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!

Questions?