MALIGNANT ARRHYTHMIAS / SUDDEN CARDIAC DEATH M. Kozák Department of Medicine and Cardiology, University hospital Brno SCD • sudden unexpected death caused by loss of heart function (1 hour time window ) • sudden collapse • no pulse • no breathing • loss of consciousness RBBB VT LBBB VT FVT 0 100 200 300 400 1 2 3 4 5 6 0 10 20 30 40 1 2 3 4 5 6 whole population multirisk coronary event LVEF < 35 % VT/VF comb. SCD-HeFT AVID CASH MADIT Number of events x 1000incidence % /year INCIDENCE / SCD TOTAL NUMBER Myerburg et al., Circulation, 1998 SCD USA 200-400.000/ year Gillum R.F., Circul 1989 SCD EU 2.500/day Pisa Z., Sudden death 1980 Malignant arrhythmias 80 - 90% Gillum R.F., Pisa Efficacy of CPR 10-15% SCD - STATISTICS SCD x AGE • incidence 1SCD/100.000 inhabitants < 35 (x 1/1000 u population > 35) • acute forms CAD 20-39 - 76% SCD Kuller et al. JAMA 1966,198:158 Kuisma et al, Resuscitation 1995, Steinberger et al Am J Cardiol 1996 PARIS PROSPECTIVE STUDY • 7.079 man, age 43-52 years (1967-1972), follow-up 23 years •Jouven X et al. Circulation. 1999;99:1978-1983 Schéma studie no AA 353 účinná AA 190 redukce TM -50% ICD neúčinná AA 161 redukce TM -27% EP guided terapie 351 PSK pozit. 704 p. (35%) RANDOMIZACE PSK neg. 1435 p.(65%) ICHS, EFLK pod 40%, NSKT 2202 pacientů PSK MUSTT •0.5 •0.6 •0.7 •0.8 •0.9 •1 •1 Year •2 Years •3 Years •4 Years •5 Years •SurvivalRate IA propa amio sotalol ost IA+mex žádné ICD MORTALITY – HISTORY x TODAY •SCD 33,6% x 12,7% •SCD 33,6% x 12,7% MORTALITY – HISTORY x TODAY SCD/ PP •ACEI (SOLVD - 23% NSS, V-HeFT - 31% NSS, CHFSTAT -52% NSS) • ACEI therapy – lower risk of SCD • more than 50% pts. treated ACEI can profit from SCD prophylaxis •amiodaron (CHFSTAT,CAMIAT, EMIAT) •Do not prolong survival with LV dysfunction •BB (CIBIS II, BEST, MERIT-HF) • downgrade risk of SCD • prolong survival of pts with CHF • OPT + revascularization CADCHS) • ICD / CRT ICD • RFA • Heart transplant • Surgery of CHF (MVP, aneurysmectomy) SCD PREVENTION Profile of resuscitated patient CAD (1. manifestation) 64 - 90 % (25 %) 64 years old man 81 % MI in anamn. 45% Cobb et al, Circulation, 1992 Who? 50% 20011996 Denní doba - souhrn 1 0,00 0,10 0,20 0,30 0,40 0,50 0,60 0,70 0,80 0,90 1,00 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 hodiny relativníčet. CIRCADIAN OCCURENCE N = 72 n = 506 p < 0.01 When? M.Kozak et al., PACE 2003 Where? witness 60% without 40% 60% 40% witness without at home 75% public places 16% other 9% Becker et al. Circulation. 1998,97:2106-2109 • airports • industrial zones • golf clubs • fitcenters • casinas Incidence => 0.03 (30 places = 1 CA) Atkins et al. Prehospital Disaster Med 1996, 11:47-49 ICD IN SECONDARY PREVENTION OF SCD ČR -75/1mil ICD IN SECONDARY PREVENTION OF SCD • MI + NSVT + LV dysf. = 2 year mortality > 30% • MI + NSVT + LV dysf. + EPS + = 50% 1. Anderson. CIRC 1978 2. Bigger. CIRC 1984 3. Buxton. Am J C 1984 4. Wilber CIRC 1990 0 20 40 60 80 100 0 4 8 12 16 20 23 24 Months Survival inducible/nonsupresible VT (Wilber et al) CAD + NSVTICD - PRIMARY PREVENTION For which patient? • A number of previous ICD studies* indicate patients are remarkably similar with respect to: – Age – Left Ventricular Ejection Fraction – Percentage with Coronary Artery Disease – NYHA classification Prophylactic patient is not different *Sources: Moss, A, et al; N Engl J Med 1996; 335: 1933-40 Buxton, A, et al; N Engl J Med 1999; 341: 1882-90 AVID Investigators; N Engl J Med 1997; 337: 1576-83 MADIT Schema of study 5year follow-up 39 deaths CONV group n=101 AAx 5year follow-up 15 deaths -54% TM reduction ICD group n=95 EPS + prokainamide nonsupressible arrhythmia n=196 CAD pts, LVEF < 35% + NSVT > 120/min ICD IN PRIMARY PREVENTION OF SCD ICD - PRIMARY PREVENTION •Documented episodes of NSVT in CAD post MI patients and LVEF < 0.35, sustained VT inducible in EPS. MADIT II ICD IN PRIMARY PREVENTION OF SCD Moss AJ et al, CEPR 2002, 6(4), 463-465 MADIT II ICD IN PRIMARY PREVENTION OF SCD Moss AJ et al, CEPR 2002, 6(4), 463-465 • ICD group (N=742) 105 (14,2%) deaths • CONV therapy (N=490) 97 (19,8%) • 31% reduction of deaths in ICD group • 63% reduction of mortality - QRS > 120 ms • 4.12.5. CAD post MI, LV dysfunction, LVEF < 0.30, QRS > 120ms, NYHA II, 6 m post IM, standard pharmacotherapy (bb) ICD IN PRIMARY PREVENTION OF SCD ICD IN PRIMARY PREVENTION OF SCD - CZ • 2004 5,5% • 2005 7% • 2006 22,8% • 2007 34 % • 2008 39% • 2009 46% •2010 – 2019 - 75% primary preventive implantation RISK STRATIFICATION LVEF > 35% LVEF < 35% Klingenheben et al., A.N.E.2003,8(1):68-74 HRTRISK STRATIFICATION • PPV - 30% • NPV - 96% Steinberg JS., Regan A., Sciacca R.,et al., Am J Cardiol 1992;69:13-21 Breithardt G., Schwartzmaier J., Borggrefe M.,etal., Eur Heart J 1983;4:487-95 RISK STRATIFICATION TWARISK STRATIFICATION RISK STRATIFICATION •Ghuran Am J Cardiol 2002 • Prophylactic ICD patient is not different to the general ICD population • NNT ratio is low and reduced in time • ICD therapy is cost effective • Prophylactic pts require a full featured device, just like any other pt CONCLUSION CONCLUSION • No of PP ICD implantation is growing • Each fifth pt in CZ is implanted from PP reasons • The most frequent - combined indication PP ICD + CRT CRT CRT INDICATION • 4.10. HF, stand. Rx 6 months (NYHA II/ III 6 m, NYHA IV) LVEF < 35%, QRS > 150 ms, 120-150ms, dyssynchrony Stay in AAI Stay in DDD . Daily test . or 12 spontaneous events > 100 cycles AAI Minimalizace komorové stimulace ICD Medtronic CareLink ® (2090W) Programmer • wireless Conexus™ activator Patient Look system Lower fluid = higher transthoracal impedance Higher fluid = lower transthoracal impedance better worse MEDTRONIC OPTIVOL ® BIO MDT STJ GDT 2003 2004 2005 2006 2007 2008 Renewal/Inductive/Frontier CareLink Network (’02) Directo - CareLink Programmer & RemoteView Home Monitoring (‘02) Home Monitoring II HouseCall HouseCall Plus HouseCall Plus Frontier CareLink Network UP TO DATE STATUS Patient Device Cardio Messenger BIOTRONIK Service Center Implant with Home Monitoring Cardio Report Physician Patient Home Monitoring Housecall + Medtronic CareLink® Monitor Medtronic CareLink Network Paceart® System Electronic Medical Record (EMR) CareLink and Paceart Integration COGNIS TELIGEN Objem (cm3) 32.5 31.5 / 30.5* Tloušťka (mm) 9.9 9.9 Hmotnost (g) 72.0 71.0 •ICD HARDWARE •Nová technologie baterie Li/MnO2 •ICD HARDWARE •Dual Shock, Bipolar Defibrillator Lead •(One IS-1 and two DF-1 Connectors) •Single Four-pole High / Low Voltage Connector •Four-pole Brady Lead •(Two IS-1 Connectors) •Single Four-pole Low Voltage Connector • Summary - Lead •ICD HARDWARE IS - 4 Hlava ICD •ICD HARDWARE •Mapping capabilities •ICD ELEKTRODY •Dynamic Noise Algorithm - D.N.A. •ICD SOFTWARE •SVC coil •RV coil •RV tip •Device •. •ICD SOFTWARE •ICD SOFTWARE •LV capture management •Anatomie nervus phrenicus •ICD SOFTWARE •L •- •+ •LV-Tip  LV- Ring •L •- •+ •LV-Tip  RV- Ring •L •- •+ •LV-Ring  LV- Tip •L •-•+ •LV-Ring  RV- Ring •Stimulační konfigurace v prevenci stimulace n. phrenicus •ICD SOFTWARE •ICD SOFTWARE y = 0.9841x + 1.4614 R2 = 0.9769 0 10 20 30 40 50 60 0 10 20 30 40 50 60 Aortic VTI at IEGM VV (cm) MaxAorticVTI Series1 Linear (Series1) •Meine, et al. “An Intracardiac EGM Method for VV Optimization During Cardiac Resynchronization Therapy” Heart Rhythm Journal 3 (5) May 2006 [abstract AB30-5]. •97.69% korelace! •Porterfield, et al. “Device based intracardiac delay optimization vs. echo in ICD patients (Acute IEGM AV/PV and VV Study)” Europace Vol 8 Supp 1 July 2006 [abstract #6178]. •AV delay •VV delay •ICD SOFTWARE •1 Worley, et.al “Optimization of cardiac resynchronization: left atrial electrograms measured at implant eliminates the need for echo and identifies patients where AV optimization is not possible” Journal of Cardiac Failure Aug. 2004 Vol. 10, Issue 4, Pg S62. •Trvání P vlny je odrazem aktivace PS + LS. QuickOpt™ na základě tohoto intervalu počítá optimální S/P AV zpoždění k zajištění max. preloadu a umožnění správného načasování uzávěru Mi chlopně. •Elektronická optimalizace snímaného a stimulovaného AV zpoždění •ICD SOFTWARE V-V optimalizace: rozdíl časování spont. depolarizace (D) •RV IEGM •time •QRS at RV site •LV IEGM •time •QRS at LV site •T •peak detection window D •Vedení v myokardu je definováno P/S testem. Cílem je aktivovat PK i LK tak, aby se stimulované elektrické aktivační vlny setkaly na IVS. •ICD SOFTWARE •RV PACE •time •LV IEGM •time •QRS •T •Pace one chamber •Sense at the other •peak detection window •Pacing Spike •IVCD V-V optimalizace:rychlost aktivačních vln (e) •ICD SOFTWARE •LV PACE •time •RV IEGM •time •QRS •T •Pace one chamber •Sense at the other •peak detection window •Pacing Spike •IVCD •ICD SOFTWARE TROUBLESHOOTINGS Kozák M, Sepši M, Křivan L et al. Cardiol 2002;11(4):259-263 Kozák M, Křivan L, Semrád B et al. Cor Vasa 1999;41(5):252-254 4 (2,9%) 5 (3,6%) KOMPLIKACE Křivan L, Kozák M, Sepši M et al. Cardiol 2001;10(5):238-242 Křivan L, Kozák M, Sepši M et al. Čas Lék čes 2004;143:521-525 4 pac, 2x ICD kapsa, 2x IE TROUBLESHOOTINGS KOMPLIKACE 68.6 13.6 11.6 4.7 1.2 68.6 13.6 11.6 4.7 1.2 1 2 3 4 5 6 Příčina nevhodné terapie 0 10 20 30 40 50 60 70 80 Podílpřípadů[%] 1-SVT fisi 2-SVT flusi 3-SVT sinusová tachykardie 4-detekce artefaktů 5-VT nedetekovaná n=258 68.6 13.6 11.6 4.7 1.2 68.6 13.6 11.6 4.7 1.2 1 2 3 4 5 6 Příčina nevhodné terapie 0 10 20 30 40 50 60 70 80 Podílpřípadů[%] 1-SVT fisi 2-SVT flusi 3-SVT sinusová tachykardie 4-detekce artefaktů 5-VT nedetekovaná n=258 5 5 . 8 2 4 . 4 1 2 . 0 3 . 1 2 . 3 0 . 8 0 . 4 1 . 2 5 5 . 8 2 4 . 4 1 2 . 0 3 . 1 2 . 3 0 . 8 0 . 4 1 . 2 1 2 3 4 5 6 7 8 0 1 0 2 0 3 0 4 0 5 0 6 0 Podílpřípadů[%] 1-ATP 2-CV 3-CV+ATP 4-Indukce VT/VF nevh. terapie 5-Spontánní 6-Všechny terapie nevhodné 7-Jiné 8-Neuvedeno Po čet arytmických bou ří u jednotlivých pacient ů 63% 11% 11% 11% 5% 1 2 3 4 7 Počet arytmických bouří 0 2 4 6 8 10 12 14 Početpacientů n=19 Křivan L, Kozák M, Vlašínová J et al., Cor Vasa 1999;41(2):112-115 Křivan L, Kozák M, Sepši M et al., Med Sci Monit 2005;11(9):CR426-429 ATP - antitachykardická stimulace, CV - kardioverze SVT - supraventrikulární tachykardie, V komorová tachykardie Innapropriate Rx - 35%pat. Arrhythmic storms - 14% pat. Innapropriate Rx TROUBLESHOOTINGS Křivan L, Kozák M, Semrád B. Cardiol 1999;8(2):59-64 Křivan L, Kozák M, Sepši M et al. Čas Lék čes 2004;143:521-525 KOMPLIKACE TROUBLESHOOTINGS 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 AV uzel Fokální síňová tachykardie Komorová tachykardie Fibrilace síní Přídatná dráha Flutter síní AVNRT 0 10 20 30 40 50 60 70 80 90 počet rok Počty výkonů RFA za období 1996-2006 RFA VT I. II. III. IV. SCD ? ? 1 2 1 2 3 4 5 6 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 I. II. III. IV. SCD ? ? 1 2 1 2 3 4 5 6 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 FENOTYPE GENOTYPE Novotný, Vojtíšková, Semrád, et al. Cor Vasa 2000;42:260-2 PREVENTIVE PROGRAMMS LQTsy