pacemaker mediated tachycardia... or not?
TRANSCRIPT
EP Teaching
21 Oct 2016 Supervisor: Dr Tan Boon Yew
History 69 Chinese Female
ICMP • CRTD implanted 2012, baseline NYHA 2 post CRT
• AdmiMed for CCF symptoms – 2nd admission in last 2 years – Diuresed well – Referred for EP consult for mulPple episodes of “NSVT” noted on telemetry
– Carvedilol increased to 12.5mg bd (SBP 95mHg) ... but cannot be suppressed!
Telemetry
Now what?
1. Increase Carvedilol to 25mg BD 2. Switch to Bisoprolol and take out another BP
lowering drug 3. Amiodarone 4. Ablate 5. Interrogate Device 6. Don’t Know
Pre CRT ECG
Name: CHUA CHAI TEEN, MRN: S0147783H Age: 56 Yrs DOB: 24/12/1954 Gender: Female Ethnic origin: Unknown Date: 05/11/2011 05:06:13
Height: Unknown Weight: Unknown SINUS RHYTHM
PROBABLE ABERRANTLY CONDUCTED SUPRAVENTRICULAR EXTRASYSTOLES
LEFT AXIS DEVIATION
BROAD R IN I, V5 OR V6
PROLONGED QRS DURATION
LEFT BUNDLE BRANCH BLOCK
Q WAVES IN INFERIOR LEADS
T WAVE INVERSION ALSO PRESENT
INFERIOR INFARCTION AS PREVIOUSLY
SUMMARY: NO SIGNIFICANT CHANGE
COMPARED TO ECG(S) OF 04/11/2011 14:16:05
PR: 186 P Axis: 77
QRS Dur: 142 QRS Axis: -34
QT: 428 T Axis: 160
QTc: 491 HR: 79
QT Disp: 64 BP:
Requested By: Taken By: HNUA
ECG Cart Serial Number: Location:
Undefined: Undefined:
DX:
RX:
Previous ECG: 04/11/2011 14:16:05 (Abnormal ECG) Abnormal ECG
PRELIMINARY REPORT - PHYSICIAN MUST REVIEW(. .)
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
II
SHS - Singhealth - NHC - National Heart Centre - W44 - Ward 44 F 0.5 - 150 Hz 25 mm/sec 10 mm/mV
Post CRT ECG
Name: chua chai teen, MRN: S0147783H Age: 61 Yrs DOB: 24/12/1954 Gender: Female Ethnic origin: Unknown Date: 03/10/2016 20:50:14
Height: Unknown Weight: Unknown REGULAR VENTRICULAR PACING
NO FURTHER ANALYSIS MADE BECAUSE OF PACEMAKER RHYTHM.
NO OTHER FINDINGS
SUMMARY: SOME ABNORMALITIES NO LONGER PRESENT
COMPARED TO ECG(S) OF 03/10/2016 14:40:49
PR: 0 P Axis: 53
QRS Dur: 128 QRS Axis: -171
QT: 482 T Axis: -25
QTc: 494 HR: 63
QT Disp: 124 BP:
Requested By: Taken By: HNUC
ECG Cart Serial Number: Location: US81305433
Undefined: BLK4,LVL7/ECG04 Undefined:
DX:
RX:
Previous ECG: 03/10/2016 14:40:49 (Abnormal ECG) Abnormal ECG
PRELIMINARY REPORT - PHYSICIAN MUST REVIEW
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
II
SHS - Singhealth - NHC - National Heart Centre - W47B - Ward 47B F 0.5 - 100 Hz 25 mm/sec 10 mm/mV (US81)
ECG during “NSVT”
Name: chua chai teen, MRN: S0147783H Age: 61 Yrs DOB: 24/12/1954 Gender: Male Ethnic origin: Unknown Date: 03/10/2016 09:33:29
Height: Unknown Weight: Unknown REGULAR VENTRICULAR PACING
NO FURTHER ANALYSIS MADE BECAUSE OF PACEMAKER RHYTHM.
NO OTHER FINDINGS
SUMMARY: SOME ABNORMALITIES NO LONGER PRESENT
COMPARED TO ECG(S) OF 17/03/2016 04:03:54
PR: 0 P Axis: -20
QRS Dur: 190 QRS Axis: 167
QT: 382 T Axis: -20
QTc: 503 HR: 104
QT Disp: 42 BP:
Requested By: Taken By: gaes
ECG Cart Serial Number: chua
chai teen
Location: s0147783h
Undefined: Undefined:
DX:
RX:
Previous ECG: 17/03/2016 04:03:54 (Abnormal ECG) Abnormal ECG
PRELIMINARY REPORT - PHYSICIAN MUST REVIEW
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
II
SHS - Singhealth - SGH - Singapore General Hospital - GCAE - Accident and Emergency F 60~ 0.15 - 100 Hz 25 mm/sec 10 mm/mV (US40)
CRT Se`ngs
• Mode DDD • Base Rate 60 • Paced AV delay 150ms • Sensed AV delay 100ms • Max Track Rate 110 • LV -‐> RV, 40ms • PVARP 275ms • PVAB 100ms
13! sr.Iunr Mrnlcer'rltCHUA CHAI TEEN ID S0147783HUnify Quadra- 3251-4OQ CRT-D 1064845lmplanting Physician: DR TEO WS
5 Oct 201612=23
lrrClinic
Page 1 of 1
Presenting RhYthm Freeze5 Oct 201611:42
Key Param€torsModeBase RateRest RatePaced AV DelaYSensed AV DelaYMax Track RateMax Sensor RateHysteresis RateACaprM ConfirmRVCapru ConfirmLVCapil ConfirmAF SuppressionilNegative AV HYsteresis/SearchRate ResPonsive AV DelaYRate ResPonsive PVARP/V RetVentricular Safefi StandbY
1:Markers2: 110,0 mm/mV3: A Sense Amp A.ltoca!!-1J0J1mfllrny
Unify Quadrars 3251-4OQ CRT-D (1064845 prC'E'9A)
Merl'in'" PCS (#12053842 3330 v21'1 2 rev 1)
DDD60 min'1otf150 ms100 ms1'10 min'1110 min-toffoffoffoffoffotfMediumLowOn
4: V Sense AmP Ar.rtoGain (0,9 mmimV)5: LV Distaltip 1 - Mid 2 Autocain (0,7 mm/mv)
Presenting Rhythm Freeze Page 1 of 1
5C,c'2016 12"23
ili tt ]unr Mrotcer'CHUA CHAI TEEN ID S0147783HUnify Quadra- 3251-4OQ CRT'D '1064845
lmplanting PhYsician: DR TEo WS
5 Oct 2016L2223
ln-Clinic
Page 1 of 1
Freeze CaPture5 Oct 2016 l1:57
l(ey ParametersModeBase RateRest RatePaced AV DelaYSensed AV DelaYMax Track RateMax Sensor RateHysteresis RateACapil ConfirmRVCapil ConfirmLVCapil ConfirmAF SuPPressionruNegative AV HYsteresis/SearchRate ResPonsive AV DelaYRate ResPonsive PVARP/V RefVentricular Safety StandbY
1:Markers
DDD60 min-1off150 ms100 ms110 min-1110 min'toffoffoffoffoffoffMediumLowOn
4: V Sense AmP Autocain (0,9 mm/l11V)
5: LV Distaltip 1 - Mid 2 AutoGain (0,7 mmlnV)2: 110,0 mmlmV3: A Bioolar AutoGain (10,0 Eq4nV)
Unify QuadrarM 3251-4OQ CRT-D (1064845 prC'E'9A)
Meriin* PCS (#12053842 3330 v21'1'2 rev 1)
Freeze CaPture Page 1 of 'l
50d2016 12"23
Now what?
1. Increase Carvedilol to 25mg BD 2. Switch to Bisoprolol and take out another BP
lowering drug 3. Amiodarone 4. Ablate 5. Interrogate Device -‐> Refer EP 6. Don’t Know
DDD pacing @ 60
AAI @ 90
VVI BiV
VVI LV
VVI RV
DDD RV 0.25mV
PMT Mechanism
• PVC/PAC è
PMT Mechanism
• PVC/PAC è retrograde VA conducPon
PMT Mechanism
• PVC/PAC è retrograde VA conducPon è A-‐sensed è
PMT Mechanism
• PVC/PAC è retrograde VA conducPon è A-‐sensed è Paced AVI triggered
PMT Mechanism
• PVC/PAC è retrograde VA conducPon è A-‐sensed è Paced AVI triggered è V-‐paced
PMT Mechanism
• PVC/PAC è retrograde VA conducPon è A-‐sensed è Paced AVI triggered è V-‐paced è retrograde VA èèè…
PMT Mechanism • PVC/PAC è retrograde VA conducPon è A-‐sensed è Paced AVI triggered è V-‐paced è retrograde VA èèè…
• Morphologies during DDD BiV pacing different from PMT BiV pacing – ContribuPon from the 3 wave fronts:
• His septal acPvaPon • RV pace • LV pace
– During PMT: loss of His contribuPon
