Management of the Patient Presenting with Wide Complex Tachycardia Samir Saba, MD Director, Cardiac Electrophysiology

Definition Heart rate > 100 b/min QRS > 120 ms

Differential Diagnosis Supraventricular tachycardia with aberrancy Pre-excited tachycardia Motion artifact Paced rhythm Ventricular tachycardia Idiopathic Non-idiopathic

Importance of diagnosing VT Sensitivity versus Specificity In all patients with WCT, VT is the diagnosis in 80% of cases

SVT with aberrancy Typical RBBB Typical LBBB

Typical bundle morphology LBBB RBBB

LBBB in AVRT

RBBB and AVRT

Pre-excited Tachycardia Manifest versus concealed AP

WPW

WPW

Antidromic AVRT

Atrial Flutter with Preexcitation

AF with Preexcitation

Motion artifact Failure to recognize artifact is common: 94% of internists 58% of cardiologists 38% of EP

Motion Artifact Recognize artifact by: Marching the high frequency signal across the WCT Looking at other available leads

Paced ECG

Paced ECG Paced Not Paced

Ventricular Tachycardia Idiopathic RVOT VT LVOT VT Lt fascicular VT Non-idiopathic ICM NICM HCM Channelopathy (LQTS, Brugada, etc…)

RVOT VT

LVOT VT

Left fascicular VT

Other Classifications for VT Morphology: Monomorphic Polymorphic Bidirectional Mechanisms: Reentry Automaticity Triggered activity Drug susceptibility: Verapamil sensitive Adenosine sensitive

Repetitive VT

MMVT

Non-idiopathic VT

Ventricular Tachycardia

Bidirectional VT

Mechanisms of VT

Approach to Management History Physical Exam ECG EP Study

History Age (if >35 yrs, VT>85%) Symptoms (palpitations, syncope, LH, diaphoresis, angina, seizures, CA…) Circumstances: N/V/D (electrolytes) PMH: Cardiac disease, MI, CHF, ICD, RF Family history: SCD, arrhythmias Medications: QT prolongation, digoxin, diuretics, etc… Habits: Drugs

Physical Examination Hemodynamic Stability Signs of acute CHF Sternal wound PVD Stroke PM/ICD Evidence of AV dissociation (cannon A waves, marked fluctuations in BP, variable S1 intensity) Maneuvers: CSM, pharmacologic interventions (lidocaine, adenosine, BB, verapamil)

Other tests Laboratory tests: K, Mg, plasma concentrations of drugs (dig, procan, etc…) CXR: cardiomegaly Echo: structural abnormalities

ECG In NSR: AV dissociation Ischemia Fusion beats Acute MI During WCT: AV dissociation Fusion beats Capture beats Morphology Width of QRS Morphology of the bundles Electrical axis Precordial concordance In NSR: Ischemia Acute MI Old MI Long QT Brugada pattern LVH Epsilon waves

AV dissociation

Fusion beat

ECG

ECG

Therapy Acute Management: For the Unstable patient: Emergent synchronized cardioversion If QRS and T cannot be distinguished then defibrillation Cautious use of sedatives and analgesics For the Stable patient: Class I or III AAD Treatment of associated conditions (ischemia, electrolytes,…) Elective cardioversion Interrogation of ICD or PM if present

Therapy Chronic Management: AAD: EPS+/-RFA ICD class IC or III, if structurally normal hearts class III, if structurally abnormal hearts (with ICD) EPS+/-RFA Stand alone therapy in idiopathic VT Adjunctive therapy (+/-AAD) in ischemic VT ICD For primary and secondary prevention of SCD

Indication for EPS

EP Study Induce the arrhythmia Activation or Pace mapping Ablation

Activation Map for VT

RVOT VT: pace map

Special Case: NSVT EF≤35%, then ICD EF>40%, no ICD 35%<EF≤40%, then EPS and ICD if EPS+ (MUSTT trial) In all these cases, -blockers and other AAD can be used if NSVT is symptomatic.

Summary DDX of WCT includes VT, SVT with aberrancy, preexcited tachycardia, artifact, and paced rhythm. VT accounts for 80% Diagnosis hinges of good history, PE, ECG Acute management depends on stability of patient. In the unstable patient, immediate cardioversion or defibrillation is recommended Long term management armamentarium includes: AAD, Ablation, ICD

Holter Monitor in a Mouse

EPS in a Mouse

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