射頻消融治療ICD術(shù)后電風(fēng)暴的療效分析
發(fā)布時(shí)間：2018-10-29 22:29
【摘要】：目的:射頻導(dǎo)管消融治療已成為治療植入型心律轉(zhuǎn)復(fù)除顫器(implantable cardioverter defibrillator,ICD)術(shù)后電風(fēng)暴的重要手段。本文通過回顧性分析在我院接受導(dǎo)管射頻消融的22例ICD術(shù)后電風(fēng)暴患者的手術(shù)方式及隨訪結(jié)果探討導(dǎo)管射頻消融的療效與安全性。方法:研究對象為2012年12月至2016年1月的22例在南方醫(yī)科大學(xué)珠江醫(yī)院因ICD術(shù)后電風(fēng)暴行射頻消融術(shù)住院患者,部分患者植入器械為心臟再同步化治療-除顫器(CRT-D),需排除術(shù)中或程控證實(shí)引起ICD/CRT-D治療的病因?yàn)榉鞘宜?室顫患者。1例術(shù)前考慮左室流出道特發(fā)性室速,行激動(dòng)標(biāo)測和起搏標(biāo)測。其余21例均于竇性心律下先于心內(nèi)膜面行電壓標(biāo)測。同時(shí)尋找局部異常電位。如電壓標(biāo)測提示無低電壓區(qū),則結(jié)合激動(dòng)標(biāo)測及起搏標(biāo)測尋找靶點(diǎn),如仍無理想靶點(diǎn),則建立心外膜通路行電壓標(biāo)測、激動(dòng)及起搏標(biāo)測。所有患者消融前均行程序刺激嘗試誘發(fā)臨床室速。如電壓標(biāo)測出明顯低電壓區(qū)域,并結(jié)合起搏標(biāo)測確定室速與低電壓區(qū)相關(guān),則不尋找緩慢傳導(dǎo)區(qū)或關(guān)鍵峽部,對低電壓區(qū)域行基質(zhì)改良,重點(diǎn)消融低電壓區(qū)局部異常電位區(qū)域。如無低電壓區(qū)域,則對起搏及激動(dòng)標(biāo)測下理想靶點(diǎn)進(jìn)行消融。所有消融方式終點(diǎn)均為多點(diǎn)心室程序刺激及靜脈滴注異丙腎上腺素均不能誘發(fā)心動(dòng)過速。術(shù)后所有患者行起搏器程控及電話隨訪�；颊吣�20例、女2例,年齡(53.39± 13.99)歲。其中擴(kuò)張性心肌病6例,缺血性心肌病6例,Brugada綜合征2例,致心律失常右室心肌病3例,心肌致密化不全1例,無明確結(jié)構(gòu)性心臟病4例。消融術(shù)前1周發(fā)作室速(14.5±14.9)次,接受ICD/CRT-D治療次數(shù)(9.3±9.9)次。單純行心內(nèi)膜標(biāo)測患者為16例,心內(nèi)膜結(jié)合心外膜標(biāo)測為6例,共進(jìn)行26次手術(shù)。術(shù)中消融所有室速者共22例,消融臨床室速但能誘發(fā)非持續(xù)性室速者為1例,術(shù)后仍能誘發(fā)臨床室速為3例,19例患者于心內(nèi)膜及(或)心外膜標(biāo)測到低電壓去區(qū)域,行基質(zhì)改良。消融即刻完全成功率為84.6%(22/26),部分成功率為3.9%(1/26),失敗率為11.5%(3/26),手術(shù)即刻總體有效率為88.5%(23/26)。末次術(shù)后隨訪(21.6± 12.1)月,室性心動(dòng)過速復(fù)發(fā)5例,其中心室電風(fēng)暴發(fā)作4例,1例雖發(fā)作室速但未進(jìn)展為心室電風(fēng)暴的患者為室速頻率下降未觸發(fā)ICD抗心動(dòng)過速治療。隨訪期間4例患者死亡,3例與電風(fēng)暴再發(fā)相關(guān);另1例患者因呼吸衰竭死亡,隨訪至死亡無室速及電風(fēng)暴再發(fā)。導(dǎo)管消融遠(yuǎn)期完全成功率、部分成功率及失敗率分別為77.3%(17/22)、4.5%(1/22)及18.2%(4/22),總體有效率為81.8%(18/22)。所有患者術(shù)中、術(shù)后未出現(xiàn)心包填塞等嚴(yán)重并發(fā)癥。結(jié)論:1.導(dǎo)管射頻消融是治療ICD術(shù)后電風(fēng)暴的一種安全有效的方法,能顯著減少電風(fēng)暴及室速的發(fā)作。2.低電壓區(qū)及局部異常電位的存在是器質(zhì)性心臟病及遺傳性離子通道病電風(fēng)暴發(fā)作的基礎(chǔ),低電壓區(qū)基質(zhì)改良為消融成功的最重要保證。3.心內(nèi)膜消融無法根治的頑固性室速,可考慮行心外膜標(biāo)測與消融。4.結(jié)合不同基礎(chǔ)心臟病變特點(diǎn)有助于快速尋找興趣區(qū)域,標(biāo)測消融靶點(diǎn),節(jié)省手術(shù)時(shí)間,減少手術(shù)并發(fā)癥。
[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.
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R541.7
本文編號：2299016
[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.
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R541.7
【參考文獻(xiàn)】
相關(guān)期刊論文 前8條
1 余金波;楊兵;張鳳祥;居維竹;陳紅武;楊剛;顧凱;酈明芳;陳明龍;;高密度標(biāo)測在器質(zhì)性心臟病室性心律失常電風(fēng)暴導(dǎo)管消融中的應(yīng)用[J];中華心律失常學(xué)雜志;2016年01期
2 華偉;丁立剛;;心臟性猝死的預(yù)防與前景[J];中國循環(huán)雜志;2014年12期
3 茅魁;蔡鑫;;植入型心律轉(zhuǎn)復(fù)除顫器植入術(shù)后電風(fēng)暴發(fā)生及其治療進(jìn)展[J];中國全科醫(yī)學(xué);2013年10期
4 王祖祿;韓雅玲;梁延春;王冬梅;梁明;臧紅云;;經(jīng)導(dǎo)管射頻消融心律轉(zhuǎn)復(fù)除顫器植入后電風(fēng)暴[J];中華心律失常學(xué)雜志;2009年02期
5 李毅剛;;心肌梗死后室性心動(dòng)過速的消融治療[J];中國心臟起搏與心電生理雜志;2006年02期
6 郭成軍;呂樹錚;張英川;張金榮;;心室電風(fēng)暴的機(jī)制與起搏作用的實(shí)驗(yàn)觀察[J];中國心臟起搏與心電生理雜志;2006年02期
7 張澍;陳新;;積極開展惡性室性心律失常導(dǎo)管消融治療以預(yù)防心臟性猝死[J];中華心律失常學(xué)雜志;2007年02期
8 鄒德玲;馬淑梅;孫英賢;;植入心律轉(zhuǎn)復(fù)除顫器后發(fā)生電風(fēng)暴一例[J];中華心律失常學(xué)雜志;2007年01期
，本文編號：2299016
本文鏈接：http://sikaile.net/yixuelunwen/xxg/2299016.html
最近更新
教材專著
