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Aritmie ventricolari nei giovani.pptx
- 1. San Raffaele Hospital - Milano - Italy Sorrento, 28.10.2021 Disclosures: none Congresso Nazionale ANCE Pasquale Vergara MD, Ph-D Aritmie ventricolari nei giovani: quando rassicurare, quando approfondire, quando ricorrere all’ablazione?
- 2. The roadmap
- 4. 1. Stratificazione extrasistolia ventricolare burden complessità risposta all’esercizio cardiopatia origine
- 5. ⇝ >10’000 BEV/ 24 h ⇝ BEV >10% dei battiti quotidiani Burden Circ AE 2012;5:229–236 -->riduzione della funzione sistolica
- 6. ⇝ triplette e runs di TV non sostenuta » sospetto di cardiopatia ⇝ BEV indotti dallo sforzo »Tachicardia ventricolare catecolaminergica Complessità e risposta allo sforzo Circ AE 2012;5:229–236
- 7. Ventricular arrhythmias in the absence of structural heart disease Origine ⇝ LV ⇝ RV I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
- 8. Ventricular arrhythmias in the absence of structural heart disease Origine ⇝ LV endo ⇝ RV epicardium
- 9. Killu AM, Stevenson WG. Heart 2018;0:1–12. doi:10.1136/heartjnl-2017-311590 Ventricular arrhythmias in the absence of structural heart disease Tachicardia dal ventricolo destro
- 10. Ventricular arrhythmias in the absence of structural heart disease Cardiopatia strutturale Killu AM, Heart 2018;0:1–12 ⇝ TV in assenza di cardiopatia
- 11. Ventricular arrhythmias in the absence of structural heart disease ⇝Cardiopatia aritmogena del ventricolo destro ⇝Miocardite ⇝Cardiopatie congenite »Tetralogia di Fallot »Difetto interventricolare ⇝Neoplasie ed amartomi Cardiopatia strutturale nei giovani
- 13. ⇝Valutare Risonanza magnetica Sospetto di cardiopatia?
- 15. Etiology as a predictor of recurrence after catheter ablation of VAs in paediatric patients ⇝98 bambini (5.4 anni: 0.1-15.1anni) Tachicardie ventricolari in età infantile Pfammatter,JACC 1999;33:2067–72 ⇝36% LV disfunction » 12% scompenso cardiaco o sincope ⇝@ follow-up di 47 mesi nessun decesso » VT insorte nel 1° anno: prognosi migliore (risoluzione nel 89%) » VT insorte dopo 1° anno: risoluzione nel 56% » VT destre risoluzione nel 76% vs 37% nelle sinistre
- 16. ESC Guidelines: VT treatment in pediatric age Catheter ablation
- 17. Etiology as a predictor of recurrence after catheter ablation of VAs in paediatric patients ⇝81 pazienti @ OSR: ablazione BEV/TV Ablazione di aritmie ventricolari pediatriche JCE 2021 Idiopathic (N=55) Fascicular (N=12) Structural HD (14) Total (N=81) p value Age (years) Mean (SD) 15.3 (2.3) 15.9 (1.7) 16.0 (2.3) 15.5 (2.2) 0.42 Gender (M) n (%) 40 (72.7%) 7 (58.3%) 11 (78.6%) 58 (71.6%) 0.49 SCD family history 0 (0.0%) 0 (0.0%) 2 (14.3%) 2 (2.5%) 0.007 Age at presentation (years) 12.9 (3.3) 13.2 (3.2) 13.1 (2.8) 13.0 (3.1) 0.93 Presentation with: -Near syncope n (%) 7 (12.7%) 2 (16.7%) 4 (28.6%) 13 (16.0%) 0.35 -Palpitations n (%) 32 (58.2%) 12 (100.0%) 14(100.0%) 58 (71.6%) <0.001 -Heart failure n (%) 0 (0.0%) 1 (8.3%) 2 (14.3%) 3 (3.7%) 0.03 -ICD Shock n (%) 1 (1.8%) 0 (0.0%) 7 (50.0%) 8 (9.9%) <0.001 -Syncope n (%) 2 (3.6%) 4 (33.3%) 6 (42.9%) 12 (14.8%) <0.001 ICD n (%) 1 (1.8%) 1 (8.3%) 8 (57.1%) 10 (12.3%) <0.001 LVEF (%) Mean (SD) 58.4 (6.2) 59.8 (3.5) 54.3 (7.1) 57.9 (6.2) 0.06 LVEDV (ml) Mean (SD) 60.8 (13.2) 64.2 (8.8) 67.7 (21.1) 62.5 (14.4) 0.37 PVBs number/24h Mean (SD) 27515.5 (15963.9) 29200.0 (17326.3) 32201.0 (23617.3) 28558.0 (17604.1) 0.81 Beta blockers n (%) 29 (52.7%) 6 (50.0%) 9 (64.3%) 44 (54.3%) 0.70 Class I AADs n (%) 6 (10.9%) 3 (25.0%) 3 (21.4%) 12 (14.8%) 0.34 CCBs n (%) 0 (0.0%) 1 (8.3%) 0 (0.0%) 1 (1.2%) 0.06
- 18. Etiology as a predictor of recurrence after catheter ablation of VAs in paediatric patients Recidiva dopo ablazione ⇝ 14 pazienti (14.7%) hanno avuto una recidiva aritmica dopo ablazione: » 11 (33.3%) dopo ablazione di TV e 3 (6.2%) dopo ablazione BEV (p<0.001). ⇝ 1 paziente (1%) è deceduto dopo 26 mesi per storm elettrico ⇝ la presenza di cardiopatia strutturale è un predittore indipendente di recidiva all’analisi multivariata sec Cox (HR=5.56, CI 95% 2.68 -11.54, p<0.001).
- 19. CONCLUSIONI ⇝ In presenza di extrasistolia ventricolare nel giovane bisogna identificare l’eventuale presenza di cardiopatia ⇝ L’extrasistolia ventricolare isolate a cuore sano spesso non richiede trattamento, ma solo monitorggio periodico ⇝ L’ablazione di tachicardia ventricolare a cuore sano è efficace e sicura anche nel giovane ⇝ La presenza di Cardiopatia strutturale è predittore di recidiva dopo ablazione transcatetere
Editor's Notes
- Illustration explaining the fundamental difference in QRS morphology between sinus rhythm and ventricular tachycardia. In sinus rhythm, the depolarisation wavefront is rapidly conducted through the Purkinje system (yellow arrow), resulting in a narrow QRS complex in the absence of bundle branch block (top). However, rhythms that originate within the ventricular muscle produce a depolarisation wavefront that propagates slowly through the myocardium before engaging the conducting system. This results in a wide QRS with initial slow onset (bottom).
- Illustration explaining the fundamental difference in QRS morphology between sinus rhythm and ventricular tachycardia. In sinus rhythm, the depolarisation wavefront is rapidly conducted through the Purkinje system (yellow arrow), resulting in a narrow QRS complex in the absence of bundle branch block (top). However, rhythms that originate within the ventricular muscle produce a depolarisation wavefront that propagates slowly through the myocardium before engaging the conducting system. This results in a wide QRS with initial slow onset (bottom).
- figure 4 Outflow tract ventricular tachycardia. (A) Right ventricular outflow tract tachycardia—characterised by left bundle branch block morphology in lead V1, inferior axis (positive in II, III, aVF). Note also the negative QRS in aVL and aVR (superior leads) as the vector is moving inferiorly away from the positive electrodes of these leads at the left and right arms, respectively. (B) Left ventricular outflow tract tachycardia—early transition in the QRS from lead V1 to V2 is seen.
- Mechanisms of ventricular arrhythmias. The most common mechanism of ventricular tachycardia is re-entry, especially in patients with structurally abnormal hearts (A). Re-entry is due to a circulating wavefront revolving around an anatomical obstacle, usually a region of scar (as shown), or region of functional conduction block. Other mechanisms include afterdepolarisations (B) and enhanced automaticity (C).
- Mechanisms of ventricular arrhythmias. The most common mechanism of ventricular tachycardia is re-entry, especially in patients with structurally abnormal hearts (A). Re-entry is due to a circulating wavefront revolving around an anatomical obstacle, usually a region of scar (as shown), or region of functional conduction block. Other mechanisms include afterdepolarisations (B) and enhanced automaticity (C).