Ventricular tachycardia
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Transcript of Ventricular tachycardia
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VENTRICULAR TACHYCARDIA
Dr. Y. Sridhar M.D.Consultant Intensivist
Dept. of Critical Care MedicineApollo Health City, Hyderabad
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Definition• Wide complex rhythm QRS>0.12s
• Rate > 100 (or120) bpm
• Origin: from one of the Ventricles i.e., distal to the bundle of His.
• Three or more consecutive beats on a ECG.
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Classification
• Duration of Episodes
• Morphology
• Symptoms
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1.Duration of Episodes• Three or More beats on an ECG at a rate
>100bpm originating from Ventricles
• Non Sustained VT : If rhythm self-terminates
spontaneously in less than 30seconds
• Sustained VT : If rhythm lasts > 30seconds
(Even if it self-terminates spontaneously after
30s)
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2.Morphology
• Monomorphic VT : same configuration beat to beat.
• Polymorphic VT : Continually changing QRS morphology
• Sinusoidal VT :sinusoidal appearance of rhythm
• Accelerated idioventricular rhythm (AIVR)
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Monomorphic VT
• Most common cause : circuit through a region of old MI.
• Idiopathic VT (less common) No identifiable cause.
• Right Ventricular outflow tract (RVOT) tachycardia: MC Idiopathic VT
LBBB Morphology with inferior axis.
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Polymorphic VTCauses• Active cardiac Ischemia• Electrolyte Disturbances• Drug Toxicity• FamilialTorsade de pointes (twisting of points)• Waxing and waning QRS amplitude during
tachycardia associated with prolonged QT interval
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• Sinusoidal VT: seen in severe electrolyte disturbances • Hyperkalemia• Hypocalcemia• Hypomagnesemia
• AIVR» Wide complex ventricular rhythm at a rate of 40-
120bpm» Usually hemodynamically stable» MC cause :reperfusion arrhytmia in first 12hrs after
acute MI or during periods of elevated sympathetic tone.
» Typically preceded by sinus slowing» No treatment necessary. Self terminates.
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Pathophysiology• Monomorphic VT :
• Increased automaticity of a single point in
either left or right ventricle
• Reentry circuit within the ventricle
• Polymorphic VT :
• Abnormalities in ventricular muscle
repolarization
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Etiology• Structural Heart Disease : MI, Cardiomyopathies
(HCM), Myocarditis• Electrolyte Abnormalities : Hypokalemia,
Hyperkalemia, Hypocalcemia, Hypomagnesemia• Sympathomimetic agents : Ionotropes.• Drug toxicity : Digitalis, Methamphetamine, Cocaine• Systemic diseases : Sarcoidosis, RA, SLE.• Structural Congenital Disorders : Right ventricular
dysplasia, TOF
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EtiologyProlonged QT Interval• Acquired :
• K Channel blocking medication : Quinidine, Erythromycin, Clarithromycin,Haloperidol, Droperidol
• Type 1A antiarrythmics : sotalol, amiodarone,
• Congenital : • Brugada syndrome• Congenital long and short QT syndromes• Catecholamingeric polymorphic VT
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Diagnosis• “All WCT is VT until proven otherwise”• AV dissociaton : Dissociation of P wave from QRS
complex.• QRS Concordance : Absence of rS or Rs complex in any
precordial lead• RS > 100ms• Capture beats : Supraventricular beat conducts to
ventricle depolarising ahead of the next tachycardia beat• Fusion beats : Depolarisation simultanously with
excitation from a ventricular focus.
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BRUGAGADA CRITERIA
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Ultra simple Brugada Criteria
• In 2010 Joseph Brugada published simplified criteria
• Measuring R wave peak time (RWPT) in Lead Ⅱ• RWPT > 50ms• It measures duration of onset of QRS to first
change in polarity
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Differential Diagnosis
• SVT with aberrant intraventricular conduction
• Preexcited Tachycardia (associated with or
mediated by accessory pathway)
• BBB
• Ventricular paced rhythms
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Symptoms• Chest Pain• Light headedness• Palpitations• Syncope• Sudden Cardiac Death (SCD) :
• Ambulatory ECG records at SCD have shown 50-60% at sustained monomorphic VT as the initial event.
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Treatment
Depends on Hemodynamics• Unstable VT
• Stable VT
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ACLS Cardiac Arrest Algorithm.
Neumar R W et al. Circulation 2010;122:S729-S767
Copyright © American Heart Association
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Stable VT
• Anti arrhythmic drug (AAD) therapy
• Implantable Cardioverter-Defibrillator (ICD)
• Catheter Ablation Therapy (CAT)
• Antiarrhythmic surgery
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Tachycardia Algorithm.
Neumar R W et al. Circulation 2010;122:S729-S767
Copyright © American Heart Association
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AMIODARONE• Large volume of distribution & long half life• Contraindications
• Iodine sensitivity• Sinus bradycardia• Heart block
• Precautions• Incompatible with NS• Preferable via CVC
• Adverse effects– Short term : Skin reactions,Brady, hypotension, corneal
microdeposits.
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AMIODARONE– Long term :
• Pulmonary fibrosis, alveolitis, pneumonitis• Liver dysfunction..monitor LFT• Hypo or Hyperthyroidism (check TFT before
starting)• Peripheral neuropathy, myopathy, Cerebellar
dysfunction.• Concomitant Beta and Calcium channel
Blockers: Increased risk of bradycardia, AV Block
• Potentiates effect of Digoxin, Theophylline and Warfarin– Reduce dose
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Implantable cardioverter-defibrillator (ICD)
• ICD therapy compared with conventional AAD associated with mortality reduction of 23-55% depending on risk group.
• Current ICD options:– Single chamber – Dual chamber – Biventricular cardiac resynchronization– Multilevel shock discharge for VT or VF
Complications: Inappropriate shock discharge
Defibrillator stormInfectionsExacerbation of HF
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External Defibrillator
• Automated external Defibrillator
• Wearable automatic defibrillator– Worn under the clothing– Delivers shock whenever VF is detected.
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• Procedure targets origin of VT• Useful in recurrent VT or “VT storm”.• Catheter is placed into heart chambers through femoral
vein• Radiofrequency energy is applied which produces a
small burn of about 4 to 5mm in diameter• Currently recommended in early treatment of VT when
AAD are not preferred or tolerated.
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Figure 2. Mapping of VT. A 3-dimensional real-time map of the ventricle (created during the procedure) merged with a computed tomography scan (obtained before the procedure).
Tung R et al. Circulation 2010;122:e389-e391
Copyright © American Heart Association
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Recurrent VT : Long term Management
• Risk of recurrence after successful resuscitation : 30-40%
• Management of Intercurrent diseases• Implantable Cardioverter Defibrillator• Long term therapy on Amiodarone.
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Antiarrhythmic surgery
• Surgical resection of arrhythmogenic focus• Cardiac Sympathectomy• Aneurysm resection
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Thank you!