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Osservazioni cliniche nei pazienti aritmie ed insufficienza cardica Clinical Observations in the Arrhythmic Heart Failure Patients Mariell Jessup MD Professor.

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Presentation on theme: "Osservazioni cliniche nei pazienti aritmie ed insufficienza cardica Clinical Observations in the Arrhythmic Heart Failure Patients Mariell Jessup MD Professor."— Presentation transcript:

1 Osservazioni cliniche nei pazienti aritmie ed insufficienza cardica Clinical Observations in the Arrhythmic Heart Failure Patients Mariell Jessup MD Professor of Medicine University of Pennsylvania Philadelphia, Pennsylvania

2 HF and Arrhythmias  ICDs: the good, the bad, and the ugly.  VT ablation.  PVC-induced cardiomyopathy.

3 HF and Arrhythmias  ICDs: the good, the bad, and the ugly.  VT ablation.  PVC-induced cardiomyopathy.

4 450,000 1 U.S. Census Bureau, Statistical Abstract of the United States: American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures Heart and Stroke Statistical Update, American Heart Association. 4 Circulation. 2001;104: Magnitude of SCA in the US Breast Cancer 2 SCA 4 42,156 40, , ,366 AIDS 1 Lung Cancer 2 Stroke 3 SCA claims more lives each year than these other diseases combined #1 Killer in the U.S.

5 Severity of Heart Failure and Modes of Death MERIT-HFStudy Group. LANCET 1999; 353: NYHA Class III n = 103 NYHA Class II n = 103 NYHA Class IV n = 27 64% 12% 24% 11% 56% 33% 59% 15% 26%

6 Bayés de Luna A. Am Heart J. 1989;117: Underlying Arrhythmias of Sudden Cardiac Arrest Bradycardia 17% Monomorphic VT 62% Primary VF 8% Polymorphic VT 13%

7 ICD’s and survival in CHF Buxton AE, at al. (MUST-T) NEJM 1999;341: Bristow MR, et al. (COMPANION) NEJM 2004;350: Moss AJ, et al. ( MADIT-II) NEJM 2002;346: Kadish A, et al. (DEFINITE) NEJM 2004;350: Year Survival MADIT- II ICD MUST-T ICD COMPANION ICD DEFINITE ICD MADIT- II No ICD MUST-T No ICD COMPANION No ICD DEFINITE No ICD

8 Exner, Klein. J Cardiovasc Electrophysiol 2003; 14:574

9 ICD Implant Procedures-UPENN

10

11 MADIT-II Greenberg et al. JACC 2004;43:1459

12 Hohnlosser et al. NEJM 2004; 351:2481 Post MI

13 Risk-criteria group ICD+OMT (%) OMT only (%) p All patients (mean LVEF 35%), n= LVEF 90 bpm (mean LVEF 32%), n= NSVT >150 bpm (mean LVEF 41%), n= Steinbeck G. American College of Cardiology 2009 Scientific Sessions; March 31, 2009; Orlando, FL. All-cause mortality at 36 months by treatment group and risk-stratification criteria in IRIS The IRIS trial

14 JACC 2009; 53:e1-90

15

16 HF and Arrhythmias  ICDs: the good, the bad, and the ugly.  VT ablation.  PVC-induced cardiomyopathy.

17 Circulation 2004;109:2924

18 ICDs: the UGLY infection

19

20 Closed pocket infection Eroding ICD pocket

21 HF and Arrhythmias  ICDs: the good, the bad, and the ugly.  VT ablation.  PVC-induced cardiomyopathy.

22 NEJM 2008; 359:

23 Das et al. Cardiol Clin 2008; 26: Classification of Ventricular Arrhythmias

24 Zipes et a. Circulation 2006; 114:e

25 VT Ablations (UPENN) ( N = 1176 ablation procedures) YEARYEAR Number of VT Ablations 221

26 (N=65) (N=65) P value Male59 (91%)58 (89%) ns Age67 ± 9.2 yrs67 ± 8.9 yrs ns LVEF27 ± 7%23 ± 9% < 0.01 Previous ICD 35 (54%)61 (94%)< 0.01 Amiodarone 32 (49%)51 (79%) < 0.01 Post MI patients referred for VT ablation Marchlinski et al Circulation 2008

27 Clinical presentation in 100 consecutive patients referred for VT ablation (Sick Patients – Unstable) 93% 68% 18% 14% %

28 UPENN VT Ablations (N= 775) Tet, Sarcoid, Non OT VT, etc 512 (66%) 263 (34%)

29 Recurrence vs. clinical benefit Segal OR: Heart Rhythm

30 Circulation Arrhyth Electrophysiol 2008; 1:

31 Circulation 2007; 116:1998 *Low bipolar voltage surrounding the valves *Low voltage abnormalities extending toward more apical segments of the RV or LV.

32 Assomull et al. JACC 2006;48:1977

33 Electrical storm: definition Occurrence of 3 or more distinct episodes of VT and/or VF within a 24-hour period resulting in device intervention. –Incidence: 10-28% over 1-3 year (secondary prevention) –Prognosis: 2-7-fold higher risk of death

34 Electrical storm in patients with ICDs implanted earlier AVID MADIT II Huang and Traub Prog Cardiov Dis 2008; 51(3):

35 Eur Heart J 2006; 27: 3027 Electrolyte imbalance Ischemia Heart failure exacerbation Medication non-compliance identified cause in 13% !!!

36 Electrical storm in the ICD era. Huang and Traub Prog Cardiov Dis 2008; 51(3):

37 HF and Arrhythmias  ICDs: the good, the bad, and the ugly.  VT ablation.  PVC-induced cardiomyopathy.

38 Circulation 2005; 112:

39 J Interv Card Electrophysiol 2007; 20:9-13

40 University of Pennsylvania Medical Center


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