Diagnoses and Treatments of
Cardiac Arrhythmias
Jian Chen
Hjerteavdelingen
Haukeland Universitetssykehus
Arytmier
• Tachyarytmi
• Bradyarytmi
– Sinus tachykardi
– Sinus bradykardi
– Atrietachykardi
– Syk sinus syndrom og
sinoatrialt blokk
– AV nodal tachykardi
– Preeksitasjon (WPW)
– Atrieflutter og atrieflimmer
– Ventrikkeltachykardi
(Sinus arrest og brady-taky syndrom)
– AV blokk
•
1. grad
•
2. grad (Type I og II eller
Wenckebachs og Mobitz)
•
3. grad
– Ventrikkelflutter og flimmer
– Ekstrasystoler
– Grenblokk og fasikelblokk
Arrhythmias and diseases
• Cardiac causes
– Coronary artery disease: VT, VF, Afib, AFL.
– Hypertension: VT, Afib, AFL.
– Valvular disease: Afib, VT.
– Cardiomyopathy: VT, VF, Afib.
– Pulmonary heart disease: Afib, AT, AFL.
– Congestive heart failure: various types.
– Congenital heart disease: various types.
– Postcardiac surgery
• Non-cardiac causes: hyperthyroidism, electrolyte disorder ……
• Arrhythmias in patients without heart disease: WPW, AV nodal
tachycardia, atrial flutter, atrial fibrillation, ventricular tachycardia…
Symptoms
• Palpitation
• Shortness of breath/Dyspnea
• Dizziness/Pre-syncope/Syncope
• Chest pain
• Fatigue
• Polyuria
• Decrease of working capacity/Exercise intolerance
• Sudden death
• Complications: heart failure, peripheral embolism,
cerebral attack
Diagnosis and evaluation
•
History and physical examination
•
12-lead electrocardiogram (ECG)
•
Echocardiography/Transoesophageal echocardiography
•
Exercise test
•
Blood tests
•
Chest radiograph/CT/MRI
•
Holter (24-hour ECG)
•
R-test (7-day ECG)
•
Telemetry
•
Reveal monitor (invasive)
•
Electrophysiological study (invasive)
Sinusrytme
Papirhastighet 25 mm/sek
Rytme eksemplene
Sinusrytme
• P-takkene kommer regelmessig og blir etterfulgt av et QRS-kompleks.
• PQ-tid mellom 0, 12 - 0,22 sekunder
• Frekvens mellom 60 og 100 pr.min.
Sinusrytme som øker i frekvens ved inspirasjon og reduserer frekvens
ved ekspirasjon kalles sinusarytmi eller varierende sinusrytme
Sinusbradykardi: Som sinusrytme, men frekvens under 60 pr.min.
Sinustakykardi: Som sinusrytme, men frekvens over 100 pr.min.
Tredjegrads AV - blokk(med ventrikulær erstatningsrytme)
Atriefrekvens 80/ min, Ventrikkelfrekvens 37/min
Tredjegrads AV - blokk(med nodal erstatningsrytme)
Atriefrekvens 86/min, Ventdkkelfrekvens 42/min.
Tredjegrads AV - blokk med to ORS-kompleks og mange P-takker
Atrial fibrillation
Ventrikkeltachykardi
Sinusrytme med kort ventrikkeltachykardi
Tosade de pointes ventrikkeltachykardi
Ventrikkelflimmer
• Svært rask ventrikkelfrekvens
• Ingen pumpefunksjon
Sinusrytme som slår om til ventrikkelflimmer
R.TEST EKG opptaker
Programmerings tabell
Oversikt over EKG strips
Detalj forstørring i eget vindu
24-time EKG (Holter)
24-time EKG (Holter)
24-time EKG (Holter)
®
Reveal Plus Insertable Loop Recorder
• Offers up to 14 months of continuous, leadless ECG
monitoring
– Minimally invasive, outpatient procedure
• Patient and auto triggered to capture ECG
– Programmable to store up to 42 minutes of ECG
• High diagnostic yield (65-88%)1,2
Patient Activator
1
2
Reveal® Plus ILR
Krahn, Am. J Card, 1998; 82:117-119.
Reveal Syncope Validation Project Multi-center Study
9790 Programmer
Implantation with Auto Activation Modes
Reveal® Plus Clinical Study
• Implant zone for optimal auto activation performance*
• Implant parallel to the midline
in the region
• From left parasternal area to
the mid-clavicular line
• First to the fourth rib
Implanting in this zone helps minimize inappropriate auto activation
–
motion artifact due to body/arm movement and changes in posture
* Reveal® Plus Clinical Study, Medtronic data on file
®
Implanting Reveal Plus
• Procedure Room
or Cath Lab
• Out patient
procedure
• Sterile technique
• Local anaesthesia
®
Implanting Reveal Plus
• Single incision
(2 cm in length)
• Subcutaneous
pocket
• Electrodes facing
the skin
• Secure with
sutures
• Wound care as
with pacemaker
implant
Using the Activator
• Place Activator directly over
device
– Activator communicates with
ILR within 2 inches (5cm)
• Press white button and observe
flashing light
– Green light above  symbol:
Activation successful
– Yellow light above
symbol:
Activation NOT successful
• Repeat until green light is
observed
Viewing Events:
First Zoom Level
Mechanisms of cardiac arrhythmias
(tachycardia)
Automaticity
Enhanced normal automaticity
Abnormal automaticity
Trigger activity
Early afterdepolarizations
Delay afterdepolarizations
Reentry
Terapi
• Bradykardi
– Pacemaker
• Tachykardi
– Antiarytmika
– Kardioversjon / Defibrillering - ekstern/intern
SVT (WPW), Afib (MAZE, Kryokirurgi)
– Kirurgi
(1979)
VT (ACB, aneurysmectomi, endokardial reseksjon,
encircling ventriculotomi, kryokirurgi)
– Fulgurasjon (1982)
– Ablasjon (1987)
Antiarrhythmic drugs
Class I: interfere with sodium channels
Ia: Quinidine, Disopyramide
Ib: Lidocaine, Phenytoin, Mexiletine
Ic: Flecainide, Ibutilide, Propafenone
Class II: beta-blockers - block the effects of catecholamine at the
β1-adrenergic receptors
Class III: block potassium channels
Amiodaron (Cordarone)
Dronedaron (Multaq)
(Sotalol)
Class IV: Calcium-channel blockers
Others: Digitalis, Adenosine, Magnesium, etc.
Pacemaker treatment for bradycardias
Anode
Katode
Pacemaker – Pulse generator
Pacemaker – Leads
ECG – Cardiac pacing
DDD / 60 / 120
ECG – Cardiac pacing
DDD / 60 / 120
Implantable Cardioverter Defibrillators –
Treatment for severe ventricular arrhythmias
Implantable Cardioverter Defibrillators 1989 - 2000
ICD Evolution — Today
•
Small devices – Pectoral site
•
First-line therapy for VT/VF
patients
•
Transvenous, single incision
•
Local anesthesia; conscious
sedation
•
Short hospital stays
•
Few complications
•
Perioperative mortality < 1%
•
Programmable therapy options
•
Single- or dual-chamber therapy
•
Battery longevity up to 9 years
•
More than 55,000 implants/year
Tachycardia – Reentrant mechanism
Slutten av 1960 årene
HRA
HRA
His
CS
His
CS
RVA
RVA
Typical (common) atrial flutter
Right atrial flutter – reentrant circuit along the
tricuspid valve
CARTO mapping
Scar-related atrial flutter in the right atrium
CARTO mapping
Left atrial flutter – reentrant circuit on the
posterior wall
CARTO mapping
Focal atrial tachycardia
Counterclockwise atrial flutter
EnSite non-contact mapping
Atrial fibrillation (Focus firing from the LSPV)
EnSite non-contact mapping
Integration of CT and 3-D mapping
Magnetic navigation - Stereotaxis
Fasit til EKG øvelser
1. Normal EGK
2. Akutt nedeveggsinfarkt, bradykardi
3. Venstre ventrikkel hypertrofi
4. Ventrikkeltakykardi
5. Atrieflimmer
6. 2. grads AV blokk
7. Ventrikkel ekstrasystoler og kort løp
ventrikkeltakykardi