缺血性心肌病和梗死相关冠状动脉慢性完全闭塞患者中预防性基质导管消融对植入式心脏复律除颤器干预的影响。

Impact of preventive substrate catheter ablation on implantable cardioverter-defibrillator interventions in patients with ischaemic cardiomyopathy and infarct-related coronary chronic total occlusion.

机构信息

Cardiology Department, University Medical Centre Ljubljana, Zaloška 7, 1000 Ljubljana, Slovenia.

Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.

出版信息

Europace. 2024 May 2;26(5). doi: 10.1093/europace/euae109.

AIMS

Primary prevention patients with ischaemic cardiomyopathy and chronic total occlusion of an infarct-related coronary artery (CTO) are at a particularly high risk of implantable cardioverter-defibrillator (ICD) therapy occurrence. The trial was designed to evaluate the efficacy of preventive CTO-related substrate ablation strategy in ischaemic cardiomyopathy patients undergoing primary prevention ICD implantation.

METHODS AND RESULTS

The PREVENTIVE VT study was a prospective, multicentre, randomized trial including ischaemic patients with ejection fraction ≤40%, no documented ventricular arrhythmias (VAs), and evidence of scar related to the coronary CTO. Patients were randomly assigned 1:1 to a preventive substrate ablation before ICD implantation or standard therapy with ICD implantation only. The primary outcome was a composite of appropriate ICD therapy or unplanned hospitalization for VAs. Secondary outcomes included the primary outcome's components, the incidence of appropriate ICD therapies, cardiac hospitalization, electrical storm, and cardiovascular (CV) mortality. Sixty patients were included in the study. During the mean follow-up of 44.7 ± 20.7 months, the primary outcome occurred in 5 (16.7%) patients undergoing preventive substrate ablation and in 13 (43.3%) patients receiving only ICD [hazard ratio (HR): 0.33; 95% confidence interval (CI): 0.12-0.94; P = 0.037]. Patients in the preventive ablation group also had fewer appropriate ICD therapies (P = 0.039) and the electrical storms (Log-rank: P = 0.01). While preventive ablation also reduced cardiac hospitalizations (P = 0.006), it had no significant impact on CV mortality (P = 0.151).

CONCLUSION

Preventive ablation of the coronary CTO-related substrate in patients undergoing primary ICD implantation is associated with the reduced risk of appropriate ICD therapy or unplanned hospitalization due to VAs.

目的

患有缺血性心肌病和梗死相关冠状动脉（CTO）慢性完全闭塞的一级预防患者，植入式心脏复律除颤器（ICD）治疗的发生风险特别高。该试验旨在评估在接受一级预防 ICD 植入的缺血性心肌病患者中，预防性 CTO 相关底物消融策略的疗效。

方法和结果

PREVENTIVE VT 研究是一项前瞻性、多中心、随机试验，纳入射血分数≤40%、无记录到室性心律失常（VA）且有冠状动脉 CTO 相关瘢痕证据的缺血性患者。患者按 1:1 随机分配到 ICD 植入前预防性基质消融组或仅 ICD 植入的标准治疗组。主要终点是 ICD 治疗的适当性或 VA 导致的计划性住院的复合终点。次要终点包括主要终点的组成部分、适当 ICD 治疗的发生率、心脏住院、电风暴和心血管（CV）死亡率。共纳入 60 例患者。在平均 44.7±20.7 个月的随访期间，预防性基质消融组有 5 例（16.7%）患者和仅接受 ICD 治疗组的 13 例（43.3%）患者发生主要终点事件[风险比（HR）：0.33；95%置信区间（CI）：0.12-0.94；P=0.037]。预防性消融组的患者也较少发生适当的 ICD 治疗（P=0.039）和电风暴（Log-rank：P=0.01）。虽然预防性消融也减少了心脏住院（P=0.006），但对 CV 死亡率无显著影响（P=0.151）。