Permanent Tachyc cardi ardias as Permanent Tachy J J. . Janou - - PDF document

Permanent Tachy Permanent Tachyc cardi ardias as

J J. . Janou Janouš šek ek Klinik f. Kinderkardiologie Klinik f. Kinderkardiologie Universit Universitä ät Leipzig, Herzzentrum t Leipzig, Herzzentrum

M Mechanisms echanisms

• Ectopic activity

Ectopic activity

» » Focal Focal (e (ectopic ctopic) ) atrial atrial tachycardia tachycardia (FAT (FAT, , AE AET) T) » » Junctional ectopic (His bundle) Junctional ectopic (His bundle) tachycardia tachycardia (JET) (JET)

• Reentry

Reentry

» » Permanent junctional reciprocating Permanent junctional reciprocating tachycardia (PJRT) tachycardia (PJRT)

Rationale of therapeutic approach Rationale of therapeutic approach

• Natural history

Natural history

• Severity of symptoms

Severity of symptoms

• Risk

Risk of tachycardia

• f tachycardia-
• induced

induced cardiomyopathy cardiomyopathy versus versus Benefits and r Benefits and risk isks s of drug therapy

• f drug therapy

and catheter ablation and catheter ablation

Indications for Indications for RF RF catheter ablation catheter ablation in childern in childern: : Class Class I I

Resuscitated cardiac arrest in WPW Syncope in WPW

» Min. preexc. RR <250 msec during AFib » AC ERP <250 msec

Incessant SVT with ventricular

dysfunction

Friedman RA et al., PACE 2002 NASPE Expert Consensus Conference

Recurrent symptomatic SVT refractory to

drug therapy, age >4 yrs

Cardiac surgery prohibiting further

approach to arrhythmogenic substrate (TCPC)

Incessant SVT with normal ventricular

function

Indications for Indications for RF RF catheter ablation catheter ablation in childern in childern: : Class Class II A II A

Friedman RA et al., PACE 2002 NASPE Expert Consensus Conference

Focal Focal ( (ectopic ectopic) ) atrial tachycardia atrial tachycardia

AET originating from septal focus AET originating from septal focus

Main features Main features

• P wave of first beat identical to

P wave of first beat identical to subsequent beats subsequent beats

• Warming

Warming-

• up and cooling

up and cooling-

• down

down phenomenon phenomenon

• May have AV block during running

May have AV block during running tachycardia tachycardia

• No induction by pacing

No induction by pacing

AET / adenosine AET / adenosine

EAT – heart rate profile

Before ablation After ablation

Tachycardia induced CMP Tachycardia induced CMP

Prior to therapy 1 year after ablation

Natural history and therapeutic Natural history and therapeutic response response

• Tachycardia induced CMP

Tachycardia induced CMP

» » Higher risk with higher heart rates and Higher risk with higher heart rates and permanent tachycardia permanent tachycardia

• Spontaneous resolution

Spontaneous resolution1

1

» » <3 yrs.: 78 %, <3 yrs.: 78 %, ≥ ≥3 yrs: 16 % (p<0.001) 3 yrs: 16 % (p<0.001)

• Pharmacological control

Pharmacological control1

1

» » <3 yrs.: 91 %, <3 yrs.: 91 %, ≥ ≥3 yrs: 37 % (p<0.001) 3 yrs: 37 % (p<0.001)

• Recurrence possible!

Recurrence possible!

1 1 Salerno

Salerno JC JC et al., JACC 2004 et al., JACC 2004

AET AET Sinus r. Sinus r.

AET from right upper pulm. vein AET from right upper pulm. vein AET from right upper pulm. vein AET from right upper pulm. vein

RAO LAO

Junctional Junctional ectopic tachycardia ectopic tachycardia (JET) (JET)

1 s

ECG ECG

1 s

Main features Main features

• Congenital, adult and postoperative form

Congenital, adult and postoperative form

• Congenital form

Congenital form

» » Family Family history (up to 55.6 %) history (up to 55.6 %)1

1

» » Progression into CAVB Progression into CAVB2,6

2,6

» » Spontaneous rate acceleration Spontaneous rate acceleration1

1

» » High incidence of heart High incidence of heart failure (up to 60 %) failure (up to 60 %)1

1

» » Therapy: Therapy:

– – Propafenone Propafenone3

3, Amiodarone

, Amiodarone1

1, Amiodarone+IC

, Amiodarone+IC4

4

– – Cave: digoxin Cave: digoxin1

1, proarrhythmia

, proarrhythmia4

4

– – Ablation Ablation5

5

• Adult form

Adult form

» » Later in life, better Later in life, better tolerated, lower tolerated, lower HRs HRs

1Villain E et al. Circulation 1990, 2Henneveld H et al. Heart 1998, 3Paul T et al. J Am Coll Cardiol 1992, 4Sarubbi B et al. Heart 2002, 5Fishberger SB et al. PACE 1998, 6Dubin AM et al. HeartRhythm 2004

Permanent Permanent junctional reciprocating junctional reciprocating tachycardia tachycardia (PJRT) (PJRT)

Main features Main features

• Posteroseptal pathway

Posteroseptal pathway

• Retrograde conduction

Retrograde conduction

• nly
• nly
• Decremental properties

Decremental properties

• Incessant

Incessant

• Tachycardia induced

Tachycardia induced CMP CMP

Adapted using Mazgalev TN et al., Circulation 2001

L Long RP, short PR

• ng RP, short PR

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

1 s 1 s

Diagnostic clue Diagnostic clue

300 360 360 180 200 220

PJRT PJRT – – multicenter multicenter study study

• N = 85

N = 85

• Age at diagnosis

Age at diagnosis 0 0-

• 20

20 yrs yrs ( (median median 3 3 mo mo) )

• Follow

Follow-

• up median

up median 8.2 8.2 yrs yrs

• CHF 28 %

CHF 28 %

» » resolved with medical Tx resolved with medical Tx in in all all

• Success of medical Tx

Success of medical Tx: 94 % : 94 %

» » amio amiodarone darone/ /verapamil verapamil + digoxin + digoxin

• Spontaneous resolution: 22 %

Spontaneous resolution: 22 %

• Death: 2 pts with persistent LV dysfunction

Death: 2 pts with persistent LV dysfunction

Vaksmann G et al., Heart 2005

PJRT mapping and ablation PJRT mapping and ablation

354 ms 329 ms

Ventricular extrastimulus RF energy application Retrograde block