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Recurrent ventricular arrhythmia after cardiac surgery

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  • 1. Management of Post-Management of Post- Cardiac SurgeryCardiac Surgery Ventricular ArrhythmiasVentricular Arrhythmias Salah Eldin Atta, MDSalah Eldin Atta, MD Consultant Electrophysiology,Consultant Electrophysiology, SBCC, Al-Dammam, KSASBCC, Al-Dammam, KSA Associate Professor of Cardiology,Associate Professor of Cardiology, Assiut University, EgyptAssiut University, Egypt
  • 2. Objectives:Objectives:  Importance and Epidemiology ofImportance and Epidemiology of Ventricular Arrhythmias after cardiacVentricular Arrhythmias after cardiac surgery.surgery.  Aetiology and mechanisms.Aetiology and mechanisms.  Diagnosis and Risk assessmentDiagnosis and Risk assessment  Acute management of different types ofAcute management of different types of post operative Ventricular Arrhythmiaspost operative Ventricular Arrhythmias  Long term management.Long term management.
  • 3. Why to bother about postoperativeWhy to bother about postoperative Ventricular Rhythms/Arrhythmias?Ventricular Rhythms/Arrhythmias?  Indicator of irritability in the ventricles thatIndicator of irritability in the ventricles that may be an alarm of a serious aetiology.may be an alarm of a serious aetiology.  Haemodynamic effects due to loss of atrialHaemodynamic effects due to loss of atrial kick, and dys-synchrony in the contractionkick, and dys-synchrony in the contraction which can significantly decrease cardiacwhich can significantly decrease cardiac output specially with ↑ rate.output specially with ↑ rate.  Evidence of relation to worse outcome.Evidence of relation to worse outcome.
  • 4. EPIDEMIOLOGIC FEATURESEPIDEMIOLOGIC FEATURES • Venricular ectopy, including non sustainedVenricular ectopy, including non sustained ventricular tachycardia (NSVT) is seen inventricular tachycardia (NSVT) is seen in about 50% of patients during and afterabout 50% of patients during and after cardiac surgery but are not related tocardiac surgery but are not related to mortality if with good LV function.mortality if with good LV function.  Conversely, Sustained VT and ventricularConversely, Sustained VT and ventricular fibrillation occur rarely after cardiacfibrillation occur rarely after cardiac surgery (0.4 - 1.4% reported in varioussurgery (0.4 - 1.4% reported in various studies) but are life threatening and affectsstudies) but are life threatening and affects outcome.outcome. (Raimondo et al, J Am Coll Cardiol 2004, Yeung et al 2004)
  • 5. Time of initial episode of postoperative ventricular tachycardia ,Yeung et al, 2004
  • 6. General factors prediposing to post cardiac surgery VT • Hemodynamic instability • Electrolyte-abnormalities • Metabolic disturbances • Drugs a)Sympathomimetics, inotropes b) Antiarrhythmics. • Sepsis, Tissue trauma, inflammation or indwelling catheters.
  • 7. Three main Categories of Cardiac surgeries related to post-op. VT in the following order: 1. Coronary Artery Bypass Surgery (CABG). 2. Surgery for Valvular Heart Disease. 3. Surgery for Congenital Heart Disease.
  • 8.  age > 65 years,  female gender,  body mass index < 25 kg/m2,  unstable angina,  moderate or poor LV function, and the need for inotropes and an intra-aortic balloon pump.  On pump duration, Off-pump surgery showed a substantial but non-significant protective effect against VT/VF (Raimondo et al JACC 2004). 1-Risk Factors of Post CABG1-Risk Factors of Post CABG Ventricular ArrhythmiasVentricular Arrhythmias
  • 9.  The most likely and reversible cause is residual myocardial ischemia  Inadequate myocardial protection, myocardial reperfusion. Transmural re-entry, oxygen free radicles and Ca overload causing enhanced automaticity or triggered activity are possible mechanisms.  grafting a non-collateralized occluded vessel supplying an infarcted zone may help survival of purkinje cells at scar borders that may create re-entry circuits (Steinberg et al 1999) . Causes of Post CABGCauses of Post CABG Ventricular ArrhythmiasVentricular Arrhythmias
  • 10.  Recurrent VT after aortic or mitral valveRecurrent VT after aortic or mitral valve surgery is rare but often due to reentry in asurgery is rare but often due to reentry in a region of ventricular scar and is bimodal inregion of ventricular scar and is bimodal in prersentation with either early postop. orprersentation with either early postop. or years later occurrence.years later occurrence.  The scars are often, but not always, locatedThe scars are often, but not always, located in proximity to a valve annulus. Scars arein proximity to a valve annulus. Scars are usually 2ry to the original disease but may beusually 2ry to the original disease but may be related to the procedure. (Ekardt et al 2007)related to the procedure. (Ekardt et al 2007) 2- VT after valve surgery2- VT after valve surgery
  • 11.  Commonest aetiology of sudden death in postop. children between the ages of 1 and 16y is Postoperative tetralogy of Fallot and the incidence ↑ over years (1.6%) (Wren 1996).  The site of the ventricular tachycardia was found by intraoperative mapping to be due to re-entry in the right ventricular outflow tract, and related to the use of ahe use of a right ventricular outflow tract patch,right ventricular outflow tract patch, right ventricular outflow tact aneurysms and pulmonic insufficiency. (Harrison et al 1997) 3- Ventricular Arhythmia post3- Ventricular Arhythmia post congenital heart Surgerycongenital heart Surgery
  • 12. Diagnosis and Treatment (When and How to interfere?)
  • 13. Ventricular arrhythmias include: 1- Premature ventricular contractions (PVCs). 2- Non sustained Ventricular Tachycardia. 3- Sustained Ventricular Tachycardia (Monomorphic or polymorphic). 4- Incessant VT and Electerical Storm. 4- Ventricular Fibrillation.
  • 14. PREMATURE VENTRICULARPREMATURE VENTRICULAR COMPLEXES (PVCs)COMPLEXES (PVCs)  The impulse arise in one ventricle, so no PThe impulse arise in one ventricle, so no P wave and wide QRS > 120ms.wave and wide QRS > 120ms.  T wave is large ,opposite in direction toT wave is large ,opposite in direction to QRS.QRS.  Compensatory or noncompensatoryCompensatory or noncompensatory pausepause  Fixed or variable coupling interval.Fixed or variable coupling interval.
  • 15. Significance of PVC’sSignificance of PVC’s  Less important if already present pre-Less important if already present pre- operatively and monomorphic.operatively and monomorphic.  Very Frequent PVC’s can decreaseVery Frequent PVC’s can decrease cardiac output.cardiac output.  Can lead to more serious ventricularCan lead to more serious ventricular arrhythmias, such as VT or VF.arrhythmias, such as VT or VF.  The significance of the causes behindThe significance of the causes behind the PVC’s.the PVC’s.
  • 16. When to be concerned aboutWhen to be concerned about PVC’s?PVC’s?
  • 17. 1. When they Occur at the rate of or greater than 8 per minute.
  • 18. 2. Polymorphic (Multifocal) PVCs
  • 19. 3. R - on - T PVCs
  • 20. 4. Bigeminy PVCs (every other beat is a PVC)
  • 21. 5. Runs of two (2) or more PVCs in a row.
  • 22. Management of PVC’s and NSVTManagement of PVC’s and NSVT • Simple PVC’s usually do not requireSimple PVC’s usually do not require RxRx • Exclude and manage anyExclude and manage any precipitating cause (Ischaemia,precipitating cause (Ischaemia, Electrolytes, Sepsis)Electrolytes, Sepsis) • Frequent PVC’s can be suppressedFrequent PVC’s can be suppressed by atrial pacing.by atrial pacing. • If symptom producing can beIf symptom producing can be suppressed with beta blockers orsuppressed with beta blockers or safe AA.safe AA.
  • 23. VENTRICULARVENTRICULAR TACHYCARDIATACHYCARDIA  VT consists of at least three orVT consists of at least three or more consecutive PVCs at a ratemore consecutive PVCs at a rate of 100bpm.of 100bpm.  Types:- Nonsustained <30sTypes:- Nonsustained <30s sustained > 30s.sustained > 30s.  Rhythm- Regular / slightlyRhythm- Regular / slightly irregularirregular  Rate 100 to 250 / minRate 100 to 250 / min
  • 24. Algorithm for wide complex tachycardia diagnosisAlgorithm for wide complex tachycardia diagnosis from ESC guidelines 2010from ESC guidelines 2010
  • 25. AV dissociationAV dissociation
  • 26. FUSION & CAPTURE BEATSFUSION & CAPTURE BEATS  Diagnostic of VTDiagnostic of VT  Seen in VT of lower rates(< 160)Seen in VT of lower rates(< 160)  Capture beat- sinus beatCapture beat- sinus beat  Fusion beat- hybrid beat due to occasionalFusion beat- hybrid beat due to occasional sinus & ventricular activation capturing thesinus & ventricular activation capturing the ventricles together.ventricles together.
  • 27. QRS Duration and AXISQRS Duration and AXIS  QRS >140ms good indicator of VTQRS >140ms good indicator of VT  QRS 120- 140 ms only 50% have VT (WellensQRS 120- 140 ms only 50% have VT (Wellens et al)et al)  RBBB with left axis deviation is of little helpRBBB with left axis deviation is of little help  LBBB with extreme LAD ( northwest) axisLBBB with extreme LAD ( northwest) axis Extreme axis is rarely seen in SVT withExtreme axis is rarely seen in SVT with aberrancy.aberrancy.  Concordance in the precordial leads and QRSConcordance in the precordial leads and QRS morphology criteria (wellens criteria andmorphology criteria (wellens criteria and Brugada criterial)Brugada criterial)
  • 28. CONCORDANCE of QRS in precordial leads (60%CONCORDANCE of QRS in precordial leads (60%))
  • 29.  If not Sure of the diagnosis, considerIf not Sure of the diagnosis, consider the wide complex tachycardia as VTthe wide complex tachycardia as VT and manage accordingly.and manage accordingly.
  • 30. Treatment Pts with clinicallyPts with clinically stable monomorphic VTstable monomorphic VT  I- Exclude and treat the underlying cause a. myocardial ischemia, reperfusion b. hypoxemia c. digitalis toxicity, epinephrine, aminophyline d. hypokalemia, hypomagnesaemia e. anemia f. CHF g. Sepsis, fever h. acidosis i. bradycardia j. anxiety
  • 31. 2- Pharmacological treatment of Pts2- Pharmacological treatment of Pts with clinically stable VTwith clinically stable VT  Amiodarone 150-300mg bolus overAmiodarone 150-300mg bolus over 10min. then1mg/min 6hrs,10min. then1mg/min 6hrs, 0.5mg/min 18hrs, can be continued0.5mg/min 18hrs, can be continued for several days.for several days.  Lidocaine 1 to 1.5 mg/kg bolusLidocaine 1 to 1.5 mg/kg bolus every 5-10min to max 3mg/kgevery 5-10min to max 3mg/kg Infusion 1-4mg/min, ProcainamideInfusion 1-4mg/min, Procainamide 30mg/min to 17mg/kg.30mg/min to 17mg/kg. till termination or becoming unstable.till termination or becoming unstable.
  • 32. Management of unstableManagement of unstable sustained ventricular tachycardiasustained ventricular tachycardia Pts with clinically unstable VTPts with clinically unstable VT (angina, shock, cerebral hypoperfusion )(angina, shock, cerebral hypoperfusion )  Prompt DC shock within one minute.Prompt DC shock within one minute.  High rt parasternal – apexHigh rt parasternal – apex  Paddle size 8-12cmPaddle size 8-12cm  Area of both paddles 50 sq.cmArea of both paddles 50 sq.cm  Sync.-monophasic(200-360J) orSync.-monophasic(200-360J) or Biphasic (100-200JBiphasic (100-200J  After conversion, AAD and correctAfter conversion, AAD and correct cause.cause.  If not reverted start ACLS protocol.If not reverted start ACLS protocol.
  • 33. Incessant VT and electerical stormelecterical storm :  Defintion:Defintion: Ventricular tachycardia that repeatedlyVentricular tachycardia that repeatedly recurs and persistsrecurs and persists for more than half of afor more than half of a 24-h period despite repeated attempts24-h period despite repeated attempts toto terminate the arrhythmia is designatedterminate the arrhythmia is designated "incessant.""incessant." Recurrence for >3 times/24 hrs ofRecurrence for >3 times/24 hrs of sustained VT requiring interference issustained VT requiring interference is referred to as electerical storm.referred to as electerical storm.
  • 34. Incessant VT–VF managementIncessant VT–VF management  Exclude the possibility of ongoingExclude the possibility of ongoing myocardial ischemia and correction ofmyocardial ischemia and correction of residual ischaemia, may need coronaryresidual ischaemia, may need coronary angiography. VT may be the only sign.angiography. VT may be the only sign.  Correct general reversible causes,Correct general reversible causes,  Consider proarrhythmia if the VT becameConsider proarrhythmia if the VT became slower and incessant after AAD.slower and incessant after AAD.TreatmentTreatment is directed at maintaining hemodynamicis directed at maintaining hemodynamic support untilsupport untilthe drug is excreted. Avoidthe drug is excreted. Avoid combinations of AADs.combinations of AADs.
  • 35.  Intra-aortic balloon counter-pulsationIntra-aortic balloon counter-pulsation cancan also be helpful for haemodynamic supportalso be helpful for haemodynamic support  Sedation and even general anesthesiaSedation and even general anesthesia quiets episodesquiets episodes and restores stability inand restores stability in some cases.some cases.  Implantable cardioverter defibrillator is notImplantable cardioverter defibrillator is not indicated for acute management ofindicated for acute management of patients with electrical storms.patients with electrical storms. Incessant VT and electerical stormelecterical storm :
  • 36.  Catheter ablation is an important option forCatheter ablation is an important option for management of incessantmanagement of incessant monomorphicmonomorphic VT and can be life-saving.VT and can be life-saving.  When hemodynamicWhen hemodynamic stability can bestability can be maintained, presence of the tachycardiamaintained, presence of the tachycardia facilitatesfacilitatesmapping to identify the source ofmapping to identify the source of the arrhythmia.the arrhythmia. Incessant VT and electerical stormelecterical storm :
  • 37. 3D mapping guided RF ablation of VT
  • 38.  However, 10% to 20% of patients haveHowever, 10% to 20% of patients have reentry circuitsreentry circuits that are not successfullythat are not successfully ablated. The location of some circuitsablated. The location of some circuits deepdeep to the endocardium or in the epicardium,to the endocardium or in the epicardium, are importantare importantcauses for failure.causes for failure.  For patients with incessant VT, remainingFor patients with incessant VT, remaining options then include arrhythmia surgery,options then include arrhythmia surgery, placement of a ventricularplacement of a ventricular assist device, orassist device, or cardiac transplantation.cardiac transplantation. Incessant VT and electerical stormelecterical storm :
  • 39. Polymorphic VTPolymorphic VT Torsades de PointesTorsades de Pointes VT characterized byVT characterized by  QRS complexes of changing amplitude thatQRS complexes of changing amplitude that appear to twist around the isoelectric line &appear to twist around the isoelectric line & occur at rates of 200 to 250 /minoccur at rates of 200 to 250 /min  With Prolonged QT intervals generallyWith Prolonged QT intervals generally exceeding 500 msecexceeding 500 msec  U wave can also become prominent&U wave can also become prominent& merge with T wavemerge with T wave
  • 40. ManagementManagement  Correct electrolytes, IV K/magnesiumCorrect electrolytes, IV K/magnesium  Temporary ventricular or atrial pacing+Temporary ventricular or atrial pacing+ ICDICD  Lidocaine, mexiletine or phenytoin canLidocaine, mexiletine or phenytoin can be triedbe tried  K channel activating drugs pinacidil,K channel activating drugs pinacidil, cromakalimcromakalim  Cause of long QT should be treatedCause of long QT should be treated  Consider ischaemia if without long QTConsider ischaemia if without long QT
  • 41. Ventricular Fibrillation:  A lethal arrhythmia: no coordinated electerical activity in the heart, essentially there is no pulse or cardiac output.  Rhythm: none  QRS: no clearly discernable QRS complex; wave forms look chaotic.  Two types:Two types:  Fine: can look like A-fib without QRS complexes,Fine: can look like A-fib without QRS complexes, amplitude of waves <3mm.amplitude of waves <3mm.  Coarse: generally more irregular, amplitude ofCoarse: generally more irregular, amplitude of waves >3mmwaves >3mm
  • 42. Guidelines of CPR in the postoperative patient
  • 43. Amiodarone Vs LidocaineAmiodarone Vs Lidocaine  The ARREST and ALIVE triaLs, have Led to theThe ARREST and ALIVE triaLs, have Led to the expert consensus that ‘amiodarone shouLd beexpert consensus that ‘amiodarone shouLd be considered as the first Line antiarrhythmic drugconsidered as the first Line antiarrhythmic drug that shouLd be given to patients withthat shouLd be given to patients with VF/puLseLess VT that persists after 2–3 shocksVF/puLseLess VT that persists after 2–3 shocks pLus adequate CPR and use of a vasopressorpLus adequate CPR and use of a vasopressor although only very short term benefit could bealthough only very short term benefit could be proved.proved.  Lidocaine, may be used as an aLternative butLidocaine, may be used as an aLternative but onLy if amiodarone is not avaiLabLe.onLy if amiodarone is not avaiLabLe.
  • 44. Long term therapyLong term therapy  Depends on LV function.Depends on LV function.  MADIT I &II, MUSTT, SCDMADIT I &II, MUSTT, SCD studies EF<35% ICDstudies EF<35% ICD  Hybrid therapy ICD + drugs.Hybrid therapy ICD + drugs. (AVID,CIDS)(AVID,CIDS)  Beta-Blockers, Class III agents-Beta-Blockers, Class III agents- amiodarone, sotalolamiodarone, sotalol (EMIAT,CAMIAT,GESICA trails),(EMIAT,CAMIAT,GESICA trails),  Radiofrequency ablation ifRadiofrequency ablation if recurrent monomorphic VT.recurrent monomorphic VT.
  • 45. ConclusionConclusion Post CABG Sust. Vent. Tachyarryth. Ventricular Fibrillation Defib. IV Amio,Lido Identify/Treat ppt factors No further AA therapy Recurrence Defib, Use other IV drugs Unsuccessful Continue CPR as guidelines Successful Continue the drugs, consider long term ICD Ventricular tachycardia Unstable Use V-Fib Protocol Stable IV Amiodarone, Lido, Brety Treat Ppt factors, Defib0 Recurrence Use VT recurr. Protocol,, IPB, consider RF ablation and ICD. No recurrence No further therapy MANAGEMENT OF POST CABG VT/VF No Recurrence