Kim Y H, Sosa-Suarez G, Trouton T G, O'Nunain S S, Osswald S, McGovern B A, Ruskin J N, Garan H
Cardiac Unit, Massachusetts General Hospital, Harvard Medical School, Boston 02114.
Circulation. 1994 Mar;89(3):1094-102. doi: 10.1161/01.cir.89.3.1094.
Recurrent sustained ventricular tachycardia (VT) is not responsive to antiarrhythmic drugs in the majority of patients, who therefore need therapy with nonpharmacological methods. We evaluated prospectively the feasibility, safety, and efficacy of transcatheter radiofrequency (RF) ablation of VT in 21 selected patients with ischemic heart disease and VT.
Twenty-one patients with ischemic heart disease and recurrent, drug-refractory VT documented by 12-lead ECG were selected who had sufficient hemodynamic tolerance of VT to undergo transcatheter mapping. Documented clinical VT was reproduced by programmed cardiac stimulation (PCS), and the site of origin was localized by a combination of techniques, including pace mapping, activation-sequence mapping, recordings of middiastolic potentials, and application of resetting and entrainment principles. RF current at 55 V was applied (3.8 +/- 3.1 applications per patient) for as long as 30 seconds at a time to target sites. Twenty-four distinct clinical VTs (mean cycle length, 445 +/- 52 milliseconds) were mapped and ablated in 21 patients. In 17 of 21 patients (81%), the procedure was acutely successful, and the target clinical VT could no longer be induced by PCS after the procedure, whereas in 4 patients, clinical VT remained inducible. By contrast, VTs with shorter cycle length and different QRS morphology than the ablated VT could still be induced by PCS in 12 of 21 patients. One patient died in intractable congestive heart failure 10 days after the procedure, and the remaining 20 are alive at the end of the follow-up period. The majority of the patients continued to be treated with at least one additional mode of antiarrhythmic therapy; 12 patients were still taking antiarrhythmic drugs, and 9 patients received an implantable cardioverter/defibrillator. During a mean follow-up period of 13.2 +/- 5.0 months, 9 of 20 patients (45%) had recurrent VT. In 4 patients, the recurrent VT was different than the previously ablated one. Clinical VT recurred in all 4 patients in whom RF ablation had been acutely unsuccessful. Four patients with recurrent VT underwent repeat RF ablation procedures that were acutely successful and had no further recurrence.
Transcatheter RF ablation is feasible but has only moderately high efficacy in a small, selected group of patients with ischemic heart disease and drug-refractory, highly frequent, hemodynamically tolerated, sustained VT. In the majority of the patients, this treatment technique is palliative rather than definitive, and many of the patients continue to require other methods of antiarrhythmic therapy.
复发性持续性室性心动过速（VT）在大多数患者中对抗心律失常药物无反应，因此这些患者需要采用非药物方法进行治疗。我们前瞻性评估了经导管射频（RF）消融治疗21例选定的缺血性心脏病合并室性心动过速患者的可行性、安全性和有效性。
选取21例经12导联心电图记录证实为缺血性心脏病且复发性、药物难治性室性心动过速的患者，这些患者对室性心动过速具有足够的血流动力学耐受性以进行经导管标测。通过程控心脏刺激（PCS）重现记录到的临床室性心动过速，并结合多种技术定位起源部位，包括起搏标测、激动顺序标测、舒张中期电位记录以及应用重置和拖带原理。每次以55V的射频电流（每位患者平均应用3.8±3.1次）向靶点持续施加30秒。在21例患者中对24种不同的临床室性心动过速（平均周期长度为445±52毫秒）进行了标测和消融。21例患者中有17例（81%）手术即刻成功，术后经PCS不能再诱发目标临床室性心动过速，而4例患者的临床室性心动过速仍可诱发。相比之下，21例患者中有12例经PCS仍可诱发周期长度较短且QRS形态与消融的室性心动过速不同的室性心动过速。1例患者在术后10天死于顽固性充血性心力衰竭，其余20例在随访期末仍存活。大多数患者继续接受至少一种其他抗心律失常治疗方式；12例患者仍在服用抗心律失常药物，9例患者接受了植入式心脏复律除颤器治疗。在平均13.2±5.0个月的随访期内，20例患者中有9例（45%）发生复发性室性心动过速。4例患者的复发性室性心动过速与先前消融的不同。在所有4例射频消融手术即刻未成功的患者中均出现了临床室性心动过速复发。4例复发性室性心动过速患者接受了再次射频消融手术，手术即刻成功且未再复发。
经导管射频消融在一小部分选定的缺血性心脏病且药物难治、频发、血流动力学耐受性良好的持续性室性心动过速患者中是可行的，但疗效仅为中等程度。在大多数患者中，这种治疗技术是姑息性而非根治性的，许多患者仍需要其他抗心律失常治疗方法。
