Arrhythmology, Pacing and Electrophysiology Unit, Cardiology Department, Central Lisbon Hospital University Center, Portugal.
Arrhythmology, Pacing and Electrophysiology Unit, Cardiology Department, Central Lisbon Hospital University Center, Portugal.
Rev Port Cardiol (Engl Ed). 2021 Nov;40(11):865-873. doi: 10.1016/j.repce.2021.11.006.
Recurrent ventricular tachycardia (VT) episodes have a negative impact on the clinical outcome of implantable cardioverter-defibrillator (ICD) patients. Modification of the arrhythmogenic substrate has been used as a promising approach for treating recurrent VTs. However, there are limited data on long-term follow-up.
To analyze long-term results of VT substrate-based ablation using high-density mapping in patients with severe left ventricular (LV) dysfunction and recurrent appropriate ICD therapy.
We analyzed 20 patients (15 men, 55% with non-ischemic cardiomyopathy, age 58±15 years, LV ejection fraction 32±5%) and repeated appropriate shocks or arrhythmic storm (>2 shocks/24 h) despite antiarrhythmic drug therapy and optimal heart failure medication. All patients underwent ventricular programmed stimulation (600 ms/S3) to document VT. A sinus rhythm (SR) voltage map was created with a three-dimensional electroanatomic mapping system (CARTO, Biosense Webster, CA) using a PentaRay® high-density mapping catheter (Biosense Webster, CA) to delineate areas of scarred myocardium (ventricular bipolar voltage ≤0.5 mV - dense scar; 0.5-1.5 mV - border zone; ≥1.5 mV - healthy tissue) and to provide high-resolution electrophysiological mapping. Substrate modification included elimination of local abnormal ventricular activities (LAVAs) during SR (fractionated, split, low-amplitude/long-lasting, late potentials, pre-systolic), and linear ablation to obtain scar homogenization and dechanneling. Pace-mapping techniques were used when capture was possible. The LV approach was retrograde in nine cases, transseptal in five and epi-endocardial in four. In two patients ablation was performed inside the right ventricle.
LAVAs and scar areas were modified in all patients. Mean procedure duration was 149 min (105-220 min), with radiofrequency ranging from 18 to 70 min (mean 33 min) and mean fluoroscopy time of 15 min. Non-inducibility was achieved in 75% of cases (in four patients with hemodynamic deterioration and an LV assist device, VT inducibility was not performed). There were two cases of pericardial tamponade, drained successfully. During a follow-up of 50±24 months, 65% had no VT recurrences. Among the seven patients with recurrences, three underwent redo ablation and four, with fewer VT episodes, received appropriate ICD therapy. There were five hospital readmissions due to heart failure decompensation, one patient died in the first week after unsuccessful ablation of a VT storm and three died (stroke and pneumonia) >1 year after ablation.
Catheter ablation based on substrate modification is feasible and safe in patients with frequent VTs and severe LV dysfunction. This approach may be of clinical relevance, with potential long-term benefits in reducing VT burden.
复发性室性心动过速（VT）发作对植入式心脏复律除颤器（ICD）患者的临床预后有负面影响。已经使用心律失常基质的修饰作为治疗复发性 VT 的一种有前途的方法。然而，关于长期随访的数据有限。
分析使用高密度标测在严重左心室（LV）功能障碍和复发性适当 ICD 治疗的患者中基于 VT 基质的消融的长期结果。
我们分析了 20 名患者（15 名男性，55%为非缺血性心肌病，年龄 58±15 岁，LV 射血分数 32±5%）和重复适当的电击或心律失常风暴（>2 次电击/24 小时）尽管进行了抗心律失常药物治疗和最佳心力衰竭药物治疗。所有患者均进行心室程控刺激（600 ms/S3）以记录 VT。使用三维电解剖标测系统（CARTO，Biosense Webster，CA）使用 PentaRay®高密度标测导管（Biosense Webster，CA）创建窦性节律（SR）电压图，以描绘瘢痕心肌区域（心室双极电压≤0.5 mV-致密瘢痕；0.5-1.5 mV-边界区；≥1.5 mV-健康组织）并提供高分辨率电生理标测。基质修饰包括消除 SR 期间的局部异常心室活动（LAVA）（碎裂、分裂、低幅度/持续时间长、晚期电位、收缩前期）和线性消融以获得瘢痕均匀化和去通道化。当可以捕获时，使用起搏映射技术。LV 方法在 9 例中为逆行，在 5 例中为经间隔，在 4 例中为心外膜-心内膜。在 2 例患者中，消融是在右心室内部进行的。
所有患者均对 LAVA 和瘢痕区域进行了修饰。平均手术时间为 149 分钟（105-220 分钟），射频时间为 18 至 70 分钟（平均 33 分钟），平均透视时间为 15 分钟。75%的病例实现了不可诱导性（在 4 例因血流动力学恶化和左心室辅助装置而无法进行 VT 诱导的患者中）。有 2 例发生心包填塞，成功引流。在 50±24 个月的随访中，65%的患者没有 VT 复发。在 7 例复发患者中，3 例接受了再次消融，4 例复发次数较少，接受了适当的 ICD 治疗。因心力衰竭失代偿导致 5 例住院，1 例患者在 VT 风暴不成功消融后的第一周死亡，3 例患者在消融后 1 年以上死亡（中风和肺炎）。
基于基质修饰的导管消融在复发性 VT 发作和严重 LV 功能障碍的患者中是可行且安全的。这种方法可能具有临床相关性，有可能长期减少 VT 负荷。
