Dr. Ajay Naik MD, DM, DNB, FACC, FHRSiseindia.org/ecg_presentation/07_VT Dr Ajay Naik Final.pdf ·...
Transcript of Dr. Ajay Naik MD, DM, DNB, FACC, FHRSiseindia.org/ecg_presentation/07_VT Dr Ajay Naik Final.pdf ·...
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Dr. Ajay Naik
MD, DM, DNB, FACC, FHRS Cardiac Electrophysiologist,
Director, CIMS Hospital
Ahmedabad, India
Education
• DM and DNB Cardiology, KEM Hospital, Mumbai 1998
• EP Fellowship: Cedars-Sinai Medical Center, Los Angeles, USA 1999-2001
• FACC (2003), FAPSC (2008), FHRS (2010), FESC (2014).
Work Profile
• Working in Ahmedabad and visiting tertiary care centers internationally.
• Numerous publications in major international journals.
• Principal investigator for numerous multinational drug and device clinical trials
• International and national faculty for Cardiac Electrophysiology.
• Director of Core Laboratory
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VT:
Varied Etiologies, Myriad Presentations
DR. AJAY NAIK
MD, DM, FACC, FHRS
Cardiac Electrophysiologist
Director,
Ahmedabad, India
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25-yrs-old gentleman, palpitations
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Panic in the ER……
• NCT / WCT
• VT / SVT with aberrancy
• Normal heart / SHD
• QRS morph: LBBB-like pattern, inferior axis
QRS transition V2 - 3
• Treat with:
• Verapamil / Adeno / Amio / Cardiovert?
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RVOTT
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RVOTT
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2/4/2019 7
Clinical Presentation – RVOTT
• Palpitations, Dizziness, Pre/syncope
• Induced with exercise or other hyperadrenergic
states (?cAMP mediated Triggered activity)
• Repetitive monomorphic VT is a variant
• No evidence of structural heart disease (SHD)
• Responds to CCB, B, combination
• RF Ablation has a high success rate (90%)
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RVOTT focus
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2/4/2019 DR. AJAY M. NAIK, MD, DM, DNB CARE
CARDIOLOGY CONSULTANTS 9
RVOTT
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During ablation, VT terminated
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2/4/2019 11
Ventricular Arrhythmias • Mechanism Reentry, Triggered, Automaticity
• Rate Slow, Fast
• Duration NSVT, Sustained
• Site of origin RV / LV / Endocardial / Epicardial
• Location Septal / Outflow / Apical / Basal
• Morphology Monomorphic / Polymorphic
• Substrate Normal heart/ CAD/ Myopathy
• Hemodynamic Stable / Unstable
• Exercise Induced / Not induced by exercise
• Drug responsiveness and amenability to RFA
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Clinical circumstances
• 1. Idiopathic VT
• 2. VT in SHD
• 3. VT in presence of ICD
• 4. VT storm
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Etiologies of VT • VT in structurally normal hearts
– Monomorphic (RVOTT, LVOTT, ILVT)
– Polymorphic (LQTS, Brugada, Channelopathies)
• VT related to CAD, Acute vs. Old MI (scarred myocardium, LV dysfunction)
• VT related to non-ischemic heart disease
– CMP, ARVD, Sarcoidosis, Myocarditis
• VT related to drugs (Proarrhythmias)
60%
5%
25%
5%
5%
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2/4/2019 14
Idiopathic VT
• VT occurring in patients with normal hearts
• Outflow Tract Tachycardia (RVOT / LVOT)
• Idiopathic Left Ventricular Tachycardia
(Fascicular Tachycardia) (?Papillary muscle
related VT)
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2/4/2019 15
RVOTT
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Case2: 33-yrs-old gentleman, palpitations (2002)
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Q1. Where does the VT arise from ?
• A. Outflow Tract region
• B. Basal region
• C. Apical region
• D. Not a VT.
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2/4/2019 DR. AJAY M. NAIK, MD, DM, DNB CARE
CARDIOLOGY CONSULTANTS 18
ARVD – VT
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2/4/2019 DR. AJAY M. NAIK, MD, DM, DNB CARE
CARDIOLOGY CONSULTANTS 19
ARVD – VT
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ARVD
• Structural Heart Disease
• RV is dilated with aneurysms, sacculations
• Fat replaces myocardial cells
• Multiple morphologies of VT arising from RV
• Epsilon wave on EKG
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ARVD
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2/4/2019 DR. AJAY M. NAIK, MD, DM, DNB CARE
CARDIOLOGY CONSULTANTS 22
ARVD – Epsilon wave
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RV Angiogram
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RV Angiogram
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Treated medically for 10 years…
• BB, Amiodarone
• CHF
• Recurrent VT
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ICD implanted… 26.4.2013
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ICD implanted… 26.4.2013
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VT episode
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ATP accelerated VT…Shock successful
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Case 3: 35-yr-old gentleman…
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Case 3: 35-yr-old gentleman…
• Severe palpitations past 6 hrs.
• Similar episodes several times past 4 yrs
• Echo Normal
• CAG Normal
• Was put on Amiodarone
• Developed hypothyroidism
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2/4/2019 DR. AJAY M. NAIK, MD, DM, DNB CARE
CARDIOLOGY CONSULTANTS 32
ILVT
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Q2. Where does the VT arise from ?
• A. Outflow Tract region
• B. Basal region
• C. Apical region
• D. Not a VT.
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Rapid tachycardia
• “Narrow looking” WCT
• RBBB-like pattern, left superior axis
• ?SVT / VT
• Treat with:
• Verapamil / Adeno / Amio / Cardiovert?
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ILVT
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Clinical Presentation – ILVT
• Young pts, Male predominance
• Palpitations, Occasional syncope
• Incessant VTs may cause Tachycardiomyopathy
• Respond to Verapamil
• Success rate of RF Ablation almost 90%
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2/4/2019 DR. AJAY M. NAIK, MD, DM, DNB CARE
CARDIOLOGY CONSULTANTS 37
ILVT, Slower
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2/4/2019 38
ILVT
• Arises near the basal or midseptal area of LV
• RBBB pattern, Left superior axis
• Normal sinus rhythm ECG
• T inversions in inferolateral leads may be seen
• Likely reentrant in nature, using left bundle
ramifications Purkinje system
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2/4/2019 DR. AJAY M. NAIK, MD, DM, DNB CARE
CARDIOLOGY CONSULTANTS 39
After ILVT termination
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ILVT ablation
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Sinus rhythm
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Case 4: 23-yrs-old girl, palpitations…
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Q3. Where does the VT arise from ?
• A. Outflow Tract region
• B. Basal region
• C. Apical region
• D. Not a VT.
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Case 4: 23-yrs-old girl, palpitations…
• Severe palpitations past 2 hrs.
• Similar episodes several times past 1 year
• Normal heart
• QRS morph: RBBB-like pattern, inferior axis
• Treat with:
• Verapamil / Adeno / Amio / Cardiovert?
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LVOTT
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LVOT Tachycardia
• A variant of Outflow tract tachycardia
• (? 10% of cases)
• Early precordial transition
• Arises from the LVOT region
• Triggered activity
• Respond to Verapamil
• Focus may occasionally be close to LMCA
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LVOT VT
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2/4/2019 53
Idiopathic VTs..
• Idiopathic VT are a distinct subset
• Structural Heart Disease has to be ruled out
• Despite being VTs, they respond to Verapamil
• RVOTT, ILVT are exquisitely amenable to RF
ablation therapy
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Etiologic Classification of VT
• VT in structurally normal hearts
– Monomorphic (RVOTT, LVOTT, ILVT)
– Polymorphic (LQTS, Brugada, Channelopathies)
• VT related to CAD, Acute vs. Old MI (scarred myocardium, LV dysfunction)
• VT related to non-ischemic heart disease
– CMP, ARVD, Sarcoidosis, Myocarditis
• VT related to drugs (Proarrhythmias)
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VT morphology definitions
• Monomorphic VT:
• Similar QRS configuration from beat to beat. Some
variability in QRS morphology at initiation is not
uncommon, followed by stabilization of the QRS
morphology
• Multiple Monomorphic VTs:
• More than one morphologically distinct monomorphic
VT, occurring as different episodes or induced at
different times.
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VT morphology definitions
• Polymorphic VT:
• Continuously changing QRS configuration from beat
to beat indicating a changing ventricular activation
sequence.
• Pleomorphic VTs:
• More than one morphologically distinct QRS
complex occurring during the same episode of VT,
but the QRS is not continuously changing.
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Etiologies of SCD
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60
VAs in Ischemic Heart Disease
Myerburg R. N Engl J Med 2008;359:2245-253
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Acute MI
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DR. AJAY NAIK, MD, DM, DNB, FACC 62
Holter – “Heart Attack”
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DR. AJAY NAIK, MD, DM, DNB, FACC 63
Holter – SCD
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Apple and Oranges…
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• MI / ACS SCA
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Polymorphic VT during ACS
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• VT in first 24 hours :
– Does not affect long term prognosis
– Does not require long term suppressive therapy,
– Ischemia correction is the key
• VT occurring later :
– Increased hospital and long-term mortality,
– More common in patients with transmural infarction and left ventricular dysfunction,
– Likely to be sustained
– Induces marked hemodynamic deterioration
VAs in ACS
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Case 5: 48-yr-old, chest pain, syncope, SCA
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Post Defibrillation... J point elevation
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Case 6: 67-yrs-old gentleman, syncope
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Case 6: 67-yrs-old gentleman, syncope
• CAD,
• Severe LV dysfunction, LVEF 20%
• CABG
• Incessant VT
• Multiple shocks given
• On AAD.
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VT1
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VT2
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MI Scar Related Sustained Monomorphic VT Circuit
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Scar mapping and Ablation
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Scar VT
1. Post Myocardial infarction
2. Non ischemic cardiomyopathy Dilated cardiomyopathy
Post Myocarditis
ARVD
RV Cardiomyopathy
Sarcoidosis
Hypertrophic CMP
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Myocardial Scar and VT
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Case 7: 75-yrs-old gentleman, CAD, LV dysfunction,
Unconscious
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Q4. What is happening?
• A. “Heart Attack”
• B. “Sudden Cardiac Arrest”
• C. Both
• D. Neither
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Repeated shocks, metabolic corrections, incessant VT
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Post RFA, stablized, AV sequential pacing
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Case 8: 46-yr-old gentleman, MI in past, unconscious
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After DC Cardioversion…
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Q5. What is happening?
• A. “Heart Attack”
• B. “Sudden Cardiac Arrest”
• C. Both
• D. Neither
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On Amiodarone therapy… Acute issues
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Amiodarone : Long term therapy issues
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Amiodarone Pulmonary Toxicity
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Case 9: 30-yrs-old lady, RHD, pre-BMV
Treated for AF in the ICU …. Seizures
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Q6. What is the ECG abnormality?
• A. PVCs
• B. QT prolongation
• C. T wave alternans
• D. All of the above
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DR. AJAY NAIK, MD, DM, DNB, FACC 106
Temporary Pacing
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Management and FU
• Dual Chamber ICD implant done
• BMV performed
• 5 year follow up: doing well
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Channelopathies
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Long QT Syndrome
RR:700 ms
QT:400 ms QTc: 480 ms
Notched T waves
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DR. AJAY NAIK, MD, DM, DNB, FACC 111
Long QT Syndrome Prolonged QT Interval
Syncope/Fainting
Malignant Ventricular Arrhythmias - Torsades de Pointes
Sudden Death
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High risk features in LQTS
• QT>500 ms
• H/O syncope/ SCD
• Female
• LQT2/ LQT3
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Cumulative Probability of LQTS – related
Death With Beta-Blockers
Years on Beta-Blockers
Cu
mu
lati
ve P
rob
ab
ilit
y (
%)
or
Card
iac A
rrest/
LQ
TS
– R
ela
ted
Death
0 1 2 3 4 5
40
30
20
10
0
Prior aborted cardiac
arrest
Syncope only
Asymptomatic
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Case 10: 40-yr-old lady
• 40-yr-old lady with repeated convulsions on
27.5.2004
• Used to fall down and get up in 5 minutes once
a month over past 15 years.
• Was assumed to have “Mata”
• This time, somebody found her to have a fast
pulse….
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40-yr-old lady, repeated convulsions
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DR. AJAY NAIK, MD, DM, DNB, FACC 117
40-yr-old lady, repeated convulsions
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DR. AJAY NAIK, MD, DM, DNB, FACC 118
40-yr-old lady, repeated convulsions
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Q7. What is the ECG abnormality?
• A. Atrial Fibrillation
• B. Acute MI
• C. Torsade de pointes
• D. Artifact
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DR. AJAY NAIK, MD, DM, DNB, FACC 120
40-yr-old lady, repeated convulsions
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DR. AJAY NAIK, MD, DM, DNB, FACC 121
AAIR pacemaker, 100 bpm + β blockers
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40-yr-old lady, repeated convulsions
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Short QT syndrome
Short QT syndrome
QT = 225 msec
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Case 11: 40-yr-old gentleman…syncope
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After recovery…
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Case 12: 67-yr-old gentleman, unconscious in
backyard •
131
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Osborn wave
•^ Osborn JJ. Experimental hypothermia: Respiratory and blood pH •changes in relation to cardiac function. Am J Physiol 1953; 175: 389-398.
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After 24 hours, recovered fully
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Case 13: 45-yrs-old gentleman, presyncope
Bidirectional VT
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Polymorphic VT - CPVT
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Class I
• Beta blockers are indicated for patients who
are clinically diagnosed with CPVT on the
basis of the presence of spontaneous or
documented stress-induced ventricular
arrhythmias. (Level of Evidence: C)
• Implantation of an ICD with use of beta
blockers is indicated for patients with CPVT
who are survivors of cardiac arrest
Catecholaminergic Polymorphic
Ventricular Tachycardia
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Case 14: 60-yrs-old lady, HCM
• Normal coronaries
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Case 14: 60-yrs-old lady, HCM,
SCD in 2 sibs
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SCD risk
• Normal coronaries
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Identify the Patient at High Risk
• H/O SCD
• Family H/O SCD
• Genotype
• VT
• Syncope
• IVS>29mm
• Younger age at diagnosis
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Case 15: 33-yrs-old gentleman…
• Treated for PVCs in Jan 2011
• LVEF 45%
• No inducible VT on EPS (1.2.2011)
• Rapid VT (30.3.2011)
• Cardiac Sarcoidosis (CECT, Biopsy)
• ICD implanted (24.6.2011)
• VT storm, LVEF 15% (4.7.2011)
• Incessant VTs of various morphologies, shocks.
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33-yr-old gentleman, VT 1
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VT 2
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1 VT3: LBBB L ax, 550 ms CL, 110 bpm
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1 VT4:“RBBB” LSupAx, 330 ms CL,180 bpm
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1 VT5: LBBB LSupAx, 330 ms CL, 180 bpm
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VT5
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PLEOMORPHIC VT
VT12345 combined RV and LV
VT1
VT4 VT5 VT5
VT3
VT2 VT2
VT3
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1 Resting ECG, AV sequential pacing
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5 years follow up
• No VT / VF / shocks for > 5 years
• 25.12.2016 doing well after 5 years (LVEF 25%)
• Resumed work
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Inflammatory Cardiomyopathy
• Sarcoidosis
• Tuberculous myocarditis
• “Granulomatous Myocarditis”
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Electrical Storm
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Homogenization of Substrate
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Summary
• Ventricular arrhythmias may range from
“benign” to life-threatening Electrical Storms
• Etiology and Substrate is closely linked to
outcome.
• Co-ordinated Clinical, SHD and
Electrophysiologic management is paramount
• VT management requires astute, refined
acumen in an established arrhythmia center for
optimal outcome.
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Dr AJAY NAIK
MD DM DNB FACC FHRS