Vester E G, Perings C, Kuhls S, Ochiulet-Vester J, Strauer B E
Abteilung für Kardiologie, Pneumologie und Angiologie, Heinrich-Heine-Universität Düsseldorf.
Z Kardiol. 1995 Jun;84(6):443-58.
Ischemia is considered to be one of the most important trigger mechanisms of ventricular tachyarrhythmias, i.e., tachycardia (VT) and fibrillation (VF) in coronary artery disease (CAD). The aim of the study was 1) to investigate the relationship between ischemia and inducibility of VT/VF, and 2) to address the question, if removal of ischemia leads to suppression, resp. noninducibility of arrhythmias. In 30 patients (pts) with CAD (healed myocardial infarction in 73%, acute myocardial infarction excluded) and sustained malignant ventricular arrhythmias (VF in 47%, VT in 37%, and arrhythmogenic syncope in 16%) the myocardial lactate extraction (MLE) was calculated by measuring the arterio venous coronary lactate difference simultaneously during programmed ventricular stimulation. Eighteen pts (group A, "lactate-positive") showed a significant decrease of MLE from +16 +/- 13% at rest to -18 +/- 24% during stimulation just before induction of VT/VF (p < 0.0005). During recovery up to 10 min following termination of VT/VF MLE returned to normal range (+19 +/- 16%). In 12 pts (group B, "lactate-negative") MLE showed no significant change between rest, stimulation, and recovery. Compared to group B pts, group A pts demonstrated a significantly higher number and degree of coronary lesions as well as regions with reversible ischemia during 201Tl- scintigraphy. Lactate-positive pts presented spontaneous arrhythmias of higher frequency and had usually a two- or three-vessel disease, while lactate-negative pts presented arrhythmias of lower frequency and had more often a one-vessel disease with ventricular aneurysm. 17/18 (94%) group A pts underwent coronary bypass grafting (11) or balloon angioplasty (6) and were rendered noninducible during post interventional PVS in 94%, showing also a normalized MLE in 87% of cases. In group B only 4/12 pts were suitable for revascularization and could be rendered noninducible in only 50% of cases. With respect to the success-rate of the anti-ischemic therapy in terms of arrhythmia suppression, a lactate-positive result during primary PVS had a sensitivity of 89%, a specificity of 75%, a positive predictive value of 94%, and a negative predictive value of 60%.
in about 60% of pts with VT/VF and significant CAD a correlation between ischemia and inducibility could be demonstrated. MLE during PVS has a highly significant predictive value for the effect of an antiischemic intervention on arrhythmia induction.
缺血被认为是冠状动脉疾病（CAD）中心室快速性心律失常，即室性心动过速（VT）和颤动（VF）最重要的触发机制之一。本研究的目的是：1）研究缺血与VT/VF可诱导性之间的关系；2）探讨去除缺血是否会导致心律失常的抑制，即不可诱导性。在30例CAD患者（73%有陈旧性心肌梗死，排除急性心肌梗死）和持续性恶性室性心律失常患者（47%为VF，37%为VT，16%为致心律失常性晕厥）中，通过在程控心室刺激期间同时测量冠状动脉动静脉乳酸差值来计算心肌乳酸摄取（MLE）。18例患者（A组，“乳酸阳性”）在VT/VF诱导前刺激期间，MLE从静息时的+16±13%显著下降至-18±24%（p<0.0005）。在VT/VF终止后的恢复过程中，直至10分钟时MLE恢复至正常范围（+19±16%）。12例患者（B组，“乳酸阴性”）的MLE在静息、刺激和恢复之间无显著变化。与B组患者相比，A组患者在201Tl闪烁扫描期间显示出明显更多的冠状动脉病变数量和程度以及可逆性缺血区域。乳酸阳性患者出现的自发性心律失常频率更高，通常为双支或三支血管病变，而乳酸阴性患者出现的心律失常频率较低，更常见的是单支血管病变合并室壁瘤。A组17/18（94%）患者接受了冠状动脉搭桥术（11例）或球囊血管成形术（6例），在介入后程控心室刺激期间94%的患者变为不可诱导性，87%的病例中MLE也恢复正常。B组中只有4/12例患者适合血运重建，仅50%的病例可变为不可诱导性。就心律失常抑制方面的抗缺血治疗成功率而言，初次程控心室刺激期间乳酸阳性结果的敏感性为89%，特异性为75%，阳性预测值为94%，阴性预测值为60%。
在约60%的VT/VF和显著CAD患者中，可证明缺血与可诱导性之间存在相关性。程控心室刺激期间的MLE对抗缺血干预对心律失常诱导的效果具有高度显著的预测价值。
