University of Michigan, Ann Arbor, Michigan, USA.
Bordeaux University Hospital and University of Bordeaux, Bordeaux, France; INRIA, Sophia Antipolis, France.
JACC Clin Electrophysiol. 2020 Apr;6(4):448-460. doi: 10.1016/j.jacep.2019.11.020. Epub 2020 Jan 29.
The goal of this study was to assess the value of a stepwise, image-guided ablation approach in patients with cardiomyopathy and predominantly intramural scar.
Few reports have focused on catheter-based ventricular tachycardia (VT) ablation strategies in patients with predominantly intramural scar.
The study included patients with predominantly intramural scar undergoing VT ablation. A stepwise strategy was performed consisting of a localized ablation guided by conventional mapping criteria followed by a more extensive ablation if VT remained inducible. The extensive ablation was guided by the location and extent of intramural scarring on delayed enhanced-cardiac magnetic resonance imaging. A historical cohort who did not undergo additional extensive ablation was identified for comparison. A novel measurement, the scar depth index (SDI), indicating the percent area of the scar at a given depth, was correlated with outcomes.
Forty-two patients who underwent stepwise ablation (median age 61 years [interquartile range: 55 to 69 years], 35 male patients, median left ventricular ejection fraction 36.0% [25.0% to 55.0%], ischemic [n = 4] or nonischemic cardiomyopathy [n = 38]) were followed up for a median of 17 months (8 to 36 months). A stepwise approach resulted in a 1-year freedom from VT, death, or cardiac transplantation of 76% (32 of 42). Patients who underwent additional extensive ablation had a lower risk of events than a clinically similar historical cohort (N = 19) (hazard ratio: 0.30; 95% CI: 0.13 to 0.68; p < 0.004). SDI was associated with worse long-term outcomes (hazard ratio: 1.03; 95% CI: 1.01 to 1.06%; p = 0.03), SDI >16.5% was associated with failed ablation (area under the curve: 0.84; 95% CI: 0.71 to 0.97).
Stepwise ablation using delayed enhanced-cardiac magnetic resonance guidance is a novel approach to VT ablation in patients with predominantly intramural scarring. The SDI correlates with immediate procedural and long-term outcomes.
本研究旨在评估在以心壁内瘢痕为主的心肌病患者中，采用逐步、图像引导消融方法的价值。
很少有研究关注以心壁内瘢痕为主的患者的导管室性心动过速（VT）消融策略。
本研究纳入了以心壁内瘢痕为主行 VT 消融的患者。采用逐步策略，包括根据常规标测标准指导的局部消融，如果 VT 仍然可诱发性，则进行更广泛的消融。广泛消融由延迟增强心脏磁共振成像上的瘢痕位置和范围指导。为了进行比较，确定了未行额外广泛消融的历史对照队列。引入了一种新的测量指标，即瘢痕深度指数（SDI），它表示给定深度处瘢痕的面积百分比。
42 例行逐步消融的患者（中位年龄 61 岁[四分位间距：55 岁至 69 岁]，35 名男性患者，中位左心室射血分数 36.0%[25.0%至 55.0%]，缺血性[4 例]或非缺血性心肌病[38 例]）接受了中位 17 个月（8 个月至 36 个月）的随访。采用逐步方法，1 年无 VT、死亡或心脏移植的患者比例为 76%（42 例中的 32 例）。行额外广泛消融的患者发生事件的风险低于临床相似的历史对照队列（N=19）（风险比：0.30；95%可信区间：0.13 至 0.68；p<0.004）。SDI 与较差的长期预后相关（风险比：1.03；95%可信区间：1.01 至 1.06%；p=0.03），SDI>16.5%与消融失败相关（曲线下面积：0.84；95%可信区间：0.71 至 0.97）。
采用延迟增强心脏磁共振指导的逐步消融是治疗以心壁内瘢痕为主的 VT 消融的一种新方法。SDI 与即刻手术和长期预后相关。
