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Osservazioni cliniche nei
pazienti aritmie ed
insufficienza cardica
Clinical Observations in the Arrhythmic Heart
Failure Patients
Mariell Jessup MD
Professor of Medicine
University of Pennsylvania
Philadelphia, Pennsylvania
HF and Arrhythmias
ICDs: the good, the bad, and the ugly.
VT ablation.
PVC-induced cardiomyopathy.
HF and Arrhythmias
ICDs: the good, the bad, and the ugly.
VT ablation.
PVC-induced cardiomyopathy.
Magnitude of SCA in the US
Stroke3
Lung
Cancer2
Breast
Cancer2
AIDS1
1
2
3
4
167,366
157,400
SCA claims
more lives
each year
than these
other
diseases
combined
40,600
42,156
U.S. Census Bureau, Statistical Abstract of the United States: 2001.
American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures 2001.
2002 Heart and Stroke Statistical Update, American Heart Association.
Circulation. 2001;104:2158-2163.
450,000
SCA 4
#1 Killer
in the U.S.
Severity of Heart Failure and Modes of Death
12%
26%
64%
24%
59%
15%
33%
NYHA Class III
NYHA Class II
56%
n = 103
11%
MERIT-HF Study Group.
LANCET 1999; 353:2001-2007
NYHA Class IV
n = 27
n = 103
CHF
Other
Sudden Death
Underlying Arrhythmias of
Sudden Cardiac Arrest
Polymorphic VT 13%
Bradycardia
17%
Monomorphic VT
62%
Bayés de Luna A. Am Heart J. 1989;117:151-159
Primary VF
8%
ICD’s and survival in CHF
MUST-T ICD
100 --
MADIT- II ICD
COMPANION ICD
90 --
DEFINITE ICD
80 -MUST-T No ICD
70 --
MADIT- II No ICD
COMPANION
No ICD
60 --
DEFINITE No ICD
50 -0
1
2
3
Year
Buxton AE, at al. (MUST-T) NEJM 1999;341:1882-90
Moss AJ, et al. ( MADIT-II) NEJM 2002;346:877-83
Bristow MR, et al. (COMPANION) NEJM 2004;350:2140-50
Kadish A, et al. (DEFINITE) NEJM 2004;350:2151-8
Exner, Klein. J Cardiovasc Electrophysiol 2003; 14:574
ICD Implant Procedures-UPENN
662
700
541
600
500
400
395
356
502
473
414
411
431
342
300
200
100
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
U.S. Heart Failure Device Market & Adoption
Net Prevalence *
ICD Only
CRT =>
CRT-D
Estimated
Adoption
Secondary Prevention
(SCA/VF/VT)
246,000
230,000
16,000
82%
Genetics
(HCM, LQTS, etc.)
88,000
88,000
N/A
20%
SCD-HeFT1
534,000
534,000
N/A
22%
High Risk Post-MI
(MADIT, MUSTT, MADIT II)1
116,000
116,000
N/A
22%
MIRACLE & COMPANION
396,000
N/A
396,000
31%
1,380,000
968,000
412,000
~ 35%
Indications
Total Indicated Patients
•Net Prevalence is indicated prevalence minus 15% economic exclusion and minus 20% clinical exclusion.
1.
2.
Class II & III, narrow QRS, excluding CRT indicated patients, not overlapping with SCA/VT/VF survivors
Incremental, not overlapping with SCD-HeFT population (i.e. MI, LVEF ? 30% and no HF)
MADIT-II
Greenberg et al. JACC 2004;43:1459
Hohnlosser et al. NEJM 2004; 351:2481
Post MI
The IRIS trial
All-cause mortality at 36 months by
treatment group and risk-stratification
criteria in IRIS
Risk-criteria group
ICD+OMT OMT only p
(%)
(%)
All patients (mean LVEF
35%), n=898
22.0
22.9
0.76
LVEF <40% and HR >90
bpm (mean LVEF 32%),
n=602
24.6
25.0
0.91
NSVT >150 bpm (mean
LVEF 41%), n=296
17.2
18.7
0.71
Steinbeck G. American College of Cardiology 2009
Scientific Sessions; March 31, 2009; Orlando, FL.
JACC 2009; 53:e1-90
JACC 2009; 53:e1-90
HF and Arrhythmias
ICDs: the good, the bad, and the ugly.
VT ablation.
PVC-induced cardiomyopathy.
Circulation 2004;109:2924
ICDs: the UGLY
infection
ICDs: the UGLY
infection
Closed pocket infection
Eroding ICD pocket
HF and Arrhythmias
ICDs: the good, the bad, and the ugly.
VT ablation.
PVC-induced cardiomyopathy.
NEJM 2008; 359:1009-17
Classification of Ventricular Arrhythmias
Das et al. Cardiol Clin 2008; 26:459-479
Zipes et a. Circulation 2006; 114:e385-484
VT Ablations (UPENN) 1999 -2008
( N = 1176 ablation procedures)
221
2008
2007
2006
2005
Y
E
A
R
2004
2003
2002
2001
2000
1999
0
20
40
60
80
100 120 140 160 180 200 220
Number of VT Ablations
Post MI patients referred for VT ablation
1993-1997
(N=65)
2004-2005
(N=65)
P value
Male
59 (91%)
58 (89%)
ns
Age
67 ± 9.2 yrs
67 ± 8.9 yrs
ns
LVEF
27 ± 7%
23 ± 9%
< 0.01
Previous
ICD
35 (54%)
61 (94%)
< 0.01
Amiodarone
32 (49%)
51 (79%)
< 0.01
Marchlinski et al Circulation 2008
Clinical presentation in 100 consecutive patients
referred for VT ablation (Sick Patients – Unstable)
93%
68%
18%
Number with ICD
"VT Storm" or
Incessant
VT/Daily VT
14%
Frequent but not
<5 shocks or
daily episodes or episodes/month
shocks
100
90
80
70
60
%
50
40
30
20
10
0
UPENN VT Ablations (N= 775)
1999- 2006
300
512 (66%)
250
200
279
263 (34%)
100
176
116
47
VT CAD
VT
RVCM*
47
VT
LVCM
RVOT
150
LVOT
40
70
50
0
Idio LV Other
VT Tet, Sarcoid, Non OT VT, etc
Recurrence vs. clinical benefit
0.03 0.46
Segal OR: Heart Rhythm 2005
Circulation Arrhyth Electrophysiol 2008; 1:153-161
*Low bipolar voltage
surrounding the valves
*Low voltage abnormalities
extending toward more
apical segments of
the RV or LV.
Circulation 2007; 116:1998
Assomull et al. JACC 2006;48:1977
Electrical storm: definition
• Occurrence of 3 or more distinct episodes of VT
and/or VF within a 24-hour period resulting in
device intervention.
– Incidence: 10-28% over 1-3 year (secondary prevention)
–Prognosis: 2-7-fold higher risk of death
Electrical storm
in patients with ICDs implanted earlier
AVID
MADIT II
Huang and Traub Prog Cardiov Dis 2008; 51(3): 229-236
Electrolyte imbalance
Ischemia
Heart failure exacerbation
Medication non-compliance
identified cause in 13% !!!
Eur Heart J 2006; 27: 3027
Electrical storm in the ICD era.
Huang and Traub Prog Cardiov Dis 2008; 51(3): 229-236
HF and Arrhythmias
ICDs: the good, the bad, and the ugly.
VT ablation.
PVC-induced cardiomyopathy.
Circulation 2005; 112:1092-1097
J Interv Card Electrophysiol 2007; 20:9-13
University of Pennsylvania Medical Center