ventricular tachycardia€¦ · ventricular tachycardia alexander mazur, md professor, university...
TRANSCRIPT
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Ventricular Tachycardia
Alexander Mazur, MD
Professor, University of Iowa Carver College of Medicine
No Disclosures
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Learning Objectives
• Recognize different types of VT
• Understand mechanisms of different types of VT
• Distinguish between VT in patients with and without structural heart disease
• Understand therapeutic approaches to VT in patients with and without structural heart disease
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Ventricular ArrhythmiaPVCs
Non-sustained VT: ≥ 3 beats < 30 sec Sustained VT: ≥ 30 sec or syncope or hemodynamic compromise
VF
Structurally Normal Heart Structural Heart Disease
Idiopathic Channelopathies
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Ventricular Tachycardia
• Monomorphic: Uniform beat-to-beat QRS morphology
• Pleomorphic: > one distinct QRS morphology during same VT episode
• Polymorphic: Variable beat-to-beat QRS morphology and axis
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Electrophysiological Mechanisms
• Reentry
• Triggered activity (EADs and DADs)
• Abnormal automaticity
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“Idiopathic” Ventricular Arrhythmia
Tanawuttwwat et al. Eur Heart J 2016
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Outflow Tract VT
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
+
+
+
-
- -
III
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VT in Structural Heart DiseaseDid you mean: dilated cardiomyopathy arrhythmia substrate
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dilated cardiomyopathy arrhythmia
Post Myocardial Infarction Scar Myocardial Fibrosis in Dilated Cardiomyopathy
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Monomorphic VT
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Atrial TachycardiaAtrial FlutterAVNRTAVRT (orthodromic)
Atrial TachycardiaAtrial FlutterAVNRTAVRT (antidromic)
Wellens HJJ, Heart 2001
SVT Aberrant Conduction
SVT Accessory Pathway (WPW)
VT
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ECG Criteria Supporting VT
Alzand BSN and Crijns HJGM, Europace 2011
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Bundle Branch Reentrant VTAlexander Mazur, Jairo Kusniec Boris Strasberg, “Bundle Branch Reentrant 90
Ventricular Tachycardia”
further validation. Application of the pacing maneuvers during bundle branch reentry is often
hampered by fast VT rates commonly associated with hemodynamic compromise. Furthermore,
entrainment of BBR VT by atrial pacing has a limited success and usually requires isoproterenol
infusion to improve atrio-ventricular (AV) nodal conduction.
Figure 2. Twelve-lead ECG during a spontaneous episode of bundle branch reentrant
tachycardia (A). Surface ECG leads I, II, III, V1, V2, V6 (B) or II, III, V1 (C) and intracardiac
recordings from the His bundle (His) and right ventricular apex (RVA) during bundle branch
reentrant tachycardia induced in the same patient. The recordings show many characteristic
diagnostic features of bundle branch reentrant tachycardia: (1) typical LBBB morphology and
left superior axis (A); (2) AV dissociation (C); (3) H preceding every V with the HV interval
(112 ms) greater than that recorded during sinus rhythm (68 ms) (B and C); (5) H precedes the
right bundle deflection. This sequence is consistent with ventricular activation through the right
bundle branch and is appropriate for a LBBB morphology of tachycardia (B); (6) spontaneous
changes in the HH intervals preceded similar changes in the VV intervals (C); and (7)
spontaneous termination of tachycardia with retrograde conduction block to H (C). A, H, RB,
and V denote atrial, His bundle, right bundle, and ventricular electrograms, respectively. (From:
Mazur A, Iakobishvili Z, Kusniec J, Strasberg B. Bundle branch reentrant ventricular
tachycardia in a patient with the Brugada electrocardiographic pattern. A.N.E. 2003;8:252-255,
with permission of Blackwell Futura Publishing, Inc.)
Interfascicular tachycardia
Interfascicular tachycardia has been less commonly reported9,19,28,32-34. BBR and interfascicular
tachycardia may be present in the same patient9,19,33,34. The tachycardia usually has RBBB
morphology. The orientation of the frontal plain axis is variable and may depend on the
Indian Pacing and Electrophysiology Journal (ISSN 0972-6292), 5(2): 86-95 (2005)
His
Left Bundle
Right Bundle
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Fascicular VTLAF
LPF
Left Bundle
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Short-Coupled Variant of Torsades de Pointes
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Heart Rhythm Case Reports 2019;5:363-366
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Circulation 2019;139:2315-2325
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Torsades de Pointes
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Bidirectional VT
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Sudden Death Prophylaxis • Sustained VT in patients with cardiomyopathies:
• Is associated with a high risk of SD
• Usually an indication for an ICD - the only proven modality (versus antiarrhythmics and catheter ablation) that prolongs survival in these patients
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Antiarrhythmic Drugs
• Adjunctive to ICD - to minimize painful ICD shocks
• Limited efficacy
• Increased risk of pro-arrhythmia
• High rate of discontinuation because of intolerance and side effects
• Class I - contraindicated (negative inotropic properties and possible risk of pro-arrhythmia)
• Class III: Amiodarone, Sotalol, Dofetilide (?)
• Others: Mexiletine (Class IIB), Ranolazine (Late sodium current blocker)
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Antiarrhythmic Drugs for Prevention of Ventricular Arrhythmia in Patients with ICD
VT Recurrence All-Cause Mortality
Santangeli et al. Heart Rhythm 2016;13:1552-1559
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Catheter Ablation
2019 HRS/EHRA/APHRS/LAHRS Expert Consensus statement on Catheter Ablation of Ventricular Arrhythmias
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• 259 ICD patients with recurrent VT despite AADs
• Randomized to escalated-AADs vs ablation
• Escalated AADs: • Amiodarone (if amiodarone-naive)
• On amiodarone - ↑ > 300 mg/day or + mexiletine
• Primary endpoint: a composite of death or appropriate ICD shocks for VT/VF
• F-U 27.9 ± 17.1 months
• Primary outcomes: 68.5% AADs vs 59.1% ablation
• VT recurrence: 33.1% AADs vs 24.1% ablation
N Engl J Med 2016;375:111-121
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Use of Amiodarone at baseline No use of Amiodarone at baseline
N Engl J Med 2016;375:111-121
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2019 HRS/EHRA/APHRS/LAHRS Expert Consensus statement on Catheter Ablation of Ventricular Arrhythmias
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2017 AHA/ACC/HRS Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Death
Most Common Mechanism of Monomorphic VT in Patients with Ischemic Cardiomyopathy is Scar-
Related Reentry
2019 HRS/EHRA/APHRS/LAHRS Expert Consensus statement on Catheter Ablation of Ventricular Arrhythmias
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2017 AHA/ACC/HRS Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Death
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Take Away Points
• Idiopathic VTs are usually benign
• The most common mechanism of monomorphic VT in patients with structural heart disease is scar-related reentry
• Sustained VT in patients with cardiomyopathies is associated with high risk of sudden death. ICD is the only proven modality for prevention of sudden death in these patients.
• The role of antiarrhythmic medications and ablation in patients with an ICD is prevention of recurrent ICD shocks. There is no proven mortality benefit.
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Thank You and Stay Safe!