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DetectingandManagingVentricularArrhythmias(fromWearablePatches,
WCDs,toICDsandAblation)
DavidE.Krummen,MDDirectorofElectrophysiology,VASanDiego
ProfessorofClinicalMedicine,UCSDMedicalCenter
FundingSourcesandDisclosures1. Funding:
1. AHA (10BGIA3500045)2. UCSD CTRI Galvanizing Engineering in Medicine Research
Grant3. NIH/UC CAI Grant4. UCSD Rady Grant5. National Institutes of Health, Grant UL1TR001442
2. Disclosures1. Consulting: Abbott Labs via an Institutional Consulting
Agreement managed by UCSD2. Equity in Vektor Medical.3. EP Fellowship Support from Biosense-Webster, Biotronik,
Boston Scientific, Medtronic, and St. Jude Medical
3. Acknowledgements: 1. This work was supported by the National Biomedical
Computing Resource and the UCSD Supercomputer Cluster (NIH P41 GM103426)
LectureOutline
• DetectingVentricularArrhythmias• ECG• Holters andEventMonitors• Smartwatches• ILRs
• ManagingVentricularArrhythmias• WCDs• ICDs• AntiarrhythmicTherapy• Ablation
ECG
• Firstdiagnostictestinapt withastablewideQRScomplextachycardiaonamonitor
• VTisthemostcommondxforadultswithunderlyingstructuralheartdisease
• CriteriasupportingVTinclude:AVdissociation,aQRScomplex>0.14s,monophasicRwaveinaVR,specificQRSmorphologies,theabsenceofanRScomplexinallprecordialleads,andanRSinterval>100msinatleast1precordiallead
• Exceptionsoccur!• Forpatientswithpreexistingbundlebranchblock,comparisonwithECGduringsinusrhythmisimportant
ECG
• ECGmayindicatethepresenceofstructuralheartdiseasesuchaspriorMIorchamberenlargement,oritmayprovideevidenceoftheunderlyingsubstrateforthearrhythmia• Itmayalsorevealevidenceofinheritedarrhythmiadisorders:longQTsyndrome,Brugadasyndrome,andARVC• MicrovoltTwavealternansandthesignalaveragedECGareinconclusive,assuchthesetestsarenotroutinelyused• ExceptionisthepotentialuseofsignalaveragedECGinpatientswithARVC
AmbulatoryECGMonitoring• AHoltermonitororaneventrecorderishelpful indiagnosing suspectedarrhythmias,establishingtheirfrequency, relatingthemtosymptoms,andassessingtheresponsetotreatment
• VTisoccasionallydocumented• AHolterrecordingisappropriatewhensymptomsoccuratleastonceadayorwhenquantitationofPVCs/NSVTisdesired
• Adhesivepatchmonitorscanrecordforweeksandallowforcontinuous short-term1-leadmonitoringandpatientactivationforsymptoms
• Studieshaveshownsatisfactorypatientcompliance,andarrhythmiadetection - withsomemonitors,detectedarrhythmiasarenotdiscovereduntilthepatchisreturned foranalysis
• Importantly,whenthesuspicionofVAinapatientishigh, outpatientmonitoring isinappropriate
Smartwatches• Multinational cardiovascularremotecohortstudycoordinatedattheUCSF
• 9750participantsenrolled intheHealtheHeart Studyand51patientsundergoing cardioversionattheUniversityofCalifornia,SanFrancisco,wereenrolledbetweenFebruary2016andMarch2017.
• 9750participantsenrolled intheremotecohort.• Thereweremorethan139millionheartratemeasurementsonwhichthedeepneuralnetworkwastrained.
• Sensitivitywas98.0%andspecificitywas90.2%forAF.• ExploratoryanalysisofpersistentAFinambulatoryparticipants,thesensitivitywas67.7%andspecificitywas67.6%.
• Study found thatsmartwatchcoupledwithadeepneuralnetworkcanpassivelydetectAFbutwithsomelossofsensitivityandspecificityagainstacriterion-standardECG.
Tison etal.JAMACardiology2018
ILRs
• ProvidecontinuousrhythmmonitoringandstoredrecordingsofEGMsbasedonpatientactivationorpresetparameters,allowingaprolongedmonitoringperiodofa2-3years
• Inpatientswithsporadicsymptoms,includingsyncope,implantablerecordersareusefulindiagnosingserioustachyarrhythmias(includingVA)andbradyarrhythmias
• Generallyreservedforpatientsinwhomotherambulatorymonitoringisnonrevealing
• A25%addedyieldindiagnosishasbeendescribedafteranunrevealingeventmonitor
• Inastudyofpatientswithsyncope,theILRhadagreaterdiagnosticyieldthan“conventional”testingwithexternalmonitoring,tilttabletestingandEPstudy
Echo
• Assessmentofglobalandregionalfunction,valvularfcn,alongwithassessmentforadultcongenitalheartdiseaseisrequiredinpatientswithVAorSCD,includingpatientswithcardiomyopathy,HF,priorMI,familyhistoryofcardiomyopathyorSCD,oraninheritedstructuralheartdiseaseassociatedwithSCD
• LVEFisastrong,independentpredictorofSCDandcardiovascularmortalityandadeterminantofeligibilityforICDimplantationforprimarypreventionofSCD
• InSCD-HeFT (theSuddenCardiacDeathinHeartFailureTrial),thebenefitoftheICDwasnotdependentonthemodality(i.e.,echo,radionuclideangiography,orcontrastangiograms)bywhichtheLVEFwasassessed
CardiacImaging
• VAorSCAcanbeaninitialmanifestationofischemicheartdisease,cardiomyopathicprocesses,ormyocarditis.CardiacCTandcardiacMRIallowforevaluationofstructuralheartdiseaseandassessmentofLVandRVfunctionincludingquantificationofLVEF,LVmassandvolume,valvularstructureandcoronaryanatomyincludinganomalouscoronaryorigins.CardiacMRIcanbeusefulintheevaluationformyocardialscarandinfiltrativeprocessesevidentaslategadoliniumenhancement(5-9).CardiacMRIalsoprovideshighqualityassessmentofLVandRVfunction,size,anddegreeoffibrosisandisparticularlyusefulinarrhythmogenicrightventricularcardiomyopathyandHCM.
Biomarkers
• Elevatedlevelsofnatriureticpeptides—B-typenatriureticpeptide(BNP)orN-terminalpro-BNP—areassociatedwithincreasedriskofSCAandappropriateICDtherapies,evenafteradjustmentofLVEFandotherriskfactors
• Inanolderadultpopulation,higherbaselinelevelsofN-terminalpro-BNPwereassociatedwithSCDovera16-yearfollow-upperiod
• UseofbiomarkershasnotbeenshowntobeusefulforselectingpatientsforICDs
• Astudyof4431patientsfoundhigh-sensitivitytroponintobeonlyweaklypredictiveofSCD
• Therearenodataonwhetherhigh-sensitivitytroponincanimprovethecurrentSCDpredictionalgorithms.
Genetictesting
• Thedecisiontoproceedwithgenetictestingrequiresdiscussionregardingtheclinicaluseoftheinformationtobeobtainedforboththeprobandandfamilymembers,aswellasconsiderationoftheimportantpsychological,financial,employment,disability,andlifeinsuranceimplicationsofpositivegenotyping
• Geneticcounselinggenerallyoccursbeforeproceedingwithgenetictesting,andisoptimallyprovidedbygeneticcounselorsincollaborationwithphysicians
• Acombinedapproachofgeneticcounselingwithmedicalguidancemayappropriatelybalancethedecisiononanindividualbasis.
CardiacCatheterizationorCTCoronary
• Althoughrandomizedstudiesareunavailable,coronaryangiographyhasanimportantroleinestablishingorexcludingthepresenceofsignificantobstructiveischemicheartdiseaseinpatientswithSCAorthosewithlife-threateningVA
• RecurrentpolymorphicVTorVFcanbeduetoongoingmyocardialischemiathatresolveswithcoronaryrevascularization
• AcoronaryangiogrammaynotbewarrantedifanonischemiccauseofSCAisestablished
• CoronaryandCTangiographyalsohaveanimportantroleexcludingthepresenceofanomalousoriginofthecoronaryarteriesthatmaycauseSCD
WCD• Awearablecardioverter-defibrillator:• ExternaldevicetodetectandtreatVTorVF• Usedforseveralmonths• 4monitoringelectrodes,3defibrillationelectrodes,andadefibrillationunit
WCDTherapyforVF
• RandomizedVESTtrialwasnegativeformortalitybenefitfromWCTuse• AnimportantissuefromtheVESTtrialwascompliance• FurtherworkisneededtorefinetheWCDtorealizethepotentialbenefits
Defibrillators
• Defibrillationishighlyeffectiveinterminatinglife-threateningVA
• TransvenousICD,asubcutaneousimplantablecardioverter-defibrillator,awearablecardioverter-defibrillatororanexternaldefibrillator
• ICDswithepicardialsensingandpacingleadsarestillbeingimplantedinsomepatientsespeciallythosewithcertainformsofcongenitalheartdisease
• Robustdatafromhigh-qualityRCTssupportitsuseinvariouspatientpopulationsincludingsurvivorsofcardiacarrest,patientswithVTandstructuralheartdisease,andpatientswithsignificantLVdysfunction.
SICD
• Thesubcutaneousimplantablecardioverter-defibrillatorwasdesignedtoavoidtheneedforvenousaccessandsomeofthecomplicationsofinsertingtransvenouslead(s)includingpneumothorax,hemothorax,andcardiactamponade
• ConsiderforpatientswithlimitedvenousaccesssuchaspatientswithESRD
• Inastudyof27patientswithESRD,thesubcutaneousimplantablecardioverter-defibrillatorwasnotassociatedwithanincreasedriskofproceduralcomplicationsorinappropriateshocks
• Maybepreferredinpatientswhoareathighriskofinfection,suchasptswithapriordeviceinfection,ESRD,diabetesmellitus,orwhoarechronicallyimmunosuppressed.
SICD
• Thesubcutaneousimplantablecardioverter-defibrillatorisincapableofbradycardiapacing,biventricularpacing,orantitachycardiapacing• Ptswhomayneedtheseinterventionsshouldnotbeofferedasubcutaneousimplantablecardioverter-defibrillator• SometimespatientswithSICDsneedpacing;thiscanbeperformedaslongasthepacingisnotunipolar• Leadlesspacinginthissettingisunderevaluation
Ablation
• CatheterablationisanimportanttreatmentoptionforpatientswithVAwhenantiarrhythmicmedicationsareineffective,nottolerated,ornotdesiredbythepatient• MonomorphicVAusuallyhaveanoriginorsubstratethatcanbetargetedforablation• EarlystudiesinablationofVFshowpromise• Problemslimitingablationsuccessincludeinabilitytoinduceanarrhythmia,ororiginofthearrhythmiafromaninaccessiblelocationinthemyocardium
VAAblationinPatientswithNoApparentStructuralHeartDisease• VAthatarenotassociatedwithunderlyingstructuralheartdiseaseorageneticarrhythmiasyndromearecommonlyreferredtoasidiopathic• MostidiopathicVAaremonomorphicandbasedonafocalmechanismoftriggeredactivityorabnormalautomaticity• CatheterablationofidiopathicVAisusuallyaccomplishedwithendocardialcatheterization,thoughanepicardialapproachthroughthecoronaryvenouscirculationorasubxiphoidpericardialpuncturemayoccasionallyberequired
SurgeryforVAs
• CardiacsurgeryasastandaloneprocedureforVTisrarelyperformed
• Hasaroleinsomehighlysymptomaticpatients,whenantiarrhythmicmedicationsandcatheterablationfailsorarenotpossible
• Surgicalablationoftachycardiacanalsobeperformedatthetimeofothercardiacsurgicalinterventions
• Theprocedurerequiresdetailedcharacterizationofthearrhythmiausuallywithpreoperativeimagingandmapping
• BestundertakenatcentersandwithcollaborationbetweenexperiencedsurgeonsandEPs.
LectureSummary
• DetectingVentricularArrhythmias• ECG• Holters andEventMonitors• Smartwatches• ILRs
• ManagingVentricularArrhythmias• WCDs• ICDs• AntiarrhythmicTherapy• Ablation
Ho,…,Krummen.HeartRhythmCaseReports
Thankyou!
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