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Arrhythmia and Devices in HF

Arrhythmia and Devices in HF. Dr Amirhossein Azhari E lectrophysiologist. Premature Ventricular Contractions (PVCs). Irritable focus causes ventricles to depolarize before the SA node fires Premature beat that has a wide QRS

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Arrhythmia and Devices in HF

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  1. Arrhythmia and Devices in HF DrAmirhosseinAzhari Electrophysiologist

  2. Premature Ventricular Contractions (PVCs) • Irritable focus causes ventricles to depolarize before the SA node fires • Premature beat that has a wide QRS • QRS and T wave of a PVC usually point in opposite direction from one another • “Bad PVCs” – more than 6/minute, coupled, multifocal, and on or near the T wave of the previous sinus beat • Suppressed by lidocaine.

  3. Coupled PVCs

  4. Multifocal PVCs

  5. R-on-T Phenomenon: May cause a run of PVCs or Vfib

  6. Vtach: 3 or more PVCs in a row • Wide QRS with a regular pattern and a rate of 150-200 • Patient will usually lose consciousness • Treated with lidocaine; may help to have patient cough if they are still conscious • May require DC shock

  7. Vtach

  8. Vtach Remember, 3 or more PVCs in a row is a run of Vtach

  9. Vfib • Many ectopic foci firing at the same time • There is no regular pattern as in Vtach • No effective cardiac output! • Requires CPR and DC shock, ie, Defibrillation

  10. Vfib This is “coarse” vfib

  11. Vfib This is “fine” vfib

  12. Epidemiology of VA & SCD Classification of Ventricular Arrhythmia by Clinical Presentation • Hemodynamically stable • ♥Asymptomatic • ♥Minimal symptoms, e.g., palpitations • Hemodynamically unstable • ♥ Presyncope • ♥ Syncope • ♥ Sudden cardiac death • ♥ Sudden cardiac arrest

  13. Epidemiology of VA & SCD Classification of Ventricular Arrhythmia by Electrocardiography • Nonsustained ventricular tachycardia (VT) • ♥Monomorphic • ♥Polymorphic • Sustained VT • ♥Monomorphic • ♥Polymorphic • Bundle-branch re-entrant tachycardia • Bidirectional VT • Torsades de pointes • Ventricular flutter • Ventricular fibrillation

  14. Nonsustained Monomorphic VT

  15. Nonsustained LV VT

  16. Sustained Monomorphic VT 72-year-old woman with CHD

  17. Nonsustained Polymorphic VT

  18. Sustained Polymorphic VTExercise induced in patient with no structural heart disease

  19. Bundle Branch Reentrant VT

  20. Ventricular Flutter Spontaneous conversion to NSR (12-lead ECG)

  21. VF with Defibrillation (12-lead ECG)

  22. Wide QRS Irregular Tachycardia:Atrial Fibrillation with antidromic conduction in patient with accessory pathway – Not VT

  23. Epidemiology of VA & SCD Classification of Ventricular Arrhythmia by Disease Entity • Chronic coronary heart disease • Heart failure • Congenital heart disease • Neurological disorders • Structurally normal hearts • Sudden infant death syndrome • Cardiomyopathies • ♥Dilated cardiomyopathy • ♥Hypertrophic cardiomyopathy • ♥Arrhythmogenic right ventricular (RV) • cardiomyopathy

  24. Epidemiology of VA & SCD Incidence of Sudden Cardiac Death Reused with permission from Myerburg RJ, Kessler KM, Castellanos A. Circulation 1992;85:12-10.

  25. Mechanisms and Substrates Mechanisms of Sudden Cardiac Death in 157 Ambulatory Patients • Ventricular fibrillation - 62.4% • Bradyarrhythmias (including advanced AV block and asystole) - 16.5% • Torsades de pointes - 12.7% • Primary VT - 8.3% Bayes de Luna et al. Am Heart J 1989;117:151–9.

  26. Clinical Presentations of Patients with VA & SCD • Asymptomatic individuals with or without electrocardiographic • abnormalities • Persons with symptoms potentially attributable to ventricular • arrhythmias • ♥Palpitations • ♥Dyspnea • ♥Chest pain • ♥Syncope and presyncope • VT that is hemodynamically stable • VT that is not hemodynamically stable • Cardiac arrest • ♥Asystolic (sinus arrest, atrioventricular block) • ♥VT • ♥Ventricular fibrillation (VF) • ♥Pulseless electrical activity

  27. Therapy • Acute • Hemodynamically Stable • Hemodynamically UnStable

  28. Therapies for VA • Antiarrhythmic Drugs • ♥Beta Blockers: Effectively suppress ventricular ectopic beats & arrhythmias; reduce incidence of SCD • ♥Amiodarone: No definite survival benefit; some studies have shown reduction in SCD in patients with LV dysfunction especially when given in conjunction with BB. Has complex drug interactions and many adverse side effects (pulmonary, hepatic, thyroid, cutaneous) • ♥Sotalol: Suppresses ventricular arrhythmias; is more pro-arrhythmic than amiodarone, no survival benefit clearly shown • ♥Conclusions: Antiarrhythmic drugs (except for BB) should not be used as primary therapy of VA and the prevention of SCD

  29. Therapies for VA • Non-antiarrhythmic Drugs • ♥ Electrolytes: magnesium and potassium administration can favorably influence the electrical substrate involved in VA; are especially useful in setting of hypomagnesemia and hypokalemia • ♥ ACE inhibitors, angiotensin receptor blockers and aldosterone blockers can improve the myocardial substrate through reverse remodeling and thus reduce incidence of SCD • ♥ Antithrombotic and antiplatelet agents: may reduce SCD by reducing coronary thrombosis • ♥ Statins: have been shown to reduce life-threatening VA in high-risk patients with electrical instability • ♥ n-3 Fatty acids: have anti-arrhythmic properties, but • conflicting data exist for the prevention of SCD

  30. Hazard ratio Trial Name, Pub Year LVEF, other features N = 196 MADIT-I 0.35 or less, NSVT, EP positive 1996 0.46 AVID N = 1016 Aborted cardiac arrest 1997 0.62 N = 900 0.35 or less, abnormal SAECG and scheduled for CABG CABG-Patch 1.07 1997 N = 191 CASH* Aborted cardiac arrest 2000 0.83 Aborted cardiac arrest or syncope CIDS N = 659 2000 0.82 0.30 or less, prior MI MADIT-II N = 1232 2002 0.35 or less, NICM and PVCs or NSVT 0.69 DEFINITE N = 458 0.35 or less, MI within 6 to 40 days and impaired cardiac autonomic function 2004 0.65 N = 674 DINAMIT 2004 1.08 0.35 or less, LVD due to prior MI and NICM N = 1676 SCD-HeFT 2005 0.77 1.8 1.0 1.2 0.6 0.4 0.8 1.4 1.6 ICDbetter Therapies for VA ICDs: Results from Primary and Secondary Prevention Trials

  31. Therapies for VA • Primary Prevention of SCD (1) • Recommendations in previously published guidelines for prophylactic • ICD therapy based on LVEF are inconsistent: ♥ Different LVEFs were chosen for inclusion in trials ♥ Average EF in such trials was substantially lower than the cutoff value for enrollment ♥ Subgroup analyses in various trials have not been consistent in their implications ♥ No trials contained randomized patients with intermediate LVEF

  32. Therapies for VA • Primary Prevention of SCD (2) • Because of these inconsistencies, the recommendations in this • guideline were constructed to apply to patients with an EF ≤ to a • range of values • The next several slides compare the recommendations of • previously published guidelines with those in this one and the • reasoning behind the writing committee’s decision

  33. Therapies for VA • Primary Prevention of SCD (3) • LV dysfunction due to MI, LVEF ≤ 30%, NYHA class II, III • 2005 ACC/AHA HF: Class I; LOE B • 2005 ESC HF: Class I; LOE A • 2004 ACC/AHA STEMI: Class IIa; LOE B • 2002 ACC/AHA/NASPE PM/ICD: Class IIa; LOE B • 2006 ACC/AHA/ESC VA/SCD: Class I; LOE A • Note: The VA/SCD Guideline has combined all trials that enrolled patients with LV dysfunction due to MI into one recommendation

  34. Therapies for VA • Primary Prevention of SCD (4) • LV dysfunction due to MI, LVEF 30-35%, NYHA class II, III • 2005 ACC/AHA HF: Class IIa; LOE B • 2005 ESC HF: Class I; LOE A • 2004 ACC/AHA STEMI: N/A • 2002 ACC/AHA/NASPE PM/ICD: N/A • 2006 ACC/AHA/ESC VA/SCD: Class I; LOE A • Note: The VA/SCD Guideline has combined all trials that enrolled patients with LV dysfunction due to MI into one recommendation

  35. Therapies for VA • Primary Prevention of SCD (5) • LV dysfunction due to MI, LVEF 30-40%, NSVT, positive EP study • 2005 ACC/AHA HF: N/A • 2005 ESC HF: N/A • 2004 ACC/AHA STEMI: Class I; LOE B • 2002 ACC/AHA/NASPE PM/ICD: Class IIb; LOE B • 2006 ACC/AHA/ESC VA/SCD: Class I; LOE A • Note: The VA/SCD Guideline has combined all trials that enrolled patients with LV dysfunction due to MI into one recommendation

  36. Therapies for VA • Primary Prevention of SCD (6) • LV dysfunction due to MI, LVEF ≤ 30%, NYHA class I • 2005 ACC/AHA HF: Class IIa; LOE B • 2005 ESC HF: N/A • 2004 ACC/AHA STEMI: N/A • 2002 ACC/AHA/NASPE PM/ICD: N/A • 2006 ACC/AHA/ESC VA/SCD: Class IIa; LOE B • Note: The VA/SCD Guideline has expanded the range of LVEF ≤ 30-35% for patients with LVD due to MI and NYHA class I into one recommendation

  37. Therapies for VA • Primary Prevention of SCD (7) • LV dysfunction due to MI, LVEF ≤ 31-35%, NYHA class I • 2005 ACC/AHA HF: N/A • 2005 ESC HF: N/A • 2004 ACC/AHA STEMI: N/A • 2002 ACC/AHA/NASPE PM/ICD: N/A • 2006 ACC/AHA/ESC VA/SCD: Class IIa; LOE B • Note: The VA/SCD Guideline has expanded the range of LVEF ≤ 30-35% for patients with LVD due to MI and NYHA class I into one recommendation

  38. Therapies for VA • Primary Prevention of SCD (8) • Nonischemic cardiomyopathy, LVEF ≤ 30%, NYHA class II, III • 2005 ACC/AHA HF: Class I; LOE B • 2005 ESC HF: Class I; LOE A • 2004 ACC/AHA STEMI: N/A • 2002 ACC/AHA/NASPE PM/ICD:N/A • 2006 ACC/AHA/ESC VA/SCD: Class I; LOE B • Note: The VA/SCD Guideline has combined all trials of nonischemic cardiomyopathy, NYHA class II, III into one recommendation

  39. Therapies for VA • Primary Prevention of SCD (9) • Nonischemic cardiomyopathy, LVEF 30-35%, NYHA class II, III • 2005 ACC/AHA HF: Class IIa; LOE B • 2005 ESC HF: Class I; LOE A • 2004 ACC/AHA STEMI: N/A • 2002 ACC/AHA/NASPE PM/ICD:N/A • 2006 ACC/AHA/ESC VA/SCD: Class I; LOE B • Note: The VA/SCD Guideline has combined all trials of nonischemic cardiomyopathy, NYHA class II, III into one recommendation

  40. Therapies for VA • Primary Prevention of SCD (10) • Nonischemic cardiomyopathy, LVEF ≤ 30%, NYHA class I • 2005 ACC/AHA HF: Class IIb; LOE C • 2005 ESC HF: N/A • 2004 ACC/AHA STEMI: N/A • 2002 ACC/AHA/NASPE PM/ICD:N/A • 2006 ACC/AHA/ESC VA/SCD: Class IIb; LOE B • Note: The VA/SCD Guideline has expanded the range of LVEF to ≤ 30-35% for patients with nonischemic cardiomyopathy and NYHA class I into one recommendation

  41. Therapies for VA • Primary Prevention of SCD (11) • Nonischemic cardiomyopathy, LVEF ≤ 31-35%, NYHA class I • 2005 ACC/AHA HF: N/A • 2005 ESC HF: N/A • 2004 ACC/AHA STEMI: N/A • 2002 ACC/AHA/NASPE PM/ICD: N/A • 2006 ACC/AHA/ESC VA/SCD: Class IIb; LOE B • Note: The VA/SCD Guideline has expanded the range of LVEF to ≤ 30-35% for patients with nonischemic cardiomyopathy and NYHA class I into one recommendation

  42. ICD Leads – Single versus Dual coil

  43. ICD History The original AID device had two electrodes, one a spring was placed in the Vena Cava, the other a cup designed to conform to the cardiac apex 1980

  44. 209 cc 80 cc 113 cc 80 cc 72 cc 54 cc 39.5 cc 36 cc 62 cc 49 cc 39.5 cc 39.5 cc 39 cc 39 cc Medtronic Implantable Defibrillators (1989-2001)

  45. Detection VF Detection ! VF Therapy !! F F F F F F F F F F

  46. Fib Zone 1 2 3 4 5 6 7 8 9 10 11 12 Initiate Therapy Detect Analyse Charge Detection

  47. 310 340 300 290 330 320 300 310 Rate Branch Calculation - Example VT Detection: 8 intervals < 350 ms VT Detect 290 300 300 330 340 320 310 310 Median Ventricular Cycle Length = (310 + 310) / 2 = 310 ms

  48. ICD Therapies - ATP

  49. ATP Definition • ATP = Antitachycardia Pacing • ATP = Therapeutic intervention using standard bradycardia pacing algorithms and energy levels in an effort to bring the heart out of a reentrant tachycardia and restore its normal rhythm

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