效的。然而，在存在有组织的左心室（LV）心腔内血栓的情况下，心内膜消融可能具有挑战性。我们的目标是分析已确诊存在陈旧性血栓的患者进行VT消融的结果。
我们回顾了344例因SHD接受VT消融的连续患者的临床和手术数据。术前经胸超声心动图（TTE）在4例患者中发现了陈旧性心腔内血栓，心内超声心动图（ICE）在另外4例患者中也发现了血栓。总共报告了8例可检测到血栓的病例系列。所有患者（1名女性，年龄：67±7岁）均有心肌梗死后室壁瘤（在首次心肌梗死后20±8年），血栓组织良好，无活动结构。血栓底部下方的致心律失常基质无法明显定位；然而，在其附近成功进行了导管消融。共需要2.4±1.2次手术来消除VT复发。8例患者中有3例（38%）作为第二次选择性手术进行了心外膜消融。未观察到手术或围手术期并发症。在14±15个月的随访期间，2例患者（25%）出现偶发VT复发。
与TTE相比，ICE似乎对LV血栓的检测更敏感，并且有助于标测/消融导管的实时导航。除了潜在的血栓栓塞风险外，大血栓可能会妨碍进入心律失常环路的“关键”部分，在某些情况下需要进行心外膜消融。
