Electrocardiography & Cardiac Arrhythmias Saeed Oraii MD, Cardiologist Interventional...
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![Page 1: Electrocardiography & Cardiac Arrhythmias Saeed Oraii MD, Cardiologist Interventional Electrophysiologist Tehran Arrhythmia Clinic.](https://reader036.fdocuments.us/reader036/viewer/2022062305/56649c925503460f9494dba9/html5/thumbnails/1.jpg)
Electrocardiography&
Cardiac Arrhythmias
Saeed Oraii MD, Cardiologist
Interventional Electrophysiologist
Tehran Arrhythmia Clinic
![Page 2: Electrocardiography & Cardiac Arrhythmias Saeed Oraii MD, Cardiologist Interventional Electrophysiologist Tehran Arrhythmia Clinic.](https://reader036.fdocuments.us/reader036/viewer/2022062305/56649c925503460f9494dba9/html5/thumbnails/2.jpg)
Tehran Arrhythmia Center
Some slides have accompanied notes. To view them you can right
click on the screen, choose ‘Screen’ and then ‘Speaker Notes’.
![Page 3: Electrocardiography & Cardiac Arrhythmias Saeed Oraii MD, Cardiologist Interventional Electrophysiologist Tehran Arrhythmia Clinic.](https://reader036.fdocuments.us/reader036/viewer/2022062305/56649c925503460f9494dba9/html5/thumbnails/3.jpg)
Tehran Arrhythmia Center
ECG
A graphic recording of electrical potentials generated by the heart
A noninvasive, inexpensive and highly versatile test
![Page 4: Electrocardiography & Cardiac Arrhythmias Saeed Oraii MD, Cardiologist Interventional Electrophysiologist Tehran Arrhythmia Clinic.](https://reader036.fdocuments.us/reader036/viewer/2022062305/56649c925503460f9494dba9/html5/thumbnails/4.jpg)
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Normal Pathway of Electrical Conduction
![Page 5: Electrocardiography & Cardiac Arrhythmias Saeed Oraii MD, Cardiologist Interventional Electrophysiologist Tehran Arrhythmia Clinic.](https://reader036.fdocuments.us/reader036/viewer/2022062305/56649c925503460f9494dba9/html5/thumbnails/5.jpg)
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Cardiac Action Potential
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Cardiac action potentials from different locations have different shapes
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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.
![Page 8: Electrocardiography & Cardiac Arrhythmias Saeed Oraii MD, Cardiologist Interventional Electrophysiologist Tehran Arrhythmia Clinic.](https://reader036.fdocuments.us/reader036/viewer/2022062305/56649c925503460f9494dba9/html5/thumbnails/8.jpg)
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Electrocardiograph 1903
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Normal Electrocardiogram
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ECG WaveformsLabeled alphabetically beginning with the P wave
Tehran Arrhythmia Center
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QRS-T Cycle Corresponds to Different Phases of Ventricular
Action Potential
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Limb Leads
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Precordial Leads
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Position of Precordial Electrodes
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Precordial Leads
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3-D Representation of Cardiac Electrical Activity
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Timing Intervals
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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.
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Limb Leads Directions
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Vector Concept
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Ventricular Depolarization
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QRS Axis
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Determination of QRS Axis
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Direction of Propagation
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Determination of QRS Axis
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Determination of QRS Axis
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Main Vector
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Normal QRS Axis
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Left Axis Deviation
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Right Axis Deviation
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Major ECG Abnormalities
Tehran Arrhythmia Center
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Right Atrial Enlargement
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Left Atrial Enlargement
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Left Ventricular Hypertrophy
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Tehran Arrhythmia Center
Right Ventricular Hypertrophy
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RVH, RA enlargement
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Left Bundle Branch Block
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Tehran Arrhythmia Center
Left Bundle Branch Block
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Tehran Arrhythmia Center
Right Bundle Branch Block
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RBBB
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RBBB, RAD (Bifascicular Block)
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Tehran Arrhythmia Center
RBBB, LAD (Bifascicular Block)
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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
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Acute Ischemia
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Tehran Arrhythmia Center
Myocardial Infarction
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Acute Pericarditis
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Metabolic Abnormalities
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Hyper-kalemia K 6.9
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Same patient
K 3.9
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Tehran Arrhythmia Center
Hypothermia, Osborn Wave
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Hypothermia, Corrected
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Tehran Arrhythmia Center
Right Axis Deviation
Tehran Arrhythmia Center
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Superior P Wave Axis
Tehran Arrhythmia Center
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Normal Sinus Rhythm
Tehran Arrhythmia Center
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Anterior MI
Tehran Arrhythmia Center
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RBBB and Inferior MI
Tehran Arrhythmia Center
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LA Enlargement and Prolonged PR Interval
Tehran Arrhythmia Center
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LBBB
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
LA Enlargement and Prolonged PR Interval
Tehran Arrhythmia Center
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Left Anterior Hemiblock
Tehran Arrhythmia Center
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LVH and LA Enlargement
Tehran Arrhythmia Center
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Anterior MI
Tehran Arrhythmia Center
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Old Inferior MI
Tehran Arrhythmia Center
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RA Enlargement
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
RBBB, LAH, Prolonged PR (Trifascicular Block)
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
RBBB and Inferior MI
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
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Cardiac Arrhythmias
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
Normal Pathway of Electrical Conduction
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Normal Sinus Rhythm
• Normal and constant P wave contours
• Normal P wave axis
• Rate between 60 and 100 bpm
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Tehran Arrhythmia Center
Normal Sinus Rhythm
Tehran Arrhythmia Center
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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
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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 60-100 bpm.
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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
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Tehran Arrhythmia Center
Sinus Tachycardia
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Tehran Arrhythmia Center
Sinus TachycardiaCauses
• 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
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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
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Tehran Arrhythmia Center
Sinus Bradycardia
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Tehran Arrhythmia Center
Sinus Bradycardia Causes
• Hypothyroidism
• Drugs
• During vomiting or vasovagal syncope
• Increased intracranial pressure
• Hypoxia, hypothermia
• Infections
• Depression
• Jaundice
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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
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Tehran Arrhythmia Center
Sinus Arrhythmia
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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
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Tehran Arrhythmia Center
Wandering PacemakerECG
• 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
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Tehran Arrhythmia Center
Wandering Pacemaker
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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
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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
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Tehran Arrhythmia Center
Sinus Node DysfunctionECG Manifestations
• Sinus bradycardia
• Sinus pauses
• Sinus arrest
• Atrial asystole
• Sinus exit block
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Tehran Arrhythmia Center
Sinus Pause
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Tehran Arrhythmia Center
Sinoatrial Exit Block1st and 2nd degree
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Tehran Arrhythmia Center
Sinus Node DysfunctionEtiology
• Most often in elderly as an isolated phenomenon
• Drugs
• Infiltration of atrial myocardium
• Interruption of blood supply
• Hypothyroidism, advanced liver disease, severe hypoxia, acidemia …
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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)
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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
<bradycardia-tachycardia syndrome>
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
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
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Tehran Arrhythmia Center
Sick Sinus SyndromeDiagnosis
• 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.
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Tehran Arrhythmia Center
Normal SNRT
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Tehran Arrhythmia Center
Abnormal SNRT
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Tehran Arrhythmia Center
SA Block during Overdrive Pacing
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Tehran Arrhythmia Center
Sinus Arrest after Termination of AF
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Tehran Arrhythmia Center
Loop Recorder Showed Junctional Rhythm during Syncope
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Tehran Arrhythmia Center
Sinus arrest with syncope
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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
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Tehran Arrhythmia Center
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Tehran Arrhythmia Center
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
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Tehran Arrhythmia Center
AV Conduction DisturbancesClinical 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
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Tehran Arrhythmia Center
AV BlockTypes
• 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
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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.
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Tehran Arrhythmia Center
First Degree AV Block
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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.
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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
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Tehran Arrhythmia Center
WB
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Tehran Arrhythmia Center
Wenckebach Block
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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
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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
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Tehran Arrhythmia Center
Mobitz Type II Second Degree AV Block
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Tehran Arrhythmia Center
Mobitz Type II Second Degree AV Block
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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
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Tehran Arrhythmia Center
2:1 AV Block
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Tehran Arrhythmia Center
2:1 AV Block
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Tehran Arrhythmia Center
2:1 AV block
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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.
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Tehran Arrhythmia Center
Complete AV block
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Tehran Arrhythmia Center
Complete AV blockIsorhythmic AV Dissociation
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Tehran Arrhythmia Center
Advanced AV block
Block in two or more consecutive P waves
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Tehran Arrhythmia Center
AV Conduction DisturbancesEtiology
• 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
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Tehran Arrhythmia Center
Investigation of the Site of AV Conduction Disease by
Electrophysiologic Study (EPS)
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Tehran Arrhythmia Center
Cardiac Pacemakers
• The treatment of symptomatic bradyarrhythmias is implantation of cardiac pacemakers.
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Tehran Arrhythmia Center
Cardiac Pacing
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Tehran Arrhythmia Center
First Implanted Pacemaker
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Tehran Arrhythmia Center
Common Uses for Permanent Pacemaker Therapy
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Tehran Arrhythmia Center
AV Block With Carotid Massage
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Tehran Arrhythmia Center
Long Asystole
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Tehran Arrhythmia Center
Sinus Pauseand
Junctional Escape Beats
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Tehran Arrhythmia Center
Sinus Pauseand Junctional Escape Beats
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
Bradycardia- Tachycardia Syndrome
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Tehran Arrhythmia Center
Mobitz Type I (Wenckebach)
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Tehran Arrhythmia Center
2:1 AV block
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
Complete Heart Block
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
Sinus Pause
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
Sinus Arrhythmia
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
Sinus Tachycardia
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
Wandering Pacemaker
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
Sinus Tachycardia
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
Wandering Pacemaker
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
Asystole and Junctional Escape Rhythm
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Tehran Arrhythmia Center
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Tehran Arrhythmia Center
Tachyarrhythmias
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TachyarrhythmiasMechanisms
Automaticity
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TachyarrhythmiasMechanisms
Triggered activity
Tehran Arrhythmia Center
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TachyarrhythmiasMechanisms
Reentry
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
Premature Complexes
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Tehran Arrhythmia Center
Ventricular Premature Complexes
Compensatory Pause
Interpolated VPC
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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
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Tehran Arrhythmia Center
Variability of Ventricular Ectopy with Age
• Effect of age on probability (%) ofhaving more than agiven number ofPVCs per 24 hoursin subjects withnormal hearts.
0%
10%
20%
30%
40%
50%
60% > 0 PVCs
> 50 PVCs
> 100 PVCs
10-29 30-39 40-49 50-59 60-69
Data from Kostis JB. Circulation. 1981;63(6):1353.
Age
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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.
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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
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Tehran Arrhythmia Center
Atrial Fibrillation
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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.
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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
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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
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Tehran Arrhythmia Center
Atrial Fibrillation
• Therapeutic Goals:– Control of ventricular rate– Restoration and maintenance of sinus rhythm– Prevention of thromboembolism
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Tehran Arrhythmia Center
Atrial Flutter
• Regular atrial tachyarrhythmia with atrial rate between 250-350 bpm.
• Flutter waves are seen as saw-tooth like atrial activity
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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.
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Tehran Arrhythmia Center
Atrial Flutter Circuit
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Tehran Arrhythmia Center
Atrial Flutter
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
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
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Tehran Arrhythmia Center
Paroxysmal Supraventricular Tachycardia (PSVT)
• Usually at a rate of 150-250 bpm
• No organic heart disease in the majority
• Presentations– Palpitations– Chest discomfort,dyspnea, lightheadedness– Frank syncope– SCD
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Tehran Arrhythmia Center
PSVT
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
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
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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.
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Tehran Arrhythmia Center
Longitudinal Dissociation Within AV Node
Slow Pathway
Fast Pathway
Atrium
His Bundle
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Tehran Arrhythmia Center
AVNRT
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Tehran Arrhythmia Center
AVNRT
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Tehran Arrhythmia Center
Preexcitation
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Tehran Arrhythmia Center
Wolff-Parkinson-White Syndrome
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
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%.
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Tehran Arrhythmia Center
AVRT
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Tehran Arrhythmia Center
Concealed Accessory Pathway
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
PSVTTreatment
• Vagal maneuvers particularly carotid sinus massage
• AV nodal blocking drugs– Adenosine– Verapamil– Propranolol– Digoxin
• DC cardioversion if hypotensive
• Radiofrequency ablation
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Tehran Arrhythmia Center
Electrophysiologic Study (EPS)
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Tehran Arrhythmia Center
Catheter Positions at Fluoroscopy
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Tehran Arrhythmia Center
Intracardiac Recordings
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Tehran Arrhythmia Center
Radiofrequency Ablation (RFA)
Through femoral vein and right atrium
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Tehran Arrhythmia Center
Loss of Delta during RF Burn
Tehran Arrhythmia Center
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Tehran Arrhythmia Center
Loss of Delta during Burn
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Tehran Arrhythmia Center
Ventricular ArrhythmiasDefinitions
• 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 60-100 bpm
• Ventricular Tachycardia (VT), rate over 100 bpm • Ventricular Flutter, regular large oscillations at a rate of
150-300 bpm• Ventricular Fibrillation (VF), irregular undulations of
varying contour and amplitude
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Tehran Arrhythmia Center
Ventricular TachycardiaClassification
• 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
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Tehran Arrhythmia Center
Salvos
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Tehran Arrhythmia Center
Sustained Monomorphic VT
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Tehran Arrhythmia Center
Sustained Polymorphic VT
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Tehran Arrhythmia Center
VT, Holter Recording
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Tehran Arrhythmia Center
VTPresentations
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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
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Tehran Arrhythmia Center
Electrocardiographic Differentiation of VT vs. SVT with Aberrancy
• Clinical history
• AV dissociation
• QRS morphology
• QRS axis
• Fusion beat
• Capture beat
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Tehran Arrhythmia Center
A-V Dissociation, Fusion, and Capture Beats in VT
Fisch C. Electrocardiography of Arrhythmias. 1990;134.
ECTOPY FUSION CAPTURE
V1 E F C
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Tehran Arrhythmia Center
Fusion and Capture Beats in VT
Fisch C. Electrocardiography of Arrhythmias. 1990;135.
F C C
C C
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Tehran Arrhythmia Center
VTPrognosis
• 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
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Tehran Arrhythmia Center
Ventricular Fibrillation
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Tehran Arrhythmia Center
Sudden Death Syndrome
• Incidence– 400,000 - 500,000/year in U.S.– Only 2% - 15% reach the
hospital– Half of these die before
discharge
• High recurrence rate
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Tehran Arrhythmia Center
Underlying Arrhythmia of Sudden Death
VT62% Bradycardia
17%
Torsadesde Pointes
13%
PrimaryVF8%
Adapted from Bayés de Luna A. Am Heart J. 1989;117:151-159.
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Tehran Arrhythmia CenterTehran Arrhythmia Center
Snapshot of Death
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Tehran Arrhythmia CenterTehran Arrhythmia Center
Return of LifeNot the usual case !
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Tehran Arrhythmia Center
Clinical Substrates Associated with VF Arrest
• Coronary artery disease• Idiopathic cardiomyopathy• Hypertrophic cardiomyopathy• Long QT syndrome• RV dysplasia• Rarely: WPW syndrome
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Tehran Arrhythmia Center
VT/VFTherapeutic Options
• Antiarrhythmic drugs
• Anti-tachycardia pacing
• Radiofrequency ablation
• Implantable defibrillators
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Tehran Arrhythmia Center
Earliest Defibrillator in Clinical Use, 1899
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Tehran Arrhythmia Center
First Implantable Defibrillator 1970
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Tehran Arrhythmia Center
Thoracotomy Lead System, the technique
used at the beginning
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Tehran Arrhythmia Center
Nonthoracotomy Lead System
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Tehran Arrhythmia Center
Pectoral ImplantationThe Current Technique
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Tehran Arrhythmia Center
Tiered Therapy Defibrillators
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Tehran Arrhythmia Center
Defibrillator Function
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Tehran Arrhythmia Center
Interrogated ICD EventVT, treated appropriately by burst pacing therapy
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Tehran Arrhythmia Center
Interrogated ICD EventVT (CL 320ms), no response to burst pacing therapy
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Tehran Arrhythmia Center
Interrogated ICD EventVT (CL 320ms), cardioverted by DC shock
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Tehran Arrhythmia Center
Clinical Uses of Defibrillator Therapy
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Tehran Arrhythmia Center
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Congenital Long QT Syndrome
A Frequently Missed Diagnosis
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Tehran Arrhythmia Center
Long QT Interval
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Tehran Arrhythmia Center
Long QT Interval
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Tehran Arrhythmia Center
Long QT Interval
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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!
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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
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Tehran Arrhythmia Center
Brugada SyndromeDefinition
• Clinical-electrocardiographic diagnosis based on:
- High incidence of sudden cardiac death
- Structurally normal heart
- Characteristic ECG pattern
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Tehran Arrhythmia Center
ECG Abnormalities
• ST segment elevation in V1-V3
• QRS complex resembling RBBB
• J-point elevation
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Tehran Arrhythmia Center
Brugada ECG Pattern
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Tehran Arrhythmia Center
Brugada ECG Pattern
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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. 1997
• Thai men correlated to Brugada, SUNDS Hum. Mol. Gen. 2002
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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 10 000)
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
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Tehran Arrhythmia Center
Clinical ManifestationsSudden cardiac deathSyncope, 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 importanceThe only treatment is currently implantation of an
‘Implantable Cardioverter Defibrillator’.