Osservazioni cliniche nei pazienti aritmie ed

insufficienza cardicaClinical Observations in the Arrhythmic

Heart Failure Patients

Mariell Jessup MDProfessor of Medicine

University of PennsylvaniaPhiladelphia, 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.

450,000

1 U.S. Census Bureau, Statistical Abstract of the United States: 2001.2 American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures 2001.3 2002 Heart and Stroke Statistical Update, American Heart Association.4 Circulation. 2001;104:2158-2163.

Magnitude of SCA in the US

Breast Cancer2

SCA 4

42,15640,600

157,400

167,366

AIDS1

Lung Cancer2

Stroke3 SCA claims more lives each year than these

other diseases combined

#1 Killer in the U.S.

Severity of Heart Failure and Modes of Death

MERIT-HF Study Group. LANCET 1999; 353:2001-2007

NYHA Class III

n = 103NYHA Class II

n = 103

NYHA Class IV

n = 27

64%

12%

24%

11%

56%

33%

59%

15%

26%

Bayés de Luna A. Am Heart J. 1989;117:151-159

Underlying Arrhythmias of Sudden Cardiac Arrest

Bradycardia17%

Monomorphic VT62% Primary VF

8%

Polymorphic VT 13%

ICD’s and survival in CHF

Buxton AE, at al. (MUST-T) NEJM 1999;341:1882-90 Bristow MR, et al. (COMPANION) NEJM 2004;350:2140-50Moss AJ, et al. ( MADIT-II) NEJM 2002;346:877-83 Kadish A, et al. (DEFINITE) NEJM 2004;350:2151-8

0 1 2 3 Year

Su

rviv

al

100 --

90 --

80 --

70 --

60 --

50 --

MADIT- II ICD

MUST-T ICD

COMPANION ICD

DEFINITE ICD

MADIT- II No ICD

MUST-T No ICD

COMPANION No ICD

DEFINITE No ICD

Exner, Klein. J Cardiovasc Electrophysiol 2003; 14:574

ICD Implant Procedures-UPENN

0

100

200

300

400

500

600

700

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

356 342395

541502 473

662

414 411 431

U.S. Heart Failure Device Market & Adoption

22%N/A534,000534,000SCD-HeFT1

31%396,000N/A396,000MIRACLE & COMPANION

20%N/A88,00088,000Genetics (HCM, LQTS, etc.)

412,000

N/A

16,000

CRT =>

CRT-D

~ 35%968,0001,380,000Total Indicated Patients

22%116,000116,000High Risk Post-MI (MADIT, MUSTT, MADIT II)1

82%230,000246,000Secondary Prevention (SCA/VF/VT)

EstimatedAdoption

ICD OnlyNet Prevalence *Indications

•Net Prevalence is indicated prevalence minus 15% economic exclusion and minus 20% clinical exclusion.

1. Class II & III, narrow QRS, excluding CRT indicated patients, not overlapping with SCA/VT/VF survivors2. Incremental, not overlapping with SCD-HeFT population (i.e. MI, LVEF ? 30% and no HF)

MADIT-IIGreenberg et al. JACC 2004;43:1459

Hohnlosser et al. NEJM 2004; 351:2481Post MI

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.

All-cause mortality at 36 months by treatment group and risk-stratification criteria in IRIS

The IRIS trial

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 UGLYinfection

ICDs: the UGLYinfection

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

Das et al. Cardiol Clin 2008; 26:459-479

Classification of Ventricular Arrhythmias

Zipes et a. Circulation 2006; 114:e385-484

0 20 40 60 80 100 120 140 160 180 200 220

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

VT Ablations (UPENN) 1999 -2008 ( N = 1176 ablation procedures)

YEAR

Number of VT Ablations

221

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

Post MI patients referred for VT ablation

Marchlinski et al Circulation 2008

0102030405060708090100

Number with ICD "VT Storm" orIncessant

VT/Daily VT

Frequent but notdaily episodes or

shocks

<5 shocks orepisodes/month

Clinical presentation in 100 consecutive patients referred for VT ablation (Sick Patients – Unstable)

93%

68%

18% 14%

%

704047

176116

47

279

0

50

100

150

200

250

300

VT CAD VTRVCM*

VTLVCM

RVOT LVOT Idio LVVT

Other

UPENN VT Ablations (N= 775) 1999- 2006

Tet, Sarcoid, Non OT VT, etc

512 (66%)

263 (34%)

Recurrence vs. clinical benefit

Segal OR: Heart Rhythm 2005

0.03 0.46

Circulation Arrhyth Electrophysiol 2008; 1:153-161

Circulation 2007; 116:1998

*Low bipolar voltage surrounding the valves*Low voltage abnormalities extending toward more apical segments of the RV or LV.

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 stormin patients with ICDs implanted earlier

AVID

MADIT II

Huang and Traub Prog Cardiov Dis 2008; 51(3): 229-236

Eur Heart J 2006; 27: 3027

Electrolyte imbalanceIschemiaHeart failure exacerbationMedication non-compliance

identified cause in 13% !!!

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 CenterUniversity of Pennsylvania Medical Center