[SCD-FORUM] 由VEENHUYZEN医师和WYSE医师解读文献—SERGE BOVEDA医师的三个专业问题

[SCD Symposium]

由VEENHUYZEN医师和WYSE医师解读文献—SERGE BOVEDA医师的 
三个专业问题
室速/室颤的可逆性诱因：真还是假？病例介绍及综述
G. D. Veenhuyzen，MD
D. George Wyse, MD, PhD

Serge Boveda医师（法国）
—你的病例报告很清楚的表明那些一过性性的原因很 
可能发生在有严重心脏疾病的患者中：大多数情况他 
们应当植入ICD进行一级预防。您不认为指南涉及的因 
一过性或可逆性的诱因引起的室速/室颤而植入ICD的 
患者应主要是指那些没有（或轻度）器质性心脏病的 
患者？

George Veenhuyzen and George Wyse医师（加拿大）
—目前的指南没有建议在因一过性或可逆性的诱因引 
起的室速/室颤患者中植入ICD，而在合并有心脏病的 
患者中除外。我们的病例的确存在多方面的心脏多方 
面的疾病，也可能确实是这些患者反复出现所谓的一 
过性或可逆性诱因导致了心律失常的持续存在。这里 
有两个难点。首先，患者还出现的其他的情况，例如 
肾脏和肺的疾病，一过性的或能被纠正的诱因（电解 
质紊乱和低氧血症）就可能反复持续存在。其次，很 
难确定是否持续存在引起心律失常的原因。例如，一 
位溺水的患者复苏后出现室颤，排除是否存在长QT综 
合征就比较困难。因而，就如同我们在文中陈述的， 
我们需要大量的临床证据来断定室速/室颤的发生是 
否真的由一过性或可纠正的诱发因素引起，并且不太 
可能复发。我认为一种简单的规则或情况不会长久的 
替代临床判断，也不会利于心血管领域指南的制订。

Serge Boveda医师 (法国)
—关于室速/室颤的“触发点”，您认为成功的消 
融“触发性室早”（就如同Michel Haïssaguerre论证的 
Purkinje或Brugada患者等）能否认为是可逆性的诱因，另 
外，没有（或只有轻度）器质性心脏病的患者能否不 
植入ICD？

George Veenhuyzen医师 (加拿大)
—我觉得现在断定消融“触发性”室早是否是彻底的 
治疗，应用在哪些病例中尚为时过早。迄今为止，对 
选择患者的报道还很少。Brugada和其他离子通道病在 
室速/室颤中占相当少部分。而室早则像园中的杂草 
一样普遍。你消除了一个室早，立即会有另一个出 
现。因而，我对现在在大多数患者中用这种方式作为 
彻底治疗的手段表示怀疑。

Serge Boveda医师 (法国)
—依据文献资料，在急性心肌缺血后多久可以考虑室 
速/室颤的诱因是一过性或可逆性的？

George Veenhuyzen医师 (加拿大)
—我认为没有瘢痕形成（陈旧性心梗）的患者在建立 
如血管再通等确定性治疗前，缺血是真正可逆的诱 
因。最好的例子是血管痉挛导致的心绞痛，能引起室 
速/室颤。正规的药物治疗（两种或多种血管扩张剂 
及他汀类药物）能够有效地控制心律失常。我就有一 
些这样的患者，他们没有植入ICD，已经存活10年以 
上。然而，重要的是，缺血在动脉粥样硬化疾病进展 
的患者或未完全开通血管的患者中中会反复发生。

--
Sergio Dubner医师‘
科委会主席
Edgardo Schapachnik医师
组委会主席

毛晔译 王玲洁校

READING THE LECTURE BY DR. VEENHUYZEN and DR WYSE. THREE EXPERT  
QUESTIONS BY DR. SERGE BOVEDA
Reversible Causes of VT/VF: Fact or Fiction? Case presentation and
review of the literature
G. D. Veenhuyzen, MD
D. George Wyse, MD, PhD


Dr. Serge Boveda (France)
- Your case report clearly shows that transient causes are more
likely to occur in patients suffering from severe heart disease: most
of the time they should be implanted with an ICD for primary
prevention. Don’t you think that guidelines concerning ICD
implantation among patients with VT/VF due to transient or reversible
disorders should mainly concern patients with no (or mild) structural
heart disease?

Dr. George Veenhuyzen and George Wyse (Canada)
- The current guidelines do not advise an ICD for VT/VF with
transient or reversible causes but are slilent on the issue of co-
existing heart disease.  It is true our case had extensive heart
disease and it may be true such patients are more likely to have
recurrence of the so-called transient or reversible cause as the
substrate for arrhythmia continues to exist.  The difficulties are
twofold.  First, in patients with other conditions such as renal and
lung disease, the transient or correctable causes (electrolyte
abnormalities and hypoxemia) continue to recurr unpredicatably.
Second, it is difficult to be sure there is not a continued
substrate.  For example, in a patient rescued from drowning and found
to have VF, it may later be difficult to exclude long QT syndrome.
Thus, as stated in our paper, it requires a great deal of clinical
judgment to determine if VT/VF had a truly tansient or correctable
cause and is unlikely to  recur.  I do not think there will ever be a
simple set of rules or conditions that replace clinical judgment and
would favor a guideline that is more permissive in this area.

Dr. Serge Boveda (France)
- Concerning the “trigger” of VT/VF, do you think that successful
ablation of the “triggering VPB’s” (as demonstrated by Michel
Haïssaguerre for Purkinje or Brugada patients…) should be considered
as a reversible cause and by the way, avoid ICD implantation in
patients with no (or mild) structural heart disease?

Dr. George Veenhuyzen (Canada)
- I think it is too early to tell if ablating "triggering" VPBs will
be complete treatment and in which cases.  So far there has been few
reports in relatively selected patients.  Brugada and other
channelopathies are a rather small number of VT/VF cases.  The thing
about VPBs are they are rather ubquitous, like weeds in your garden.
When you remove one it is soon replaced by another.  Thus, I am
doubtful at the moment that this would be a complete solution in many
patients.

Dr. Serge Boveda (France)
- Regarding with literature data, how long would you consider that VT/
VF is a transient or reversible cause after an acute myocardial
ischemia?

Dr. George Veenhuyzen (Canada)
- I think ischemia is a truly reversible cause mostly in the absence
of scar (previous infarction) until a defintive treatment like
revascularization is applied.  The best example is vasospastic angina
that causes VT/VF in an otherwise normal heart.  Good medical therapy
(two or more vasodilators and a statin) can be effective treatment.
I have a few such cases with defibrillators who have never had a
therapy from there ICD in over 10 years.   However, it is important
to remember that ischemia can return in the case of atherosclerotic
disease due to progression of disease or incomplete revascularization.


--
Dr. Sergio Dubner
President of Scientific Committee

Dr. Edgardo Schapachnik
President of Steering Committee