Mitchell Cohen MD FACC FHRS Co-Director of the Heart Center Section Chief, Pediatric Cardiology Phoenix Children s Hospital Professor of Child Health

Transcription

1 10 Annoying Reasons an Electrophysiologist Gets Called to the Cardiac ICU Mitchell Cohen MD FACC FHRS Co-Director of the Heart Center Section Chief, Pediatric Cardiology Phoenix Children s Hospital Professor of Child Health University of Arizona College of Medicine - Phoenix

2 #10 An electrophysiologist walks into the ICU to evaluate a 4 year old with truncus arteriosus following revision of an RV-PA conduit The bedside nurse informs you that the patient just had an abnormal rhythm that was REALLY FAST. You calmly go over to telemetry to review it only to find that nothing is there. the nurse informs you oh he was off telemetry at that time

3 #10 (cont.,)

4 #9 It is 6:15 pm and you are called to the cardiac ICU for a 3 month-old s/p repair of a transitional AV canal who just had a transient bradycardic event. You go over to telemetry and review the event:

5 #9 (cont.,) You calmly go back to the bedside and discuss with the intensivist that it probably was some sort of a vagal event, but why don t we just set the temporary pacing wires in a back-up VVI mode at 60 bpm. The intensivist calmly tells you there are no temporary wires, the surgeon was not expecting any rhythm issues.

6 #8 You are called to the ICU because a 14 year old with dilated cardiomyopathy just went into SVT (rate 200 bpm, BP 101/68 mmhg). He has received 6 doses of Adenosine with no response. They are about to give a bolus of Amiodarone and wanted to just give you a heads-up in case you hear about it later.. You walk up to the ICU and ask to see the 12-lead: Response: It is up on telemetry!

7 #8 Question #1: Should we give a 7 th dose of Adenosine You walk over to telemetry: You ask to sit-tight and get a 12-lead EKG:

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9 Options???? q1 more dose of Adenosine (300 ug/kg) but faster push through a larger more centrally placed IV q DC cardioversion after sedation q Amiodarone 5mg/kg IV load over 20 minutes q Sedate with Dex q Lidocaine 1 mg/kg IV over 1 minute q Esmolol 100 ug/kg bolus over 2 minutes q Wait do nothing (shift is almost over) q Verapamil IV push q All of the Above

10 You ask the bedside nurse to give 1mg/kg Lidocaine and the tachycardia breaks within 10 seconds Are you surprised that worked?

11 Same Patient the Next Day (tachycardia faster) you decide to give Adenosine

12 What Just Happened??

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14 Distinguishing SVT (aberrancy) from VT q Sometimes understanding the heart disease will help q Sometimes understanding the physiology will help q Always compare to baseline EKG q Go back and look at telemetry q How did it start (PAC, PVC)? q How did it terminate (PAC, PVC)? q Go back and look at telemetry (anything narrow) q If the patient is stable take your time.

15 Wide to Narrow at the Same Rate

16 Circulation: AHA Distinguishing SVT from VT

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18 V1 V6 V1 V6 RBBB

19 #7 A surgeon and an echocardiographer are at the bedside of a 5 month-old patient following repair of tetralogy of Fallot. Both are looking at the monitor trying to ascertain the rhythm. QUESTION: What is going on? ANSWER: Double-blind study

20 #6 It is 8 am and you are about to start a full-day of EP clinic when the ICU doctor calls and tells you that the patient s temporary pacing wires are not working. Patient is a 15 day-old arterial switch/vsd (P.O.D. #1) in complete AV block. You walk up to the ICU and observe the following:

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22 #6 (cont.,) You ask the cardiology fellow, nurse, surgical resident what has been done so far to try and reprogram the temporary pacing box:

23 Universal First Response: ØA output ØV output 20

24 More often than not: Temporary Pacing Fails for Sensing Reasons

25 sensitivity Amplitude (mv) UNDERSENSING OVERSENSING

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27 two hours later the NP calls you back to say the pacemaker is not working again. ventricular undersensing 2 hours later you are called because the nurse thinks it is still not pacing right I am seeing too many spikes. Is this an emergency?????

28 What Just Happened?

29 #5 You come in the morning after admission for a 4 day old admitted with incessant SVT. You look through telemetry & notice your pt had numerous runs of SVT (none of which you were called about). You ask the nurse what he received overnight? All of a sudden you realize you just asked a question during nursing sign-out. SHAME ON YOU

30 #4 ICU Attending to EP Doc on Call: The post-op patient just went into VT. We are thinking of starting amiodarone. EP Doc on Call to ICU Attending: Why Amiodarone? ICU Attending to EP Doc on Call: Cause that is all we have in the PYXIS

31 Is this an emergency? 4 year-old s/p redo RV-PA conduit BP 98/69 mmhg, RAP 9 mmhg, NIRS 73

32 appreciate artifact look left-to-right and right to-left

33 #3 6 hours post-op IAA, VSD s/p repair Stopped in the ICU before you left all OK 30 minutes after you arrived home phone rings I think we are in JET HR 180 (narrow), NIRS 37, Ao sat 97%, Lactate 3.1, Temp 37 Amiodarone 5 mg/kg bolus Amiodarone 5 mcg/kg/min Amiodarone 10 mg/kg bolus No change Amiodarone 5 mg/kg bolus No change æamiodarone 10 mcg/kg/min Still in JET: We are running out of Amiodarone!

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35 Managing JET and What The To Do If Amiodarone Does Not Work? q Minimize adrenergic (exogenous and endogenous) q Easier said than done q Correction of low potassium and magnesium q Temperature control q Aim 35 0 C (can go as low as 34 0 C), may need to sedate/paralyze to avoid shivering.

36 Procainamide & JET

37 Staged Prospective Approach to Post-Op JET ( )

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39 Heart Rate Response to JET

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41 Ivabradine blocks HCN (funny current) and slows sinus automaticity but also slows the ventricular rate in AF

42 Prospective Study Consecutive Study 4 out of 5 conversion who did not respond to Amiodarone

43 R- Wave Synchronized Atrial Pacing (AVT) 100 mmhg AP V s A Really the VA delay p mmhg CVP AV Delay 20 Must Be Short (100 msec) PVARP 1 s

44 #2 16 year-old TOF s/p repair (2008) Worsening PI Ł Pulmonary Valve Replacement. Repair is uneventful (TEE: No PS/PI, moderate RV dysfunction, mild LV dysfunction) Extubated in the OR Called on POD #2 because of telemetry findings from the night before (electrolytes OK) Completely asymptomatic

45 Question to the EP Doctor: Is this anything we need to worry about? Various factors such as surgical incisions, patches, ventricular volume/pressure overload contribute to the development of VT/VF Dysrhythmias increase morbidity and mortality Risk factors: QRS >180 msec (TOF) > 40 msec (TGA), LV dysfunction, LVEDP >14 mmhg, syncope, late repair, positive EP Study (TOF) BUT WHAT ABOUT NON-SUSTAINED VT Is is it predictive of future events? Does the patient need meds? ICD? Nothing?

46 What We Know About Non-Sustained VT in Asymptomatic Post-Op CHD Patients with Otherwise Seemingly Good Repairs

47 What EP Doctors Recommend in NSVT Propanolol Amiodarone Pacing

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49 Sustained VT developed in only 5 patients with documented NSVT Previous studies showed that asymptomatic NSVT (24 0 Holter) was not predictive of future VT development Conclusion: Asymptomatic NSVT, moderate-to-good ventricular function, normal or limited conduction delay (wait-and-see- strategy) EP issues must be looked at with physiologic data

50 Symptomatic NSVT is predictive of future ICD shocks (Khairy Circulation 2008 TOF Hazard Ratio 3.9)

51 q 53% of patients with sustained VT and an ICD received an appropriate shock q So unless a very obvious electrolyte disturbance, sustained VT should be treated with an ICD or ablation (anti-arrhythmic therapy not likely to suffice)

52 #1 The only thing worse than rhythm problems in the CICU are rhythm problems in the NICU

53 Thank You