Download Ventricular arrhythmias

Mechanism, diagnosis and management
of Supraventricular Tachycardias (SVT).
Atrial fibrillation and atrial flutter.
Ventricular tachycardias.
Zoltan Csanadi
Institute of Cardiology
Human arrhythmias
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Majority are based on reentry mechanism
Sustained arrhythmia: lasting for 30 sec or
longer
Tachycardia: 3 or more consecutive beats at a
rhythm faster than 120 beats/min
Most common sustained arrhythmia in human:
atrial fibrillation
Most common non-sustained arrhythmia in
human: ventricular extrasystole
Classification of supraventricular tachycardias
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AV node dependent SVTs
(Regular tachycardias)
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Atrioventricular (AV) nodal
reentry
 Typical (slow-fast)
 Atypical (fast-slow ; slowslow)
Atrioventricular (AV) reentry
 Ortodromic
 Antidromic
„True” junctional tachycardia
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Non-AV node dependent (atrial) arrhythmias
(Regulár or irregular tachycardias)
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Atrial fibrillation
Atrial macroreentry
 Isthmus-dependant (atrial flattern/flutter)
 Typical (antihoral)
 Reverz typical (horal)
 „lower loop” reentry
 Non-isthmus-dependens
 Right atrialmacroreentry
 Left atrial macrcoreentry
 Incisional (lesional) tachycardias
Focal atrial tachycardias
 Ectopic
 RA
 LA Sinus csomó tachycardiák
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Sinus node origin
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SN reentry (paroxysmal)
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Inapropriate sinus node tachycardia (chr)
Fast and slow
AV nodal
pathways in the
region of Koch
* Compact AV
node
f: fast pathway
s: slow pathway
AV nodal reentry tachycardia
Ortodromic AV reentry
Antidromic AV reentry
Ortodromic AV reentrant tachycardia
Antidromic AVRT
FBI: FAST, BROAD, IRREGULAR
Acute treatment of narrow QRS
complex tachycardias
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Vagal manuevers
Iv. Adenosine (6-12 mg rapid bolus)
Iv. Verapamil (2 mg slow injection)
Iv. beta-blocker
Classification

AV node dependent SVTs
(Regular tachycardias)
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Atrioventricular (AV) nodal
reentry
 Typical (slow-fast)
 Atypical (fast-slow ; slowslow)
Atrioventricular (AV) reentry
 Ortodromic
 Antidromic
„True” junctional tachycardia
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Non-AV node dependent (atrial) arrhythmias
(Regulár or irregular tachycardias)
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Atrial fibrillation
Atrial macroreentry
 Isthmus-dependant (atrial flattern/flutter)
 Typical (antihoral)
 Reverz typical (horal)
 „lower loop” reentry
 Non-isthmus-dependens
 Right atrialmacroreentry
 Left atrial macrcoreentry
 Incisional (lesional) tachycardias
Focal atrial tachycardias
 Ectopic
 RA
 LA Sinus csomó tachycardiák
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Sinus node origin
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SN reentry (paroxysmal)
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Inapropriate sinus node tachycardia (chr)
Atrial tachycardias
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Regular-Focal
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Regular-Macroreentry
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Rhythmic firing from a focus in RA or LA
Centrifugal impulse propagation from the focus
to the rest of the atrial myocardium
Electrically silent period between 2 beats
CL>250 msec (<240 BPM)
Mechanism (Reentry, Triggered activity, Abnormal automaticity)
Reentry around a (large) anatomical obstacle
(tricuspid-, mitral-annulus, oval fossa)
CL: 190-250 msec (240-320 BPM)
Irregular-Atrial fibrillation
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Irregularly irregular atrial activation
Focal trigger mechanism in most cases
Diffuse electrical alterations in the left atrial
myocardium
Focal atrial tachycardia
Sinus rhythm
Atrial macroreentry (flutter)
Continuous atrial electrical activity
No isoelectric line
Fixed or variable conduction to the ventricles (regular or irregular pulse)
Typical flutter
Reverse typical flutter
(anti-horal)
(horal)
Isthmusdependent atrial
flutter (antihoral)
Isthmusdependens
pitvarlebegés
horalis forgással
Ablation of the
cavotricuspid
isthmus
Transcatheter ablation
To abolish the substrates of arrhythmias.
Energy used:
DC- 1981. Gallagher, Scheinmann;
1983. Debrecen Wórum
painful, inhomogenious lesion, complications
Rádiófrekvenciás áram-1987. Huang
The most often used nowdays
Fagyasztás (cryoabláció)
In special situations
Ultrasound
Complications!
Lézer
Under clinical investigation
1
2
3
5
4
Min temperature 48 C
30-60 sec
25-70 Watt
The ICE age of ablation:
Cryo ablation
40
30
20
10
0
-10
-20
-30
-40
-50
-60
-70
-80
0
10
20
30
40
50
60
70
80
90
100
Steps in the EP Lab
1. Documentation of clinical arrhythmia preferred
2. Programmed stimulation to induce the arrhythmia
3. Compare induced and clinical arrhythmia
4. Mapping of the arrhythmia, finding critical components
5. Discuss findings with patient.
6. ABLation
7. Postablation test
Analoge mapping
Kamra
Pitvar
His
Sinus coronarius
3 D electroanatomical mapping
Clinical results with transcatheter ablation
Supraventricular arrhytmias
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PSVT
95 %+
Atrial flutter
90 %+
Atrial tachycardias 70-90 %
Atrial fibrillation
40-80 %
Ventricular arrhythmias
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Normal heart (idiopathic VT) >
80%
Structural heart disease
palliatíve, with ICD
Atrial fibrillation
Mechanism of AF: trigger foci
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Jól definiálható
szubsztrátum
Ez a
szubsztrátum
eszközösen
hozzáférhető,
modifikálható
Pulmonális
vénák szerepe!!!
Management of AF
1.
Profilaxis of thromboembolism
2.
Ventricular rate control
1.
Rhythm control
SPAF: Stroke Profilaxis in Atrial Fibrillation
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CHADS2-Score
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CHF
Hypertension
Age>75 év
Diabetes
Stroke
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CHADS2-VASC
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OAC,
NOAC
CHF
Hypertensio
Age>75
Diabetes
Stroke
Age >65
Vascular disease
Female gender
Ventricular rate controll
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Keep frequency below 110/min
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Beta-blockers, Ca-blockers, Digitalis
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Pacemaker (VVI) impl.+AV node ablation
Arrhythmia control
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Class I/C (propafenon, flecainide)
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Class III (cordarone, dronedarone, d-sotalol)
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Catheter ablation (PV isolation)
BFPV
PVP
S
SS S
Lasso
Abl
SC
S
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Standard transseptal
puncture, Heparin to
ACT of 280-350
12 F Stearable sheath
(FlexCath)
Stearable over the wire
double lumen balloon
catheter (Arctiv Front:
23-28 mm)
Occlusion of each PV,
freezing for 300 sec x 2.
(temperature -40 to
-60 C)
Pacing w high output in
SVC to capture phrenic
nerve while freezing on
the right side.
Lasso validation of PVPs
postablation
Ventricular arrhythmias
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Ventricular extrasystole
frequency, morphology
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Ventricular tachycardia
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sustained/non-sustained: 30 sec
monomorf/polymorf
Ventricular fibrillation
Ventricular extrasystole
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The most common human arrhythmia
Mostly asymptomatic
Prognostic significance only in case of organic
heart disease
Treatment is necessary in case of symptoms or
bad prognosis
Beta-blockers are first-line therapy
NSVT on Holter
Rhythm Strip During Episode
of Sudden Death
6:02 AM
6:05 AM
6:07 AM
6:11 AM
Source: After Josephson, ME
Underlying Arrhythmia of
Sudden Death
Primary
VF
8% Torsades
de Pointes
13%
VT
62%
Bradycardia
17%
Adapted from Bayés de Luna A. Am Heart J. 1989;117:151-159.
Monomorfic VT
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Organic heart diseases: MI, CMP, ARVD, heart
failure, after cardiac surgeries
Idiopathic
RVOT: LBBB+right axis dev.
 LV (posterior fasciculus) RBBB+left axis dev
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Diff. dg. of regular wide-QRS
complex tachycardia
Ventricular tachycardia (most common)
 Supraventricular tachycardia with BBB or ventricular
pre-excitation
Look for signs of A-V dissociation
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P waves appear indepently of QRS complexes
Capture or fusion beat
Tachycardias with high frequency causing hemodinamic
instability- Immediate electrical CV
Pathophysiology: Myocardium scar
Outer Loop
Bystander
Site/Pathway
Scar
Pathway
Entrance
Pathway
Exit
(Site Triggering
QRS Onset)
Scar
Inner
Pathway
VT induction with programmed
stimulation
VT termination with double
extrastimuli
Implantable Cardioverter Defibrillator (ICD)
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To treat life threatening ventricular arrhythmias
Primary prevention (profilactic): for those who are at risk
Secondary prevention: for those who already had sustained
ventricular arrhythmia
VT then VF treated
with 2 shocks at
different energy level
Successful ATP termination of VT
% Mortalitás csökkenés ICD-kezeléssel
Reduction in mortality with ICD in primary and
secunder prevention trials
75%
80
60
Arrhythmia halálozás
61%
55%
54%
31%
40
Structural heart disease
Post MI+ LV EF<30 %
Severe CHF LV EF<35 %
Inherited diseases: HCM,
ARVD, LQT, Brugada
20
1
0
27 hóap
2
3, 4
39 hóap
MADIT
% Mortalitás csökkenés ICD-kezeléssel
Összes halálozás
76%
20 hóap
MUSTT
MADIT-II
80
59%
56%
Összes halálozás
Arrhythmia halálozás
Previous arrhythmic event
33%
Aborted cardiac death
VT with SHD
60
31%
28%
40
20%
20
5
3 év
6
7
3 év
3 év
0
AVID
CASH
CIDS