TAHIARITMIILE

VENTRICULARE

Tahiaritmii cu QRS larg

R.V. - Tahiaritmii 2020 88

 Aritmii V: def. și mec.
• Reintrare >90% (miocite restante în cicatrice,
fibroză)
• activitate declanșată – PDP și PDT
• automatism anormal - RIVA în IMA

de Bakker JMT et al. JECG 2007

de Bakker JMT et al. Circulation 1993

Attin M et al. Heart Rhythm 2008 89
R.V. - Tahiaritmii 2020
R.V. - Tahiaritmii 2020 90
 Extrasistolele ventriculare

• QRS larg > 120 msec, precoce

• de obicei neprecedat de unda P, eventual unda P retrograda

• Daca nu depolarizeaza retrograd NSA: pauza compensatorie (P’P” = 2 PP)

• Uneori interpolate

• Incidenta creste cu varsta

• Cauze: stress, alcool, ischemie, miocardite, diselectrolitemii, medicamente

(AA, digoxina, etc)

R.V. - Tahiaritmii 2020 91

Clasificare si semnificatie clinica
• Clasa 0
• Clasa 1: monomorfe ocazionale < 1/’ sau 30/h
• Clasa 2: monomorfe frecvente > 1/’ sau 30/h
• Clasa 3a: polimorfe
• Clasa 3b: sistematizate (bi-/trigeminate)
• Clasa 4a: repetitive - cuplete
• Clasa 4b: repetitive 3 sau mai multe (TVNS)
• Clasa 5: R/T
Lown B et all, JAMA 1967
R.V. - Tahiaritmii 2020 92
 Clasificare si semnificatie
clinica
DUPA FRECVENTA DUPA MORFOLOGIE
• Clasa 0 • Clasa A: monomorfe, monofocale
• Clasa 1: rare < 1 / h • Clasa B: polimorfe, polifocale
• Clasa C: repetitive
• Clasa 2: putin frecvente
– Cuplete
(1-9 / ora) – Salve (3-5 ESV)
• Clasa 3: intermediare • Clasa D: TV-NS (6 ESV ® 30
(10-29 / ora) sec)
• Clasa 4: frecvente (> • Clasa E: TV-S
30 / ora)
Myerburg et al. Am J Cardiol 1984;54:1355-8.
R.V. - Tahiaritmii 2020 93
 Clasificare si semnificatie clinica

Potential maligne
Benigne Maligne
FE>35% FE<35%
ESV, TVNS,
Tip aritmie cuplete
ESV, cuplete, TVNS TVNS, TVS, FV

Moderat
Cardiopatie Lipsa Moderata
severa
Severa

Semnific. Sincopa,
Nu Nu Sincopa, MSC
hemodin. MSC

Risc MSC Minim Moderat Mare Major

Holter,
Evaluare ECG, Holter Holter
PVT, VRS
Holter, SEF

Morganroth et al. JACC 1986.

R.V. - Tahiaritmii 2020 94
 Evaluarea riscului
• simptome ( corelate cu alterarea h-d)
• ECG 12 derivații: RS (substrat) și ESV (localizare anatomică !)
• cardiopatia subiacenta
• cord N
• canalopatii
• BCI
• CMP (D,H,A)
• miocardite
• CpCo
• prezența și severitatea DVS/DVD/DbiV
• încarcătura aritmică (çè risc tahiCMP)
• răspunsul la efort (ECG de efort)
• util la cei cu cord aparent N
• controversat la cei cu CP structurale

R.V. - Tahiaritmii 2020 95

 Tratamentul ESV
• ESV, cuplete, TVNS asimptomatice: b-blocante (FE > 40%)

– NU flecainida, encainida, propafenona pe cord ischemic și/sau

DVS

• ESV frecvente in IMA: amiodarona sau betablocant IV (-/+xilina)

• Cuplete sau TVNS pe cord patologic in afara ischemiei acute:

– Amiodarona

– Ablatie prin RF a focarelor endocardice:

• PALEATIVA (?)

• curativă

R.V. - Tahiaritmii 2020 96

 Studiul CAST-I:
cresterea mortalitatii sub AA clasa I la pacienti cu IM in
antecedente

R.V. - Tahiaritmii 2020 97

 TV: definitie si caractere ECG
• Tahiaritmie regulata cu QRS > 120 msec:
– ASPECT MONOMORF sau POLIMORF

• C.p. 3 depolarizari ventriculare succesive cu frecventa

>120/min
• Durata variabila: 3 QRS ® > 30 sec (TVNS/TV)
• Disociatie atrioventriculara
– Activare atriala indepedenta sau conducere VA retrograda

• RISCURI:
– Degradare hemodinamica
– Degenerare in FV
R.V. - Tahiaritmii 2020 98
 TV monomorfa:
diagnostic

• tahiaritmie regulata > 120/

• QRS larg > 120 msec
• Disociatie AV
• Batai de fuziune
• Capturi ventriculare
•Criterii morfologice

R.V. - Tahiaritmii 2020 99

 Criterii morfologice
pe baza derivatiilor V1,2 si V6
Semnul “urechii de iepure”

• Tip BRD TSV TV

– V1,2 rsR’ R(r’)
• R monofazic
• qR
• RsR’ cu R>R’

qR
– V6 rS
• rS

R/S > 1 R/S < 1

Wellens 1978
R.V. - Tahiaritmii 2020 100
R.V. - Tahiaritmii 2020 101
 Criterii morfologice
pe baza derivatiilor V1,2 si V6
TSV TV
• Tip BRS
– V1,2 > 0.03
• R inițial larg >30 ms
• deflexiunea
descendenta S
– lentă > 0.06
– Incizură
Fără q q
– Încep. QRS ® nadir
S ≥ 60 ms

– V6
• Q sau QS

Kindwall, 1988 R.V. - Tahiaritmii 2020 102

R.V. - Tahiaritmii 2020 103
 Absenta unui complex RS in DT

Da Nu

TV Interval R – S > 100msec ?

Da Nu

TV Disociatie A-V ?

Da
Nu

TV
Criterii de VT in V1,2 si V6 ?

Da
Nu

TV
TSV cu aberanta
R.V. - Tahiaritmii 2020 104
Criteriile Vereckei V4

Vi & Vt
Unda R in AvR
.

Vi > Vt => SVT

V2

Vi=0.3 Vt= 0.65

V3
Vi < Vt => VT

** *
*
Vereckei et al, Eur Heart J, ;28:589-600,
R.V.March 2007 2020 105
- Tahiaritmii
 Disociatie AV ?

Da Nu

TV Unda R initiala in AvR ?

Da Nu

Morfologie QRS
TV “unlike BBB or FB” ?

Da
Nu

TV
Vi < Vt

Da Nu

TV TSV cu aberanta
R.V. - Tahiaritmii 2020 106
 Dg ¹ TV vs. TSV cu QRS largi
• TSV cu QRS largi
• TSV + BR pre-existent
• TSV cu aberanta de conducere
• TSV + TRAV prin mecanism antidromic (WPW)

• Dg. dif. posibil pe ECG standard la > 90% din cazuri

NB!:
• 80% din tahicardiile cu QRS larg = TV (>90% la cei cu afectare structurală
cardiaca)
• !! trat unei TV cu medicatie pentru TSV o poate destabiliza
• orice tahicardie cu QRS larg si degradare h-d = SEE

• Criterii ECG de diferentiere TV – TSV cu QRS largi:

1. Batai de fuziune; capturi V
2. Disociatia AV
3. Conducere retrograda VA (P retrograde)
4. QRS > 140 msec (m.a. >160 msec)
R.V. - Tahiaritmii 2020 107
TV polimorfa

R.V. - Tahiaritmii 2020 108

TV polimorfa: torsada varfurilor
PDP
• TV rapida, degenereaza in FV
• produsa prin PDP
• cu QT lung sau cu QT normal
• Cauze:
• sdr. de QT lung
• hipo K, hipo Mg
• AA Ia si III
• Tratament:
• MgSO4 IV
• “Overdrive pacing”
• isuprel lent
• xilina, fenitoina
• QT lung: AICD, beta-blocante,
flecainida, stelectomie.
R.V. - Tahiaritmii 2020 109
Fibrilatia
ventriculara
• Unde fibrilatorii de amplitudine diferita, in absenta
complexelor QRS
• Asistola mecanica urmata de asistola electrica
• Colaps, stop respirator si deces in 3-5 minute de la instalare
in absenta CPR
• Cauze:
– Ischemia acuta din IMA aritmii V spontane severe
– Cardiomiopatii (CMHO !) FA din WPW
– CPHT cu HVS hipoxia din BPOC
– Iatrogen: medicamente, diselectrolitemii, cateterism cardiac
– Sdr. de QT lung cu TdP SEE asincron
• Precedata sau nu de TV
R.V. - Tahiaritmii 2020 110
Tahicardia ventriculara
neparoxistica (RIVA) =
AUTOMATISM CRESCUT

R.V. - Tahiaritmii 2020 111

 Tratament TV
• TV fara decompensare hemodinamica: AA
– Xilina, procainamida, amiodaron, bB in anumite situatii
– TV digitalice: fenitoina, xilina +/- AC anti-digitalici

• TV cu hipoTA, IVS, angina, hipoperfuzie cerebrala:

– SEE sincron (> 50 J) pt cele monomorfe
– SEE asincron (>150J) pt cele polimorfe/FV
– IOT, MCE
– Bicarbonat iv daca CPR > 60 sec
– amiodaronă, Lidocaina iv (FV recur/rezistentă la SEE)

• Alternative:
– Overdrive pacing – TV monomorfe
– thump version (?!)

• Tratamentul cauzelor corectabile sau producatoare:

• Ischemia acuta
• Hipo K, hipo Mg
• BS excesiva
R.V. - Tahiaritmii 2020 112
Oprirea TV prin overdrive pacing

R.V. - Tahiaritmii 2020 113

 Tratamentul profilactic al TV
• TVNS asimptomatica pe cord normal sau

patologic: b-blocante (FE > 40%) sau

amiodaron

– NU flecainida, encainida, propafenona (CAST)

• TVS:

– DEFIBRILATOR IMPLANTABIL

– Amiodarona.
TVNS cu deteriorare
– Ablatie prin RF a focarelor endocardice hemodinamica

– Chirurgia AA
R.V. - Tahiaritmii 2020 114
 ICD / DAI Detectie

Soc ATP

Funcții anti-tahiaritmice è sonda VD

? Diagnostic
? Detecție
? Discriminare*
? Terapie
? Defibrilare/Cardioversie
Bradicardii è sonda VD AD*
? Pacing antitahicardic& VS&,#
? Detecţia bradicardiei*
? Pacing antibradicardic
? TRC# R.V. - Tahiaritmii 2020 115
 Defibrilatorul implantabil - ICD
Funcții anti-tahi è sonda VD VS&,# Bradicardii è sonda VD AD*
? Diagnostic VS&,#
? Detecție ? Detecţia bradicardiei*
? Discriminare* ? Pacing antibradicardic
? Terapie ? TRC#
? Defibrilare/Cardioversie
? Pacing antitahicardic&

Indicatii:
Proflilaxie secundară Profilaxie primară
Orice CP structurală/electrică cu un BCI FEVS<35-40%
eveniment (MSC resuscitată, TV CMD FEVS <30-35% și NYHA ≥II
sustinută, FV) la care nu se decelează CMH
o cauză reversibilă CAVD
LQT
Brugada
SQT
R.V. - Tahiaritmii 2020 116
Stimularea anti-tahicardica ATP

• Eficacitate: 70-95%
– Predictori de insucces: ≥2
morfologii si/sau ≥2LC

• Necesita energii de stimulare

inalte (stim biV pentru CRT-D)

• Risc: Accelerarea tahicardiei,

posibil – degenerare in FV

R.V. - Tahiaritmii 2020 117

R.V. - Tahiaritmii 2020 118
 Socul electric intern

• SEI face inexcitabil INTREG miocardul (zone

depolarizate alternand cu zone hiperpolarizate, in
functie de pozitia electrozilor, anatomia tesutului si de
anizotropie), urmarind intreruperea aritmiei
ventriculare si restabilirea ritmului normal

• FV/TV polimorfe = reintrari multiple variabile cu ,,miez”

anatomic si functional*

R.V. - Tahiaritmii 2020 119

R.V. - Tahiaritmii 2020 120
R.V. - Tahiaritmii 2020 121
 ICD reduc mortalitatea cu ~ 40%
atât in prevenţia primară cât şi în cea secundară
40
Control
54%
73% 51% ICD
30
39%
36%
20% 38% 0 31%
0
20
41% 0 23%

10

Prevenţie secundară Prevenţie primară

R.V. - Tahiaritmii 2020 122

Al-Khatib SM et al, Am Heart J 2005

R.V. - Tahiaritmii 2020 123

 kinje network. Catheter ablation is curative in most affected patients

Catheter ablation
.5 Interventional therapy and procedural complications
arrhythmic aresubstrate cardioverter
rare. in patients with a history of myocardial infarc-
5.1 Catheter ablation tion198 or in patients presenting with epicardial VT.199
Polymorphic VT is defined as a continually changing Psychosocial QRS morph- m
4.5.2 Anti-arrhythmic surgery
ology often associated with acute myocardial ischaemia, acquired im
defibrillator
Catheter ablation for the treatment of sustained
or inheritable channelopathies or ventricular hypertrophy. In
monomorphic ventricular tachycardia Surgical ablation of ventricular tachycardia
some of these patients who are refractory to drug treatment,
Recommendatio
Purkinje-fibre triggered polymorphic VT may be amenable to cath-
eter ablation.200,201Classa Levelb Ref.c Assessment of psyc
Recommendations Classa Levelb Recommendations Ref.c
treatment of distres
Urgent catheter ablation is Surgical ablation guided Non-invasive
by imaging of cardiac structure, best doneinbypatients magnetic with rec
recommended in patients with resonance imaging, can be used to plan and guide
preoperative and intraoperative ablation
shocks.
I B 183
scar-related heart disease presenting electrophysiological mapping
procedures for VT.198 Mapping and ablation may beDiscussion performed of qualit
with incessant VT or electrical storm. Page 25 of 87 at an experienced centre is
performed
during ongoing VT (activation mapping). 212– A three-dimensional
recommended befo
recommended in patients with VT I B
Catheter ablation is recommended in electro-anatomical mapping system 215 aid in localization
may and of
during disease
abnor-
refractory to anti-arrhythmic drug
patients with ischaemic heart disease 184– after failuremal ventricular tissue and permits catheter ablation in sinus rhythm patients.
I B therapy of catheter
and recurrent ICD shocks
Correction of electrolyte imbalances is due to 186 by experienced
ablation (substrate ablation) without induction of VT that may prove
sustained
recommended
ESC VT. in patients with
Guidelines I C 179
electrophysiologists. Page 29 of 87
haemodynamically unstable. A non-contact mappingICD a
¼ implantable
system may car
recurrent VT or VF.
Catheter ablation should be considered Class of recommenda
Surgical ablation at be the utilized
time of cardiac in patients with haemodynamically unstablebLevel VT.ofSeveral
evidence.
after
Oral atreatment
first episode with ofbeta-blockers
sustained VT in 184–role
surgery in the relief
(bypass or of symptoms
valve surgery) and
may the
be reduction of arrhythmic c
Therapy with sodium channel blockers IIa B 130 techniques, including point-by-point 216, ablation at the exit site of the
Reference(s) supporti
patients
should be with ischaemic
considered
(class heart the
during
IC) is not recommended disease
to 186, episodes
considered in inpatients
this group withof patients.
clinically IIb C
257, For symptomatic (PVCs or 217
and an ICD.
hospital prevent sudden death in patients with
stay and continued thereafter III
IIa B
B131 documented VT or re-entry
VFbut after circuit
failure of (scar
not life-threatening dechanneling),
arrhythmias deployment of linear lesion
2818 CAD or who survived myocardial 259 , short and slow NSVT), amiodarone is the drug of choice since it
in all ACS infarction.
patients without catheter ablation. sets or ablation of local abnormal ventricular activity to scar hom-
suppresses arrhythmias without worsening prognosis.293,294
ESC Guidelines

AMI
ICD ¼ implantable cardioverter defibrillator; VT ¼ ventricular tachycardia. 5.3.4 Catheterogenization,
contraindications.
260
can be used.202 – 205 Epicardial mapping and ablation are
CAD ¼ coronary artery disease; VA ¼ ventricular arrhythmia.
more
Post-MI
ablation
5.1.3.2 Use of anti-arrhythmic
VT often
drugs in acute coronary
required ininfarction,
patientsoften with dilated cardiomyopathy
Controlled defibrilla
a
Class of recommendation.
Radiofrequency a catheter
Reprogramming
Class of recommendation. ablation
a previously at a
implanted VF ¼ ventricular
VT occurs fibrillation;
in 1– 2% of ¼ ventricular
patients late after tachycardia.
myocardial
b a syndromes—general considerations
Level of ICD
Levelshould
evidence.
b be considered to avoid IIa C 272 Class of recommendation. 206 207
c c
of evidence.
specializedunnecessary
ablationICD centre
shocks.
Reference(s) supporting
followed by
recommendations. b
after an interval
Electrical (DCM)
of
cardioversionseveral oryears. or ARVC
Recurrent
defibrillation can undergoing
VTintervention
is the be treated effect-VT ablation. Potential
of choice qualitycomplica-
of life in rec
Reference(s) supporting recommendations. Level ofively
evidence.
with catheter ablation, which dramatically
1,271 reduces VT recur- 223,224
the implantation of an ICD should be c
to acutely terminate
tions VAs in ACS
ofseries patients.
epicardial Early
puncture and (possibly i.v.)
ablation are damage in to
controls.
the coron- N
ICD implantation or temporary use of a 261–administration
Reference(s)
rence supporting recommendations.
in smallof patient
beta-blockers cantreated
help in specialized
prevent recurrent centres.
arrhyth-
considered WCDin patients with
may be considered recurrent
,40 days after IIa C (5– 41%) are left
commo
The role of anti-arrhythmic drugs in the prevention of SCD in post- 267 mias.
myocardial infarction in selected patients Whether257,269,271
primary ary vasculature
ablation
Anti-arrhythmic of well-tolerated or inadvertent
drug treatmentsustained puncture of surrounding
withmonomorph-
amiodarone organs,
VT, VF or electrical
myocardial storms
infarction despite
patients with preserved ejection 170,
fraction is
5.1.1 Patients with
(incomplete scar-related
revascularization, d
heart disease
IIb C
273
ic VT in be
should patients with
phrenic
considered anonly
LVEFnerve
if.40%
episodes without
palsy
of VTaor
backup ICDfrequent
or significant
VF are is bene-bleeding resulting nounced in patients
in pericardial
complete revascularization
limited. MostLVEF
pre-existing of the data and
dysfunction,come optimal
from the CAST study,129
occurrence which ficialcan
and deserves
no longerfurther study. Untilby
be controlled then, ICD implantation
successive should be
electrical cardiover-
atheter
medicalablation
treatment.
showed has
of arrhythmias
that evolved
sodium
.48 h after theinto
channel onset an important
of
blockers (class IA and treatment In the option
IC agents) era of transvascular
considered in survivors 1,271 catheter ablation for the treatment of
tamponade. of Intravenous
a myocardiallidocaine
infarctionmaysuffering from sus-
shocks (e.g. more th
sion or defibrillation. be considered
ACS, polymorphic VT or VF). VA, theVT requirement for surgical ablation has become
r Transvenous
patients increase
with mortality
scar-related after myocardial
heart disease infarction. Class II drugs
presenting with tained
for or VT or VF
recurrent Patients
in the
sustained absence
VT or VF with
ofnotacuteVT related
ischaemia,
responding toeventoafter suc- a rarity.
post-myocardial
beta-blockers scarquently
tend togohave unrecog
a
ICD catheter
implantation
(beta-blockers) overdrive
havefor the primary
an established role in reducing mortality in cessful catheter ablation. 261 – 265
274,Anatomically on guided LV aneurysmectomy was first described While immediate
with VT m
or amiodarone or in the case of contraindications to amiodarone.
F. stimulation
Data from two ofbe
should
prevention
post-myocardial prospective
SCDconsidered
is generally
infarction ifrandomized
not
patients is IIIreducedmulticentre
VTwith ALVEF and this
trials better outcome following
In patients with recurrent VT or VF triggered by premature ven-
catheter ablation than patients
indicated ,40 days after myocardial 275 .50 years ago. Large aneurysms may be accompanied by 208 VAs, vice firing, multi-
treating p
utcome
frequentlyin patients
recurrent
protective with
despite
role may alsoischaemic
use ofin patients
persist heart IIadisease
with preserved Cdemonstrated
LVEF, tricular complexdue (PVC)to non-ischaemic
arising from partially injured cardiomyopathy.
Purkinje fibres, Five prospective
infarction. 6. Therapies for patients with
decreases the likelihood ofand map-guided resection of the and aneurysm not only improves The levels of distres
but their effect on SCD is unproven. Finally, the class III agent amio- 261 – 265
atanti-arrhythmic
catheter ablation drugsfor andVT catheter
darone has not been shown to reduce SCD in post-myocardial
subsequent catheter ablation
left ventricular
is very effective
centre studies
dysfunction
should be considered
have evaluated the- role
R.V. of catheter
Tahiaritmii 2020 ablation in the 124
(see section 6.3.2).
 nd may be the consequence or cause of LV dysfunction. PVCsblocker treatment alone [HR 0.27 (95% CI 0.14, 0.52), P , 0.001] lack of RCTs comparing catheter ablatio

org/ by guest on August 16, 2016

and
Treatment of patients with left ventricular dysfunction

PVC and structural

uns of NSVT in subjects with structural heart disease contribute andtosotalol [HR 0.43 (95% CI 0.22, 0.85), P ¼ 0.02]. However, drug substrate-based approach. In addition, there
Table C. Cardiac
n increased mortality risk, and .10 PVCsa per hour or runs of
resynchronization
discontinuation therapy
was more frequent in patients and
taking premature
sotalol or a com-ventricular respect complex
to the ideal procedural endpoint. W
defibrillator
NSVT are an acceptable marker of increased risk. in the primary
344 prevention of sudden
bination of amiodarone and a beta-blocker. The rates of study drug
If patients clinical VTs should be attempted, non-inducib

heart disease/LVD
death in patients
re symptomatic due to PVCs or NSVTs, or if PVCs or NSVTs con- in sinus rhythm with mild (New York
discontinuation at 1 year were 18.2% for amiodarone, 23.5% for so- lation may be the preferred procedural endp
a b
Heart Association class II) heart failure Recommendations Patients may Class
present Level Ref.c storms
with electrical
ribute to reduced LVEF (‘tachycardia-induced cardiomyopathy’), talol and 5.3% for beta-blocker alone.
In the SCD-HeFT trial, patients with LV dysfunction ESC
In patients with
and Guidelines acutely terminate this potentially life-threatin
frequent symptomatic
NYHA
miodarone or catheter ablation should be considered.
A high PVC burden (.24%) in patients with LV dysfunction and classa II or III bHF received PVC or
conventional HF therapy, conventional NSVT: shown to decrease the rate of recurrent ele
Recommendations Class Levelc Ref.d when compared
ather short coupling interval of the PVCs (,300 ms) suggest therapy plus amiodarone or conventional therapy and a single-
– Amiodarone should be considered. IIa with medical
B treatment
64 onl
33% in the control group to 12% in the ablation arm. Furthermo
VC-induced cardiomyopathy. CRT-D 342 is recommended
In such to reduce
patients, catheter
64
chamber ICD. Compared with conventional –HFCatheter
ablation therapy,ablation
the add- related to post-myocardial scar tend to have
should be ICD shocks decreased from
the rate of appropriate 341–31% to 9% fo
an suppress PVCs and restoreall-cause mortality
LV function. 341 in patients with a
ition of amiodarone did not 148,
increase mortality.considered. lowing catheter IIaablationBthan patients with VT
lowing catheter ablation. 343
QRS duration ≥130 ms, with an LVEF 322, cardiomyopathy. Five prospective studies hav
≤30% and with LBBB despite at least 323, The Ventricular
Catheter ablation should be Tachycardia
considered Ablation in Coronary Heart Disea
I A catheter ablation in the treatment 341–of sustaine
3 months of optimal pharmacological 325, in patients with LV dysfunction
(VTACH) study prospectively randomized IIa Bpatients with previo
6.3.2 Catheter ablation ticenter Thermocool study reported 343 an acute
therapy who are expected to survive 327, associated with PVCs. infarction, reduced ejection fraction (≤50%) a

Sustained VT
6.3 Sustained ventricular tachycardia myocardial
at least 1 year with good functional 329
as abolishment of all inducible VTs, of 49% an
haemodynamically stable VT to catheter ablation or no addition
.3.1 Drug therapy status. Prevention of ventricular tachycardia recurrences in from VT of 53% over 1886 months of follow-up
therapy, NSVT
LV ¼ left ventricular; apart ¼from subsequent
non-sustained ICD.tachycardia;
ventricular The primary
PVC ¼ endpoi
patients with left ventricular dysfunction and sustained Multi Center Investigators Group study, acu
CRT-D may be considered to prevent premature ventricular complex.
was time to first recurrence of VT or VF. The rate of survival fr
Treatment of patients with left ventricular ventricular tachycardia elimination of all inducible VTs, was achieved
for HFdysfunction
a
hospitalization in patients with a Class of recommendation.
from recurrent VT over 24 months was higher in the ablation gro
and sustained recurrent monomorphic QRS duration ≥150 ventricular
ms, irrespective of 148,
b
Level of evidence. Freedom from recurrent VA was noted in 4
c compared
Reference(s) supportingwith the control arm [47% vs. 29%, HR 0.61 (95% CI 0.3
recommendations.
tachycardia QRS morphology, and an LVEF ≤35% 327– 8 + 5 months of follow-up. In the prospectiv
despite at least 3 months of optimal Recommendations
IIb A
329, Classa Levelb0.99), P c¼ 0.045]. The mean number of appropriate ICD shocks p
Ref. tion was acutely successful in 81% of patients
patient per year decreased from 3.4 + 9.2 to 0.6 + 2.1 in patien
pharmacological therapy who are Urgent catheter ablation in334 specialized PVCs and runs of NSVTcatheter current inVT
are common was achieved in 51% of patien
Recommendations expected to Class a
surviveLevel
b
at least 1Ref.
c
year with or experienced centres is recommended undergoing ablationpatients
(P ¼ 0.018). with LV dysfunction
Catheter ablation d
and may be the consequence Mapping
or cause and
of Ablation
LV in
dysfunction.Sinus Rhythm
PVCs andto Halt
in patients presenting with incessant VT I B not affect
183 mortality.
Optimization of HF medicationgood functional status. dia Trial (SMASH-VT) evaluated the role of c
or electrical storm resulting in ICD runs of NSVTOverall, in subjects with structural
theGuidelines
success rate ofheart
catheter disease contribute
ablation for VTto is dete
826according to current HF guidelines is ESC tients with previous myocardial infarction a
I C 8 shocks. an increased mortality
mined by the risk,
amount andof.10 PVCs perscar
infarct-related hour or runs
burden, of
represent
recommended in patients withCRT-D LV ¼ cardiac resynchronization therapy defibrillator; HF ¼ heart failure; Patients underwent ICD implantation 344 for
209VF,
dysfunction and sustained VT. LBBB ¼ left bundle branch block; LVEF ¼ left Amiodarone or catheter
ventricular ejection ablation
fraction; ms ¼ is NSVT are as anlow-voltage
acceptableareas marker of increased risk.
on electro-anatomic mappingIfsystems,
patients wh
64,156, stable VT or syncope with inducible VT during
milliseconds. recommended in patients with are symptomatic
dedicateddue to
unitsPVCs
for or
the NSVTs,
treatment or if
of PVCs
patients or NSVTs
undergoing con- cathet
I B 184–
Amiodarone treatment shouldaThese be recommendations refer specifically to recurrent ICD
CRT-D, since Amiodarone
shockson
studies due ortoeffect
the catheter
sustained ablation should 64, ology testing. The control 210 arm underwent IC
tribute to ablation
186 ofLVEF
reduced VT may positively impact outcome.
(‘tachycardia-induced cardiomyopathy’),
considered to prevent VT in patients IIa C 64 VT. be
of resynchronization in patients with NYHA class II only used CRT-D. considered after a first episode of IIa B 184– None of the patients received anti-arrhythmic
with or without an ICD. b
Class of recommendation. sustained VT in patients with anamiodarone
ICD. or catheter ablation
186 tion should
was be considered.
performed using a substrate-guided
ICD implantation is recommended in
c
Level of evidence. patients undergoing catheter ablation
A high ESCPVC burden
This
Guidelines
6.3.2.2
(.24%)normal
Bundle branch
inre-entrant
patients with LV
ventricular
tachycardia
dysfunction
potentials during and a rhy
sinus
d
Reference(s) supporting recommendations. I
rather C
short panel of
coupling interval of the PVCs (,300 ms) suggest
HF ¼ heart failure; LV ¼ left ventricular; ICD ¼ implantable cardioverter whenever they ICD satisfy eligibility
¼ implantable criteria defibrillator; VT ¼ ventricular tachycardia. for VT induction. During a mean follow-up o
cardioverter
experts 342
defibrillator; VT ¼ ventricular tachycardia. for ICD. aClass of recommendation. PVC-induced cardiomyopathy.was aInsignificant
such patients, catheter
reduction ablation
in the incidence
a
Class of recommendation. Two controlled trials randomized 3618 patientsLevel
withofmild HF to op-
evidence. b Prevention of ventricular tachycardia
341
recurrences in
nebLevel
treatment should be
of evidence. Amiodarone c
or catheterpharmaco-
ablation should can suppress patients
PVCs
64, andwith
restore LV function.
bundle branch re-entrant tachycardia
c timal pharmacological therapy plus an ICD orReference(s)
optimal supporting recommendations.
d to prevent VT
Reference(s) in patients
supporting IIa
recommendations. C 64 327,329 be considered after a first episode of IIa B 184–
ithout an ICD. logical treatment plus CRT-D. sustained VT in patients with an ICD. 186
The MADIT-CRT study329 enrolled 1820 patients Dependingwhoon themildly
were underlying substrate, catheter ablation for sus-
Recommendation Classa Levelb Ref.c
tained VT may result in acute
with a VT ¼6.3 termination and reduction of recur-
failure; LV ¼ left ventricular; ICDsymptomatic (NYHA class I or II) andICD
¼ implantable cardioverter who had an LVEF
¼ implantable ≤30%defibrillator;
cardioverter Sustained
ventricular tachycardia. ventricular
Catheter ablation tachycardia
as first-line therapy is
atients with LV dysfunctionQRS
VT ¼ ventricular tachycardia. with duration
or without ≥130 ms. The initial
HF presenting report
a
Class
with sus- of rent
showed VT
a episodes
34%
recommendation. in
reduction patients
in with structural heart disease.
commendation. b
Level of evidence.
6.3.1 Drug therapy
recommended in patients presenting
I C
345,
ained
dence.
VT should be treated theaccording
primary endpoint
to recentlyof all-cause
publisheddeath
c or HF events [25.3% vs. 17.2%
HF Reference(s) supporting recommendations.
with bundle branch re-entrant 346
uidelines,
s) supportingsimilar to patientsfor
recommendations. with LV vs.
ICD dysfunction
CRT-D; without
HR 0.66VT. 8
(95%InCI
add-
0.52, 0.84),6.3.2.1 Patients In
P ¼ 0.001]. with left ventricular dysfunction tachycardia.R.V. - Tahiaritmii 2020
a long- 125