1. Ventricular Arrhythmias
August 14, 2013
Part I

2. MKSAP Item #119
A 31-year old man is evaluated in the ED after experiencing a syncopal episode while playing basketball. A friend playing with him reported that he was unconscious for about 15 seconds with no evidence of seizure-like activity. Medical history is significant for arrhythmogenic RV cardiomyopathy/dysplasia. His only medication is atenolol.
On PE, the patient is afebrile, BP is 128/76 mm Hg and pulse rate is 64/min.

3. MKSAP Item #119
ECG shows normal sinus rhythm with T wave inversions in leads V1-V3 with an epsilon wave.
Echo demonstrates moderate RV dysfunction and enlargement. Cardiovascular magnetic resonance (CMR) imaging of the heart shows dilatation and akinesia of the RV outflow tract.

4. Item 119 (con’t)
Which of the following is the most appropriate management?
Electrophysiology study
24-hour continuous ambulatory electrocardiographic monitoring
Implantable cardioverter-defibrillator placement
Looping event recorder implantation
Sotalol administration

5. MKSAP Item #54
A 52-year old woman is evaluated for a 1-year history of nonischemic cardiomyopathy. She reports feeling shortness of breath with exertion when walking up one flight of stairs or walking one city block. Medical and family histories are unremarkable. Medications are carvedilol, lisinopril, digoxin, spironolactone and furosemide.
On PE, she is afebrile, BP is 112/74 mm Hg and pulse rate is 82/min. Cardiac evaluation reveals a regular rate and rhythm, positive S3, and a grade 2/6 holosystolic murmur heard best at the apex and radiating to the axilla.

6. MKSAP Item #54 (con’t)
An ECG demonstrates sinus rhythm and left bundle branch block with QRS interval of 155 msec.
Echocardiogram shows a moderately dilated LV and severely depressed left ventricular systolic function, with an ejection fraction of 25%.

7. Item 54 (con’t)
Which of the following is the most appropriate treatment?
Biventricular pacemaker with implantable cardioverter defibrillator (ICD)
Dual chamber (right atrial and right ventricular leads) ICD
Dual chamber (right atrial and right ventricular leads) pacemaker
Single chamber (right ventricular lead) ICD

8. Classification of Ventricular Arrhythmias ACC/AHA/ESC 2006 Guidelines
Classification by Clinical Presentation
Classification by ECG
Classification by Disease Entity
JACC 2006;48:e

9. Ventricular Arrhythmias
Classification by Clinical Presentation
Hemodynamically stable
Asymptomatic (no symptoms)
Minimal symptoms (palpitations, skipped beats)
Hemodynamically unstable
Presyncope (dizziness, lightheadedness, faint)
Syncope
Sudden cardiac death
Sudden cardiac arrest
JACC 2006:e

10. Classification of Ventricular Arrhythmias ACC/AHA/ESC 2006 Guidelines
Classification by Clinical Presentation
Classification by ECG
Classification by Disease Entity
JACC 2006;48:e

11. Ventricular Arrhythmias
Classification by Electrocardiography
Nonsustained VT
Sustained VT
Bundle branch block reentrant tachycardia
Bidirectional tachycardia
Torsades de pointes
Ventricular flutter
Ventricular fibrillation
JACC 2006:e

12. Classification of Ventricular Arrhythmias ACC/AHA/ESC 2006 Guidelines
Classification by Clinical Presentation
Classification by ECG
Classification by Disease Entity
JACC 2006;48:e

13. Ventricular Arrhythmias
Classification by Disease Entity
Chronic coronary heart disease
Heart failure
Congenital heart disease
Neurological disorder
Structurally normal hearts
Sudden infant death syndrome
Cardiomyopathies (Dilated, hypertrophic, arrhythmogenic RV cardiomyopathy)
JACC 2006:e

14. Ventricular Arrhythmias
Classification by Electrocardiography
Single PVCs and nonsustained VT
Sustained VT
Bundle branch block reentrant tachycardia
Bidirectional tachycardia
Torsades de pointes
Ventricular flutter
Ventricular fibrillation
JACC 2006:e

15. Premature Ventricular Complex
Full Compensatory Pause

16. Premature Ventricular Complexes
Multifocal PVCs
PVCs in bigeminy

17. Premature Ventricular Complexes
Compensatory pause is not full
Retrograde P waves due to V-A conduction

18. Ventriculo-Atrial Conduction

19. Ventriculo-Atrial Conduction

20. Interpolated PVC

21. PVCs in Bigeminy

22. Premature Ventricular Complexes
Paired PVCs or Couplets
Trigeminy

23. Non-sustained monomorphic VT
Non-sustained Ventricular Tachycardia
3 or more PVC’s, rate >100 bpm
Less than 30 seconds duration
No hemodynamic symptoms

24. Therapy: PVC’s and Non-Sustained VT
In patients with structurally normal hearts, PVC’s including runs of non-sustained VT are not prognostically significant.
PVC’s including frequent PVCs and non-sustained VT are not targets for anti-arrhythmic therapy.

25. PVC’s and Non-Sustained VT
If the PVCs are frequent (>10,000 PVCs over a 24 hour period or >20% of total heart beats counted), LV function should be reassessed annually because it can result in tachycardia mediated CMP.
JACC 2012;59:

26. Ventricular Arrhythmias
Atria
Bifurcation of the bundle of His
Ventricles
Ventricular Arrhythmias

27. Supraventricular Arrhythmias
Atria
Bifurcation of the bundle of His
Ventricles
Supraventricular Arrhythmias

28. Not all beats with a wide QRS complex are ventricular
Wide complex beats may also be supraventricular in origin.

29. Wide Complex Beats Supraventricular Ventricular
Pre-existent bundle branch block
Accessory pathway
Aberrancy also called functional or rate related bundle branch block
Ventricular

30. Wide Complex Tachycardia
Preexistent BBB
Bypass Tract
Rate related BBB
Ventricular
Supraventricular Beats With Wide QRS Complexes

31. Aberrantly Conducted PAC

32. Aberrantly Conducted PACs

33. Wide Complex Tachycardia
Preexistent BBB
Bypass Tract
Rate related BBB
Ventricular
Supraventricular Arrhythmias With Wide QRS Complexes

34. Pre-Excitation
V1 Rhythm Strip is Continuous

35. Wide Complex Tachycardia
Preexistent BBB
Bypass Tract
Rate related BBB
Ventricular
Supraventricular Arrhythmias With Wide QRS Complexes

36. Pre-Existent Right Bundle Branch Block

37. Diagnosis?