射频消融治疗ICD术后电风暴的疗效分析

发布时间：2018-10-29 22:29

【摘要】：目的:射频导管消融治疗已成为治疗植入型心律转复除颤器(implantable cardioverter defibrillator,ICD)术后电风暴的重要手段。本文通过回顾性分析在我院接受导管射频消融的22例ICD术后电风暴患者的手术方式及随访结果探讨导管射频消融的疗效与安全性。方法:研究对象为2012年12月至2016年1月的22例在南方医科大学珠江医院因ICD术后电风暴行射频消融术住院患者,部分患者植入器械为心脏再同步化治疗-除颤器(CRT-D),需排除术中或程控证实引起ICD/CRT-D治疗的病因为非室速/室颤患者。1例术前考虑左室流出道特发性室速,行激动标测和起搏标测。其余21例均于窦性心律下先于心内膜面行电压标测。同时寻找局部异常电位。如电压标测提示无低电压区,则结合激动标测及起搏标测寻找靶点,如仍无理想靶点,则建立心外膜通路行电压标测、激动及起搏标测。所有患者消融前均行程序刺激尝试诱发临床室速。如电压标测出明显低电压区域,并结合起搏标测确定室速与低电压区相关,则不寻找缓慢传导区或关键峡部,对低电压区域行基质改良,重点消融低电压区局部异常电位区域。如无低电压区域,则对起搏及激动标测下理想靶点进行消融。所有消融方式终点均为多点心室程序刺激及静脉滴注异丙肾上腺素均不能诱发心动过速。术后所有患者行起搏器程控及电话随访。患者男20例、女2例,年龄(53.39± 13.99)岁。其中扩张性心肌病6例,缺血性心肌病6例,Brugada综合征2例,致心律失常右室心肌病3例,心肌致密化不全1例,无明确结构性心脏病4例。消融术前1周发作室速(14.5±14.9)次,接受ICD/CRT-D治疗次数(9.3±9.9)次。单纯行心内膜标测患者为16例,心内膜结合心外膜标测为6例,共进行26次手术。术中消融所有室速者共22例,消融临床室速但能诱发非持续性室速者为1例,术后仍能诱发临床室速为3例,19例患者于心内膜及(或)心外膜标测到低电压去区域,行基质改良。消融即刻完全成功率为84.6%(22/26),部分成功率为3.9%(1/26),失败率为11.5%(3/26),手术即刻总体有效率为88.5%(23/26)。末次术后随访(21.6± 12.1)月,室性心动过速复发5例,其中心室电风暴发作4例,1例虽发作室速但未进展为心室电风暴的患者为室速频率下降未触发ICD抗心动过速治疗。随访期间4例患者死亡,3例与电风暴再发相关;另1例患者因呼吸衰竭死亡,随访至死亡无室速及电风暴再发。导管消融远期完全成功率、部分成功率及失败率分别为77.3%(17/22)、4.5%(1/22)及18.2%(4/22),总体有效率为81.8%(18/22)。所有患者术中、术后未出现心包填塞等严重并发症。结论:1.导管射频消融是治疗ICD术后电风暴的一种安全有效的方法,能显著减少电风暴及室速的发作。2.低电压区及局部异常电位的存在是器质性心脏病及遗传性离子通道病电风暴发作的基础,低电压区基质改良为消融成功的最重要保证。3.心内膜消融无法根治的顽固性室速,可考虑行心外膜标测与消融。4.结合不同基础心脏病变特点有助于快速寻找兴趣区域,标测消融靶点,节省手术时间,减少手术并发症。
[Abstract]:Objective: Radiofrequency catheter ablation therapy has become an important method for the treatment of electrical storm after implantation type cardioverter defibrillator (ICD). The efficacy and safety of radiofrequency catheter ablation in 22 ICD patients undergoing radiofrequency ablation in our hospital were analyzed retrospectively. METHODS: From December 2012 to January 2016, 22 patients in the Pearl River Hospital of Southern Medical University underwent RF ablation in the Pearl River Hospital of Southern Medical University, and some patients were implanted with device as cardiac resynchronization therapy-defibrillator (CRT-D). Patients with ICD/ CRT-D treated with ICD/ CRT-D were excluded from the procedure or programmed to result in non-ventricular tachycardia/ ventricular fibrillation. In 1 case, the left ventricular outflow tract, the idiopathic ventricular tachycardia, the line agitation scale, and the pacing standard were considered. The remaining 21 cases were measured before the endocardial surface line voltage. and meanwhile, the local abnormal potential is searched. If there is no low voltage region on the voltage mark test, the target will be determined by combining the excitation mark test and the pacing standard. If there is still no ideal target point, the epicardial path line voltage standard measurement, activation and pacing standard will be established. All patients underwent procedural stimulation prior to ablation to induce clinical chamber speed. If the apparent low voltage region is measured by the voltage standard, and the determination chamber speed is related to the low voltage region in combination with the pacing standard measurement, the slow conduction region or the key isthmus portion is not searched, the substrate improvement of the low voltage region is not searched, and the local abnormal potential region of the low voltage region is mainly ablated. If there is no low voltage region, ablation is performed on the ideal targets under pacing and activation. All ablation modalities endpoints were multi-point ventricular procedure stimulation and intravenous infusion of isoproterenol could not induce tachycardia. All patients underwent pacemaker programming and telephone follow-up. There were 20 males and 2 females with age (53. 39 vs 13. 99). Among them, 6 cases of dilated cardiomyopathy, 6 cases of ischemic cardiomyopathy, 2 cases of Brugada syndrome, 3 cases of right ventricular cardiomyopathy of arrhythmia, 1 case of myocardial fibrosis and 4 without definite structural heart disease. During the first week before the ablation procedure, the rate of onset of the episode was 14. 5 Mt. 14. 9 times, and the number of treatment of ICD/ CRT-D (9. 3, 9. 9) times was accepted. Of the 16 patients with endocardial marker, the endocardial binding epicardial mapping was 6, and 26 operations were performed. During the operation, 22 cases were ablated, the rate of ablation was rapid but the rate of non-sustained ventricular tachycardia was induced in 1 case, the clinical chamber rate was still induced in 3 cases, and 19 patients were measured at the endocardial and/ or epicardium to the low voltage region and the matrix was improved. Immediate complete success rate was 84.6% (22/ 26), partial success rate was 3.9% (1/ 26), failure rate was 11.5% (3/ 26), total effective rate was 86.5% (23/ 26). In the last postoperative follow-up (21. 6 vs 12. 1), 5 patients had recurrent ventricular tachycardia, including 4 cases of ventricular electrical storm onset, 1 case with ventricular electrical storm, but the patient with ventricular electrical storm did not trigger an ICD antitachycardia treatment for ventricular tachycardia. Four patients died during follow-up and 3 were associated with an electrical storm; another patient died due to respiratory failure, followed up to death without ventricular tachycardia and an electrical storm. The complete success rate of catheter ablation, partial success rate and failure rate were 73.3% (17/ 22), 4.5% (1/ 22) and 18.2% (4/ 22), respectively. The overall response rate was 81.8% (18/ 22). No serious complications such as pericardial tamponade occurred during all patients. Conclusion: 1. Catheter radiofrequency ablation is a safe and effective method for the treatment of postoperative electrical storms in patients with ICD, which can significantly reduce the onset of electrical storms and ventricular tachycardia. The existence of low voltage region and local abnormal potential is the basis of organic heart disease and hereditary ion channel disease. The improvement of matrix in low voltage region is the most important guarantee for the success of ablation. Endocardial ablation could not radically cure refractory ventricular tachycardia, and epicardial mapping and ablation could be considered. According to the characteristics of different basic heart diseases, the invention can quickly search the region of interest, mark the ablation target, save the operation time and reduce the complications of the operation.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R541.7

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