Management of ventricular tachycardia in patients with cardiac sarcoidosis.
Management of ventricular tachycardia in patients with cardiac sarcoidosis.
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DOI：
10.1016/j.hroo.2021.07.005
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发表时间：
2021-08
期刊：
影响因子：
--
通讯作者：
Birnie DH
中科院分区：
文献类型：
--
作者：
Viwe M;Nery P;Birnie DH
结节病是一种多系统肉芽肿性疾病，有两个不同的阶段（炎症和瘢痕）。在植入式心律转复器的靶向使用和现代心力衰竭治疗的当今时代，最近的数据表明心脏结节病（CS）的预后得到了很大改善，因此更多的患者表现为复发性室性心动过速（VT）。这篇综述强调了我们目前对CS室性心律失常的病理生理学和治疗的理解，主要关注消融术的适应症、技术和结局。纤维化区域周围的大折返现象可能是CS室性心律失常的最常见机制。炎症也可能在CS患者的心室异位引发折返中发挥作用，或通过减缓病变组织的传导。现有最佳数据表明，最初临床无症状和临床明显疾病患者的VT年发生率可能分别为1%-2%和10%-15%。目前的指南建议采取逐步的方法来管理VT。如果有活动性炎症的证据，建议的第一步是用免疫抑制剂治疗。抗心律失常药物通常同时开始，如果室性心动过速无法控制，则考虑导管消融。在血流动力学耐受的室性心动过速的情况下，激活和夹带标测和消融是有利的。基底消融针对电描记图异常区域和起搏标测良好的区域，使用线性和/或簇状损伤集，旨在消除关键峡部和/或阻断室性心动过速出口部位。20%-35%的病例需要心外膜标测消融。一般来说，诱发更多的室性心动过速形态（通常为3-4种），随后的结局（复发率为40%-50%）不如其他形式的非缺血性心肌病。CS的预后大大改善，因此，更多的患者在随访期间发生VT。可能主要与复杂的疾病基质相关，室性心动过速消融术在技术上具有挑战性，结局中等，仍有许多有待了解。
Sarcoidosis is a multisystem granulomatous disease with 2 different phases (inflammation and scar). In the current era of targeted use of implantable cardioverter-defibrillators and modern heart failure therapy, recent data indicate the prognosis of cardiac sarcoidosis (CS) is much improved, and hence more patients are presenting with recurrent ventricular tachycardia (VT). This review highlights our current understanding of the pathophysiology and management of ventricular arrhythmias in CS with the major focus on indications, techniques, and outcomes of ablation. It is likely macroreentry phenomena around areas of fibrosis is the most frequent mechanism of ventricular arrhythmia in CS. It is also possible that inflammation may play a role in initiating reentry with ventricular ectopy in CS patients, or by slowing conduction in diseased tissue. The best available data would suggest annual rates of VT of perhaps 1%–2% and 10%–15% in patients with initially clinically silent and clinically manifest disease, respectively. Current guidelines recommend a stepwise approach to VT management. The first suggested step is treatment with immunosuppression if there is evidence of active inflammation. Antiarrhythmic medications are often started at the same time, with catheter ablation considered if VT cannot be controlled. Activation and entrainment mapping and ablation are favored in the setting of hemodynamically tolerated VT. Substrate ablation targets areas of abnormal electrogram and favorable pace mapping using linear and/or cluster lesion sets with the goal of abolishing critical isthmuses and/or blocking VT exit sites. Epicardial mapping ablation is required in 20%–35% of cases. In general, more morphologies of VT are induced (often 3–4) and subsequent outcomes (recurrence rates 40%–50%) are less favorable than in other forms of nonischemic cardiomyopathy. The prognosis of CS is much improved and, as a result, more patients are developing VT during follow-up. Likely principally related to the complex disease substrate, VT ablation is technically challenging, with moderate outcomes, and much remains to be learned.
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DOI：
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发表时间：
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期刊：
JACC. Cardiovascular imaging
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通讯作者：
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