Arrhythmia: ECG--- Tachycardia_20120902_北區

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Arrhythmia: ECG--- Tachycardia_20120902_北區

  1. 1. Arrhythmia ECG Tachycardia 林亮宇 台大醫院 科部內
  2. 2. Tachycardia Surpa-ventricular tachycardia Ventricular tachycardia Ventricular fibrillation
  3. 3. Supra-ventricular tachycardia From atria -Atrial tahycardia: 100-250/min -Atrial flutter: 250-350/min -Atrial fibrillation > 350/min From AV junction: Junctional tachycardia Atrioventricular nodal reentrant tachycardia (AVNRT) Atrioventricular reciprocating tachycardia (AVRT)
  4. 4. PSVT 之電生理分類: 1. 與 sinus node 有關者 sinus tachycardia sinus node reentry tachycardia ( SAT ) 2. 與 AV node 有關者 AV nodal reentry tachycardia ( AVNRT ) AV reentry tachycardia ( AVRT ) using accessory pathway
  5. 5. AVNRT: Slow-Fast (Common), Fast-Slow (Uncommon) No “ P ” in Common Type, Clear “ P’ ” in Uncommon Type
  6. 6. AV NODAL EXTENSIONSAV NODAL EXTENSIONS CS OS Anterior extension Posterior extension Tricuspid hinge
  7. 7. Pre-excitationPre-excitation
  8. 8. Anatomical locations of Right vs. Left Accessory Pathways
  9. 9. Pre-excitationPre-excitation
  10. 10. Wide-Complex Tachycardia, r/o VT Sinus Rhythm AVRT, Antidromic
  11. 11. Ebstein’s Anomaly, WPW Syndrome
  12. 12. Avoid CCB, BB, digoxin
  13. 13. PSVT 之電生理分類 : 3. 與 atrial muscle 有關者 Atrial tachycardia Atrial flutter Atrial fibrillation
  14. 14. “AT” in A SSS Patient : Focal AT in RA
  15. 15. Atrial flutter
  16. 16. Typical Atrial Flutter: circuit & ablation IVCO-TA isthmus
  17. 17. Focal to chaotic Atrial Fibrillation Cont’d.
  18. 18. 陣發 持續
  19. 19. Circumferential PV isolation by RFCA Pappone C, Circulation 2000.
  20. 20. AVNRT, AVRT: carotid massage, adenosine, CCB, BB AT, AF, Afib Rate control: CCB, BB, digoxin, amiodarone Rhythm control (within 48 hrs and for prophylatic): -Class IA: quinidine -Class IC: propafenone -Class III: amiodarone Cardioversion Low perfusion AF, Afib within 48 hrs (TEE/anticoagulant) Prevention of embolism AF, Afib RFCA for AVNRT, AVRT, AT, AF and Afib? Management of SVT
  21. 21. Ventricular tachycardia Idiopathic VT -From RVOT -From LV inferioapical septal region: ILVT Organic VT CAD CHF Cardiomyopathy: HCM, DCM,
  22. 22. VTVT
  23. 23. ECG of VT Wide QRS complex (most VT) Must be VT VA block Capture beat or fusion beat Morphological criteria: favor VT Precordial concordance QRSd>140ms
  24. 24. VT: AV dissociationVT: AV dissociation
  25. 25. VT:VT: positive &positive & negativenegative concordanceconcordance
  26. 26. Capture beatCapture beat
  27. 27. Idiopathic Ventricular TachycardiaIdiopathic Ventricular Tachycardia DefinitionDefinition : ventricular arrhythmia that: ventricular arrhythmia that originate in hearts without structuraloriginate in hearts without structural diseasedisease Right/ left ventricular outflow tract VTRight/ left ventricular outflow tract VT (Adenosine- sensitive VT)(Adenosine- sensitive VT) Left ventricular fascicular tachycardiaLeft ventricular fascicular tachycardia (Verapamil- sensitive VT)(Verapamil- sensitive VT)
  28. 28. • MostMost common:common: RVOT,RVOT, LBBB andLBBB and inferior axisinferior axis • LessLess common:common: LVOT:LVOT: RBBB andRBBB and inferior axisinferior axis
  29. 29. Idiopathic Left Ventricular Tachycardia A-V Dissociation, RBBB and Superior Axis Favors VT,
  30. 30. Idiopathic Left Ventricular Tachycardia A-V Dissociation, RBBB and Superior Axis Favors VT,
  31. 31. Management of VT Idiopathic VT -RVOT: adenosine or verapamil -ILVT: verapamil -Both amenable to RFCA Organic VT DC shock Medication: Ib (lidocaine, mexitil), III (amiodarone, sotalol) ICD, RFCA
  32. 32. Postulated Reentry Circuit in Post-Infarct VT (Stevenson WG, 1993)
  33. 33. Torsade de Pointes (TdP) Long QT related Early after depolarization (EAD) R on T Congenital or acquired (mostly drug)-
  34. 34. Female, 22 y/o
  35. 35. Torsade de PointesTorsade de Pointes
  36. 36. Management of TdP Overdrive pacing Isoproterenol MgSO4 Beta-blockers Remove offending agents anti-histamine, antifungal, macrolide, AAD
  37. 37. With Structural heart disease HCM, ARVD Without structural heart disease Long (short) QT syndrome: NA, KChannelopathy Brugada syndrome: Na channel defect Catecholaminergic polymoprhic VT: Ryanodine Rdefect Hereditary SCD syndrome
  38. 38. Antzelevitch et al, JACC 2003; 41: 1665-71 Brugada Syndrome
  39. 39. Male, 32 y/o, Recurrent Seizures Brugada Syndrome : VF
  40. 40. V1 II V5 aVF V4 V6 CPVT Catecholaminergic Polymorphic Ventricular Tachycardia Ryanodine receptor ( RyR2 ) mutation, rise of Ca i
  41. 41. Bi-directional VT: digoxin intoxication
  42. 42. Ventricular FibrillationVentricular Fibrillation
  43. 43. ICDindication forSCDprevention in:  Post-Infarction  Cardiomyopathy, ARVD  Heart failure  Brugada /LQTS/CPVT/SQTS  Idiopathic VF
  44. 44. Thank you for your attention

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