Tehran Arrhythmia Center The Worst Scenario A 4 year old kid High - - PowerPoint PPT Presentation

Tehran Arrhythmia Center

The Worst Scenario

• A 4 year old kid
• High heart rates first noted by parents at

20 months of age.

• Family physician detected rates as high as

220 bpm at that age.

• He was visited, treated and followed at

two large referral hospitals.

4 Yr-old Kid

• An old ECG

4 Yr-old Kid

• First echocardiogram was reported as enlarged LV

sizes with good contraction and interpreted as ‘cardiomyopathy with normal EF’. Heart failure medications were prescribed.

• Repeat echocardiograms one year later were

reported as LV dysfunction with moderate MR.

• Mitral repair surgery was performed at age 3

years, complicated by an apparently hypoxic brain damage.

• The child was mentally and physically retarded

and unable to talk or walk.

4 Yr-old Kid

• He was referred by a pediatric cardiology

fellow asking: ‘Isn’t it WPW?!’

Hear Failure Survival

5-yr mortality declined by 12% per decade.

Levy et al. NEJM 2002, 347;1442

Temporal Trends in Survival

Heart Failure Mortality

Framingham: 80% of men and 70% of women under age 65 will die within 8 years. REACH: The overall median survival 4.5 yrs for women vs. 3.7 yrs for men.

Arrhythmia-induced Cardiomyopathy

• First reported as an isolated case almost a

century ago*

• Largely considered a rare cause of cardiac

damage, however:

• Over the past few years there have been

several publications that have established beyond a reasonable doubt that this condition is much more prevalent.

• Even more important is the fact that it is a

reversible and curable cause of heart failure.

*Gossage AM, Braxton Hicks JA. On auricular fibrillation. Q J Med 1913;6:435–440.

• It can be seen in association with a variety of

cardiac rhythm disorders:

Mechanisms

Atrial fibrillation Ectopic atrial tachycardia Atrial flutter Incisional atrial tachycardia PJRT JET WPW Ventricular tachycardia Isolated ventricular ectopies Pacing at fast rates PMT Thyrotoxicosis Glucagonoma

• LV dysfunction during the

tachyarrhythmias has been attributed to myocardial stunning resulting from sustained fast ventricular rates.

Pathophysiology

• High energy myocardial stores have been shown

to get depleted including diminished Na-K-ATPase activity and lower myocardial ATP and Phosphocreatine stores.

• Although the condition is typically reversible, it can

return with “a vengeance” if the original clinical scenario is allowed to recur.

Animal Experiments

• In animal experiments, it has been
• bserved as soon as 24 hours after rapid

ventricular pacing. This deterioration continues for 3–5 weeks.

• Within 48 hours of cessation of pacing,

impaired ventricular function is noted to improve and returns to normal by 1–2 weeks.

• It may not reverse completely in all cases.

Tachycardia-Induced Cardiomyopathy: A Review of Literature. PACE 2005, 710-21.

Atrial Fibrillation

The most common cause of tachycardia-induced cardiomyopathy

AF & Heart Failure

• The relationship between atrial fibrillation

and cardiomyopathy has been explored for several years.

• Atrial fibrillation itself may be the cause of

tachycardia-related or tachycardia- worsened cardiomyopathy.

• An important finding in some studies is that

cardiomyopathy with atrial fibrillation may

• ccur even with apparently well controlled

ventricular response rates.

• S. J. Asirvatham. J Cardiovasc Electrophysiol, Vol. 18, pp. 15-17, 2007

Tehran Arrhythmia Center

DCM, AF and RVR

AV node ablation

• Does not eliminate AF
• Effective in controlling

ventricular rate

• Improves:
• QoL
• Exercise tolerance
• Left ventricular function
• No deleterious effect on survival
• Induces dyssynchrony itself

Pace and Ablate

AVN ablation and PPM

• Cons:
• Permanent
• Detrimental effects of RV pacing,

especially if reduced LV function already

• Still have thromboembolic risk
• Continue to have loss of atrial

contractile function

Tehran Arrhythmia Center

Biventricular Pacing

RV LV

Tehran Arrhythmia Center

Tehran Arrhythmia Center

Biventricular Pacing

RV LV

Tehran Arrhythmia Center

Tehran Arrhythmia Center

AV Junctional Ablation

RF LV RV

Tehran Arrhythmia Center

Tehran Arrhythmia Center

Biventricular Pacing in AF

Tehran Arrhythmia Center

AVJ Ablation and CRT

Ablate and pace

• Suitable for
• AF with symptomatic rapid ventricular

rate unresponsive to drug Rx, or when drug Rx not tolerated

• Patients with a bradycardia indication

for pacing

• More suited to elderly (less requirement

for generator changes and lead revision)

AF Ablation & Heart Failure

• We have data primarily from the AFFIRM and

related studies that controlling the ventricular rate with continued anticoagulation is as good as or better than attempting to restore and maintain sinus rhythm.

• However, there are data from typically

nonrandomized trials that the quality of patients’ lives, atrial function, and ventricular function improve and perhaps mortality is reduced when successful ablation for atrial fibrillation is performed.

Potentials inside Pulmonary Veins

AF ablation: LA/PV Geometry

PV Isolation

PV potentials disappearing during radiofrequency current application

Disappearance of PV Potentials

Termination of AF during Burn

Termination of AF during Burn

Termination of AF during Burn

Persistent Junctional Reciprocating Tachycardia (PJRT)

PJRT

Persistent Junctional Reciprocating Tachycardia

PJRT

Termination & Re-initiation

RF Ablation

Termination

Sinus Rhythm

Incessant Atrial Tachycardia

Incessant Atrial Tachycardia

Incessant Atrial Tachycardia

Intra-cardiac Recordings

Success Signal at High Crista

Termination during Burn

Sinus Rhythm

Incisional Atrial Tachycardia/ Flutter

46 yr old woman with repaired ASD, incessant AT leading to heart failure

Intracardiac Recordings

Line of Low Voltage Double Potentials

RF Lesions

Termination during Burn

A NEW SCENARIO

PVC induced Cardiomyopathy

Isolated Benign PVCs

PVCs: Are they really benign?

• Isolated premature ventricular contractions

(PVCs) are common and occur in patients with any form of structural heart and valvular disease as well as in normal hearts when they are usually considered benign.

• Frequent PVCs themselves sometimes

can cause reversible LV dysfunction and PVC-induced cardiomyopathy.

Outflow Tract VT/PVCs

Frequent Ectopies

Frequent Ectopies

• At the first clinical encounter, patients often

present with both PVCs and LV dysfunction, raising the question which condition came first.

• Factors associated with the risk to develop

PVC-cardiomyopathy have been in the focus of intense investigations and include the PVC burden, duration of symptoms, QRS width, site of origin, and others.

Cardiomyopathy-inducing premature ventricular contractions: Not all animals are equal? Heart Rhythm, Vol 9, No 9, September 2012

Success Site

Loss of Ectopies

Tehran Arrhythmia Center

RFA for PVCs

• Several studies have shown the reversibility
• f LV dysfunction after ablation of PVCs.
• Can we use the results of this studies to

make a case for targeting not just symptomatic but even asymptomatic PVCs in patients manifesting cardiomyopathy?

• Should patients with NICM that meet current

guidelines for undergoing prophylactic ICD implant be screened/ablated for asymptomatic PVCs first?

Sanjay Dixit, MD. Heart Rhythm 2007

AN EXTREME SCENARIO

• 13 year old girl with progressive dyspnea

during the last four years

• Functional class III-IV
• LVEF 15-20%
• Frequent (almost incessant) ventricular

arrhythmias

• Unresponsive to intensive heart failure

therapy and several anti-arrhythmic drugs including a combination of Amiodarone and Mexiletine.

• Transplant candidate

Presenting ECG

ECG at Onset

Success signal

Termination

Final Results

Now in FC I without anti-arrhythmic drugs, LVEF 45%

ANOTHER SCENARIO

Tachycardia-Aggravated Cardiomyopathy

• 40 year-old man with progressive dyspnea, now FC

IV, on transplant list

• Incessant ventricular ectopies and VT
• Marked LV enlargement and dysfunction, LVEF 15%
• Marked LV trabeculations (Non-compaction ?)
• Frequent ectopies with normal LV function

documented 11 years ago. RFA at that time had failed.

• Biventricular ICD implanted at another center,
• bviously not working with almost incessant VT.

ECG at Onset

Anterolateral LV

Disappearance of Ectopies during Burn

Post-RF Rhythm

Effective CRT

Three years post-RFA, he is in FC I with LVEF of 30%

FINAL SCENARIO

Heart Failure with a Wide QRS

• Young girl with severe refractory heart failure

admitted in an ICU and under intravenous inotropes

• LVEF 10%
• A several-year history of treatment with the

diagnosis of asthma

• No history of palpitations or documented

arrhythmias

• Transferred to our center for implantation of

a biventricular device

DCM with wide QRS

Preexcitation

AVRT

Anteroseptal Area

Loss of Delta

Post RFA

Narrow QRS

At Least No Dyssynchrony!

Pre RFA Post RFA

Conclusion

When confronting a patient with heart failure and any kind of tachyarrhythmias incl. AF and uncontrolled ventricular rates Frequent ventricular ectopies think about: <Arrhythmia-induced Cardiomyopathy>

• r

<Arrhythmia-aggravated Cardiomyopathy> There may be a cure available!

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