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Sudden Cardiac Death; Invasive Evaluation
Alpay Çeliker MDHacettepe University
Department of Pediatric CardiologyAnkara, Türkiye
DC cardioversion by paramedics
Restoration of normal sinus rhythm
History: Total correction for FT at 1 month old
ECG: RBBB, QRS= 130 msn
ECHO: Mild PR, normal LV function
MRI: Normal RV EF, mild PR
Cardiac Cath and Electrophysiologic Study Normal hemodynamic findings Mild PR Normal AV and sinus node function No inducible SVT Ventricular stimulation:
VT induction with two PES Monomorphic VT with LBBB Rate 270 beats/min
Oral amiodarone 10 mg/kg, propranolol 1 mg/kg started
EPS after ten days VT ICD
How we can know the risk before??
Noninvasive methodsInvasive methods
Case 2
23 year old male student suddenly collapsed Ventricular fibrillation Defibrillated several
times Brain edema resolved in the following days History:
Total correction for FT at 3 years old Transannular patch, previous shunt QRS 180 ms
Cardiac cath & Electrophysiology
It was performed 5 years ago No RVOT gradient PA pressure 41/3 mean 20 mmHg Aneursymal dilation at RVOT Severe PR Moderate TR Enlarged RV Stimulation: NS Atrial Flutter, NO NSVT OR
SMVT
SCD in Operated CHD
When is an invasive evaluation needed?
What is the methodology? How we can interprete the results? Can it be used for determine the
prognosis?
Indications for Invasive Evaluation
Syncope of unknown origin Resusciated sudden cardiac arrest Ventricular tachycardia on Holter ECG Exercise induced/aggrevated ventricular
tachycardia/arrhythmia During invasive cardiac catheterisation Drug-electrophysiologic study
Methodology
Two venous, one arterial line Hemodynamic and angiographic analysis Electrophysiologic Study
Measurement of basal intervals AV conduction (Wenckebach) Sinus node functions Supraventricular tachycardia induction Ventricular tachycardia induction
Supraventricular Tachycardia Induction Programmed atrial stimulation up two three beats
basal and during isoproterenol infusion until the atrial refractory period occurs
Burst stimulation up to 150 msn pacing cycle lenght Observe the atrial flutter or IART
Sustained or non sustained Reinducibility Atrial rate Hemodymanic status during tachycardia AV conduction
Ventricular stimulation
Programmed ventricular stimulation from right ventricle apex and RVOT
PES up to three beats basal and during isoproterenol infusion at three basic cycle lenghts until the ventricular refractory period occurs
Burst stimulation up to 250 msn pacing cycle lenght Observe the ventricular tachycardia
Sustained or non sustained Reinducibility Ventricular rate Hemodymanic status during tachycardia
Programmed Ventricular Stimulation after Tetralogy Repair 252 patients at 16±12,3 years (3,3-55,6 years) FU after surgery 18,5 ±9,6 years Median age at surgery 4,5 years Transannular patch repair in 57,2% Surgical palliation in 46,3% QRS duration 146 ±36 ms, ≥ 180 ms in 19,4% and
LAH in 22,6% Moderate PR in 74,2% Syncope in 23,6%, documented VT in 16,7%,
resusiated cardiac arrest in 1,2%
Khairy P et al. Circulation 2004; 109, 1994.
Patient CharacteristicsNo Inducible Monomorphic
Polymorphic VT (N=165) VT (n=76) VT (n=11)
Age at EP study,y 14.7 24.7 25.8Clinical presentation, %
Syncope 13.4 41.3 54.5 Documented SVT 4.2 42.1 27.3
Cardiac arrest 0.6 2.6 0.0 Surgical history
Age at surgery, y 5.4 7.7 7,2 Transannular patch, % 54.0 61.8 72.7
Palliative surgery,% 37.2 67.6 36.4 Electrocardiogram
QRS duration, ms 135.3 164.7 169.1 QRS ≥180 ms, % 8.5 39.5 45.5 Lown ≥2 by Holter, % 28.7 67.8 40.0
Hemodynamics ≥Moderate PR, % 68.7 87.8 63.6
Follow-up FU after surgery, y 16.4 22.4 22.4
ICD, % 3.6 25.0 36.4 Clinical VT, % 3.8 25.5 60.0 SCD, % 5.7 11.8 40.0
PVS after Tetralogy Repair
Sustained monomorphic VT was induced in 30,2% (n=76), sustained polymorphic VT was induced in 4,4% (n=11) and 65,5 % (n=165) were noninducible.
2,7±0,6 PES and isuprel infusion in 23,5% Event occurred in 62 (24,6 %) patients after
6,5±4,5 years; VT 45 VT and SCD 14 SCD 3
Khairy P et al. Circulation 2004; 109, 1994.
Inducible VT and Clinical VT and SCD
Results of PVS Clinical VT or SCD (n,%) Total Number
Sustained monomorphic VT 41 (53 %) 76
No inducible monomorphic VT
21 (12%) 176
Sustained monomorphic or polymorphic VT
48 (55%) 87
No inducible VT 14 (8,4%) 165
Total 62 (24,6%) 252
Predictors of Inducible Sustained VT
VariableVariable ORORAge ≥ 18 y 6.0
Operation Age ≥ 7y 3.3
Syncope 4.9
Prior palliative surgery 2.9
QRS ≥ 180 ms 7.3
Modified Lown ≥ 2 3.8
Cardiothoracic ratio ≥0.60 3.3
PVS has diagnostic value and prognostic significance. Inducible sustained polymorphic VT enhanced the diagnostic yield and predictive ability.EPS should be used in risk stratification in postoperative Fallot patients
significant PR, TR right ventricular dysfunction
residuel lesions
MRIHemodynamic study
Electrophysiological study
Postop FTHistory
Resuscitation in one
Syncope&presyncope in five
Palpitation in 12
Hacettepe Serie: 46 patients Study Design
Moderate/severe PR in 26 patients (60% ) Moderate/severe PR in 26 patients (60% )
2 Sustained Monomorphic VT 4 NS-VT 1 PVR: Sustained atrial flutter and VT
Residual VSD in 6 patientsResidual VSD in 6 patients One NS-VT Three with atrial Flutter
Patient Number %
Normal 15 35
Sustained AF+fibroflutter 8 18,6
Non-sustained AF 3 6,9
SSS and AV conduction problem 8 18,6
Non-sustained VT 5 11,6
Sustained VT* 4 9,39,3
Total 43 100
Electrophysiological Findings
Conclusions
Electrophysiological study should be used in the risk stratification in patients with tetralogy surgery.
In patients with inducible VT should be treated appropriately to prevent sudden cardiac death.
In patients with negative study noninvasive methods may help in follow-up.
In patients with residual lesions need corrections to prevent ventricular arhhymias and SCD.