Freedman Benjamin L, Maher Timothy R, Tracey Madison, Santangeli Pasquale, d'Avila Andre
Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US.
Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US.
Arrhythm Electrophysiol Rev. 2023 Jun 23;12:e20. doi: 10.15420/aer.2022.24. eCollection 2023.
Classically, catheter ablation for scar-related ventricular tachycardia (VT) relied upon activation and entrainment mapping of induced VT. Advances in post-MI therapies have led to VTs that are faster and haemodynamically less stable, because of more heterogeneous myocardial fibrosis patterns. The PAINESD score is one means of identifying patients at highest risk for haemodynamic decompensation during attempted VT induction, who may, therefore, benefit from alternative ablation strategies. One strategy is to use temporary mechanical circulatory support, although this warrants formal assessment of cost-effectiveness. A second strategy is to minimise or avoid VT induction altogether by employing a family of 'substrate'-based approaches aimed at identifying VT isthmuses during sinus or paced rhythm. Substrate mapping techniques are diverse, and focus on the timing, morphology and amplitude of local ventricular electrograms - sometimes aided by advanced non-invasive cardiac imaging modalities. In this review, the evolution of VT ablation over time is discussed, with an emphasis on procedural adaptations to the challenge of haemodynamic instability.
传统上，用于治疗瘢痕相关性室性心动过速（VT）的导管消融依赖于诱发室性心动过速的激动标测和拖带标测。心肌梗死后治疗的进展导致室性心动过速速度更快且血流动力学稳定性更低，这是由于心肌纤维化模式更加不均匀所致。PAINESD评分是一种识别在尝试诱发室性心动过速期间血流动力学失代偿风险最高的患者的方法，因此这些患者可能从替代消融策略中获益。一种策略是使用临时机械循环支持，尽管这需要对成本效益进行正式评估。第二种策略是通过采用一系列基于“基质”的方法，在窦性或起搏心律期间识别室性心动过速峡部，从而尽量减少或完全避免诱发室性心动过速。基质标测技术多种多样，并且专注于局部心室电图的时间、形态和幅度，有时借助先进的非侵入性心脏成像模式。在本综述中，讨论了室性心动过速消融随时间的演变，重点是针对血流动力学不稳定挑战的手术调整。
