Ventricular Arrhythmias And Sudden Cardiac Death

Transcription

1 Ventricular Arrhythmias And Sudden Cardiac Death Magnesium And Potassium Levels In Critically Ill Patients With Supraventricular And Ventricular Arrhythmias P.I. Altieri, W. González, H.L. Banchs, N. Escobales, M. Crespo Department of Medicine and Physiology, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico Introduction: Magnesium (Mg++), Potassium (K+) and Calcium (CA+) are crucial electrolytes in maintaining a stable electrophysiological status in critically ill patients (P.) The purpose of this study was to measure the above electrolytes in critically ill P Methods: 28 consecutive P. were analyzed for abnormalities in the electrolytes status. 18 were females and 10 males with a mean age of 62 years. Results: The admission diagnosis in 95% of the cases was congestive heart failure. Levels of these electrolytes and arrhythmias were analyzed. 64% had subnormal values of Mg++ < than 2mg% (1.8 ±.2mg%). 53 % of K+ < than 4.0mg% (3.8 ±.7mg%) and CA++ < 8mg% (7.4 ±.1mg%). Lower values of the 3 (14%) and (42%) of Mg+-K+. The QTC interval was increase (>440msec) in 28%. 25% had Atrial Fibrillation (A.F.) and Ventricular Tachycardia (V.T.). Conclusion: This data shows that Mg++ and K+ deficiency produces A.F. and V.T in critically ill P.

2 Malignant Arrhythmias In Peripartum Cardiomyopathy M. Yahalom, L. Ilan-Bushari, E. Rosner, M. Jabaren, Y. Turgeman Cardiology Department, Ha Emek Medical Center, Afula, Israel Introduction: Peripartum Cardiomyopathy (PPCM) is a rare disorder, defined as the onset of acute heart failure, without demonstrable cause, in the last trimester of pregnancy, or within the first 6 months after delivery. It is often unrecognized, as symptoms of normal pregnancy mimic those of mild heart failure. PPCM is seldom presented as a cardiac arrest. Objectives: The purpose of our presentation is to raise awareness and suspicion of PPCM, even when symptoms are mild, and to suggest a clinical evaluation of pregnant women, before lethal or disabling events occur. Methods and Results: A healthy 42-yr-old woman with well documented ventricular fibrillation, was admitted to CCU after cardiac arrest and resuscitation at home, 10 days after her 5th child was born. On arrival the patient was unconscious. On examination S3 was detected. An ECG revealed sinus tachycardia of 110bpm, while an echocardiogram demonstrated global reduced left ventricular function. Brain CT and Coronary arteriography were normal. There was no evidence of pulmonary embolism on CT angiography. Serum markers of acute coronary syndrome were negative. Therapy included artificial respiration and hypothermia. The patient recovered after one week, and an automatic cardiac defibrillator (AICD) was implanted before discharge. This patient resembles another young 28-yr-old woman, who was admitted to CCU eight years ago, in her 38-week 3rd pregnancy, because of palpitations and dyspnea; on examination S3 was detected, with documented non-sustained Ventricular Tachycardia (VT), with LBBB pattern and right axis of QRS, that was successfully treated with Carvedilol and Quinidine (following obstetric consultation). An echocardiogram revealed moderate global reduced left ventricular function. In summary, 2 female patients, out of 12 patients with PPCM (16%), between the years , with the mean age of 34 years (range 24-42) have been diagnosed as suffering of PPCM, that presented with ventricular arrhythmias (one in a malignant form). Conclusion: Our conclusions: PPCM is a rare disease, that, when appears, may have a lethal or disabling presentation. Careful followup should be performed for every pregnant woman, especially in the presence of symptoms, however mild. The question of expanding perinatal care, to meticulous clinical, and electrocardiographic evaluation, should be considered.

3 The Bacterial Cultures Of Patients Developing Fever After Successful Out Of Hospital CPR N. Teodorovich, C. Shachter, G. Goltzman, M. Kagansky, Z. Vered Department of Cardiology, Asaf Harofeh Hospital and Tel Aviv University, Tel Aviv, Israel Introduction: After successful out of hospital CPR, patients frequently develop fever after admission and are treated with antibiotics. The objective of this study was to find objective evidence of infection in these patients. Methods: The data of all patients that were hospitalized in our institution after out of hospital CPR was collected from electronic database. The bacterial cultures obtained in the first 48 hours were evaluated. Results: A total of 110 patients were included. Eighty five percent were males, 35% were previously diagnosed with coronary disease. Bacterial cultures were obtained in 52 patients. Thirty seven percent had positive cultures, including contaminants. Of those, 13.5% were blood cultures. Forty five (41%) of patients survived till the end of the study. There was no correlation between positive cultures and fever, fever and mortality, and positive cultures and mortality. Conclusion: Bacterial infection is an infrequent cause of early in patients hospitalized after out of hospital CPR. Neither fever, nor positive microbial cultures are related to the patients outcome. The empiric antibiotic treatment of such patients should be restricted without proven source of infection.

4 Diagnosis And Follow-Up Of Athletes With Anomalous Origin Of The Left Circumflex Coronary Artery From The Right Aortic Sinus V. Pescatore 1, C. Basso 2, E. Brugin 1, S. Compagno 1, M. Vettori 1, D. Noventa 1, G. Thiene 1, F. Giada 1 1 Cardiovascular Department, Sports Medicine Unit, P.F. Calvi Hospital, Noale-Venice, Italy 2 Department of Cardiac, Thoracic e Vascular Sciences, University of Padua, Padua, Italy Background: Anomalous origin of coronary arteries (CA) is a cause of sudden death in the athletes. Origin of left circumflex (LCx) CA branch from the right aortic sinus or artery with a retro-aortic course, is the most frequent congenital CA anomaly. However, its clinical significance still remains unknown. The aim of the study was to assess the diagnostic value of transthoracic echocardiography (TTE) to diagnose this anomaly and to obtain follow-up data of these athletes. Methods: During pre-participation screening, 11 asymptomatic athletes (aged years) were identified with TTE suspicion of anomalous origin of LCx CA from right aortic sinus ( tubular shape of the coronary running behind the aorta). The indications for TTE were: hypertension (1), systolic murmur (3), brady-arrhythmias (1), repolarization abnormalities (2), ST-T abnormalities during stress test (1), ventricular or supraventricular arrhythmias (3). To confirm the TTE suspicion, cardiac magnetic resonance (CMR) was performed in 8 and multidetector computed tomography in 3 athletes. Results: The diagnosis of anomalous CA with a retro-aortic course was confirmed in 9/11 athletes (82%). In 8 athletes, all with anomalous origin of LCx CA from right aortic sinus and negative exercise stress test, no clinical events occurred during a mean follow-up of 24 months, despite they continued to participate in competitive sports activities. In the athlete with ST abnormalities during stress test and inducible ischemia at stress CMR with late enhancement, angiography demonstrated an anomalous origin of the right CA from the left aortic sinus running behind the aorta; this patient was disqualified from sport participation. Conclusion: These data show a good specificity of TTE in detection of CA anomalies with a retro-aortic course. In the absence of signs of myocardial ischemia, short-term prognosis of athletes with this anomaly seems good. Further diagnostic work-up is mandatory for those athletes with ST-T abnormalities during stress test in order to exclude a major CA anomaly.

5 Clinical Outcomes Of Young And Master Athletes Disqualified From Competition Because Of Cardiovascular Conditions V. Pescatore 1, C. Basso 2, E. Brugin 1, S. Compagno 1, M. Vettori 1, B. Reimers 3, D. Noventa 1, G. Thiene 2, F. Giada 1 1 Cardiovascular Department, Sports Medicine Unit, P.F. Calvi Hospital, Noale-Venice, Italy 2 Department of Cardiac, Thoracic e Vascular Sciences, University of Padua, Padua, Italy 3 Cardiovascular Department, Cardiology, Mirano hospital, Mirano-Venice, Italy Aim: To analyze the cardiovascular (CV) causes of disqualification from competitive sports in young (<35 years) and master ( 35 years) athletes consecutively screened at our Sports Medicine Centre in a 10 years time interval and to collect follow-up data. Methods: During the period, athletes (young 91%, master 9%) were screened according to Italian Protocol (history, physical examination, 12-lead ECG, exercise stress testing). CV conditions were analyzed on the basis of the reasons for proceeding with further CV examinations. Athletes with CV diseases were treated according to specific guidelines. Results: Overall, disqualified athletes were 99 (0.20%), 94 (95%) for a CV causes. They were referred for further examinations because of positive history for CV diseases (18%), heart murmurs or hypertension (9%), 12-lead ECG or stress test abnormalities (73%). Among young athletes 63 (0.19%) were disqualified for the following CV causes: rhythm and conduction abnormalities (21), bicuspid aortic valve (12), mitral valve prolapse (MVP) with ventricular arrhythmias (VA) (10), arrhythmogenic right ventricular cardiomyopathy (ARVC) (3), hypertrophic cardiomyopathy (HCM) (3), congenital coronary artery anomalies (3), myocarditis (2), dilated cardiomyopathy (1), coronary artery disease (CAD) (1), atrial septal defect (2), Kawasaki disease (1), left ventricular diverticulum (1), hypertension (2), pulmonary hypertension (1). During follow up (63±34 months) clinical course of young athletes with CV diseases was unremarkable. Among master athletes 31(1%) were disqualified for the following CV causes: MVP with VA (6), CAD (4), hypertension (3), HCM (2), ARVC (1), dilated cardiomyopathy (1), VA in myocardial fibrosis (2), and idiopathic VA (12). During follow-up (76±41 months) there were no deaths but two acute coronary syndromes. Conclusion: CV disqualification rate was higher in master than young athletes (1% vs 0.19%). Clinical course of athletes with CV diseases was favorable, probably because they were disqualified from competition and appropriately treated. These data confirm the usefulness of preparticipation screening and the key role of 12-lead ECG and stress test for the identification of CV disease potentially at risk of sudden death.

6 Current Global Practice Of Icd Testing: Everyone To His Taste?! D. Bastian 1, F. Al Kandari 2, M. Sepsi 3, F. Lorgat 4, A. Naik 5, H. Mazzetti 6, D. Becker 7, R. Sweidan 8 on behalf of PANORAMA Investigators 1 Klinikum Nürnberg - Süd, Nürnberg, Germany, 2 Kuwait Cardiac Center, Kuwait, 3 University Hospital Brno, Brno, Czech Republic, 4 Christiaan Barnard Memorial Hospital, Cape Town, South Africa, 5 Care Insititute of Medical Sciences, CIMS hospital, Gujarat India, 6 Hospital General de Agudos Juan A. Fernández, Buenos Aires, Argentina, 7 Medtronic Germany, 8 King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia Aim: Improved technology, the use for primary prevention of sudden cardiac death and potential risks of defibrillation testing (DT) have caused doubts on the necessity of intraoperative testing with Implantable Cardiac Defibrillators (ICD). Methods: PANORAMA is a long term, multi-center, prospective, non-randomized observational study. We analyzed the current practice of ICD testing at 100 hospitals across 6 geographical regions. In total 2084 subjects were implanted with an ICD (N=1405) or CRT-D (N=679) between 2005 and Results: Overall 51% devices were implanted without testing. DT ranged from 28% (Middle East) to 71 % (South Africa) and decreased over time. In 29 centers all implanted devices were tested, 38 centers tested <50% including 11 centers not testing. Conclusion: There are significant differences between and within global regions in current practice of ICD and CRT-D testing with a large proportion of not tested devices and a general trend to less testing. PANORAMA will follow up the impact of the observed differences on patient s outcome in the long term. Table 1: ICD test by region Total patients 2084 (100%) Patients tested 1020 (49%) Primary Prevention tested 554 (45%) Eastern Europe 534 (26%) 54% 42% 42% India 125 (6%) 62% 46% 32% Latin America 211 (10%) 63% 59% 43% Middle East 634 (30%) 28% 29% 15% South Africa 119 (6%) 71% 60% 52% Western Europe 461 (22%) 58% 62% 17% CRT-D tested 214 (32%) Table 2: Variable More Testing Multivariate logistic regression with endpoint ICD test and regions / CRT forced to stay in the model Odds ratio (95%CI) VF Induction at Implant (1020 pts) NO VF Induction at Implant (1064 pts) V Lead Position Not Apex 14.9 ( ) 300 (66%) 158 (34%) Impl Physician Cardiologist 3.8 ( ) 529 (67%) 264 (33%) Region: Latin America 2.4 ( ) 132 (63%) 79 (37%) Region: Eastern Europe 1.8 ( ) 286 (54%) 248 (46%) Region: India 1.6 ( ) 77 (62%) 48 (38%) Region: South Africa 1.6 ( ) 84 (71%) 35 (39%) Gender Male 1.5 ( ) 847 (50%) 832 (41%) Region: Western Europe 1.2 ( ) 266 (58%) 195 (48%) LVEF(%) 1.01 ( ) 33.1 (±13.6) 29.4 (±10.9) Less Testing Primary Prevention 0.7 ( ) 559 (45%) 680 (55%) History of AF 0.6 ( ) 186 (44%) 241 (56%) Year of Implantation 0.6 ( ) (±1.6) (±1.5) CRT ICD 0.4 ( ) 214 (32%) 465 (68%) Region: Middle East 0.1 ( ) 175 (28%) 459 (72%)

7 Follow-Up And Safety Of Implantable Cardiac Defibrillator In The Elderly J. Morales, M. Ortiz, M. Cortes, R. Robledo Electrophysiology Department of the National Medical Center 20 de Noviembre, ISSSTE, Mexico City, Mexico Introduction: The ICD (implantable cardioverter defibrillator) is a worlwide accepted therapy for preventing ventricular arrhythmias, however in the elderly there is a trend to diminish the amount of devices implanted in part due to other comorbidities that increases the general mortality and in part because of age itself. Nowadays the life expectancy has increase and these patients could have a better quality of life and survival. The aim of this study is to show that is a safety procedure and could be helpfully in this kind of patients without increasing the mortality and the secondary effects of the therapy like inappropriate shocks. Patients and Methods: We retrospectively included all patients 70 years or older send for ICD implantation from june 2002 to september 2011; we collected the data from the files since the day of the implantation until December We used central tendency meters for statistical analysis. Results: We included 15 patients (pts) with median age of 74 years old (rank 70-84). There were 93% males. The associated comorbidities were as follows: Ischemic Heart Disease 87%, Hypertension 67%, Smokers 47%, and Diabetes 20%. Only 3 patients had a resynchronization therapy. The ejection fraction was <30% in 5 pts (33.3%), 30-50% in 6 (40%), and >50% in 4 (26.6%). The reason for the implant was secondary prevention in 10 pts (66.6%) of whom only 4 had an appropriate defibrillator therapy at 4, and 270 days respectively. The site of the ventricular lead were in apex in 1 pts, middle septum in 2 pts, the other 13 in right ventricular outflow tract. There were no complications during the implant and there are no mortality during follow up. The acute and chronic pacemaker values are list in the following table. Thresolds Atrium Ventricule Sensitivity P wave R wave Impedances (Ohms) Atrium Ventricule Acute At 1 year At 3 years Shock Impedances (Ohms) Conclusions: The ICD implantation in the elderly is a safe procedure at the implant and during follow up; has the same indication than other young patients, and could increase the survival and the quality of life in this rank of age.