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Ventricular Arrhythmias August 14, 2013 Part I. MKSAP Item #119 A 31-year old man is evaluated in the ED after experiencing a syncopal episode while playing.

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Presentation on theme: "Ventricular Arrhythmias August 14, 2013 Part I. MKSAP Item #119 A 31-year old man is evaluated in the ED after experiencing a syncopal episode while playing."— Presentation transcript:

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? (A)Electrophysiology study (B)24-hour continuous ambulatory electrocardiographic monitoring (C)Implantable cardioverter-defibrillator placement (D)Looping event recorder implantation (E)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 S 3, 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? (A)Biventricular pacemaker with implantable cardioverter defibrillator (ICD) (B)Dual chamber (right atrial and right ventricular leads) ICD (C)Dual chamber (right atrial and right ventricular leads) pacemaker (D)Single chamber (right ventricular lead) ICD

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

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 JACC 2006;48:e Classification by ECG Classification by Disease Entity

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 JACC 2006;48:e Classification by ECG Classification by Disease Entity

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

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

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 Atria Ventricles Bifurcation of the bundle of His Ventricular Arrhythmias

27 Atria Ventricles Bifurcation of the bundle of His Supraventricular Arrhythmias

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

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

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

31 Aberrantly Conducted PAC

32 Aberrantly Conducted PACs

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

34 Pre-Excitation V 1 Rhythm Strip is Continuous

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

36 Pre-Existent Right Bundle Branch Block

37 Diagnosis?

38


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