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Electrocardiography & Cardiac Arrhythmias Saeed Oraii MD, Cardiologist Interventional Electrophysiologist Tehran Arrhythmia Clinic.

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Presentation on theme: "Electrocardiography & Cardiac Arrhythmias Saeed Oraii MD, Cardiologist Interventional Electrophysiologist Tehran Arrhythmia Clinic."— Presentation transcript:

1 Electrocardiography & Cardiac Arrhythmias Saeed Oraii MD, Cardiologist Interventional Electrophysiologist Tehran Arrhythmia Clinic

2 Tehran Arrhythmia Center Some slides have accompanied notes. To view them you can right click on the screen, choose ‘Screen’ and then ‘Speaker Notes’.

3 Tehran Arrhythmia Center ECG A graphic recording of electrical potentials generated by the heart A noninvasive, inexpensive and highly versatile test

4 Tehran Arrhythmia Center Normal Pathway of Electrical Conduction

5 Tehran Arrhythmia Center Cardiac Action Potential

6 Tehran Arrhythmia Center Cardiac action potentials from different locations have different shapes

7 Tehran Arrhythmia Center Electrophysiology Electric currents that spread through the heart are produced by three components –Cardiac pacemaker cells –Specialized conduction tissue –The heart muscle ECG only records the depolarization and repolarization potentials generated by atrial and ventricular myocardium.

8 Tehran Arrhythmia Center Electrocardiograph 1903

9 Tehran Arrhythmia Center Normal Electrocardiogram

10 ECG Waveforms Labeled alphabetically beginning with the P wave Tehran Arrhythmia Center

11 QRS-T Cycle Corresponds to Different Phases of Ventricular Action Potential

12 Tehran Arrhythmia Center Limb Leads

13 Tehran Arrhythmia Center Precordial Leads

14 Tehran Arrhythmia Center Position of Precordial Electrodes

15 Tehran Arrhythmia Center Precordial Leads

16 Tehran Arrhythmia Center 3-D Representation of Cardiac Electrical Activity

17 Tehran Arrhythmia Center Timing Intervals

18 Tehran Arrhythmia Center Vector Concept Cardiac depolarization and repolarization waves have direction and magnitude. They can, therefore, be represented by vectors. ECG records the complex spatial and temporal summation of electrical potentials from multiple myocardial fibers conducted to the surface of the body.

19 Tehran Arrhythmia Center Limb Leads Directions

20 Tehran Arrhythmia Center Vector Concept

21 Tehran Arrhythmia Center Ventricular Depolarization

22 Tehran Arrhythmia Center QRS Axis

23 Tehran Arrhythmia Center Determination of QRS Axis

24 Tehran Arrhythmia Center Direction of Propagation

25 Tehran Arrhythmia Center Determination of QRS Axis

26 Tehran Arrhythmia Center Determination of QRS Axis

27 Tehran Arrhythmia Center Main Vector

28 Tehran Arrhythmia Center Normal QRS Axis

29 Tehran Arrhythmia Center Left Axis Deviation

30 Tehran Arrhythmia Center Right Axis Deviation

31 Major ECG Abnormalities Tehran Arrhythmia Center

32 Right Atrial Enlargement

33 Tehran Arrhythmia Center Left Atrial Enlargement

34 Tehran Arrhythmia Center Left Ventricular Hypertrophy

35 Tehran Arrhythmia Center Right Ventricular Hypertrophy

36 Tehran Arrhythmia Center RVH, RA enlargement

37 Tehran Arrhythmia Center Left Bundle Branch Block

38 Tehran Arrhythmia Center Left Bundle Branch Block

39 Tehran Arrhythmia Center Right Bundle Branch Block

40 Tehran Arrhythmia Center RBBB

41 Tehran Arrhythmia Center RBBB, RAD (Bifascicular Block)

42 Tehran Arrhythmia Center RBBB, LAD (Bifascicular Block)

43 Tehran Arrhythmia Center Myocardial Ischemia ECG is the cornerstone in the diagnosis of myocardial ischemia Findings depend on several factors: –Nature of the process, reversible vs. irreversible –Duration, acute vs. chronic –Extent, transmural vs. subendocardial –Localization, anterior vs. inferoposterior –Other underlying abnormalities

44 Tehran Arrhythmia Center Acute Ischemia

45 Tehran Arrhythmia Center Myocardial Infarction

46 Tehran Arrhythmia Center Acute Pericarditis

47 Tehran Arrhythmia Center Metabolic Abnormalities

48 Tehran Arrhythmia Center Hyper- kalemia K 6.9

49 Tehran Arrhythmia Center Same patient K 3.9

50 Tehran Arrhythmia Center Hypothermia, Osborn Wave

51 Tehran Arrhythmia Center Hypothermia, Corrected

52 Tehran Arrhythmia Center Right Axis Deviation Tehran Arrhythmia Center

53 Superior P Wave Axis Tehran Arrhythmia Center

54 Normal Sinus Rhythm Tehran Arrhythmia Center

55 Anterior MI Tehran Arrhythmia Center

56 RBBB and Inferior MI Tehran Arrhythmia Center

57 LA Enlargement and Prolonged PR Interval Tehran Arrhythmia Center

58 LBBB Tehran Arrhythmia Center

59 LA Enlargement and Prolonged PR Interval Tehran Arrhythmia Center

60 Left Anterior Hemiblock Tehran Arrhythmia Center

61 LVH and LA Enlargement Tehran Arrhythmia Center

62 Anterior MI Tehran Arrhythmia Center

63 Old Inferior MI Tehran Arrhythmia Center

64 RA Enlargement Tehran Arrhythmia Center

65 RBBB, LAH, Prolonged PR (Trifascicular Block) Tehran Arrhythmia Center

66 RBBB and Inferior MI Tehran Arrhythmia Center

67

68 Cardiac Arrhythmias Tehran Arrhythmia Center

69 Normal Pathway of Electrical Conduction

70 Tehran Arrhythmia Center Normal Sinus Rhythm Normal and constant P wave contours Normal P wave axis Rate between 60 and 100 bpm

71 Tehran Arrhythmia Center Normal Sinus Rhythm Tehran Arrhythmia Center

72 Anatomical Aspects of Normal Sinus Node Located at the superior anterolateral portion of right atrium near its border with the superior vena cava It is an epicardial structure near sulcus terminalis From endocardial approach the closest approach is near the superior end of crista terminalis

73 Tehran Arrhythmia Center Sinus Node Function The dominant cardiac pacemaker Highly responsive to autonomic influences Decreasing rate with vagal stimulation Increasing rate with sympathetic activity Normal sinus rate under basal conditions is bpm.

74 Tehran Arrhythmia Center Sinus Tachycardia Sinus rhythm exceeding 100 bpm in adults Usually between 100 and 180 bpm but may be higher with extreme exertion Maximum heart arte decreases wit age from near 200 bpm to less than 140 bpm Gradual onset and termination

75 Tehran Arrhythmia Center Sinus Tachycardia

76 Tehran Arrhythmia Center Sinus Tachycardia Causes Common in infancy and childhood Normal response to a variety of physiological and pathological stresses –Exertion, anxiety –Hypovolemia, anemia –Fever –Congestive heart failure –Myocardial ischemia –Thyrotoxicosis Drugs Inflammation

77 Tehran Arrhythmia Center Sinus Bradycardia Sinus rhythm at a rate less than 60 bpm Can result from excessive vagal or decreased sympathetic tone as well as anatomic changes in sinus node Frequently occurs in healthy young adults, particularly well-trained athletes Sinus arrhythmia often coexists

78 Tehran Arrhythmia Center Sinus Bradycardia

79 Tehran Arrhythmia Center Sinus Bradycardia Causes Hypothyroidism Drugs During vomiting or vasovagal syncope Increased intracranial pressure Hypoxia, hypothermia Infections Depression Jaundice

80 Tehran Arrhythmia Center Sinus Arrhythmia Phasic variation in sinus cycle length Maximum minus minimum sinus cycle length exceeds 120 msec. May be considered the most common form of arrhythmia Respiratory form is a normal event Common in the young esp. with slower heart rates or enhanced vagal tone

81 Tehran Arrhythmia Center Sinus Arrhythmia

82 Tehran Arrhythmia Center Wandering Pacemaker Passive transfer of dominant pacemaker focus from sinus node to latent pacemakers in other atrial sites or AV junctional tissue Occurs in a gradual fashion over the duration of several beats

83 Tehran Arrhythmia Center Wandering Pacemaker ECG A cyclical increase in RR interval A PR interval that gradually shortens to less than 120 msec A change in P wave contour that becomes negative in lead I or II or is lost within the QRS

84 Tehran Arrhythmia Center Wandering Pacemaker

85 Tehran Arrhythmia Center Inappropriate Sinus Tachycardia Persistent sinus tachycardia at rest or with minimal exertion Usually occurs in otherwise healthy people More common in health care personnel May result from a defect in either sympathetic or vagal nerve control of sinus node automaticity or an abnormality of intrinsic heart rate Some cases may need radiofrequency ablation of sinus node

86 Tehran Arrhythmia Center Sinus Node Dysfunction Mechanisms A disease affecting a limited amount of tissue at or near the sinus node causing dysfunction of impulse formation or propagation or recovery from overdrive suppression A disease affecting the atria in general that consequently affects the sinus node function and also frequently generates atrial arrhythmias

87 Tehran Arrhythmia Center Sinus Node Dysfunction ECG Manifestations Sinus bradycardia Sinus pauses Sinus arrest Atrial asystole Sinus exit block

88 Tehran Arrhythmia Center Sinus Pause

89 Tehran Arrhythmia Center Sinoatrial Exit Block 1 st and 2 nd degree

90 Tehran Arrhythmia Center Sinus Node Dysfunction Etiology Most often in elderly as an isolated phenomenon Drugs Infiltration of atrial myocardium Interruption of blood supply Hypothyroidism, advanced liver disease, severe hypoxia, acidemia …

91 Tehran Arrhythmia Center High Vagal Tone Usually in the young Normal heart rate response during exercise Normal intrinsic heart rate Bradycardia may be severe enough to cause syncope (especially in familial form)

92 Sick Sinus Syndrome A combination of symptoms (dizziness, fatigue, confusion, syncope and congestive heart failure) caused by sinus node dysfunction Atrial tachyarrhythmias may accompany sinus node dysfunction Tehran Arrhythmia Center

93 Sick Sinus Syndrome Clinical Manifestations Predominantly seen in the elderly Most patients with sinus node dysfunction are asymptomatic Two types of presentations –Syncope or near-syncope –Fatigue or worsening heart failure

94 Tehran Arrhythmia Center Sick Sinus Syndrome Diagnosis Holter monitor recordings Intrinsic heart rate by autonomic blockade Sinus node recovery time Sinoatrial conduction time The most important step is to correlate symptoms with ECG findings.

95 Tehran Arrhythmia Center Normal SNRT

96 Tehran Arrhythmia Center Abnormal SNRT

97 Tehran Arrhythmia Center SA Block during Overdrive Pacing

98 Tehran Arrhythmia Center Sinus Arrest after Termination of AF

99 Tehran Arrhythmia Center Loop Recorder Showed Junctional Rhythm during Syncope

100 Tehran Arrhythmia Center Sinus arrest with syncope

101 Tehran Arrhythmia Center Therapy for Sick Sinus Syndrome Based mostly on symptoms and any clinical documentation of cardiac arrhythmia associated with these symptoms Drug therapy is rather limited Most effective treatment is pacing therapy Anticoagulation in certain situation

102 Tehran Arrhythmia Center

103 Heart Block Disturbance of impulse conduction Transient or permanent Due to anatomical or functional impairment Must be distinguished from interference, a normal phenomenon that is a disturbance of impulse conduction caused by physiological refractoriness due to inexcitability from a preceding impulse

104 Tehran Arrhythmia Center AV Conduction Disturbances Clinical Significance Heart block may be asymptomatic or lead to syncope or cardiac arrest Clinical significance of conduction abnormalities depend on: –The site of disturbance –The risk of progression to complete block –The probability that a subsidiary escape rhythm distal to the site of block develops and is stable

105 Tehran Arrhythmia Center AV Block Types First degree AV block Second degree AV block –Mobitz type I (Wenckebach) – Mobitz type II Third degree block (Complete heart block) High degree (advanced) AV block

106 Tehran Arrhythmia Center First Degree AV Block Conduction time is prolonged but all impulses are conducted. PR interval exceeds 0.2 sec in adults Site of conduction delay may be in the AV node (most commonly), in the His-Purkinje system or both.

107 Tehran Arrhythmia Center First Degree AV Block

108 Tehran Arrhythmia Center Second Degree AV Block Block of some atrial impulses at a time when physiological interference is not involved Non-conducted P waves can be infrequent or frequent, at regular or irregular intervals, and can be preceded by fixed or lengthening PR intervals. The association of P with QRS is not random.

109 Tehran Arrhythmia Center Mobitz Type I Second Degree AV Block Also called Wenckebach block Typical type characterized by progressive PR prolongation culminating in a non- conducted P wave Narrow QRS in most cases

110 Tehran Arrhythmia Center WB

111 Tehran Arrhythmia Center Wenckebach Block

112 Tehran Arrhythmia Center Wenckebach Block Atypical pattern in over half the cases The site of block is almost always in the AV node. Generally benign and does not advance to more advanced AV block Can occur in normal children and well- trained athletes

113 Tehran Arrhythmia Center Mobitz Type II Second Degree AV Block PR interval remains constant prior to the blocked P wave Commonly associated with bundle branch blocks

114 Tehran Arrhythmia Center Mobitz Type II Second Degree AV Block

115 Tehran Arrhythmia Center Mobitz Type II Second Degree AV Block

116 Tehran Arrhythmia Center Mobitz Type II Second Degree AV Block Site of block His-Purkinje system in most case Often antedates the development of Adams- Stokes syncope and complete AV block Never observed in normal people An indication for implantation of permanent pacemaker even in asymptomatic cases

117 Tehran Arrhythmia Center 2:1 AV Block

118 Tehran Arrhythmia Center 2:1 AV Block

119 Tehran Arrhythmia Center 2:1 AV block

120 Tehran Arrhythmia Center Complete AV block No atrial activity conducts to the ventricles AV dissociation is present. The atria and ventricles are controlled by independent pacemakers. Ventricular focus is usually located just below the site of block. Higher sites are more stable with a more faster escape rate.

121 Tehran Arrhythmia Center Complete AV block

122 Tehran Arrhythmia Center Complete AV block Isorhythmic AV Dissociation

123 Tehran Arrhythmia Center Advanced AV block Block in two or more consecutive P waves

124 Tehran Arrhythmia Center AV Conduction Disturbances Etiology Degenerative diseases are the most common causes A variety of other diseases may be responsible: myocardial infarction, drugs, acute infections, infiltrative diseases, neoplasms, etc. Hypervagotonia

125 Tehran Arrhythmia Center Investigation of the Site of AV Conduction Disease by Electrophysiologic Study (EPS)

126 Tehran Arrhythmia Center Cardiac Pacemakers The treatment of symptomatic bradyarrhythmias is implantation of cardiac pacemakers.

127 Tehran Arrhythmia Center Cardiac Pacing

128 Tehran Arrhythmia Center First Implanted Pacemaker

129 Tehran Arrhythmia Center Common Uses for Permanent Pacemaker Therapy

130 Tehran Arrhythmia Center AV Block With Carotid Massage

131 Tehran Arrhythmia Center Long Asystole

132 Tehran Arrhythmia Center Sinus Pause and Junctional Escape Beats

133 Tehran Arrhythmia Center Sinus Pause and Junctional Escape Beats Tehran Arrhythmia Center

134 Bradycardia- Tachycardia Syndrome

135 Tehran Arrhythmia Center Mobitz Type I (Wenckebach)

136 Tehran Arrhythmia Center 2:1 AV block Tehran Arrhythmia Center

137 Complete Heart Block Tehran Arrhythmia Center

138 Sinus Pause Tehran Arrhythmia Center

139 Sinus Arrhythmia Tehran Arrhythmia Center

140 Sinus Tachycardia Tehran Arrhythmia Center

141 Wandering Pacemaker Tehran Arrhythmia Center

142 Sinus Tachycardia Tehran Arrhythmia Center

143 Wandering Pacemaker Tehran Arrhythmia Center

144 Asystole and Junctional Escape Rhythm

145 Tehran Arrhythmia Center

146 Tachyarrhythmias

147 Tachyarrhythmias Mechanisms Automaticity Tehran Arrhythmia Center

148 Tachyarrhythmias Mechanisms Triggered activity Tehran Arrhythmia Center

149 Tachyarrhythmias Mechanisms Reentry Tehran Arrhythmia Center

150 Premature Complexes

151 Tehran Arrhythmia Center Ventricular Premature Complexes Compensatory Pause Interpolated VPC

152 Tehran Arrhythmia Center Premature Complexes The most common arrhythmias Detected during 24h Holter monitoring in over 60% of adults May cause palpitations or be asymptomatic May trigger more serious tachyarrhythmias May be associated with a normal heart or a variety of cardiac disturbances

153 Tehran Arrhythmia Center Variability of Ventricular Ectopy with Age Effect of age on probability (%) of having more than a given number of PVCs per 24 hours in subjects with normal hearts Data from Kostis JB. Circulation. 1981;63(6):1353. Age

154 Tehran Arrhythmia Center Ventricular Premature Complexes Without heart disease, PVCs have not been shown to be associated with any increased incidence in morbidity or mortality In the presence of underlying disease (ischemia, heart failure …) they may add to the risk of the disease. No treatment is, however, shown to definitely decrease this increased risk.

155 Tehran Arrhythmia Center Atrial Fibrillation The most common sustained arrhythmia Incidence increases progressively with age. Prevalence: 0.4% of overall population Mortality rate double that of control AF is characterized by disorganized atrial activity without discrete P waves

156 Tehran Arrhythmia Center Atrial Fibrillation

157 Tehran Arrhythmia Center Atrial Fibrillation Undulating baseline or atrial deflections of varying amplitude and frequency ranging from 350 to 600 bpm. Irregularly irregular ventricular response.

158 Tehran Arrhythmia Center Atrial Fibrillation Morbidity related to: –Excessive ventricular rate –Pause following cessation of AF –Systemic embolization –Loss of atrial kick –Anxiety secondary to palpitations –Irregular ventricular rate

159 Tehran Arrhythmia Center Atrial Fibrillation Persistent AF usually in patients with cardiovascular disease –Valvular heart disease –Hypertensive heart disease –Congenital heart disease Paroxysmal AF may occur with acute hypoxia, hypercapnia or metabolic or hemodynamic derangements Normal people with emotional stress or surgery or acute alcoholic intoxication Lone AF

160 Tehran Arrhythmia Center Atrial Fibrillation Therapeutic Goals: –Control of ventricular rate –Restoration and maintenance of sinus rhythm –Prevention of thromboembolism

161 Tehran Arrhythmia Center Atrial Flutter Regular atrial tachyarrhythmia with atrial rate between bpm. Flutter waves are seen as saw-tooth like atrial activity

162 Tehran Arrhythmia Center Atrial Flutter Atrial Flutter is a form of atrial reentry localized to right atrium. Typically the ventricular rate is half the atrial rate, but the ventricular response may be 4:1, 2:1, 1:1 etc.

163 Tehran Arrhythmia Center Atrial Flutter Circuit

164 Tehran Arrhythmia Center Atrial Flutter Tehran Arrhythmia Center

165 Atrial Flutter Most often in patients with organic heart disease Usually less long-lived than AF and may convert to AF. Control of ventricular rate is difficult in atrial flutter The most effective treatment is DC cardioversion

166 Tehran Arrhythmia Center Paroxysmal Supraventricular Tachycardia (PSVT) Usually at a rate of bpm No organic heart disease in the majority Presentations –Palpitations –Chest discomfort,dyspnea, lightheadedness –Frank syncope –SCD

167 Tehran Arrhythmia Center PSVT Tehran Arrhythmia Center

168 PSVT Mechanism Reentry in the vast majority Reentry may be localized to sinus node, atrium, AV junction or a macroreentrant circuit involving a bypass tract (WPW) In the absence of WPW, more than 90% are due to reentry through AV node or a concealed bypass tract

169 Tehran Arrhythmia Center AV Nodal Reentrant Tachycardia (AVNRT) The most common form of paroxysmal supraventricular tachycardia (about 70%) More common in women (66%) Usually a regular narrow QRS complex tachycardia No P wave is usually evident during the tachycardia. Retrograde P waves may occasionally be seen at the end of QRS.

170 Tehran Arrhythmia Center Longitudinal Dissociation Within AV Node Slow Pathway Fast Pathway Atrium His Bundle

171 Tehran Arrhythmia Center AVNRT

172 Tehran Arrhythmia Center AVNRT

173 Tehran Arrhythmia Center Preexcitation

174 Tehran Arrhythmia Center Wolff-Parkinson-White Syndrome Tehran Arrhythmia Center

175 AV Reentrant Tachycardia (AVRT) Incorporates a bypass tract as part of the tachycardia circuit. Surface ECG: –Manifest with short PR interval and delta wave (preexcitation) –Concealed with normal ECG Prevalence of ECG pattern: 0.1% to 0.3%.

176 Tehran Arrhythmia Center AVRT

177 Tehran Arrhythmia Center Concealed Accessory Pathway Tehran Arrhythmia Center

178 PSVT Treatment Vagal maneuvers particularly carotid sinus massage AV nodal blocking drugs –Adenosine –Verapamil –Propranolol –Digoxin DC cardioversion if hypotensive Radiofrequency ablation

179 Tehran Arrhythmia Center Electrophysiologic Study (EPS)

180 Tehran Arrhythmia Center Catheter Positions at Fluoroscopy

181 Tehran Arrhythmia Center Intracardiac Recordings

182 Tehran Arrhythmia Center Radiofrequency Ablation (RFA) Through femoral vein and right atrium

183 Tehran Arrhythmia Center Loss of Delta during RF Burn Tehran Arrhythmia Center

184 Loss of Delta during Burn

185 Tehran Arrhythmia Center Ventricular Arrhythmias Definitions Premature Ventricular beats –Single beats –Ventricular Bigeminy, the appearance of one PVC after each sinus beat –Couplets, two consecutive premature beats –Triplets, three consecutive premature beats –Salvos, runs of 3-10 premature beats Accelerated Idioventricular Rhythm (Slow VT), rate bpm Ventricular Tachycardia (VT), rate over 100 bpm Ventricular Flutter, regular large oscillations at a rate of bpm Ventricular Fibrillation (VF), irregular undulations of varying contour and amplitude

186 Tehran Arrhythmia Center Ventricular Tachycardia Classification Duration –Sustained VT defined as VT that persists for than 30 s or requires termination because of hemodynamic collapse –Nonsustained VT, 3 beats to 30 s Morphology –Monomorphic –Polymorphic

187 Tehran Arrhythmia Center Salvos

188 Tehran Arrhythmia Center Sustained Monomorphic VT

189 Tehran Arrhythmia Center Sustained Polymorphic VT

190 Tehran Arrhythmia Center VT, Holter Recording

191 Tehran Arrhythmia Center VT Presentations

192 Tehran Arrhythmia Center VT Etiology VT generally accompanies some form of structural heart disease most commonly: –Ischemic heart disease –Cardiomyopathies Primary electrical abnormalities –Long QT syndromes –Brugada syndrome Idiopathic VT

193 Tehran Arrhythmia Center Electrocardiographic Differentiation of VT vs. SVT with Aberrancy Clinical history AV dissociation QRS morphology QRS axis Fusion beat Capture beat

194 Tehran Arrhythmia Center A-V Dissociation, Fusion, and Capture Beats in VT Fisch C. Electrocardiography of Arrhythmias. 1990;134. ECTOPYFUSIONCAPTURE V1 EFC

195 Tehran Arrhythmia Center Fusion and Capture Beats in VT Fisch C. Electrocardiography of Arrhythmias. 1990;135. FCC CC

196 Tehran Arrhythmia Center VT Prognosis Depends on the underlying disease state –75% first year mortality in the first few weeks after MI –Poor prognosis in patients with left ventricular dysfunction –No increased risk in those with idiopathic VT

197 Tehran Arrhythmia Center Ventricular Fibrillation

198 Tehran Arrhythmia Center Sudden Death Syndrome Incidence –400, ,000/year in U.S. –Only 2% - 15% reach the hospital –Half of these die before discharge High recurrence rate

199 Tehran Arrhythmia Center Underlying Arrhythmia of Sudden Death VT 62% Bradycardia 17% Torsades de Pointes 13% Primary VF 8% Adapted from Bayés de Luna A. Am Heart J. 1989;117:

200 Tehran Arrhythmia Center Snapshot of Death

201 Tehran Arrhythmia Center Return of Life Not the usual case !

202 Tehran Arrhythmia Center Clinical Substrates Associated with VF Arrest Coronary artery disease Idiopathic cardiomyopathy Hypertrophic cardiomyopathy Long QT syndrome RV dysplasia Rarely: WPW syndrome

203 Tehran Arrhythmia Center VT/VF Therapeutic Options Antiarrhythmic drugs Anti-tachycardia pacing Radiofrequency ablation Implantable defibrillators

204 Tehran Arrhythmia Center Earliest Defibrillator in Clinical Use, 1899

205 Tehran Arrhythmia Center First Implantable Defibrillator 1970

206 Tehran Arrhythmia Center Thoracotomy Lead System, the technique used at the beginning

207 Tehran Arrhythmia Center Nonthoracotomy Lead System

208 Tehran Arrhythmia Center Pectoral Implantation The Current Technique

209 Tehran Arrhythmia Center Tiered Therapy Defibrillators

210 Tehran Arrhythmia Center Defibrillator Function

211 Tehran Arrhythmia Center Interrogated ICD Event VT, treated appropriately by burst pacing therapy

212 Tehran Arrhythmia Center Interrogated ICD Event VT (CL 320ms), no response to burst pacing therapy

213 Tehran Arrhythmia Center Interrogated ICD Event VT (CL 320ms), cardioverted by DC shock

214 Tehran Arrhythmia Center Clinical Uses of Defibrillator Therapy

215 Tehran Arrhythmia Center

216 Congenital Long QT Syndrome A Frequently Missed Diagnosis

217 Tehran Arrhythmia Center Long QT Interval

218 Tehran Arrhythmia Center Long QT Interval

219 Tehran Arrhythmia Center Long QT Interval

220 Tehran Arrhythmia Center Clinical Manifestations Long QT syndrome is characterized by the presence of a long QT interval (usually over 440 ms) and emergence of ventricular arrhythmias. The presenting arrhythmia is a polymorphic ventricular tachycardia called ‘Torsade de Pointes’. Patient present with recurrent syncope or sudden cardiac death. Early diagnosis by ‘looking at ECG’ is critical!

221 Tehran Arrhythmia Center Torsade de Pointes Prolonged QT interval associated with a polymorphic VT characterized by QRS complexes that change in amplitude and cycle length, giving the appearance of oscillations around the baseline Congenital or acquired

222 Tehran Arrhythmia Center Brugada Syndrome Definition Clinical-electrocardiographic diagnosis based on: -High incidence of sudden cardiac death -Structurally normal heart -Characteristic ECG pattern

223 Tehran Arrhythmia Center ECG Abnormalities ST segment elevation in V1-V3 QRS complex resembling RBBB J-point elevation

224 Tehran Arrhythmia Center Brugada ECG Pattern

225 Tehran Arrhythmia Center Brugada ECG Pattern

226 Tehran Arrhythmia Center History First time in 1986: a 3-year polish boy First presentation at NASPE meeting in 1991 First paper by Pedro and Josep Brugada in 1992 In the Philippines as “ bangungut” In Japan as “Pokkuri” In Thailand as “ Lai tai”, SUDS Circ Thai men correlated to Brugada, SUNDS Hum. Mol. Gen. 2002

227 Tehran Arrhythmia Center Brugada Syndrome  Prevalence in men (8:1 ratio males: females)  Familial incidence (autosomal dominant with incomplete penetrance ranging between 5 and 66 per )  True prevalence is difficult to estimate as the ECG pattern is often concealed.  It is endemic in Southeast Asia including: Thailand, Japan, Laos, Cambodia, Vietnam, the Philippines, and China.  Appearance of arrhythmic events at an average age of 40 years

228 Tehran Arrhythmia Center Clinical Manifestations Sudden cardiac death Syncope, seizure, agonal respiration, Episodes at night during sleep with labored respiration, agitation, loss of urinary control, recent memory loss Most commonly occurs during sleep, in particular during the early morning hours Early diagnosis is of utmost importance The only treatment is currently implantation of an ‘Implantable Cardioverter Defibrillator’.

229 Tehran Arrhythmia Center


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