1. Arrhythmia and Devices in HF
Dr Amirhossein Azhari
Electrophysiologist

2. Premature Ventricular Contractions (PVCs)
Irritable focus causes ventricles to depolarize before the SA node fires
Premature beat that has a wide QRS
QRS and T wave of a PVC usually point in opposite direction from one another
“Bad PVCs” – more than 6/minute, coupled, multifocal, and on or near the T wave of the previous sinus beat
Suppressed by lidocaine.

3. Coupled PVCs

4. Multifocal PVCs

5. R-on-T Phenomenon: May cause a run of PVCs or Vfib

6. Vtach: 3 or more PVCs in a row
Wide QRS with a regular pattern and a rate of
Patient will usually lose consciousness
Treated with lidocaine; may help to have patient cough if they are still conscious
May require DC shock

7. Vtach

8. Vtach
Remember, 3 or more PVCs in a row is a run of Vtach

9. Vfib Many ectopic foci firing at the same time
There is no regular pattern as in Vtach
No effective cardiac output!
Requires CPR and DC shock, ie, Defibrillation

10. Vfib
This is “coarse” vfib

11. Vfib
This is “fine” vfib

12. Epidemiology of VA & SCD
Classification of Ventricular Arrhythmia
by Clinical Presentation
Hemodynamically stable
♥ Asymptomatic
♥ Minimal symptoms, e.g., palpitations
Hemodynamically unstable
♥ Presyncope
♥ Syncope
♥ Sudden cardiac death
♥ Sudden cardiac arrest

13. Epidemiology of VA & SCD
Classification of Ventricular Arrhythmia
by Electrocardiography
Nonsustained ventricular tachycardia (VT)
♥ Monomorphic
♥ Polymorphic
Sustained VT
Bundle-branch re-entrant tachycardia
Bidirectional VT
Torsades de pointes
Ventricular flutter
Ventricular fibrillation

14. Nonsustained Monomorphic VT

15. Nonsustained LV VT

16. Sustained Monomorphic VT 72-year-old woman with CHD

17. Nonsustained Polymorphic VT

18. Sustained Polymorphic VT Exercise induced in patient with no structural heart disease

19. Bundle Branch Reentrant VT

20. Spontaneous conversion to NSR (12-lead ECG)
Ventricular Flutter
Spontaneous conversion to NSR (12-lead ECG)

21. VF with Defibrillation (12-lead ECG)

22. Wide QRS Irregular Tachycardia: Atrial Fibrillation with antidromic conduction in patient with accessory pathway – Not VT

23. Epidemiology of VA & SCD
Classification of Ventricular Arrhythmia
by Disease Entity
Chronic coronary heart disease
Heart failure
Congenital heart disease
Neurological disorders
Structurally normal hearts
Sudden infant death syndrome
Cardiomyopathies
♥ Dilated cardiomyopathy
♥ Hypertrophic cardiomyopathy
♥ Arrhythmogenic right ventricular (RV)
cardiomyopathy

24. Epidemiology of VA & SCD
Incidence of Sudden Cardiac Death
Reused with permission from Myerburg RJ, Kessler KM, Castellanos A. Circulation 1992;85:12-10.

25. Mechanisms and Substrates
Mechanisms of Sudden Cardiac Death
in 157 Ambulatory Patients
Ventricular fibrillation %
Bradyarrhythmias (including advanced AV block and asystole) %
Torsades de pointes %
Primary VT - 8.3%
Bayes de Luna et al. Am Heart J 1989;117:151–9.

26. Clinical Presentations of Patients with VA & SCD
Asymptomatic individuals with or without electrocardiographic
abnormalities
Persons with symptoms potentially attributable to ventricular
arrhythmias
♥ Palpitations
♥ Dyspnea
♥ Chest pain
♥ Syncope and presyncope
VT that is hemodynamically stable
VT that is not hemodynamically stable
Cardiac arrest
♥ Asystolic (sinus arrest, atrioventricular block)
♥ VT
♥ Ventricular fibrillation (VF)
♥ Pulseless electrical activity

27. Therapy
Acute Hemodynamically Stable Hemodynamically UnStable

28. Therapies for VA Antiarrhythmic Drugs
♥ Beta Blockers: Effectively suppress ventricular ectopic beats & arrhythmias; reduce incidence of SCD
♥ Amiodarone: No definite survival benefit; some studies have shown reduction in SCD in patients with LV dysfunction especially when given in conjunction with BB. Has complex drug interactions and many adverse side effects (pulmonary, hepatic, thyroid, cutaneous)
♥ Sotalol: Suppresses ventricular arrhythmias; is more pro-arrhythmic than amiodarone, no survival benefit clearly shown
♥ Conclusions: Antiarrhythmic drugs (except for BB) should not be used as primary therapy of VA and the prevention of SCD

29. Non-antiarrhythmic Drugs
Therapies for VA
Non-antiarrhythmic Drugs
♥ Electrolytes: magnesium and potassium administration can favorably influence the electrical substrate involved in VA; are especially useful in setting of hypomagnesemia and hypokalemia
♥ ACE inhibitors, angiotensin receptor blockers and aldosterone blockers can improve the myocardial substrate through reverse remodeling and thus reduce incidence of SCD
♥ Antithrombotic and antiplatelet agents: may reduce SCD by reducing coronary thrombosis
♥ Statins: have been shown to reduce life-threatening VA in high-risk patients with electrical instability
♥ n-3 Fatty acids: have anti-arrhythmic properties, but
conflicting data exist for the prevention of SCD

30. ICDs: Results from Primary and Secondary Prevention Trials
Therapies for VA
ICDs: Results from Primary and Secondary Prevention Trials
0.6
0.8
1.0
1.2
1.4
MADIT-I
AVID
1.6
0.4
CABG-Patch
MADIT-II
1996
1997
2002
Aborted cardiac arrest
N = 196
N = 1016
N = 900
N = 1232
0.46
0.62
1.07
0.69
Hazard ratio
ICD better
SCD-HeFT
N = 1676
2005
0.77
1.8
LVEF, other features
0.35 or less, NSVT, EP positive
0.30 or less, prior MI
0.35 or less, LVD due to prior MI and NICM
0.35 or less, abnormal SAECG and scheduled for CABG
CASH*
2000
N = 191
DEFINITE
2004
N = 458
0.65
0.35 or less, NICM and PVCs or NSVT
CIDS
N = 659
0.82
Aborted cardiac arrest or syncope
DINAMIT
N = 674
1.08
0.35 or less, MI within 6 to 40 days and impaired cardiac autonomic function
Trial Name, Pub Year
0.83

31. Primary Prevention of SCD (1)
Therapies for VA
Primary Prevention of SCD (1)
Recommendations in previously published guidelines for prophylactic
ICD therapy based on LVEF are inconsistent:
♥ Different LVEFs were chosen for inclusion in trials
♥ Average EF in such trials was substantially lower than the cutoff value for enrollment
♥ Subgroup analyses in various trials have not been consistent in their implications
♥ No trials contained randomized patients with intermediate
LVEF

32. Primary Prevention of SCD (2)
Therapies for VA
Primary Prevention of SCD (2)
Because of these inconsistencies, the recommendations in this
guideline were constructed to apply to patients with an EF ≤ to a
range of values
The next several slides compare the recommendations of
previously published guidelines with those in this one and the
reasoning behind the writing committee’s decision

33. Primary Prevention of SCD (3)
Therapies for VA
Primary Prevention of SCD (3)
LV dysfunction due to MI, LVEF ≤ 30%, NYHA class II, III
2005 ACC/AHA HF: Class I; LOE B
2005 ESC HF: Class I; LOE A
2004 ACC/AHA STEMI: Class IIa; LOE B
2002 ACC/AHA/NASPE PM/ICD: Class IIa; LOE B
2006 ACC/AHA/ESC VA/SCD: Class I; LOE A
Note: The VA/SCD Guideline has combined all trials that enrolled patients with LV dysfunction due to MI into one recommendation

34. Primary Prevention of SCD (4)
Therapies for VA
Primary Prevention of SCD (4)
LV dysfunction due to MI, LVEF 30-35%, NYHA class II, III
2005 ACC/AHA HF: Class IIa; LOE B
2005 ESC HF: Class I; LOE A
2004 ACC/AHA STEMI: N/A
2002 ACC/AHA/NASPE PM/ICD: N/A
2006 ACC/AHA/ESC VA/SCD: Class I; LOE A
Note: The VA/SCD Guideline has combined all trials that enrolled patients with LV dysfunction due to MI into one recommendation

35. Primary Prevention of SCD (5)
Therapies for VA
Primary Prevention of SCD (5)
LV dysfunction due to MI, LVEF 30-40%, NSVT, positive EP study
2005 ACC/AHA HF: N/A
2005 ESC HF: N/A
2004 ACC/AHA STEMI: Class I; LOE B
2002 ACC/AHA/NASPE PM/ICD: Class IIb; LOE B
2006 ACC/AHA/ESC VA/SCD: Class I; LOE A
Note: The VA/SCD Guideline has combined all trials that enrolled patients with LV dysfunction due to MI into one recommendation

36. Primary Prevention of SCD (6)
Therapies for VA
Primary Prevention of SCD (6)
LV dysfunction due to MI, LVEF ≤ 30%, NYHA class I
2005 ACC/AHA HF: Class IIa; LOE B
2005 ESC HF: N/A
2004 ACC/AHA STEMI: N/A
2002 ACC/AHA/NASPE PM/ICD: N/A
2006 ACC/AHA/ESC VA/SCD: Class IIa; LOE B
Note: The VA/SCD Guideline has expanded the range of LVEF ≤ 30-35% for patients with LVD due to MI and NYHA class I into one recommendation

37. Primary Prevention of SCD (7)
Therapies for VA
Primary Prevention of SCD (7)
LV dysfunction due to MI, LVEF ≤ %, NYHA class I
2005 ACC/AHA HF: N/A
2005 ESC HF: N/A
2004 ACC/AHA STEMI: N/A
2002 ACC/AHA/NASPE PM/ICD: N/A
2006 ACC/AHA/ESC VA/SCD: Class IIa; LOE B
Note: The VA/SCD Guideline has expanded the range of LVEF ≤ 30-35% for patients with LVD due to MI and NYHA class I into one recommendation

38. Primary Prevention of SCD (8)
Therapies for VA
Primary Prevention of SCD (8)
Nonischemic cardiomyopathy, LVEF ≤ 30%, NYHA class II, III
2005 ACC/AHA HF: Class I; LOE B
2005 ESC HF: Class I; LOE A
2004 ACC/AHA STEMI: N/A
2002 ACC/AHA/NASPE PM/ICD:N/A
2006 ACC/AHA/ESC VA/SCD: Class I; LOE B
Note: The VA/SCD Guideline has combined all trials of nonischemic cardiomyopathy, NYHA class II, III into one recommendation

39. Primary Prevention of SCD (9)
Therapies for VA
Primary Prevention of SCD (9)
Nonischemic cardiomyopathy, LVEF 30-35%, NYHA class II, III
2005 ACC/AHA HF: Class IIa; LOE B
2005 ESC HF: Class I; LOE A
2004 ACC/AHA STEMI: N/A
2002 ACC/AHA/NASPE PM/ICD:N/A
2006 ACC/AHA/ESC VA/SCD: Class I; LOE B
Note: The VA/SCD Guideline has combined all trials of nonischemic cardiomyopathy, NYHA class II, III into one recommendation

40. Primary Prevention of SCD (10)
Therapies for VA
Primary Prevention of SCD (10)
Nonischemic cardiomyopathy, LVEF ≤ 30%, NYHA class I
2005 ACC/AHA HF: Class IIb; LOE C
2005 ESC HF: N/A
2004 ACC/AHA STEMI: N/A
2002 ACC/AHA/NASPE PM/ICD:N/A
2006 ACC/AHA/ESC VA/SCD: Class IIb; LOE B
Note: The VA/SCD Guideline has expanded the range of LVEF to ≤ 30-35% for patients with nonischemic cardiomyopathy and NYHA class I into one recommendation

41. Primary Prevention of SCD (11)
Therapies for VA
Primary Prevention of SCD (11)
Nonischemic cardiomyopathy, LVEF ≤ 31-35%, NYHA class I
2005 ACC/AHA HF: N/A
2005 ESC HF: N/A
2004 ACC/AHA STEMI: N/A
2002 ACC/AHA/NASPE PM/ICD: N/A
2006 ACC/AHA/ESC VA/SCD: Class IIb; LOE B
Note: The VA/SCD Guideline has expanded the range of LVEF to ≤ 30-35% for patients with nonischemic cardiomyopathy and NYHA class I into one recommendation

43. ICD Leads – Single versus Dual coil

44. ICD History
The original AID device had two electrodes, one a spring was placed in the Vena Cava, the other a cup designed to conform to the cardiac apex
1980

45. Medtronic Implantable Defibrillators (1989-2001)
113 cc
209 cc
80 cc
80 cc
72 cc
54 cc
62 cc
39 cc
39.5 cc
49 cc
39.5 cc
39.5 cc
36 cc
39 cc

46. Detection
VF Detection !
VF Therapy !! F F F F F F F F F F

47. Detection Fib Zone Analyse Detect Initiate Therapy Charge 1 2 3 4 5 67 8 9 10 11 12
Detect
Initiate Therapy
Charge

48. Rate Branch Calculation - Example
VT Detection: 8 intervals < 350 ms
VT Detect
340
300
290
330
320
310
290
300
300
310
310
320
330
340
Median Ventricular Cycle Length
= ( ) / 2
= 310 ms

49. ICD Therapies - ATP

50. ATP Definition ATP = Antitachycardia Pacing
ATP = Therapeutic intervention using standard bradycardia pacing algorithms and energy levels in an effort to bring the heart out of a reentrant tachycardia and restore its normal rhythm
As in previous devices, ATP is still available for the VT Zone (for 2 Zone configurations) and for VT-1 and VT-2 (for 3 Zone configurations).
The change for Unity is that ATP is now available for Therapy 1and Therapy 2 in these Zones.
Even though ATP is now available for more therapy options, the device still has hierarchal rules on what therapies will be available after each therapy is delivered. For example, if VT-1 is detected and ATP and CVRT therapies are all delivered for the VT-1 episode, if the rhythm accelerates to a VT-2 episode, the device will skip ATP therapies and deliver a CVRT shock that is greater than or equal to the last delivered shock.
Note: All ATP therapies are considered equal in the hierarchy. An ATP delivery with 200 ms between each burst is not considered more aggressive than an ATP delivery with 400 ms between each burst. It is up to the clinician to program the ATP therapy 2 to be more aggressive than ATP therapy 1.

51. VT based on reentry

52. VT
1 sec

53. Proparly Timed Electrical Stimulation

54. ATP

55. ATP
arrhythmia
ATP
Sinus rhythm
1 sec

58. ICD and CRT guidelines 2013 primary prevention

67. Electromagnetic Interference and Implantable Devices

68. It is important to know not only what sources of interference are of potential concern, but also how external interference actually affects pacemakers, implantable cardioverter-defi brillators (ICDs) and cardiac resynchronization therapy (CRT) systems.

70. Electromagnetic fields have both an electric field, measured in volts per meter (V/m), and a magnetic field. The magnetic flux density is measured in milliteslas (mT).

72. Pacemaker and ICD Responses to Electromagnetic Interference

73. The most frequent responses :
Inappropriate inhibition
triggering of pacemaker stimuli
reversion to asynchronous pacing
ICD tachyarrhythmia detection.
much less frequent:
Reprogramming of operating parameters
Permanent damage to the device circuitry
Electrode-tissue interface

74. Sources of Electromagnetic
Interference in Daily Life

75. Cellular Telephones and Other Wireless Communication Devices
Although isolated case reports have suggested the potential for severe interactions, most research indicates that deleterious interactions are unlikely to happen with normal cellphone use.
There was no clinically significant EMI episodes when the telephone was placed in the normal position over the ear..

76. Maintaining an activated cellphone at least 6 inches (15 cm) from the device prevents interactions.
The FDA has issued simple recommendations to minimize the risks:
Patients should avoid carrying their activated cellphone in a breast or shirt pocket overlying an implanted device.
A wireless telephone in use should be held to the ear opposite the side where the device is implanted.

77. Gates
No spurious detections occurred during a 10- to 15-second walk through the gates. All of the patients with serious interactions had an abdominal implant; however, by multivariate analysis, diminished R-wave amplitude and a Ventritex ICD were the only predictors of interactions.

78. Metal Detectors
Handheld metal detectors typically operate at a frequency of 10 to 100 kHz.
one report of a spurious ICD shock triggered by a handheld metal detector in an airport.
Guidant ICDs reverted to “monitor-only” mode after being exposed to metal detectors.

79. Current FDA recommendations state that it is safe for patients with implanted cardiac devices to walk through a metal detector gate, although the alarm may be triggered by the generator case.
If scanning with a handheld metal detector is needed, patients should ask the security personnel not to hold the detector close to the implanted device longer than is absolutely necessary.
A manual personal search can also be requested

80. Direct Current Cardioversion and Defibrillation
The risk of damage to the implanted device depends:
on the amount of energy applied
the characteristics of the device and lead,
and the distance between the paddles or pads and the pulse generator and leads

82. Operation with electrocutering surgery

84. Incidence of complications was low (0
Incidence of complications was low (0.8 cases per 100 years of surgical practice).

85. THE END

86. Thanks for your
attention