Surgical ablation of ventricular tachycardia with sequential map-guided subendocardial resection: electrophysiologic assessment and long-term follow-up.
Surgical ablation of ventricular tachycardia with sequential map-guided subendocardial resection: electrophysiologic assessment and long-term follow-up.
复制标题
通过顺序图引导心内膜下切除术来手术消融室性心动过速：电生理评估和长期随访。
DOI：
10.1161/01.cir.77.1.131
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发表时间：
1988
期刊：
影响因子：
37.8
通讯作者：
DiMarco,JP
中科院分区：
文献类型：
--
作者：
Haines,DE;Lerman,BB;Kron,IL;DiMarco,JP
本文介绍一种新的手术技术--标测引导下连续心内膜下切除术（SER），用于治疗45例冠心病所致持续性室性心动过速。该技术的特点是在常温心肺转流期间进行标测引导SER或低温消融，然后进行重复的程控刺激序列，以评估切除的充分性。患者的平均年龄为59 ± 10岁，平均左心室射血分数为34 ± 12%。25例（56%）患者在过去2个月内有心肌梗死病史。心室切开术后，34例（76%）患者出现可诱导的单形性室性心动过速。这些患者在常温旁路期间接受了重复的室性心动过速诱导和标测序列，随后进行连续的SER或冷冻消融，直到持续的单形性室性心动过速不再可诱导。27例患者共诱导了60次离散的可标测心动过速，7例患者有10次离散的心动过速，速度太快，无法准确标测。在其余11例患者中，在心室切开术和SER（包括所有视觉可识别的瘢痕）后未诱导室性心动过速。平均心肺转流时间为102 +/- 27 min。45例患者中有41例（91%）存活至出院，41例患者中有35例（85%）在未使用所有抗心律失常药物的情况下进行术后电生理评价时无诱导性室性心动过速。其余6例患者在药物治疗后未出现可诱导的室性心动过速。所有四名手术死亡者术前均患有难治性心脏衰竭。在19 +/- 12个月的随访中，有4例心脏性猝死，无非致命性室性心动过速复发。另有7例心脏病死亡。42个月时，心脏存活率为0.57，无心血管事件为0.76。因此，在没有心源性休克的情况下，序贯标测图引导SER技术实现了：（1）在可接受的灌注时间内的高手术存活率，（2）出色的长期心律失常控制，（3）与左心室功能相似且无室性快速性心律失常病史的患者的存活率相当。
A new operative technique of sequential map-guided subendocardial resection (SER) was used in 45 consecutive patients for the treatment of sustained ventricular tachycardia due to coronary artery disease. This technique is characterized by map-guided SER or cryothermic ablation during normothermic cardiopulmonary bypass, followed by repeated sequences of programmed stimulation to assess adequacy of resection. The patients' mean age was 59 +/- 10 years and the mean left ventricular ejection fraction was 34 +/- 12%. Twenty-five (56%) patients had a history of myocardial infarction within the previous 2 months. After ventriculotomy, 34 patients (76%) had inducible monomorphic ventricular tachycardia. These patients underwent repeated sequences of ventricular tachycardia induction and mapping during normothermic bypass followed by successive SER or cryothermic ablation until sustained monomorphic ventricular tachycardia was no longer inducible. Twenty-seven patients had a total of 60 discrete, mappable tachycardias induced and seven patients had 10 discrete tachycardias that were too fast to accurately map. In the remaining 11 patients, no ventricular tachycardia was inducible after ventriculotomy and SER, which included all visually identifiable scar, was performed. The mean cardiopulmonary bypass time was 102 +/- 27 min. Forty-one of 45 patients (91%) survived to hospital discharge, and 35 of 41 patients (85%) had no inducible ventricular tachycardia at postoperative electrophysiologic evaluation performed in the absence of all antiarrhythmic drugs. The remaining six patients had no inducible ventricular tachycardia with drug therapy. All four operative nonsurvivors had refractory cardiac collapse preoperatively. Over 19 +/- 12 months of follow-up, there were four sudden cardiac deaths and no nonfatal recurrences of ventricular tachycardia. There were seven additional cardiac deaths. Actuarial cardiac survival was 0.57, and freedom from arrhythmic events was 0.76 at 42 months. Thus, in the absence of cardiogenic shock, the technique of sequential map-guided SER achieves: (1) a high operative survival with acceptable perfusion times, (2) excellent long-term arrhythmia control, and (3) survival comparable to that in patients with similar left ventricular function and no history of ventricular tachyarrhythmia.