TACHYARRHYTHMIAs. Pawel Balsam, MD, PhD
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1 TACHYARRHYTHMIAs Pawel Balsam, MD, PhD
2 SupraVentricular Tachycardia Atrial Extra Systole Sinus Tachycardia Focal A. Tachycardia AVRT AVNRT Atrial Flutter Atrial Fibrillation
3 Ventricular Tachycardia Ventricular Extra systole VT ( reentry ) Ventricular Flutter Ventricular Fibrillation
4 ARRHYTHMIAs
5 Diagram of Atrio-Ventricular (AV) Nodal Reentry
6 AV-Nodal Reentrant Tachycardia Regular Narrow QRS No P-waves
7 AVNRT ECG HR=150 atrial activation over the retrograde fast pathway
8 AV-Nodal Reentrant Tachycardia Clinical Aspects Palpitations Tachycardia of sudden onset and end Heart beats to the neck Rarely cause of syncope Typically 4-10 episodes per year Duration: minutes to hours
9 AV-Nodal Reentrant Tachycardia Therapy Acute treatment: - Vagal maneuvers - Adenosine - Verapamil Chronic treatment - catheter ablation - (Verapamil, β-blockers)
10 AV Nodal Modification Slow pathway fibers travel from the region of the coronary sinus os toward the more anterior and superior AV node. Fast pathway fibers are closer to the His bundle.
11 ARRHYTHMIAs
12 AV Anatomy His
13 AV-Reentrant Tachycardia Regular Narrow QRS PR>RP P P
14 ECG of Accessory Pathway Concealed Delta Wave
15 Tachycardia circuits utilizing an accessory pathway
16 ECG - Right Accessory Pathway in sinus rhythm Delta Wave
17 IC - Right Accessory Pathway Short AV interval => near the accessory pathway Initiation of Ventricular Activation
18 ECG - Orthodromic Tachycardia Retrograde conduction over the AP CL = 235 ms P wave PR>RP
19 IC - Orthodromic Tachycardia Retrograde conduction over the AP Normal HV HRA activation before LA (CS) => right AP.
20 Wolf-Parkinson-White syndrome WPW syndrome was defined as a combination of: delta wave, short PR, Tachycardia. (without proving the mechanism) Short PR interval, less than (120 ms) (in SR) Slurred upstroke to the QRS indicating preexcitation (delta wave) Broad QRS
21 Left Accessory Pathway The left atrium, The Mitral valve annulus, The left ventricle, The accessory pathway with para-annular attachment onto the left atrium.
22 AV-Reentrant Tachycardia Clinical Aspects Palpitations Tachycardia of sudden onset and end May cause syncope (overt pathways) - risk of sudden death Typically 4-10 episodes per year Duration: minutes to hours
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25 AV-Reentrant Tachycardia Therapy Acute treatment: - Vagal manoeuvres - Adenosine - class Ic-drugs (e.g. flecainide) Chronic treatment - catheter ablation - (class Ic-drugs, β-blockers) Verapamil and digoxin!!! Surgery (in the past...)
26 Ablation of left Accessory Pathways Retrograde aortic approach Tip is placed 1. underside of the mitral annulus 2. top of the mitral valve on the atrial portion of the atrioventricular groove. IC - fusion of atrial and ventricular ECGs with an AP potential
27 Ablation of left Accessory Pathways Trans-septal approach
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29 ARRHYTHMIAs
30 Typical Atrial Flutter atrial CL ms often 2:1 conduction - ventricular rate 150 narrow QRS or BBB
31 Atrial Flutter
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33 Atrial Flutter - 2:1 AV conduction The sawtooth can usually be seen in the leads II, III and avf if one looks closely. Sometimes in V1. Suspect 2:1 flutter when you see a rate of about 150 bpm.
34 Typical Atrial Flutter A characteristic 'sawtooth' or 'picket-fence' waveform of an intra-atrial re-entry circuit usually at about 300 bpm. This patient was taking rather too much digoxin and has a very slow ventricular response.
35 Atrial Flutter Clinical Aspects Palpitations Tachycardia (2:1 conduction) Dyspnoea Angina pectoris Rarely asymptomatic Symptoms related to severity of underlying heart disease
36 Atrial Flutter Therapy Electrical cardioversion Catheter ablation Antiarrhymic drugs - risk of 1:1 conduction Amiodarone, sotalol, flecainide
37 Atrial Flutter - CARTO Baseline Map - 8 points Nie można wyświetlić obrazu. Na komputerze może brakować pamięci do otwarcia obrazu lub obraz może być uszkodzony. Uruchom ponownie komputer, a następnie otwórz plik ponownie. Jeśli czerwony znak x nadal będzie wyświetlany, konieczne może być usunięcie obrazu, a następnie ponowne wstawienie go. His TA - Inf Inf-Sep Inf-Lat ICV - Ant Ant-Sep Ant-Lat
38 Atrial Flutter Ablation Line Between TA - Inf and ICV - Ant
39 ARRHYTHMIAs
40 Atrial Fibrillation No P-waves Variable RR-intervals Narrow QRS or BBB
41 Atrial Fibrillation
42 Atrial Fibrillation +LBBB
43 Atrial Fibrillation Background and Aetiology Most frequent supraventricular tachycardia Age-dependent increase - 1% of total population - 3-4% > 60 years. - 7% > 70 years. Often related to cardiovascular diseases - hypertension - organic heart disease
44 Atrial Fibrillation Clinical Aspects Paroxysmal, permanent or persistent AF Absolute arrhythmia Bradycardia or tachycardia Palpitations Dyspnoea and/or angina Very rarely syncope Frequently asymptomatic Significant risk of thromboembolic complications
45 Atrial Fibrillation Guidelines for the management of atrial fibrillation The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC) 2010
46 AF natural time course
47 EHRA score of AF-related symptoms
48 Questions to be answered
49 Atrial Fibrillation Therapy Rate control Rhythm control Prevention of thromboembolism
50 CHADS2-VASC
51
52 AF - management
53 Acute management
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56 Ventricular Extrasystole Premature No P wave Wide QRS
57 Ventricular premature beats (VPBs)
58 Ventricular bigeminy A ventricular premature beat follows each normal beat
59 Ventricular Extrasystole Clinical Aspects Often no symptoms Palpitations Symptoms depend on incidence May induce other arrhythmias - ventricular tachycardia
60 Ventricular Extrasystole Therapy Often no therapy necessary Antiarrhythmic drugs - Cave: CAST-data (catheter ablation)
61 Ventricular Tachycardia wide QRS no P waves no typical BBB
62 Ventricular Tachycardia 70 yrs, previous myocardial infarction, on a beta-blocker, after a shock, sinus rhythm.
63 VT Overview Ischemic (Post MI) Scar related Slow conduction pathways Re-entry mechanism Idiopathic VT Not associated with detectable structural heart disease. Usually Focal mechanism RVOT
64 Ventricular Tachycardia Clinical Aspects Tachycardia Palpitations Dyspnoea Angina pectoris (Pre)syncope Sudden death
65 Ventricular Tachycardia Therapy Sustained VT always requires patients evaluation (and therapy) Antiarrhythmic drugs Catheter ablation Antitachycardia surgery Implantable cardioverter/defibrillator
66 Ischemic VT The basic treatment approach is to block the conduction through the critical slow pathway. Normal Endocardium Scar Slow Pathway
67 Scar related VT
68 Ventricular Flutter/Fibrillation no QRS detectable
69 Ventricular Fibrillation
70 Ventricular Flutter/Fibrillation Background and Aetiology Patients with organic heart disease - coronary artery disease, - acute MI or - post MI - cardiomyopathies Rarely in healthy subjects - idiopathic VF Rarely in pts. with WPW-syndrome Degeneration of ventricular tachycardia
71 Ventricular Flutter/Fibrillation Clinical Aspects Syncope within seconds Dramatical drop of blood pressure Generalised ischemia Asystole within minutes Sudden cardiac death
72 Ventricular Flutter/Fibrillation Therapy Immediate resuscitation Defibrillation as soon as possible After survival careful examination - Heart catheterization - Electrophysiologic study Therapy of 1st choice: ICD-implantation
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