Department of Internal Medicine (J.A.B.), Cleveland Clinic, OH.
Cardiovascular Medicine (O.M.W., K.G.T., W.I.S., M.K., M.D., M.B., B.B., T.J.D., T.D.C., D.J.C., J.R., D.O.M., N.V., M.J.N., M.K.C., P.J.T., B.D.L., A.A.H.), Cleveland Clinic, OH.
Circ Arrhythm Electrophysiol. 2020 May;13(5):e007669. doi: 10.1161/CIRCEP.119.007669. Epub 2020 Apr 12.
There is paucity of data regarding radiofrequency ablation for ventricular tachycardia (VT) in patients with cardiogenic shock and concomitant VT refractory to antiarrhythmic drugs on mechanical support.
Patients undergoing VT ablation at our center were enrolled in a prospectively maintained registry and screened for the current study (2010-2017).
All 21 consecutive patients with cardiogenic shock and concomitant refractory ventricular arrhythmia undergoing bailout ablation due to inability to wean off mechanical support were included. Median age was 61 years, 86% were men, median left ventricular ejection fraction was 20%, 81% had ischemic cardiomyopathy, and PAINESD score was 18±5. The type of mechanical support in place before the procedure was intra-aortic balloon pump in 14 patients (67%), Impella CP in 2, extracorporeal membrane oxygenation in 2, extracorporeal membrane oxygenation and intra-aortic balloon pump in 2, and extracorporeal membrane oxygenation and Impella CP in 1. Endocardial voltage maps showed myocardial scar in 19 patients (90%). The clinical VTs were inducible in 13 patients (62%), whereas 6 patients had premature ventricular contraction-induced ventricular fibrillation/VT (29%), and VT could not be induced in 2 patients (9%). Activation mapping was possible in all 13 with inducible clinical VTs. Substrate modification was performed in 15 patients with scar (79%). After ablation and scar modification, the arrhythmia was noninducible in 19 patients (91%). Seventeen (81%) were eventually weaned off mechanical support successfully, but 6 (29%) died during the index admission from persistent cardiogenic shock. Patients who had ventricular arrhythmia and cardiogenic shock on presentation had a trend toward lower in-hospital mortality compared with those who presented with cardiogenic shock and later developed ventricular arrhythmia.
Bailout ablation for refractory ventricular arrhythmia in cardiogenic shock allowed successful weaning from mechanical support in a large proportion of patients. Mortality remains high, but the majority of patients were discharged home and survived beyond 1 year.
在因无法脱离机械支持而导致心源性休克和同时伴有对抗心律失常药物难治性室性心动过速（VT）的患者中，射频消融治疗 VT 的数据很少。
我们中心接受 VT 消融的患者被纳入一个前瞻性维护的登记处，并对本研究进行筛选（2010-2017 年）。
共纳入 21 例连续因无法脱离机械支持而接受抢救性消融的因心源性休克和同时伴有难治性室性心律失常的患者。中位年龄为 61 岁，86%为男性，中位左心室射血分数为 20%，81%为缺血性心肌病，PAINESD 评分为 18±5。手术前使用的机械支持方式为主动脉内球囊泵 14 例（67%），Impella CP 2 例，体外膜肺氧合 2 例，主动脉内球囊泵和体外膜肺氧合 2 例，体外膜肺氧合和 Impella CP 1 例。心内膜电压图显示 19 例患者（90%）存在心肌瘢痕。13 例患者（62%）临床 VT 可诱发性，6 例患者（29%）室性早搏诱发心室颤动/VT，2 例患者（9%）无法诱发性 VT。所有 13 例可诱发性临床 VT 患者均可进行激动标测。15 例瘢痕患者进行了基质改良。消融和瘢痕改良后，19 例患者（91%）心律失常不再诱发性。17 例（81%）最终成功脱离机械支持，但 6 例（29%）因持续心源性休克在入院期间死亡。与出现心源性休克后出现室性心律失常的患者相比，就诊时即出现室性心律失常和心源性休克的患者住院死亡率有下降趋势。
心源性休克伴难治性室性心律失常的抢救性消融可使很大一部分患者成功脱离机械支持。死亡率仍然很高，但大多数患者出院回家并存活 1 年以上。
