Case Study 1 Mohammad Shenasa MD, PhD O’Connor Hospital San Jose, CA Biblioteca-Alexandria Alexandria-Egypt Cardio Alex June 10-13, 2014
Etiologies of Electrical Storm 1.) Acute and Chronic Congestive Heart Failure (CHF) 2.) Acute and Chronic Ischemia 3.) Drug Induced (proarrhythmia effects) 4.) Post Cardiac Surgery 5.) Post Implantable Cardioverter Defibrillator (ICD) and Cardiac Resynchronization Therapy (CRT) 6.) Electrolyte and Metabolic Disturbances 7.) Idiopathic Ventricular Fibrillation (VF), Channelopathies (Brugada) 8.) Ventricular Arrhythmias after LV Assist Devices 9.) Unknown Causes
Ventricular Arrhythmias in Patients with ICD • Patients with arrhythmia symptoms or ICD- detected arrhythmias • Monomorphic vs. polymorphic VT • Therapy to reduce VT • MADIT-RIT Trial: Delayed ICD therapy
MADIT RIT Moss, A. NEJM
12 lead ECG of a patient with Brugada syndrome. Note ST-Elevation of V 1 (Red Arrow) ICD implantation due to recurrent VT and syncope
12 lead ECG of a patient with Brugada Syndrome and Ventricular Bigeminy
Rapid VT with a heart rate of 248 bpm
Rapid nonsustained VT What would you do? 1.) Reprogram the ICD 2.) PVC ablation 3.) VT ablation 4.) Sedation 5.) Low-dose Quinidine
Management of Electrical Storm Cardiac sympathetic denervation (Vaseghi M, et al. HR 2014;11:360- Eifling M, et al. Texas Heart Inst J 2011;38(2)111-21 366)
Nakahara S et al. Circ Arrhythm Electrophysiol. 2013;6:648-654
Management of isolated implantable cardioverter-defibrillator (ICD) shocks after ventricular assist device (VAD) implantation. Nakahara S et al. Circ Arrhythm Electrophysiol. 2013;6:648-654
Management of recurrent ventricular (RV) arrhythmias after ventricular assist device (VAD) implantation. Nakahara S et al. Circ Arrhythm Electrophysiol. 2013;6:648-654
Incessant VT in a patient with anterior wall myocardial infarction detected during Holter Monitoring. 32 year old male Questions: 1.) ICD implantation? 2.) Coronary angiography and PCI? 3.) EP study and ablation? 4.) IV amiodarone?
Ibutilide induced polymorphic VT 62 year old female with Ibutilide for AF
Ibutilide induced Torsades de Pointes 62 year old female with Ibutilide for AF What would you do: 1.) DC cardioversion for AF? 2.) DC Ibutilide? 3.) Consider Amiodarone? 4.) IV Mg?
VT Storm in a patient with CHF What would you do? 1.) IV amiodarone 2.) Aggressive HF therapy 3.) LV assist devices 4.) VT Ablation
Case Study • 87 year old male • Severe Aortic stenosis • AVR in 2009 • Chronic RBBB • Admitted: Acute pneumonia in June 2014
April 22, 2008 Pre Op
March 13, 2009
April 27, 2009
May 31 87 year old post AVR (2009), admitted with pneumonia 2014
Same patient as above, EKG date 6/1/2014
EGK Date June 2, 2014: Diagnosis: 1) AF 2) Atrial Flutter 3) Atrial Tachycardia 4) Sinus tachycardia with 1 st degree AV block
Same patient as above, EKG June 5, 2014
What would you do? 1.) Follow up with Holter? 2.) Pacemaker implantation? 3.) EP study for cite of AV block
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