ΗΛΕΚΤΡΙΚΗ ΘΥΕΛΛΑ · Electrocardiographic Morphology • Monomorphic VT due to...
Transcript of ΗΛΕΚΤΡΙΚΗ ΘΥΕΛΛΑ · Electrocardiographic Morphology • Monomorphic VT due to...
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ΗΛΕΚΤΡΙΚΗ ΘΥΕΛΛΑ
ΓΕΩΡΓΙΟΣ ΣΤΑΥΡΟΠΟΥΛΟΣΒΚΚ ΓΝ ΙΠΠΟΚΡΑΤΕΙΟ
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Period of severe cardiac electrical instability manifested by recurrent ventricular arrhythmias.
Defined as the occurrence of three or more distinct episodes of ventricular tachycardia (VT) and/or ventricularfibrillation (VF) within a 24 h period, leading to appropriate ICD therapies
extensive range of clinical situations and tachyarrhythmia events
❖Dramatic Clinical presentation
❖worsens electrical and hemodynamic decompensation.Arrhythmic emergency!
❖Structural arrhythmogenic cardiomyopathies :ischemic and non-ischemic in terms of arrhythmogenic substrate, represent the gradual evolution of the underlying structural heart Disease❖inherited arrhythmic syndrome:Brugada Syndrome, CPVT early repolarisation and premature ventricular contraction-induced ventricular fibrillation❖ES is also associated with psychological morbidity from multiple implanted cardioverter defibrillator (ICD) shocks and exponential health resource utilisation
ELECTRICAL STORM
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ELECTRICAL STORM
❖Distinctive arrhythmia syndrome with its specific management issues andprognostic consequences that differ from ventricular tachycardia andventricular fibrillation episodes unrelated to storm
❖Monomorphic VT due to wavefront reentry is the most comon and doesnot require active ischemia as a trigger, and it is uncommon in patients whoare having an acute MI
Affects patient prognosis:• progressive deterioration of cardiac function from prolonged low-output states
•direct cell injury caused by frequent shocks• and/or an adverse haemodynamical effect of antiarrhythmic medication
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Electrocardiographic Morphology
• Monomorphic VT due to wavefront reentry-storm related to anidentifiable electrophysiological substrate, is the most comon and doesnot require active ischemia as a trigger, uncommon in patients who arehaving an acute MI
• Polymorphic ventricular tachycardia and ventricular fibrillation storm aremost often related to acute myocardial ischaemia, ion channelopathies oridiopathic VF, in patients with structurally normal hearts
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INCIDENCE
10-30% of ICD recipients for secondary prevention
4-7% for primary prevention may experience storm
Storm recurs in a high proportion of patients after an initial episode, and multiple storm clusters may occur in follow-up
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CLINICAL IMPLICATION
AVID trial for secondary prevention: 34 of 90 (38%) electrical storm patients died during follow-
up compared to 15% of those without electrical storm.
Patients with secondary prevention ICDs, had a 5.6-fold increase in mortality in the first 12 weeksafter ES
Electrical storm was a significant independent risk factor for subsequent death, independent ofejection fraction and other prognostic variables
MADIT II18-fold increase risk of death in the first 3months
17 of 32 patients (53%) with ICD for secondary prophylaxis
died during 3 years of follow-up, vs 19 of the 137 (14% ),
ICD patients without electrical storm.
Gatzoulis et al
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E.STORM-MORTALITY
T. Noda et al. / International Journal of Cardiology 255 (2018) 85–91
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Specific precipitants❑ acute ischemia
❑ worsening heart failure
❑ hypokalemia- hypomagnesemia
❑ proarrhythmic drug therapy
❑ hyperthyroidism
❑ infection or fever
Triggers can be identified onlyin a minority of patients
“28 of the 32 patients with ESpresented with seriouselectrical instability in theabsence of any detectablehaemodynamic, metabolic, orelectrolytic abnormality.”
K.A. Gatzoulis et al
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Risk factors• Older age
• Male gender
• lower ejection fraction,
• More advanced heart failure
• higher prevalence of cardiovascular comorbidities
• More inducible VTs
Am J Cardiol 2006;97:389 – 392
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TREATMENT
➢ICD reprogramming
➢ sympathetic blockade
(sedation, intubation, ventilation, beta blockers)
➢ anti-arrhythmic drugs
➢intervention techniques
• Catheter ablation
• neuraxial modulation (e.g., thoracic epidural anaesthesia, stellate ganglion block)
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ANTI-ARRHYTHMIC DRUGS
• Beta-blockers (Propranolol)Add beta-blockers IV in electrical storm patients already on oral beta-blocker therapy
• AmiodaroneIncidence of IV-amiodarone-refractory electrical storm ≈ 30%. • I B Antiarryhtmics
AADs carry the risk of decreasing the cycle length of re-entryVAs and make VT more stable, which may precipitate toincessant VT. Drug combinations are sometimes necessary toalter electrical instability
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Circulation. 2018;138:551–553.
TREATMENT
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TREATMENT
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TREATMENT
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RF ABLATION
ACUTE MANAGEMENT
• Carbucicchio C, Santamaria M, Trevisi N, Maccabelli G,Giraldi F, Fassini G, et al
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Outcomes of catheter ablation of ES are excellent with resolution of storm in over 90%ofpatients at1year with a low complication rate( 2%).
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PROPHYLACTIC TREATMENT:EARLY vs LATE
Journal of Cardiovascular Electrophysiology Vol. 22, No. 10, October 2011
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NEW ABLATION TECHNIQUES
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CATHETER ABLATIONOUR EXPERIENCE
Clinical arrhythmia was successfully ablated in 14 out of 19 (73.7%) cases after a singleCA procedure. A completely successful CA outcome was associated with significantly increasedES-free survival compared with a partially successful or failed procedure (Log rank PZ0.039).
S. Paraskevaidis et al.Hellenic Society of Cardiology (2017) 58, 51e56
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REAL LIFE
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Real life
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Conclusions
➢ES is expected to occur in almost one of five patients treated with an ICD for thesecondary prevention of SCD .
➢ES is most likely to occur in older ICD patients with advanced left ventriculardysfunction and CHF.
➢long-term outcome is limited by an increased cardiac mortality
➢Optimal medical therapy with blockers and angiotensin-converting enzyme inhibitors+newer therapies could reduce the incidence of this devastating complication
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➢Powerful association between improved survival and freedom from inducible VT and recurrentVT after ablation(outcomes for scar-related VT are actually superior to those achieved with pulmonary veinisolation with regard to arrhythmia recurrence)
➢VT ablation is the first ablation therapy to demonstrate a consistent mortality benefit
➢VT ablation reduces shocks ,recurrences and improves mortality on E. Storm patients(50% to75% freedom from VT
➢Existing data suggest that early ablation is better regarding arrhythmia recurrences ICD shocksand mortality
➢No data from R. Trials regarding the optimal point for Catheter ablation after ICD implant areavailable
Conclusions