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VT session
CASE 1
M/55, chest discomfort
• 10년전 chronic hepatitis C
• Chest discomfort and palpitation -1시간 지속되 응급실 내원
• IV adenosine -> verapamil
– No response
• DC cardioversion of 100 J
2010.05.15
EPS & RFCA: VT induction
fluoroscopy
VT ablation
RVOT VT • Idiopathic VT중 most common
• Induction – Exercise-induced VT
– Isoproterenol(catecholamine)
– Rapid or premature stimulation
• Mechanism – cAMP mediated triggered activity
– 보통 RVOT 주위가 그 아래의 septum에서 기원
• Clinical presentation – 젊은 환자, palpitation, syncope, fatigue
• ECG: LBBB with inferior axis(II, III, aVF에서 +)
• Tx – Vagal maneuver, adenosine, BB, verapamil로 termination
– RFCA
• DDx – ARVD(Arrhythmogenic RV dysplasia); cardiac MRI, RV biopsy
Case 2
M/24, palpitation for 2 hrs
During catheter ablation
P-Potential
ds
I
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I
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During NSR During VT
Nogami A et al. J Am Coll Cardiol. 2000;36:811–23
DP = diastolic potential
PP = presystolic Purkinje potential
Fascicular VT • The First description (Zipes et al in 1979), following triad
– Induction with atrial pacing
– RBBB with LAD (RAD is possible, Ohe et al 1988)
– Without structural heart disease
• Verapamil sensitive VT (Belhassen et al 1981)
= Idiopathic LV tachycardia
• Clinical features – 15~40 yrs (mostly male, and earlier in female)
– Syncope and SCD are very rare
– Incessant case leading to tachycardia-induced cardiomyopathy
Case 3
M/18, SCD survivor(2004.8)
2 episodes of VF – ICD implantation(2006.11)
Seizure-like events
2008. 5. 11, Multiple ICD shocks
Q. 치료 약제로 가장 적절한것은?
1. Esmolol
2. Lidocaine
3. Amiodarone
4. Sotalol
5. Quinidine
Tikkanen JT et al. N Engl J Med 2009;361:2529-37
GB Nam et al. Eur Heart J. 2010;31:330-9.
2008. 12. 22, During Quinidine po
Quinidine (-)→ 2009. 1. 16, Electrical storm
Haissaguerre M el al. J Am Coll Cardiol 2009;53:612–9
GB Nam et al. Eur Heart J. 2010;31:330-9.
Case 4
Syncope. Female/77
• Syncope after palpitation
• Treadmil test; good exercise capacity (10.5Mets)
• Echocardiogram; no structural heart disease
• Holter showed the Tachycardia-Bradycardia syndrome.
Syncope. Female/77 • She admitted for permanent PM implantation
• She collapsed and CPCR was done
• The Holter showed ….
Syncope. Female/77
Syncope. Female/77
Syncope. Female/77
Polymorphic ventricular tachycardia due to Acute coronary ischemia
• Polymorphic VT with a normal QT; ACS/cardiomyopathy or HF/idiopathic VT or, CPVT
• Lethal VAs in the setting of CAD results either from ACS or from scar
• Within seconds of ACS, there is rise in intracellular Ca2+ and extracellular potassium level, As triggering response for Ca2+ and Raised extracellular K+ results shortening in of repolarization leading to slow conduction and ultimately to inexcitability.
• Other abnormalities; Alteration of distribution of connexin 43, the production of free fatty acids and oxygen free radicals, acidosis, and an increased catecholamine level
• Intravenous lidocaine and beta blockers and myocardial re-vascularization
Case 5
M/55, cardiac arrest no previous medical history
intermittent resting chest pain, early morning chest pain and sweating -> patient collapsed.
DC cardioversion with AED due to VF (119)
male/55, cardiac arrest
ECG at ER
ECG-normal sinus rhythm/Echocardiogram-concentric LVH/Holter monitoring
Ergonovine CAG was done
male/55, cardiac arrest
isosorbide dinitrate 40mg bid
diltiazam hcl 90mg bid
nifedipine 30mg qd
olmesartan 20mg qd
male/55, cardiac arrest VF due to variant angina
3 months later.... cardiac arrest #2 re-admission due to second cardiac arrest
male/55, cardiac arrest #2
male/55, cardiac arrest #2
• What is the next steps?
1. Observation
2. Change the medication. If yes, What?
3. EPS
4. ICD
Case 6
F/15, dyspnea
Q. 진단은?
1. ST-elevation MI
2. Subendocardial MI
3. WPW syndrome
4. Acute pericarditis
5. Acute myocarditis
TTE: Severe LV dysfunction
URI History 1 weeks ago
Acute Myocarditis
Arrhythmia in Myocarditis
• Conduction abnormalities ~ life threatening VA
• Acute management: largely supportive, but may be quite
aggressive depending on the presentation.
• Sympt. bradycardia/block: temporary pacing (I-LOE C)
• Antiarrhythmic drug (amiodarone) in symptomatic NSVT or
sustained VT during the acute phase (IIa-LOE C)
• ICD and/or BiV devices: not in acute phase, in chronic
cardiomyopathy, expectation of survival with a good
functional status for more than 1 y (IIa-LOE C)
• Chaga’s disease: Trypanosoma cruzi, epicardial ablation
ACC/AHA/ESC guideline 2006
Beta-blocker & AADs: no effect during acute pahse
HF management & ventilator care in CCU
4 days later → No symptom, EF normalized.
Case 7
M/30, PALPITATION
• 85년 TOF with ASD -> pentalogy로 수술
– Primary closure of the ASD
– Patch graft of the VSD
– Infundibulectomy
– Removal of the hypertrophied RV muscle
• Paroxysmal palpitation
– intermittent
• 11년 7월7일 밤 10시경 palpitation 과 chest pain발생
– 새벽 2시에 응급실 도착
Wide QRS tachycardia
• Ventricular rate - 218 bpm
• Axis – no man’s land
• LBBB pattern
• No AV dissociation
• R-S interval ~100ms
• what is next step?
• Carotid sinus massage
– Not effective
• Adenosine 6 & 12mg IV push – Not effective
• Verapamil 5mg IV push, twice – Not effective
• Continuous IV infusion of esmolol – 수분후 seizure & LOC – Vomiting and self voiding – VT was not changed
What is next step?
• DC cardioversion of 100 J
M/24, s/p TOF(20 yrs), Amiodarone-hepatotoxicity
EKG during sinus rhtyhm
Voltage mapping
RAO view Lt lateral view
Concealed Entrainment of VT
PPI=294ms
S-QRS=66ms
TCL=277ms
I
aVF
V1
V2
ABL d
ABL p
L1,2
L3,4
L5,6
L7,8
L9,10
L11,12
L13,14
L15,16
L17,18
L19,20
Rva d
Rva p
Ref d
Stim 2
I
aVF
V1
V2
ABL d
ABL p
L1,2
L3,4
L5,6
L7,8
L9,10
L11,12
L13,14
L15,16
L17,18
L19,20
RVa d
RVa p
Ref d
Stim 3
Pace-map
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
VT ablation site
-37ms
I
aVF
V1
V2
ABL d
ABL p
L1,2
L3,4
L5,6
L7,8
L9,10
L11,12
L13,14
L15,16
L17,18
L19,20
Rva d
Rva p
Ref d
Stim 2
I
aVF
V1
V2
ABL d
ABL p
L1,2
L3,4
L5,6
L7,8
L9,10
L11,12
L13,14
L15,16
L17,18
L19,20
RVa d
RVa p
Ref d
Stim 3
I
aVF
V1
V2
ABL d
ABL p
L1,2
L3,4
L5,6
L7,8
L9,10
L11,12
L13,14
L15,16
L17,18
L19,20
RVa d
RVa p
Ref d
Stim 3
VT termination during ablation
Entrainment with concealed fusion or concealed entrainment
: Same QRS morphology
PPI>TCL+30, s-QRS>e-QRS
PPI=TCL, s-QRS=e-QRS
local potential
local potential
Stevenson WG et al. J Am Coll Cardiol. 29:1180–89
Case 8
M/48, palpitation
• 입원하여 CAG: normal
– ICD 권유받았으나 거부하고 퇴원.
• 06년 VT로 응급실 내원
• 07년 VT로 타 대학병원 입원
• 08년 11월 recurrent VT로 입원
– DC cardioverson
– Continuous IV infusion of amiodarone
– Cardiac MRI
EchoCG ( 2008.11.5.)
Next step?
• VT morphology
– Typical outflow tract VT가 아니다.
• RV enlargement and RV dysfunction
• Structurally normal heart 여부가 중요
Cardiac MRI
1) Cardiac cine - scallooped and multifocal bulging contour of aneurysmal dilatation of RV free wall - marked dilatation with decreased contraction of RV - Global systolic dysfuction and focal dyskinetic porton of RV free wall - dilatation of RVOT - prominent proliferation of trabecullae in RV chamber - No remarkable contractility and within normal range of LV chamber 2) FSE double IR-T1 4chamber - Diffuse high SI of fatty tissue infiltration along the RV free wall and surrounding RVOT esp. inner aspect of epicardium contour(Index 4, #7/6) -> low SI of saturation of fatty tissue on triple IR- T1 (index 5, #12/6)
CONCLUSION
C/W Arrhythmogenic right ventricular dysplasia( ARVD) -> fullfilment of 2 major criteria( 1. severe dilatation with multilocalized RV aneurysm, 2. fatty infiltration) for diagnosis on MRI study.
08년 11월7일 ICD implantation
• 09년 3월 입원
– 한달전부터 intermittent ICD shock
– VT/SVT discrimination
• Inappropriate shock
• Amiodarone -> beta blocker
• 09년 10월 ICD shock 7회
• ICD setting change11년 3월 ICD shock 2회있어 응급실 내원
• 11년 5월 ICD shock & chest pain
– ICD setting change
• 11년 7월 ICD shock으로 입원
– Battery change & A lead insertion
• 11년 8월 ICD shock으로 입원
– VT 7회
• 11년 11월 chest discomfort
• 20회 VT: ATP 19, shock 1회11년 11월18일
– 50여회의 VT -> ATP로 termination
– SVT 1회 -> inappropriate shock
• 11년 11월28일 VT ablation
• Add sotalol
• 11년 12월14일 ICD analysis
– VT 23회; ATP로 termination
• 이후 현재까지 VT 발생하나 ATP로 모두 termination
Case 9
M/68
• Severe AS 로 aortic valve replacement
• 수술 도중 AV block 있어, temporary pacemaker 시행 (epicardial, atrium & ventricle)
• ICU care 중 event 발생
1) Atrium 과 ventricle 에 lead 가 위치해 있다.
2) Ventricular lead 의 sensing failure 가 있다.
3) 첫 번째 defibrillation 시도가 실패하였다.
4) Ventricular lead 의 capture 기능은 정상적이다.
5) 가장 먼저 시행할 처치는 ventricular lead 의 reposition 이다.
다음 중 가장 틀린 설명은?
R on T phenomenon
• Clinical situations
1) Torsade de pointes: long QT
2) Inappropriate Pacing: sensing failure
3) Commotio cordis: chest impact
• Electrophysiologic mechanisms
– Dispersion of repolarization
– Early afterdepolarization
2) Inappropriate pacing
• Temporary pacing 시에 sensing value 를 확인하지 않을 때 흔히 발생
• Sensing value 를 확인하는 방법 – Temporary lead 를 넣고, escape rate 보다 낮게 rate 를 설정한
후, sensing value 를 서서히 올려본다
sensing 이 잘 되어 pacing 이 들어가지 않는다 (intrinsic R wave > 17 mV)
sensing 이 안 되어 pacing 이 들어간다 (intrinsic R wave < 20 mV)
Sensing value =17 mV
Sensing value =20 mV
Case 10
M/47
• Ongoing chest pain 및 syncope 을 주소로 응급실 내원
• P/Hx : DM (-), HT (-)
ER visit
ECG after cardioversion
Coronary angiogram
Left coronary artery
Right coronary arter
VT after primary intervention
ECG at discharge
f/u echoCG: EF 48%
1. 관동맥 혈류 개선이 되어도 전기적으로 불안정한 심실근에서 심실성 부정맥이 재발할 가능성이 많다.
2. 급성 심근허혈 후에 일시적으로 나타난 부정맥이므로 향후 심근허혈이 반복되지 않는다면 예후는 양호하다.
3. ICD삽입을 고려한다.
4. 급성 심근경색 후 충분한 회복기를 거쳐도 좌심실 기능이 30% 이하로 유지될 경우에 제세동기 치료가 도움이 될 수 있다.
예후 및 향후의 치료는?
Reperfusion arrhythmias (1)
– Accelerated idioventricular rhythm (AIVR)
• Ventricular ectopy (60 ~110 bpm)
• Enhanced automaticity ?
• Specific (80~90%) but non-sensitive (50~80%) for reperfusion in thrombolytic era
• In PCI era, applicable with other parameters
– VT and VF
• 4.3~8% in primary PCI
• VF: Possible sign of ongoing ischemia
• Reperfusion can reduce and cause VT/VF !
Osmancik el al, Acute Cardiac Care. 2008;10:15
– AF and AFL
• 5~7.7% in admission for AMI
• Evidence: beta blocker and ACEI/ARB
– Bradycardia
• sinus bradycardia
• AV block: 6~12%
Reperfusion arrhythmias (2)
Osmancik el al, Acute Cardiac Care. 2008;10:15
• Inclusion criteria
– MI (6~40 days)
– EF ≤ 35 %
– Cardiac autonomic dysfunction (depressed HR variablity)
Why can not early ICD save life?
• Most of non-arrhythmic deaths: CV deaths
• Procedure ? : No !
• Excessive pacing ? : No !
• Saved patients are at the high risk for CV deaths
• Shock merely transform SCD to pump failure