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

25. Algorithm for wide complex tachycardia diagnosisAlgorithm for wide complex tachycardia diagnosis
from ESC guidelines 2010from ESC guidelines 2010

26. AV dissociationAV dissociation

27. 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.

28. 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)

29. CONCORDANCE of QRS in precordial leads (60%CONCORDANCE of QRS in precordial leads (60%))

30.  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.

31. 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

32. 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.

33. 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.

35. 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.

36. 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.

37.  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 :

38.  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 :

39. 3D mapping guided RF ablation of VT

40.  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 :

41. 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

43. 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

44. 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

46. Guidelines of CPR in the postoperative patient

47. 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.

48. 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.

50. 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