dr. ajay naik md, dm, dnb, facc, fhrsiseindia.org/ecg_presentation/07_vt dr ajay naik final.pdf ·...
TRANSCRIPT
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
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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
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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%
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Idiopathic VT
• VT occurring in patients with normal hearts
• Outflow Tract Tachycardia (RVOT / LVOT)
• Idiopathic Left Ventricular Tachycardia
(Fascicular Tachycardia) (?Papillary muscle
related VT)
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RVOTT
Case2: 33-yrs-old gentleman, palpitations (2002)
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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
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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
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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
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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
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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.
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VT1
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78
VT2
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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