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

px

ds

I

px

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