Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan (Y.K., A.N., K.A., M.I.).
Bordeaux University Hospital (Centre Hospitalier Universitaire [CHU]), Electrophysiology and Ablation Unit, Pessac, France (M.H., A.D., M.H.).
Circulation. 2019 May 14;139(20):2315-2325. doi: 10.1161/CIRCULATIONAHA.118.037997.
Ventricular fibrillation (VF) storm after myocardial infarction (MI) is a life-threatening condition that necessitates multiple defibrillations. Catheter ablation is a potentially effective treatment strategy for VF storm refractory to optimal medical treatment. However, its impact on patient survival has not been verified in a large population.
We conducted a multicenter, retrospective observational study involving consecutive patients who underwent catheter ablation of post-MI refractory VF storm without preceding monomorphic ventricular tachycardia. The target of ablation was the Purkinje-related ventricular extrasystoles triggering VF. The primary outcome was in-hospital and long-term mortalities. Univariate logistic regression and Cox proportional-hazards analysis were used to evaluate clinical characteristics associated with in-hospital and long-term mortalities, respectively.
One hundred ten patients were enrolled (age, 65±11years; 92 men; left ventricular ejection fraction, 31±10%). VF storm occurred at the acute phase of MI (4.5±2.5 days after the onset of MI during the index hospitalization for MI) in 43 patients (39%), the subacute phase (>1 week) in 48 (44%), and the remote phase (>6 months) in 19 (17%). The focal triggers were found to originate from the scar border zone in 88 patients (80%). During in-hospital stay after ablation, VF storm subsided in 92 patients (84%). Overall, 30 (27%) in-hospital deaths occurred. The duration from the VF occurrence to the ablation procedure was associated with in-hospital mortality (odds ratio for each 1-day increase, 1.11 [95% CI, 1.03-1.20]; P=0.008). During follow-up after discharge from hospital, only 1 patient developed recurrent VF storm. However, 29 patients (36%) died, with a median survival time of 2.2 years (interquartile range, 1.2-5.5 years). Long-term mortality was associated with left ventricular ejection fraction <30% (hazard ratio, 2.54 [95% CI, 1.21-5.32]; P=0.014), New York Heart Association class ≥III (hazard ratio, 2.68 [95% CI, 1.16-6.19]; P=0.021), a history of atrial fibrillation (hazard ratio, 3.89 [95% CI, 1.42-10.67]; P=0.008), and chronic kidney disease (hazard ratio, 2.74 [95% CI, 1.15-6.49]; P=0.023).
In patients with MI presenting with focally triggered VF storm, catheter ablation of culprit triggers is lifesaving and appears to be associated with short- and long-term freedom from recurrent VF storm. Mortality over the long-term follow-up is associated with the severity of underlying cardiovascular disease and comorbidities in this specific patient population.
心肌梗死后（MI）室颤（VF）风暴是一种危及生命的情况，需要多次除颤。导管消融是一种对最佳药物治疗无效的 VF 风暴的潜在有效治疗策略。然而，其对患者生存的影响尚未在大规模人群中得到证实。
我们进行了一项多中心、回顾性观察性研究，纳入了连续接受 MI 后药物难治性 VF 风暴导管消融的患者，且无先前的单形性室性心动过速。消融的靶点是触发 VF 的浦肯野纤维相关室性早搏。主要结局是院内和长期死亡率。单变量逻辑回归和 Cox 比例风险分析分别用于评估与院内和长期死亡率相关的临床特征。
共纳入 110 例患者（年龄 65±11 岁；92 例男性；左心室射血分数 31±10%）。VF 风暴发生在 MI 的急性期（MI 发病后 4.5±2.5 天，在 MI 的索引住院期间）43 例（39%）、亚急性期（>1 周）48 例（44%）和恢复期（>6 个月）19 例（17%）。发现焦点触发源起源于瘢痕边界区 88 例（80%）。消融后住院期间，92 例（84%）患者 VF 风暴缓解。总体而言，30 例（27%）患者发生院内死亡。VF 发生到消融程序的时间与院内死亡率相关（每增加 1 天的优势比，1.11[95%CI，1.03-1.20]；P=0.008）。出院后随访期间，仅 1 例患者出现复发性 VF 风暴。然而，29 例（36%）患者死亡，中位生存时间为 2.2 年（四分位距，1.2-5.5 年）。长期死亡率与左心室射血分数<30%（风险比，2.54[95%CI，1.21-5.32]；P=0.014）、纽约心脏协会（NYHA）分级≥III 级（风险比，2.68[95%CI，1.16-6.19]；P=0.021）、房颤病史（风险比，3.89[95%CI，1.42-10.67]；P=0.008）和慢性肾脏病（风险比，2.74[95%CI，1.15-6.49]；P=0.023）相关。
在 MI 患者中，导管消融导致的 VF 风暴的触发灶是救生的，并与短期和长期无复发性 VF 风暴相关。在这一特定患者人群中，长期随访的死亡率与潜在心血管疾病的严重程度和合并症相关。
