dr. ajay naik md, dm, dnb, facc, fhrsiseindia.org/ecg_presentation/07_vt dr ajay naik final.pdf ·...

Dr. Ajay Naik

MD, DM, DNB, FACC, FHRS Cardiac Electrophysiologist,

Director, CIMS Hospital

Ahmedabad, India

Education

• DM and DNB Cardiology, KEM Hospital, Mumbai 1998

• EP Fellowship: Cedars-Sinai Medical Center, Los Angeles, USA 1999-2001

• FACC (2003), FAPSC (2008), FHRS (2010), FESC (2014).

Work Profile

• Working in Ahmedabad and visiting tertiary care centers internationally.

• Numerous publications in major international journals.

• Principal investigator for numerous multinational drug and device clinical trials

• International and national faculty for Cardiac Electrophysiology.

• Director of Core Laboratory

VT:

Varied Etiologies, Myriad Presentations

DR. AJAY NAIK

MD, DM, FACC, FHRS

Cardiac Electrophysiologist

Director,

Ahmedabad, India

25-yrs-old gentleman, palpitations

3

Panic in the ER……

• NCT / WCT

• VT / SVT with aberrancy

• Normal heart / SHD

• QRS morph: LBBB-like pattern, inferior axis

QRS transition V2 - 3

• Treat with:

• Verapamil / Adeno / Amio / Cardiovert?

4

RVOTT

RVOTT

2/4/2019 7

Clinical Presentation – RVOTT

• Palpitations, Dizziness, Pre/syncope

• Induced with exercise or other hyperadrenergic

states (?cAMP mediated Triggered activity)

• Repetitive monomorphic VT is a variant

• No evidence of structural heart disease (SHD)

• Responds to CCB, B, combination

• RF Ablation has a high success rate (90%)

RVOTT focus

2/4/2019 DR. AJAY M. NAIK, MD, DM, DNB CARE

CARDIOLOGY CONSULTANTS 9

RVOTT

During ablation, VT terminated

2/4/2019 11

Ventricular Arrhythmias • Mechanism Reentry, Triggered, Automaticity

• Rate Slow, Fast

• Duration NSVT, Sustained

• Site of origin RV / LV / Endocardial / Epicardial

• Location Septal / Outflow / Apical / Basal

• Morphology Monomorphic / Polymorphic

• Substrate Normal heart/ CAD/ Myopathy

• Hemodynamic Stable / Unstable

• Exercise Induced / Not induced by exercise

• Drug responsiveness and amenability to RFA

Clinical circumstances

• 1. Idiopathic VT

• 2. VT in SHD

• 3. VT in presence of ICD

• 4. VT storm

13

Etiologies of VT • VT in structurally normal hearts

– Monomorphic (RVOTT, LVOTT, ILVT)

– Polymorphic (LQTS, Brugada, Channelopathies)

• VT related to CAD, Acute vs. Old MI (scarred myocardium, LV dysfunction)

• VT related to non-ischemic heart disease

– CMP, ARVD, Sarcoidosis, Myocarditis

• VT related to drugs (Proarrhythmias)

60%

5%

25%

5%

5%

2/4/2019 14

Idiopathic VT

• VT occurring in patients with normal hearts

• Outflow Tract Tachycardia (RVOT / LVOT)

• Idiopathic Left Ventricular Tachycardia

(Fascicular Tachycardia) (?Papillary muscle

related VT)

2/4/2019 15

RVOTT

Case2: 33-yrs-old gentleman, palpitations (2002)

16

Q1. Where does the VT arise from ?

• A. Outflow Tract region

• B. Basal region

• C. Apical region

• D. Not a VT.

2/4/2019 DR. AJAY M. NAIK, MD, DM, DNB CARE

CARDIOLOGY CONSULTANTS 18

ARVD – VT

2/4/2019 DR. AJAY M. NAIK, MD, DM, DNB CARE

CARDIOLOGY CONSULTANTS 19

ARVD – VT

2/4/2019 20

ARVD

• Structural Heart Disease

• RV is dilated with aneurysms, sacculations

• Fat replaces myocardial cells

• Multiple morphologies of VT arising from RV

• Epsilon wave on EKG

ARVD

2/4/2019 DR. AJAY M. NAIK, MD, DM, DNB CARE

CARDIOLOGY CONSULTANTS 22

ARVD – Epsilon wave

RV Angiogram

23

RV Angiogram

24

Treated medically for 10 years…

• BB, Amiodarone

• CHF

• Recurrent VT

25

ICD implanted… 26.4.2013

26

ICD implanted… 26.4.2013

27

VT episode

28

ATP accelerated VT…Shock successful

29

Case 3: 35-yr-old gentleman…

Case 3: 35-yr-old gentleman…

• Severe palpitations past 6 hrs.

• Similar episodes several times past 4 yrs

• Echo Normal

• CAG Normal

• Was put on Amiodarone

• Developed hypothyroidism

2/4/2019 DR. AJAY M. NAIK, MD, DM, DNB CARE

CARDIOLOGY CONSULTANTS 32

ILVT

Q2. Where does the VT arise from ?

• A. Outflow Tract region

• B. Basal region

• C. Apical region

• D. Not a VT.

Rapid tachycardia

• “Narrow looking” WCT

• RBBB-like pattern, left superior axis

• ?SVT / VT

• Treat with:

• Verapamil / Adeno / Amio / Cardiovert?

34

ILVT

2/4/2019 36

Clinical Presentation – ILVT

• Young pts, Male predominance

• Palpitations, Occasional syncope

• Incessant VTs may cause Tachycardiomyopathy

• Respond to Verapamil

• Success rate of RF Ablation almost 90%

2/4/2019 DR. AJAY M. NAIK, MD, DM, DNB CARE

CARDIOLOGY CONSULTANTS 37

ILVT, Slower

2/4/2019 38

ILVT

• Arises near the basal or midseptal area of LV

• RBBB pattern, Left superior axis

• Normal sinus rhythm ECG

• T inversions in inferolateral leads may be seen

• Likely reentrant in nature, using left bundle

ramifications Purkinje system

2/4/2019 DR. AJAY M. NAIK, MD, DM, DNB CARE

CARDIOLOGY CONSULTANTS 39

After ILVT termination

ILVT ablation

40

Sinus rhythm

Case 4: 23-yrs-old girl, palpitations…

42

Q3. Where does the VT arise from ?

• A. Outflow Tract region

• B. Basal region

• C. Apical region

• D. Not a VT.

Case 4: 23-yrs-old girl, palpitations…

• Severe palpitations past 2 hrs.

• Similar episodes several times past 1 year

• Normal heart

• QRS morph: RBBB-like pattern, inferior axis

• Treat with:

• Verapamil / Adeno / Amio / Cardiovert?

44

LVOTT

2/4/2019 46

LVOT Tachycardia

• A variant of Outflow tract tachycardia

• (? 10% of cases)

• Early precordial transition

• Arises from the LVOT region

• Triggered activity

• Respond to Verapamil

• Focus may occasionally be close to LMCA

LVOT VT

47

49

51

52

2/4/2019 53

Idiopathic VTs..

• Idiopathic VT are a distinct subset

• Structural Heart Disease has to be ruled out

• Despite being VTs, they respond to Verapamil

• RVOTT, ILVT are exquisitely amenable to RF

ablation therapy

54

Etiologic Classification of VT

• VT in structurally normal hearts

– Monomorphic (RVOTT, LVOTT, ILVT)

– Polymorphic (LQTS, Brugada, Channelopathies)

• VT related to CAD, Acute vs. Old MI (scarred myocardium, LV dysfunction)

• VT related to non-ischemic heart disease

– CMP, ARVD, Sarcoidosis, Myocarditis

• VT related to drugs (Proarrhythmias)

VT morphology definitions

• Monomorphic VT:

• Similar QRS configuration from beat to beat. Some

variability in QRS morphology at initiation is not

uncommon, followed by stabilization of the QRS

morphology

• Multiple Monomorphic VTs:

• More than one morphologically distinct monomorphic

VT, occurring as different episodes or induced at

different times.

VT morphology definitions

• Polymorphic VT:

• Continuously changing QRS configuration from beat

to beat indicating a changing ventricular activation

sequence.

• Pleomorphic VTs:

• More than one morphologically distinct QRS

complex occurring during the same episode of VT,

but the QRS is not continuously changing.

Etiologies of SCD

60

VAs in Ischemic Heart Disease

Myerburg R. N Engl J Med 2008;359:2245-253

Acute MI

DR. AJAY NAIK, MD, DM, DNB, FACC 62

Holter – “Heart Attack”

DR. AJAY NAIK, MD, DM, DNB, FACC 63

Holter – SCD

64

Apple and Oranges…

65

• MI / ACS SCA

66

Polymorphic VT during ACS

• VT in first 24 hours :

– Does not affect long term prognosis

– Does not require long term suppressive therapy,

– Ischemia correction is the key

• VT occurring later :

– Increased hospital and long-term mortality,

– More common in patients with transmural infarction and left ventricular dysfunction,

– Likely to be sustained

– Induces marked hemodynamic deterioration

VAs in ACS

Case 5: 48-yr-old, chest pain, syncope, SCA

Post Defibrillation... J point elevation

Case 6: 67-yrs-old gentleman, syncope

72

Case 6: 67-yrs-old gentleman, syncope

• CAD,

• Severe LV dysfunction, LVEF 20%

• CABG

• Incessant VT

• Multiple shocks given

• On AAD.

73

74

VT1

76

77

78

VT2

80

MI Scar Related Sustained Monomorphic VT Circuit

Scar mapping and Ablation

84

Scar VT

1. Post Myocardial infarction

2. Non ischemic cardiomyopathy Dilated cardiomyopathy

Post Myocarditis

ARVD

RV Cardiomyopathy

Sarcoidosis

Hypertrophic CMP

Myocardial Scar and VT

Case 7: 75-yrs-old gentleman, CAD, LV dysfunction,

Unconscious

87

Q4. What is happening?

• A. “Heart Attack”

• B. “Sudden Cardiac Arrest”

• C. Both

• D. Neither

Repeated shocks, metabolic corrections, incessant VT

89

90

Post RFA, stablized, AV sequential pacing

Case 8: 46-yr-old gentleman, MI in past, unconscious

After DC Cardioversion…

Q5. What is happening?

• A. “Heart Attack”

• B. “Sudden Cardiac Arrest”

• C. Both

• D. Neither

On Amiodarone therapy… Acute issues

Amiodarone : Long term therapy issues

Amiodarone Pulmonary Toxicity

Case 9: 30-yrs-old lady, RHD, pre-BMV

Treated for AF in the ICU …. Seizures

97

99

100

101

102

Q6. What is the ECG abnormality?

• A. PVCs

• B. QT prolongation

• C. T wave alternans

• D. All of the above

104

105

DR. AJAY NAIK, MD, DM, DNB, FACC 106

Temporary Pacing

107

Management and FU

• Dual Chamber ICD implant done

• BMV performed

• 5 year follow up: doing well

108

Channelopathies

Long QT Syndrome

RR:700 ms

QT:400 ms QTc: 480 ms

Notched T waves

DR. AJAY NAIK, MD, DM, DNB, FACC 111

Long QT Syndrome Prolonged QT Interval

Syncope/Fainting

Malignant Ventricular Arrhythmias - Torsades de Pointes

Sudden Death

High risk features in LQTS

• QT>500 ms

• H/O syncope/ SCD

• Female

• LQT2/ LQT3

Cumulative Probability of LQTS – related

Death With Beta-Blockers

Years on Beta-Blockers

Cu

mu

lati

ve P

rob

ab

ilit

y (

%)

or

Card

iac A

rrest/

LQ

TS

– R

ela

ted

Death

0 1 2 3 4 5

40

30

20

10

0

Prior aborted cardiac

arrest

Syncope only

Asymptomatic

Case 10: 40-yr-old lady

• 40-yr-old lady with repeated convulsions on

27.5.2004

• Used to fall down and get up in 5 minutes once

a month over past 15 years.

• Was assumed to have “Mata”

• This time, somebody found her to have a fast

pulse….

40-yr-old lady, repeated convulsions

DR. AJAY NAIK, MD, DM, DNB, FACC 117

40-yr-old lady, repeated convulsions

DR. AJAY NAIK, MD, DM, DNB, FACC 118

40-yr-old lady, repeated convulsions

Q7. What is the ECG abnormality?

• A. Atrial Fibrillation

• B. Acute MI

• C. Torsade de pointes

• D. Artifact

DR. AJAY NAIK, MD, DM, DNB, FACC 120

40-yr-old lady, repeated convulsions

DR. AJAY NAIK, MD, DM, DNB, FACC 121

AAIR pacemaker, 100 bpm + β blockers

40-yr-old lady, repeated convulsions

Short QT syndrome

Short QT syndrome

QT = 225 msec

Case 11: 40-yr-old gentleman…syncope

After recovery…

Case 12: 67-yr-old gentleman, unconscious in

backyard •

131

Osborn wave

•^ Osborn JJ. Experimental hypothermia: Respiratory and blood pH •changes in relation to cardiac function. Am J Physiol 1953; 175: 389-398.

After 24 hours, recovered fully

Case 13: 45-yrs-old gentleman, presyncope

Bidirectional VT

Polymorphic VT - CPVT

Class I

• Beta blockers are indicated for patients who

are clinically diagnosed with CPVT on the

basis of the presence of spontaneous or

documented stress-induced ventricular

arrhythmias. (Level of Evidence: C)

• Implantation of an ICD with use of beta

blockers is indicated for patients with CPVT

who are survivors of cardiac arrest

Catecholaminergic Polymorphic

Ventricular Tachycardia

Case 14: 60-yrs-old lady, HCM

• Normal coronaries

Case 14: 60-yrs-old lady, HCM,

SCD in 2 sibs

SCD risk

• Normal coronaries

Identify the Patient at High Risk

• H/O SCD

• Family H/O SCD

• Genotype

• VT

• Syncope

• IVS>29mm

• Younger age at diagnosis

Case 15: 33-yrs-old gentleman…

• Treated for PVCs in Jan 2011

• LVEF 45%

• No inducible VT on EPS (1.2.2011)

• Rapid VT (30.3.2011)

• Cardiac Sarcoidosis (CECT, Biopsy)

• ICD implanted (24.6.2011)

• VT storm, LVEF 15% (4.7.2011)

• Incessant VTs of various morphologies, shocks.

33-yr-old gentleman, VT 1

VT 2

1 VT3: LBBB L ax, 550 ms CL, 110 bpm

1 VT4:“RBBB” LSupAx, 330 ms CL,180 bpm

1 VT5: LBBB LSupAx, 330 ms CL, 180 bpm

VT5

PLEOMORPHIC VT

VT12345 combined RV and LV

VT1

VT4 VT5 VT5

VT3

VT2 VT2

VT3

1 Resting ECG, AV sequential pacing

5 years follow up

• No VT / VF / shocks for > 5 years

• 25.12.2016 doing well after 5 years (LVEF 25%)

• Resumed work

Inflammatory Cardiomyopathy

• Sarcoidosis

• Tuberculous myocarditis

• “Granulomatous Myocarditis”

Electrical Storm

Homogenization of Substrate

Summary

• Ventricular arrhythmias may range from

“benign” to life-threatening Electrical Storms

• Etiology and Substrate is closely linked to

outcome.

• Co-ordinated Clinical, SHD and

Electrophysiologic management is paramount

• VT management requires astute, refined

acumen in an established arrhythmia center for

optimal outcome.

Dr AJAY NAIK

MD DM DNB FACC FHRS