Dr Ranjith MP     Senior Resident Department of CardiologyGovernment Medical college        Kozhikode
Mechanisms of VTVT arises distal to the bifurcation of the His bundle in the specialized conduction system, ventricular m...
Mechanisms of VT                 Disorders of impulse formationEnhanced automaticity    Can occur in virtually all cardi...
Mechanisms of VT                    Disorders of impulse formationAutomatic ventricular arrhythmias     Premature ventri...
Mechanisms of VT                 Disorders of impulse formationTriggered activityPause-dependent triggered activity     ...
Mechanisms of VT          Disorders of impulse formationTriggered activity                                       Figure A...
Mechanisms of VT                        Disorders of impulse conductionRe-entry (circus movements)                    Ele...
Mechanisms of VT                   Disorders of impulse conduction       Premature Beat Impulse      CardiacRepolarizing T...
Mechanisms of VT                        Disorders of impulse conductionRe-entry (circus movements)                       ...
Mechanisms of VT                        Disorders of impulse conductionRe-entry (circus movements)            Cardiac    ...
Mechanisms of VT                   Disorders of impulse conductionReentrant ventricular arrhythmias     Premature ventri...
Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventri...
Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventri...
Healed MI is the most frequent clinical setting for the development of sustained VTThe first episode of VT can occur yea...
Focal activation by abnormal automaticity in the ischemic border zonea/c ischemia activates KATP channels causing an inc...
Focal discharge by Ca overload & triggered activity in the form of delayed or early after-depolarizations - not been prov...
Reentry is the mechanism underlying the VT associated with healed or healing MI (>95%)         The ability to reproducib...
Important determinants of arrhythmia risk after MI          The extent of myocardial necrosis          Presence of sept...
Electrophysiologic substrate for VT develops in the first 2 weeks after MI - remain indefinitelyTriggers – Acute ischemi...
Reentry – macro/ micro reentryRepolarization of individual myocardial cells not homogenous. Some cells excitable, some r...
Sinus rhythm mapping in a patient with VT in the setting of extensive healed anteriorinfarction. The map is color-coded to...
In the setting of an old MI, the ECG during VT is affected by              The size of infarction              The regi...
Presence of Q waves (qR, QR or Qr) in related leads Notched or wide QRS complexes Low QRS voltage Multiple ventricular...
Surface ECG tends to locate the reentry circuit exit rather than the VT originLocation should be defined in 3 axes:     ...
Lateral wall VT     RBBB pattern     Wider QRS complexesSeptal VT     LBBB pattern     Narrower QRS complexes
The QRS axis in inferior leads indicates the sequence of activation between the superior and inferior walls Inferior MI ...
Predominant polarity of QRS complexes in precordial leads can help discriminate between VTs from the basal or the apical ...
The key determinant of hemodynamic tolerance         Tachycardia rate         Left ventricular function         Develo...
Goal of long-term therapy- prevention of SCD & recurrence of symptomsAsymptomatic NSVT with NLVEF- no treatmentSymptoma...
subendocardial resection of arrhythmogenic focusCryoablationLaser vaporizationPhotocoagulation
Patients resuscitated from VF when coronaryrevascularization is not possible, and there is evidence ofprior MI and signif...
Primary prevention ICD is reasonable in patients with LVdysfunction due to prior MI who are at least 40 days post-MI,and ...
Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventri...
Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventri...
DCM has a propensity to the development of ventricular arrhythmias and sudden deathIncidence of DCM - 4 to 8 cases per 1...
Multiple factors responsible for VT in DCM
Myocardial fibrosis/scar - may act as sites for reentry          At autopsy, extensive subendocardial scarring in the LV...
Diastolic Ca overload caused by decreased sacrcoplasmic reticulum Ca2+–adenosine triphosphatase pumpAfterdepolarizations...
Increased sympathetic tonePurkinje system conduction delay Increased endocardial surface area in dilated atrium or vent...
Macro reentry - dominant mechanismBundle branch reentry ventricular tachycardia (BBRVT) is the most characteristicBBRVT...
Severity of LV dysfunction - most powerful predictorSCD is significantly greater in patients with syncope Laboratory va...
 Vesnarinone Trial (VEST) showed a significant association between the degree of QRS prolongation and mortality          ...
ACEI – reduction in SCD due to VT (37% vs 46%) new VT developed less frequent at 1,2 yrs in enalapril group (VHeFT-II tr...
Amiodarone            Used only on specific arrhythmic indications             Reduces ICD shock frequency , without wo...
Biventricular pacing- severe drug refractory heart failure , in elderly     Improve systolic function by shortening the ...
Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventri...
Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventri...
Commonly occurs in disease with severe LV dysfunction like DCM & conduction abnormalities in the HPSBBR VT may also be s...
Macro re-entrant circuit employing     His Bundle     Both bundle branches     Ramifications of left bundle     Trans...
May present with LBBB or RBBB morphology depending on the antegrade conductionLBBB morphology is common                 ...
VT QRS       Activation       Morphology   SequenceLBBB                LB-H-RB-VRBBB                RB- H-LB-V
Surface ECG in sinus rhythm - non-specific or typical bundle branch block patterns with prolonged QRS durationTotal inte...
Electrophysiologic features During tachy QRS morphology is commonly LBBB type His electrograms precede each V HV interv...
Electrophysiologic features
Electrophysiologic featuresBlock in Bundle branches or HPS will terminate the tachy Ablation of RB renders tachycardia n...
The reentrant circuit involves superior and inferior division of the left bundleRBBB and anterior or posterior fascicula...
HV interval shorter than sinus rhythmLB potential before HIS deflections
High recurrence rate after drugsRFA - first line therapy Treatment of choice for BBR VT is ablation of the RBA PPI sho...
Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventri...
Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventri...
Most frequent – ARVDExtensive myocardial fibrosis - substrate for reentry                                           RV o...
ECG in sinus rhythm1.   Prolonged QRS duration ≥ 110 ms in V1-V3 (Sens-55%, Spec-100%)2.   T wave inversion in right preco...
Ventricular arrhythmias are usually exercise-relatedSensitive to catecholaminesMost Common- LBBB morphology VTUp to 12...
VT in ARVD may be confused with RVOT VT                                       O’Donnell D ET et al. Eur Heart J.         ...
High Risk FeaturesYounger patientsRecurrent syncopeHistory of cardiac arrest or sustained VTClinical signs of RV failu...
Documented VT/VF on c/c OMT, have reasonable expectation of survival- ICD to prevent SCD                   I             ...
Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventri...
Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventri...
SCD in adults with asymptomatic HCM- 1%                                 NSVT – 8%On 24-hr Holter -90% have ventricular a...
In LVH action potential prolongation is due to a decrease in Ito. This results in nonhomogeneous repolarization and prope...
Pharmacologic Treatment          Beta-blockers, verapamil, amiodarone          Long term prophylactic pharmacologic the...
1. Family history of premature HCM-related death2. Unexplained syncope, particularly in young patients,   or if demonstrat...
Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventri...
Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventri...
Ventricular Tachycardia in Patients after  Surgery for Congenital Heart DiseaseMost information concerning patients with ...
Ventricular Tachycardia in Patients after  Surgery for Congenital Heart DiseaseMechanism of VT is reentry involving the R...
Ventricular Tachycardia in Patients after Surgery for Congenital Heart DiseaseThe risk of VT can be assessed by QRS durat...
Ventricular Tachycardia in Patients after Surgery for Congenital Heart Disease                            TreatmentAntiar...
References- Journal1. Relationship between the 12-lead electrocardiogram during ventricular tachycardia   and endocardial ...
References- Journal5. A Comprehensive Approach to Management of Ventricular Arrhythmias, Fred   Kusumoto. Cardiol Clin 26 ...
References – Text Books1. Zipes 5th ed. Cardiac Electrophysiology From Cell to Bedside2. Basic Cardiac Electrophysiology f...
THANK YOU
MCQ-1True statement regarding AVRDA. Ventricular arrhythmias are usually exercise-relatedB. Sensitive to catecholaminesC....
MCQ-1True statement regarding AVRDA. Ventricular arrhythmias are usually exercise-relatedB. Sensitive to catecholaminesC....
MCQ-212 lead ECG of BBR-VT is given below. The antegrade conduction through------------A. Right bundle branchB. Left bund...
MCQ-212 lead ECG of BBR-VT is given below. The antegrade conduction through------------A. Right bundle branchB. Left bund...
MCQ-3 Exists site of the VT circuit given below is ?A. LV lateral wallB. SeptumC.   Right ventricleD. Both B & C
MCQ-3 Exists site of the VT circuit given below is ?A. LV lateral wallB. SeptumC.   Right ventricleD. Both B & C
MCQ-4A 45yr old smoker with past history of hospitalization for chest pain presented to causality with palpitation and hy...
MCQ-4A 45yr old smoker with past history of hospitalization for chest pain presented to causality with palpitation and hy...
MCQ-5A 39 yr old smoker with hypotension in ED was stabilized with DC cardio version and his echo is shown below(Left sid...
MCQ-5A 39 yr old smoker with hypotension in ED was stabilized with DC cardio version and his echo is shown below(Left sid...
MCQ-6All are true about BBR- VT except?A. High recurrence rate after drugsB. Treatment of choice for BBR VT is ablation o...
MCQ-6All are true about BBR- VT except?A. High recurrence rate after drugsB. Treatment of choice for BBR VT is ablation o...
MCQ-7VT in post TOF repair patients are due to the effect of all except?  A.   Years of chronic cyanosis  B.   Presence o...
MCQ-7VT in post TOF repair patients are due to the effect of all except?  A.   Years of chronic cyanosis  B.   Presence o...
MCQ-8 Sudden death risk factors in HCM are all except?A. Family history of premature HCM-related deathB. Unexplained sync...
MCQ-8 Sudden death risk factors in HCM are all except?A. Family history of premature HCM-related deathB. Unexplained sync...
Dr ranjith mp,ventricular tachycardia in abnormal heart dr ranjith mp
Dr ranjith mp,ventricular tachycardia in abnormal heart dr ranjith mp
Dr ranjith mp,ventricular tachycardia in abnormal heart dr ranjith mp
Dr ranjith mp,ventricular tachycardia in abnormal heart dr ranjith mp
Dr ranjith mp,ventricular tachycardia in abnormal heart dr ranjith mp
Dr ranjith mp,ventricular tachycardia in abnormal heart dr ranjith mp
Dr ranjith mp,ventricular tachycardia in abnormal heart dr ranjith mp
Dr ranjith mp,ventricular tachycardia in abnormal heart dr ranjith mp
Dr ranjith mp,ventricular tachycardia in abnormal heart dr ranjith mp
Dr ranjith mp,ventricular tachycardia in abnormal heart dr ranjith mp
Dr ranjith mp,ventricular tachycardia in abnormal heart dr ranjith mp
Dr ranjith mp,ventricular tachycardia in abnormal heart dr ranjith mp
Dr ranjith mp,ventricular tachycardia in abnormal heart dr ranjith mp
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Dr ranjith mp,ventricular tachycardia in abnormal heart dr ranjith mp

  1. 1. Dr Ranjith MP Senior Resident Department of CardiologyGovernment Medical college Kozhikode
  2. 2. Mechanisms of VTVT arises distal to the bifurcation of the His bundle in the specialized conduction system, ventricular muscle, or combinations of bothDisorders of impulse formation  Enhanced automaticity  Triggered activity Disorders of impulse conduction  Re-entry (circus movements)
  3. 3. Mechanisms of VT Disorders of impulse formationEnhanced automaticity  Can occur in virtually all cardiac tissues  Occurs due to increasing the rate of diastolic depolarization or changing the threshold potential  Can arise from cells that have reduced maximum diastolic potentials, often at membrane potentials positive to −50 mV
  4. 4. Mechanisms of VT Disorders of impulse formationAutomatic ventricular arrhythmias  Premature ventricular complexes  Ventricular tachycardia associated with:  Acute myocardial infarction or ischemia  Electrolyte and acid-base disturbances, hypoxemia  Increased sympathetic tone
  5. 5. Mechanisms of VT Disorders of impulse formationTriggered activityPause-dependent triggered activity  Early afterdepolarization (phase 3)  Polymorphic ventricular tachycardiaCatechol-dependent triggered activity  Late afterdepolarizations (phase 4)  Idiopathic right ventricular tachycardia
  6. 6. Mechanisms of VT Disorders of impulse formationTriggered activity Figure A :- Early afterdepolarizations in phase 3 of the AP Figure B :- Late afterdepolarizations seen in late phase 3 or phase 4 of the AP
  7. 7. Mechanisms of VT Disorders of impulse conductionRe-entry (circus movements) Electrical Impulse Cardiac Conduction Tissue Fast Conduction Path Slow Conduction Path Slow Recovery Fast Recovery  Two distinct pathways that come together at beginning and end to form a loop  A unidirectional block in one of those pathways  Slow conduction in the unblocked pathway
  8. 8. Mechanisms of VT Disorders of impulse conduction Premature Beat Impulse CardiacRepolarizing Tissue (long Conductionrefractory period)) TissueFast Conduction Path Slow Conduction PathSlow Recovery Fast Recovery An arrhythmia is triggered by a premature beat The fast conducting pathway is blocked because of its longrefractory period so the beat can only go down the slowconducting pathway
  9. 9. Mechanisms of VT Disorders of impulse conductionRe-entry (circus movements) Cardiac Conduction Tissue Fast Conduction Path Slow Conduction Path Slow Recovery Fast Recovery The wave of excitation from the premature beat arrives at the distal end of the fast conducting pathway, which has now recovered and therefore travels retrogradely (backwards) up the fast pathway
  10. 10. Mechanisms of VT Disorders of impulse conductionRe-entry (circus movements) Cardiac Conduction Tissue Fast Conduction Path Slow Conduction Path Slow Recovery Fast Recovery  On arriving at the top of the fast pathway it finds the slow pathway has recovered and therefore the wave of excitation ‘re-enters’ the pathway and continues in a ‘circular’ movement. This creates the re-entry circuit
  11. 11. Mechanisms of VT Disorders of impulse conductionReentrant ventricular arrhythmias  Premature ventricular complexes  Idiopathic left ventricular tachycardia  Bundle branch reentry  Ventricular tachycardia and fibrillation when associated with chronic heart disease:  Previous myocardial infarction  Cardiomyopathy
  12. 12. Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventricular CardiomyopathiesHypertrophic CardiomyopathyAfter Surgery for Congenital Heart Disease
  13. 13. Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventricular CardiomyopathiesHypertrophic CardiomyopathyAfter Surgery for Congenital Heart Disease
  14. 14. Healed MI is the most frequent clinical setting for the development of sustained VTThe first episode of VT can occur years after infarct healingClinical presentation- tolerated sustained VT to SCDIncidence reduced from 3% to 1%
  15. 15. Focal activation by abnormal automaticity in the ischemic border zonea/c ischemia activates KATP channels causing an increase in extracellular K along with acidosis and hypoxia in the cardiac muscleMinor increases in extracellular K depolarize the myocardiocyte’s RMP , which can increase tissue excitability in early phases of ischemia
  16. 16. Focal discharge by Ca overload & triggered activity in the form of delayed or early after-depolarizations - not been proven experimentally
  17. 17. Reentry is the mechanism underlying the VT associated with healed or healing MI (>95%)  The ability to reproducibly initiate and terminate VT with programmed ventricular extrastimuli- the sine qua non of reentry  Induction of VT in coronary disease is stimulation site specific  An inverse relationship of the extrastimulus coupling interval to the onset of the first tachycardia beat is observed in many VTs
  18. 18. Important determinants of arrhythmia risk after MI  The extent of myocardial necrosis  Presence of septal involvement  Degree of left ventricular dysfunctionAnatomic substrate – extensive scarVT consistently arises from surviving myocytes within extensive areas of infarction Conduction is slow & discontinuous, owing to fibrosis and abnormalities in gap junction distribution & function
  19. 19. Electrophysiologic substrate for VT develops in the first 2 weeks after MI - remain indefinitelyTriggers – Acute ischemia – Surges in the autonomic tone – Heart failureOnce sustained monomorphic VT occurs, risk continues indefinitely, even if acute ischemia & heart failure are adequately controlled Josep Brugada et al JACC Vol. 37, No. 2, 2001:529–33
  20. 20. Reentry – macro/ micro reentryRepolarization of individual myocardial cells not homogenous. Some cells excitable, some refractory
  21. 21. Sinus rhythm mapping in a patient with VT in the setting of extensive healed anteriorinfarction. The map is color-coded to represent bipolar electrogram voltage: red (representingdense scar) denotes = 0.5 mV, purple = 1.5 mV, and the intervening colors represent voltagevalues in between. Multiple inducible VTs of varied morphology were localized tocircuits within the scar
  22. 22. In the setting of an old MI, the ECG during VT is affected by  The size of infarction  The region of infarction  The region within the scar where the circuit is located  The proximity to the His-Purkinje system  The influence of concomitant pharmacological agents
  23. 23. Presence of Q waves (qR, QR or Qr) in related leads Notched or wide QRS complexes Low QRS voltage Multiple ventricular tachycardia morphologies Paroxysmal sustained episodes
  24. 24. Surface ECG tends to locate the reentry circuit exit rather than the VT originLocation should be defined in 3 axes:  septal vs lateral walls  superior vs inferior walls  apical vs basal regionsBundle branch block patterns -sequence of ventricular activation
  25. 25. Lateral wall VT  RBBB pattern  Wider QRS complexesSeptal VT  LBBB pattern  Narrower QRS complexes
  26. 26. The QRS axis in inferior leads indicates the sequence of activation between the superior and inferior walls Inferior MI  Superior axis (80%)Anterior MI  Superior axis (55% )  Inferior axis (45%)
  27. 27. Predominant polarity of QRS complexes in precordial leads can help discriminate between VTs from the basal or the apical regionsVT from the apex  Negative concordant R progressionVT from the basal  Positive concordant R progression
  28. 28. The key determinant of hemodynamic tolerance  Tachycardia rate  Left ventricular function  Development of ischemia, and mitral insufficiencyHemodynamic collapse – cardioversionIntravenous procainamide, sotalol, and amiodarone have been demonstrated to have superior efficacy
  29. 29. Goal of long-term therapy- prevention of SCD & recurrence of symptomsAsymptomatic NSVT with NLVEF- no treatmentSymptomatic NSVT in pts with NLVEF- betablockersCardiac arrest survivors / SUS VT in ↓LVEF- ICDPrimary pvt - ICD > Amiod- pvt of SCD
  30. 30. subendocardial resection of arrhythmogenic focusCryoablationLaser vaporizationPhotocoagulation
  31. 31. Patients resuscitated from VF when coronaryrevascularization is not possible, and there is evidence ofprior MI and significant LV dysfunction I IIa I IIa IIbIIb III III LV dysfunction due to MI who present withhemodynamically unstable VT I IIa I IIa IIb IIb III IIIPrimary prevention - LV dysfunction due to prior MI whoare at least 40 days post-MI and have an LVEF 30%-40% &NYHA II or III I I IIa IIa IIb IIb III III
  32. 32. Primary prevention ICD is reasonable in patients with LVdysfunction due to prior MI who are at least 40 days post-MI,and have an LVEF 30%-35% & NYHA I I IIa I IIa IIb IIb III III ICD implantation is reasonable in patients with post-MIwith normal LV function and recurrent VT I I IIa IIa IIb IIb III III
  33. 33. Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventricular CardiomyopathiesHypertrophic CardiomyopathyAfter Surgery for Congenital Heart Disease
  34. 34. Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventricular CardiomyopathiesHypertrophic CardiomyopathyAfter Surgery for Congenital Heart Disease
  35. 35. DCM has a propensity to the development of ventricular arrhythmias and sudden deathIncidence of DCM - 4 to 8 cases per 100,000 populationIncidence of VT – 50-60% DCM, resp for 8-50% deathsGenetics - Relationship between individual genotypes and arrhythmogenicity is poorly understood
  36. 36. Multiple factors responsible for VT in DCM
  37. 37. Myocardial fibrosis/scar - may act as sites for reentry  At autopsy, extensive subendocardial scarring in the LV in 33% & multiple patchy areas of replacement fibrosis in 57%Sustained stretch-induced shortening of refractory period and AP duration, predisposing to reentryShort, pulsatile, stretch-induced after depolarizations
  38. 38. Diastolic Ca overload caused by decreased sacrcoplasmic reticulum Ca2+–adenosine triphosphatase pumpAfterdepolarizations induced by increased Na+-Ca2+ exchanger activityHypokalemia, hypomagnesemia (often related to diuretic use)Increased circulating catecholamines
  39. 39. Increased sympathetic tonePurkinje system conduction delay Increased endocardial surface area in dilated atrium or ventricle Drugs (antiarrhythmics, digoxin, sympathomimetic)
  40. 40. Macro reentry - dominant mechanismBundle branch reentry ventricular tachycardia (BBRVT) is the most characteristicBBRVT - Responsible for VT in up to 41% of DCMMacro-reentrant circuit involving the His-Purkinje system, usually with antegrade conduction over the RBB and retrograde conduction over the LBB
  41. 41. Severity of LV dysfunction - most powerful predictorSCD is significantly greater in patients with syncope Laboratory values - low serum sodium and increased plasma norepinephrine, renin, and ANP,BNPLBBB & of first- and second-degree AV block has been associated with poor outcome
  42. 42.  Vesnarinone Trial (VEST) showed a significant association between the degree of QRS prolongation and mortality Gottipaty V, et al. J Am Coll Cardiol 33:145A, 1999
  43. 43. ACEI – reduction in SCD due to VT (37% vs 46%) new VT developed less frequent at 1,2 yrs in enalapril group (VHeFT-II trial)
  44. 44. Amiodarone  Used only on specific arrhythmic indications  Reduces ICD shock frequency , without worsening heart failure (SCDHeFT)Implantable Cardioverter-Defibrillators  AMIOVIRT- No difference in mortality ( amio vs ICD)  SCD-HeFT - Significant reduction in total mortality in ICD groupCatheter ablation
  45. 45. Biventricular pacing- severe drug refractory heart failure , in elderly  Improve systolic function by shortening the duration of mechanical systole and increasing dP/dt  Improve diastolic function by prolonging diastolic filling time  Reduce presystolic MR by earlier activation of the lateral papillary muscle without the adverse effect on the sympathetic nervous system seen with inotropic agents
  46. 46. Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventricular CardiomyopathiesHypertrophic CardiomyopathyAfter Surgery for Congenital Heart Disease
  47. 47. Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventricular CardiomyopathiesHypertrophic CardiomyopathyAfter Surgery for Congenital Heart Disease
  48. 48. Commonly occurs in disease with severe LV dysfunction like DCM & conduction abnormalities in the HPSBBR VT may also be seen in:  Myotonic dystrophy  Hypertrophic cardiomyopathy  Ebstein anomaly  Following valvular surgery  Proarrhythmia due to Na channel blockers Presyncope, syncope or sudden death - VT with fast rates > 200 bpm
  49. 49. Macro re-entrant circuit employing  His Bundle  Both bundle branches  Ramifications of left bundle  Transeptal myocardium
  50. 50. May present with LBBB or RBBB morphology depending on the antegrade conductionLBBB morphology is common BBR –LBBB: - antegrade direction -RB & reterograde LB BBR –RBBB:- antegrade direction-LB & reterograde RB
  51. 51. VT QRS Activation Morphology SequenceLBBB LB-H-RB-VRBBB RB- H-LB-V
  52. 52. Surface ECG in sinus rhythm - non-specific or typical bundle branch block patterns with prolonged QRS durationTotal interruption of conduction in one of the BB would theoretically prevent occurrence of reentryCan occur in patients with relatively narrow QRS complex - functional conduction delay
  53. 53. Electrophysiologic features During tachy QRS morphology is commonly LBBB type His electrograms precede each V HV interval during tachycardia > HV in baseline Changes in V–V interval follow the changes in H–H Delay in HPS conduction facilitates induction
  54. 54. Electrophysiologic features
  55. 55. Electrophysiologic featuresBlock in Bundle branches or HPS will terminate the tachy Ablation of RB renders tachycardia noninducibleVT of myocardial origin mimics BBR-LB pattern VT – can be differentiated by the presence of rapid intrinsicoid deflection due to initial ventricular activation through the HPS in the later
  56. 56. The reentrant circuit involves superior and inferior division of the left bundleRBBB and anterior or posterior fascicular block is present during sinus rhythmusually has RBBB morphologyAntegrade - LAF & retro – LPF –RADAntegrade- LPF & retro – LAF- LAD
  57. 57. HV interval shorter than sinus rhythmLB potential before HIS deflections
  58. 58. High recurrence rate after drugsRFA - first line therapy Treatment of choice for BBR VT is ablation of the RBA PPI should be implanted if the post-ablation HV interval is 100 ms or longerICD implant should be considered if myocardial VT occur spontaneously or are inducible or if EF < 35%
  59. 59. Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventricular CardiomyopathiesHypertrophic CardiomyopathyAfter Surgery for Congenital Heart Disease
  60. 60. Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventricular CardiomyopathiesHypertrophic CardiomyopathyAfter Surgery for Congenital Heart Disease
  61. 61. Most frequent – ARVDExtensive myocardial fibrosis - substrate for reentry RV outflow tract RV apex RV inflow segments Marcus fi et al.Circulation 1982; 65:384–398
  62. 62. ECG in sinus rhythm1. Prolonged QRS duration ≥ 110 ms in V1-V3 (Sens-55%, Spec-100%)2. T wave inversion in right precordial leads (Seen in 60%)3. Epsilon wave (Seen in 30%)4. Low-voltage QRS amplitude (Indicate severe cases)
  63. 63. Ventricular arrhythmias are usually exercise-relatedSensitive to catecholaminesMost Common- LBBB morphology VTUp to 12 VT morphologies have been reported in a single patientRBBB VT - LV involvement or a left septal breakthrough site
  64. 64. VT in ARVD may be confused with RVOT VT O’Donnell D ET et al. Eur Heart J. 2003;24:801-810, 2003.
  65. 65. High Risk FeaturesYounger patientsRecurrent syncopeHistory of cardiac arrest or sustained VTClinical signs of RV failure or LV involvementPatients with or having a family member with the high risk ARVD gene (ARVD2)Increase in QRS dispersion ≥ 40 msec  QRS dispersion = max measured QRS minus min measured QRS
  66. 66. Documented VT/VF on c/c OMT, have reasonable expectation of survival- ICD to prevent SCD I I IIa IIa IIa IIb IIb III III BSevere disease LV inv, FH of SCD, undiagnosed syncope, on c/c OMT I I IIa IIa IIa IIb IIb III III CAmiodarone or sotalol effective , when ICD not feasible I I IIa IIa IIa IIb IIb III III CAblation can be adjunctive I I IIa IIa IIa IIb IIb III III CEP testing might be useful for risk assessment I I IIa IIa IIa IIb IIb III III C
  67. 67. Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventricular CardiomyopathiesHypertrophic CardiomyopathyAfter Surgery for Congenital Heart Disease
  68. 68. Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventricular CardiomyopathiesHypertrophic CardiomyopathyAfter Surgery for Congenital Heart Disease
  69. 69. SCD in adults with asymptomatic HCM- 1% NSVT – 8%On 24-hr Holter -90% have ventricular arrhythmias Prevalence of ventricular and supraventricular arrhythmias on 24-hour Holter recording in 178 patients from a community-based population of patients with hypertrophic cardiomyopathy J Am Coll Cardiol 45:697-704, 2005
  70. 70. In LVH action potential prolongation is due to a decrease in Ito. This results in nonhomogeneous repolarization and propensity for EAD Hypertrophied myocytes may produce DAD due to an increase in Ca loadAbnormal pacemaker current (If) has been reported in LVH. Intensity of this current increases with beta adrenergic stimulationIn LVH the density of Ito is reduced. The density of ICaL and IK is unchanged and density of If is increased
  71. 71. Pharmacologic Treatment  Beta-blockers, verapamil, amiodarone  Long term prophylactic pharmacologic therapy now not recommended in high-risk populationICD implantation is reasonable for patients who have 1 or more major risk factor for SCD. (Level of Evidence: C)
  72. 72. 1. Family history of premature HCM-related death2. Unexplained syncope, particularly in young patients, or if demonstrated to be arrhythmia-based3. Frequent, multiple, or prolonged episodes of NSVT4. Hypotensive or attenuated BP response to exercise5. Extreme LVH with maximum wall thickness ≥ 30 mmPresence or magnitude of LVOT obstruction has not proved to be aconsistently strong independent risk factor for SCD in HCM and thereforedoes not constitute a sole justification for prophylactic ICD implantation
  73. 73. Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventricular CardiomyopathiesHypertrophic CardiomyopathyAfter Surgery for Congenital Heart Disease
  74. 74. Coronary Artery DiseaseDilated CardiomyopathyBundle Branch Re-entry Ventricular TachycardiaArrhythmogenic Right Ventricular CardiomyopathiesHypertrophic CardiomyopathyAfter Surgery for Congenital Heart Disease
  75. 75. Ventricular Tachycardia in Patients after Surgery for Congenital Heart DiseaseMost information concerning patients with VT and congenital heart disease pertains to TOFVT in these patients are due to the effect of  Years of chronic cyanosis  Presence of a ventriculotomy  Elevation of RV pressures  Severe pulmonic regurgitation with RV dysfunctionThese factors lead to myocardial fibrosis, resulting reentrant circuits
  76. 76. Ventricular Tachycardia in Patients after Surgery for Congenital Heart DiseaseMechanism of VT is reentry involving the RVOT, either at the site of anterior rt. ventriculotomy or at VSD patchThe incidence of VT significantly higher in patients with RVSP >60 mm Hg and RVEDP > 8 mm HgZeltser et al showed RV volume overload is the most important predictor of inducible ventricular arrhythmias J Thorac Cardiovasc Surg 130:1542-1548, 2005
  77. 77. Ventricular Tachycardia in Patients after Surgery for Congenital Heart DiseaseThe risk of VT can be assessed by QRS duration Syncope & VT- squares Sudden death- triangles Syncope with Afl- star Gatzoulis MA et al. Circulation 95:401-404, 1997
  78. 78. Ventricular Tachycardia in Patients after Surgery for Congenital Heart Disease TreatmentAntiarrhythmics medicationRadiofrequency catheter ablationSurgical CryoablationICD implantationA combined approach of correcting significant structural abnormalities with intra-operative EP-guided ablation may reduce the potential risk of deterioration in ventricular function
  79. 79. References- Journal1. Relationship between the 12-lead electrocardiogram during ventricular tachycardia and endocardial site of origin in patients with coronary artery disease. John M. et al. Circulation 77, No. 4, 759-766, 1988.2. Coronary Artery Revascularization in Patients With Sustained Ventricular Arrhythmias in the Chronic Phase of a Myocardial Infarction: Effects on the Electrophysiologic Substrate and Outcome. Josep Brugada et al JACC Vol. 37, No. 2, 2001:529–333. Ventricular Tachycardia in Coronary Artery Disease . B. Benito, M.E. Josephson / Rev Esp Cardiol. 2012;xx(x):xxx–xxx4. Role of Ablation Therapy in Ventricular Arrhythmias. Mithilesh K. Das et al. Cardiol Clin 26 (2008) 459–4795. Ventricular Arrhythmias in Heart Failure Patients Ronald Lo, Henry H. Hsia. Cardiol Clin 26 (2008) 381–403
  80. 80. References- Journal5. A Comprehensive Approach to Management of Ventricular Arrhythmias, Fred Kusumoto. Cardiol Clin 26 (2008) 481–4966. Relationship between the 12-lead electrocardiogram during ventricular tachycardia and endocardial site of origin in patients with coronary artery disease, J M Miller et al. Circulation. 1988;77:759-7667. Arrhythmogenic right ventricular cardiomyopathy: A cause of sudden death in young people, A. Thomas mcrae et al, Cleveland clinic journal of medicine volume 68 ,No.5, 2001:459-4678. Ventricular arrhythmias in idiopathic dilated cardiomyopathy K Von Olshausen et al. Br Heart J 1984; 51: 195-2019. Non-Sustained Ventricular Tachycardia in Hypertrophic Cardiomyopathy: An Independent Marker of Sudden Death Risk in Young Patients. Lorenzo Monserrat et al, Vol. 42, No. 5, 2003:873–910. Sustained Ventricular Tachycardia in Adult Patients Late After Repair of Tetralogy of Fallot. David A. Harrison et al. JACC Vol. 30, No. 5,November 1, 1997:1368–73
  81. 81. References – Text Books1. Zipes 5th ed. Cardiac Electrophysiology From Cell to Bedside2. Basic Cardiac Electrophysiology for the Clinician .2nd ed. José Jalife, MD3. Clinical arrhythmology and electrophysiology: a companion to Braunwald’s heart disease 8th ed.4. Handbook of Cardiac Electrophysiology. Andrea Natale MD.5. Management of Cardiac Arrhythmias, edited by Leonard I. Ganz, MD, 2002
  82. 82. THANK YOU
  83. 83. MCQ-1True statement regarding AVRDA. Ventricular arrhythmias are usually exercise-relatedB. Sensitive to catecholaminesC. Most Common- LBBB morphology VTD. All are true
  84. 84. MCQ-1True statement regarding AVRDA. Ventricular arrhythmias are usually exercise-relatedB. Sensitive to catecholaminesC. Most Common- LBBB morphology VTD. All are true
  85. 85. MCQ-212 lead ECG of BBR-VT is given below. The antegrade conduction through------------A. Right bundle branchB. Left bundle branchC. Left posterior fascicleD. Left anterior fascicle
  86. 86. MCQ-212 lead ECG of BBR-VT is given below. The antegrade conduction through------------A. Right bundle branchB. Left bundle branchC. Left posterior fascicleD. Left anterior fascicle
  87. 87. MCQ-3 Exists site of the VT circuit given below is ?A. LV lateral wallB. SeptumC. Right ventricleD. Both B & C
  88. 88. MCQ-3 Exists site of the VT circuit given below is ?A. LV lateral wallB. SeptumC. Right ventricleD. Both B & C
  89. 89. MCQ-4A 45yr old smoker with past history of hospitalization for chest pain presented to causality with palpitation and hypotension. Patient was stabilized with DC cardio version and taken to echo lab. His presentation ECG shown below. Echo likely to show?A. LV apical aneurysmB. RWMA anterior wallC. RWMA Inferior wallD. RV outflow aneurysm
  90. 90. MCQ-4A 45yr old smoker with past history of hospitalization for chest pain presented to causality with palpitation and hypotension. Patient was stabilized with DC cardio version and taken to echo lab. His presentation ECG shown below. Echo likely to show?A. LV apical aneurysmB. RWMA anterior wallC. RWMA Inferior wallD. RV outflow aneurysm
  91. 91. MCQ-5A 39 yr old smoker with hypotension in ED was stabilized with DC cardio version and his echo is shown below(Left side) . His presentation ECG is most likely to be ? B A C D
  92. 92. MCQ-5A 39 yr old smoker with hypotension in ED was stabilized with DC cardio version and his echo is shown below(Left side) . His presentation ECG is most likely to be ? B A C D
  93. 93. MCQ-6All are true about BBR- VT except?A. High recurrence rate after drugsB. Treatment of choice for BBR VT is ablation of the RBC. Usually has LBBB morphologyD. V precede each his electrograms
  94. 94. MCQ-6All are true about BBR- VT except?A. High recurrence rate after drugsB. Treatment of choice for BBR VT is ablation of the RBC. Usually has LBBB morphologyD. V precede each his electrograms
  95. 95. MCQ-7VT in post TOF repair patients are due to the effect of all except? A. Years of chronic cyanosis B. Presence of a ventriculotomy C. Elevation of RV pressures D. Severe pulmonic regurgitation with RV dysfunction E. None
  96. 96. MCQ-7VT in post TOF repair patients are due to the effect of all except? A. Years of chronic cyanosis B. Presence of a ventriculotomy C. Elevation of RV pressures D. Severe pulmonic regurgitation with RV dysfunction E. None
  97. 97. MCQ-8 Sudden death risk factors in HCM are all except?A. Family history of premature HCM-related deathB. Unexplained syncope, particularly in young patients, or if demonstrated to be arrhythmia-basedC. Hypotensive or attenuated BP response to exerciseD. Presence or magnitude of LVOT obstruction
  98. 98. MCQ-8 Sudden death risk factors in HCM are all except?A. Family history of premature HCM-related deathB. Unexplained syncope, particularly in young patients, or if demonstrated to be arrhythmia-basedC. Hypotensive or attenuated BP response to exerciseD. Presence or magnitude of LVOT obstruction
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