Arrhythmia and Devices in HF - PowerPoint Presentation

Slide1

Arrhythmia and Devices in HF

Dr

Amirhossein

Azhari

E

lectrophysiologist

Slide2

Premature Ventricular Contractions (PVCs)

Irritable focus causes ventricles to depolarize before the SA node firesPremature beat that has a wide QRSQRS 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 beatSuppressed by lidocaine.

Slide3

Coupled PVCs

Slide4

Multifocal PVCs

Slide5

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

Slide6

Vtach: 3 or more PVCs in a row

Wide QRS with a regular pattern and a rate of 150-200Patient will usually lose consciousnessTreated with lidocaine; may help to have patient cough if they are still consciousMay require DC shock

Slide7

Vtach

Slide8

Vtach

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

Slide9

Vfib

Many ectopic foci firing at the same timeThere is no regular pattern as in VtachNo effective cardiac output!Requires CPR and DC shock, ie, Defibrillation

Slide10

Vfib

This is “coarse” vfib

Slide11

Vfib

This is “fine” vfib

Slide12

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

Slide13

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

Slide14

Nonsustained Monomorphic VT

Slide15

Nonsustained LV VT

Slide16

Sustained Monomorphic VT

72-year-old woman with CHD

Slide17

Nonsustained Polymorphic VT

Slide18

Sustained Polymorphic VTExercise induced in patient with no structural heart disease

Slide19

Bundle Branch Reentrant VT

Slide20

Ventricular Flutter

Spontaneous conversion to NSR (12-lead ECG)

Slide21

VF with Defibrillation (12-lead ECG)

Slide22

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

Slide23

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

Slide24

Reused with permission from Myerburg RJ, Kessler KM, Castellanos A. Circulation 1992;85:12-10.

Epidemiology of VA & SCD

Incidence of Sudden Cardiac Death

Slide25

Ventricular fibrillation - 62.4%

Bradyarrhythmias (including advanced AV block and asystole) - 16.5%Torsades de pointes - 12.7%Primary VT - 8.3%

Mechanisms of Sudden Cardiac Deathin 157 Ambulatory Patients

Mechanisms and Substrates

Bayes de Luna et al. Am Heart J 1989;117:151–9.

Slide26

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

Slide27

Therapy

Acute

Hemodynamically Stable

Hemodynamically

Un

Stable

Slide28

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

Therapies for VA

Slide29

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

Therapies for VA

Slide30

0.6

0.8

1.0

1.2

1.4

MADIT-I

AVID

1.6

0.4

CABG-Patch

MADIT-II

1996

1997

1997

2002

Aborted cardiac arrest

N = 196

N = 1016

N = 900

N = 1232

0.46

0.62

1.07

0.69

Hazard ratio

ICD

better

SCD-HeFT

N = 1676

2005

0.77

1.8

LVEF, other features

0.35 or less, NSVT, EP positive

0.30 or less, prior MI

0.35 or less, LVD due to prior MI and NICM

0.35 or less, abnormal SAECG and scheduled for CABG

CASH*

2000

N = 191

Aborted cardiac arrest

DEFINITE

2004

N = 458

0.65

0.35 or less, NICM and PVCs or NSVT

CIDS

2000

N = 659

0.82

Aborted cardiac arrest or syncope

DINAMIT

2004

N = 674

1.08

0.35 or less, MI within 6 to 40 days and impaired cardiac autonomic function

Trial Name, Pub Year

0.83

Therapies for VA

ICDs: Results from Primary and Secondary Prevention Trials

Slide31

Primary Prevention of SCD (1)Recommendations in previously published guidelines for prophylacticICD 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

Therapies for VA

Slide32

Primary Prevention of SCD (2)Because of these inconsistencies, the recommendations in thisguideline were constructed to apply to patients with an EF ≤ to arange of valuesThe next several slides compare the recommendations of previously published guidelines with those in this one and thereasoning behind the writing committee’s decision

Therapies for VA

Slide33

Primary Prevention of SCD (3)LV dysfunction due to MI, LVEF ≤ 30%, NYHA class II, III2005 ACC/AHA HF: Class I; LOE B2005 ESC HF: Class I; LOE A2004 ACC/AHA STEMI: Class IIa; LOE B2002 ACC/AHA/NASPE PM/ICD: Class IIa; LOE B2006 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

Therapies for VA

Slide34

Primary Prevention of SCD (4)LV dysfunction due to MI, LVEF 30-35%, NYHA class II, III2005 ACC/AHA HF: Class IIa; LOE B2005 ESC HF: Class I; LOE A2004 ACC/AHA STEMI: N/A2002 ACC/AHA/NASPE PM/ICD: N/A2006 ACC/AHA/ESC VA/SCD: Class I; LOE ANote: The VA/SCD Guideline has combined all trials that enrolled patients with LV dysfunction due to MI into one recommendation

Therapies for VA

Slide35

Primary Prevention of SCD (5)LV dysfunction due to MI, LVEF 30-40%, NSVT, positive EP study2005 ACC/AHA HF: N/A 2005 ESC HF: N/A2004 ACC/AHA STEMI: Class I; LOE B2002 ACC/AHA/NASPE PM/ICD: Class IIb; LOE B2006 ACC/AHA/ESC VA/SCD: Class I; LOE ANote: The VA/SCD Guideline has combined all trials that enrolled patients with LV dysfunction due to MI into one recommendation

Therapies for VA

Slide36

Primary Prevention of SCD (6) LV dysfunction due to MI, LVEF ≤ 30%, NYHA class I2005 ACC/AHA HF: Class IIa; LOE B2005 ESC HF: N/A2004 ACC/AHA STEMI: N/A2002 ACC/AHA/NASPE PM/ICD: N/A2006 ACC/AHA/ESC VA/SCD: Class IIa; LOE BNote: 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

Therapies for VA

Slide37

Primary Prevention of SCD (7)LV dysfunction due to MI, LVEF ≤ 31-35%, NYHA class I2005 ACC/AHA HF: N/A2005 ESC HF: N/A2004 ACC/AHA STEMI: N/A2002 ACC/AHA/NASPE PM/ICD: N/A2006 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

Therapies for VA

Slide38

Primary Prevention of SCD (8)Nonischemic cardiomyopathy, LVEF ≤ 30%, NYHA class II, III2005 ACC/AHA HF: Class I; LOE B2005 ESC HF: Class I; LOE A2004 ACC/AHA STEMI: N/A2002 ACC/AHA/NASPE PM/ICD:N/A2006 ACC/AHA/ESC VA/SCD: Class I; LOE BNote: The VA/SCD Guideline has combined all trials of nonischemic cardiomyopathy, NYHA class II, III into one recommendation

Therapies for VA

Slide39

Primary Prevention of SCD (9) Nonischemic cardiomyopathy, LVEF 30-35%, NYHA class II, III2005 ACC/AHA HF: Class IIa; LOE B2005 ESC HF: Class I; LOE A2004 ACC/AHA STEMI: N/A2002 ACC/AHA/NASPE PM/ICD:N/A2006 ACC/AHA/ESC VA/SCD: Class I; LOE BNote: The VA/SCD Guideline has combined all trials of nonischemic cardiomyopathy, NYHA class II, III into one recommendation

Therapies for VA

Slide40

Primary Prevention of SCD (10) Nonischemic cardiomyopathy, LVEF ≤ 30%, NYHA class I2005 ACC/AHA HF: Class IIb; LOE C2005 ESC HF: N/A2004 ACC/AHA STEMI: N/A2002 ACC/AHA/NASPE PM/ICD:N/A2006 ACC/AHA/ESC VA/SCD: Class IIb; LOE BNote: 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

Therapies for VA

Slide41

Primary Prevention of SCD (11)Nonischemic cardiomyopathy, LVEF ≤ 31-35%, NYHA class I2005 ACC/AHA HF: N/A2005 ESC HF: N/A2004 ACC/AHA STEMI: N/A2002 ACC/AHA/NASPE PM/ICD: N/A2006 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

Therapies for VA

Slide42

Slide43

ICD Leads – Single versus Dual coil

Slide44

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

ICD History

Slide45

Medtronic Implantable Defibrillators (1989-2001)

209 cc

113 cc

80 cc

80 cc

72 cc

54 cc

62 cc

49 cc

39.5 cc

39 cc

39.5 cc

39.5 cc

39 cc

36 cc

Slide46

F

F

Detection

F

F

F

F

F

F

F

F

VF Detection !

VF Therapy !!

Slide47

Fib Zone

Detection

Detect

Initiate Therapy

Charge

Analyse

1

2

3

4

5

6

7

8

9

10

11

12

Slide48

VT Detection: 8 intervals < 350 ms

Rate Branch Calculation - Example

340

300

290

330

320

300

310

310

340

300

290

330

320

300

Median Ventricular Cycle Length

= (310 + 310) / 2

= 310 ms

310

310

VT Detect

Slide49

ICD Therapies - ATP

Slide50

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

Slide51

VT based on reentry

Slide52

VT

1 sec

Slide53

Proparly Timed Electrical Stimulation

Slide54

ATP

Slide55

ATP

arrhythmia

ATP

Sinus rhythm

1 sec

Slide56

Slide57

Slide58

ICD and CRT guidelines2013primary prevention

Slide59

Slide60

Slide61

Slide62

Slide63

Slide64

Slide65

Slide66

Slide67

Electromagnetic Interference andImplantable Devices

Slide68

It is important to know not only what

sources of

interference are of potential concern, but also

how external

interference actually affects pacemakers,

implantable

cardioverter-defi

brillators

(ICDs) and

cardiac resynchronization

therapy (CRT)

systems.

Slide69

Slide70

Electromagnetic

fields have both

an electric

field, measured in volts per meter (V/m),

and a

magnetic field. The magnetic flux density is

measured in

milliteslas

(

mT

).

Slide71

Slide72

Pacemaker

and ICD Responses

to

Electromagnetic

Interference

Slide73

The

most frequent responses

:

Inappropriate inhibition

triggering

of pacemaker

stimuli

reversion to

asynchronous

pacing

ICD tachyarrhythmia detection

.

much less frequent:

Reprogramming

of

operating parameters

Permanent

damage to the device

circuitry

E

lectrode-tissue interface

Slide74

Sources

of

Electromagnetic

Interference

in Daily Life

Slide75

Cellular Telephones and Other WirelessCommunication Devices

Although isolated case reports have suggested

the potential

for severe

interactions,

most research

indicates that

deleterious interactions are unlikely

to happen

with normal cellphone

use.

There

was no clinically significant EMI

episodes when

the telephone was placed in the normal

position over

the ear

.

.

Slide76

Maintaining an activated cellphone at

least 6

inches (15 cm) from the device prevents

interactions.

The

FDA has issued simple recommendations to

minimize the risks:

Patients

should avoid carrying their

activated cellphone

in a breast or shirt pocket overlying

an implanted

device

.

A wireless telephone in use

should be

held to the ear opposite the side where the

device is

implanted.

Slide77

Gates

No spurious

detections occurred during a 10- to

15-second walk

through the

gates. All

of the patients with

serious interactions

had an abdominal implant; however,

by multivariate

analysis, diminished R-wave amplitude

and a

Ventritex

ICD were the only predictors of

interactions.

Slide78

Metal Detectors

Handheld

metal detectors

typically operate at a frequency of 10

to 100 kHz.

one

report of a spurious

ICD shock

triggered by a handheld metal detector in

an airport.

Guidant

ICDs

reverted to

“monitor-only” mode after being exposed to

metal detectors.

Slide79

Current

FDA recommendations state that it is safe for patients with implanted cardiac devices to walk through a metal detector gate, although the alarm may be triggered by the generator case

.

If scanning with a handheld metal detector is needed, patients should ask the security personnel not to hold the detector close to the implanted device longer than is absolutely necessary.

A manual personal search can also be requested

Slide80

Direct Current Cardioversionand Defibrillation

The

risk of damage to the implanted device

depends:

on the amount of energy

applied

the

characteristics of

the device and lead,

and

the distance between

the paddles

or pads and the pulse generator and leads

Slide81

Slide82

Operation with

electrocutering

surgery

Slide83

Slide84

Incidence of

complications was low (0.8 cases per

100 years

of surgical practice).

Slide85

THE END

Slide86

Thanks for your

attention