mariell jessup md professor of medicine university of pennsylvania philadelphia, pennsylvania
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Osservazioni cliniche nei pazienti aritmie ed insufficienza cardica Clinical Observations in the Arrhythmic Heart Failure Patients. Mariell Jessup MD Professor of Medicine University of Pennsylvania Philadelphia, Pennsylvania. HF and Arrhythmias. ICDs: the good, the bad, and the ugly. - PowerPoint PPT PresentationTRANSCRIPT
Osservazioni cliniche nei pazienti aritmie ed
insufficienza cardicaClinical Observations in the Arrhythmic
Heart Failure Patients
Mariell Jessup MDProfessor of Medicine
University of PennsylvaniaPhiladelphia, Pennsylvania
HF and Arrhythmias
ICDs: the good, the bad, and the ugly.
VT ablation.
PVC-induced cardiomyopathy.
HF and Arrhythmias
ICDs: the good, the bad, and the ugly.
VT ablation.
PVC-induced cardiomyopathy.
450,000
1 U.S. Census Bureau, Statistical Abstract of the United States: 2001.2 American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures 2001.3 2002 Heart and Stroke Statistical Update, American Heart Association.4 Circulation. 2001;104:2158-2163.
Magnitude of SCA in the US
Breast Cancer2
SCA 4
42,15640,600
157,400
167,366
AIDS1
Lung Cancer2
Stroke3 SCA claims more lives each year than these
other diseases combined
#1 Killer in the U.S.
Severity of Heart Failure and Modes of Death
MERIT-HF Study Group. LANCET 1999; 353:2001-2007
NYHA Class III
n = 103NYHA Class II
n = 103
NYHA Class IV
n = 27
64%
12%
24%
11%
56%
33%
59%
15%
26%
Bayés de Luna A. Am Heart J. 1989;117:151-159
Underlying Arrhythmias of Sudden Cardiac Arrest
Bradycardia17%
Monomorphic VT62% Primary VF
8%
Polymorphic VT 13%
ICD’s and survival in CHF
Buxton AE, at al. (MUST-T) NEJM 1999;341:1882-90 Bristow MR, et al. (COMPANION) NEJM 2004;350:2140-50Moss AJ, et al. ( MADIT-II) NEJM 2002;346:877-83 Kadish A, et al. (DEFINITE) NEJM 2004;350:2151-8
0 1 2 3 Year
Su
rviv
al
100 --
90 --
80 --
70 --
60 --
50 --
MADIT- II ICD
MUST-T ICD
COMPANION ICD
DEFINITE ICD
MADIT- II No ICD
MUST-T No ICD
COMPANION No ICD
DEFINITE No ICD
Exner, Klein. J Cardiovasc Electrophysiol 2003; 14:574
ICD Implant Procedures-UPENN
0
100
200
300
400
500
600
700
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
356 342395
541502 473
662
414 411 431
U.S. Heart Failure Device Market & Adoption
22%N/A534,000534,000SCD-HeFT1
31%396,000N/A396,000MIRACLE & COMPANION
20%N/A88,00088,000Genetics (HCM, LQTS, etc.)
412,000
N/A
16,000
CRT =>
CRT-D
~ 35%968,0001,380,000Total Indicated Patients
22%116,000116,000High Risk Post-MI (MADIT, MUSTT, MADIT II)1
82%230,000246,000Secondary Prevention (SCA/VF/VT)
EstimatedAdoption
ICD OnlyNet Prevalence *Indications
•Net Prevalence is indicated prevalence minus 15% economic exclusion and minus 20% clinical exclusion.
1. Class II & III, narrow QRS, excluding CRT indicated patients, not overlapping with SCA/VT/VF survivors2. Incremental, not overlapping with SCD-HeFT population (i.e. MI, LVEF ? 30% and no HF)
MADIT-IIGreenberg et al. JACC 2004;43:1459
Hohnlosser et al. NEJM 2004; 351:2481Post MI
Risk-criteria group ICD+OMT (%)
OMT only (%)
p
All patients (mean LVEF 35%), n=898
22.0 22.9 0.76
LVEF <40% and HR >90 bpm (mean LVEF 32%), n=602
24.6 25.0 0.91
NSVT >150 bpm (mean LVEF 41%), n=296
17.2 18.7 0.71
Steinbeck G. American College of Cardiology 2009 Scientific Sessions; March 31, 2009; Orlando, FL.
All-cause mortality at 36 months by treatment group and risk-stratification criteria in IRIS
The IRIS trial
JACC 2009; 53:e1-90
JACC 2009; 53:e1-90
HF and Arrhythmias
ICDs: the good, the bad, and the ugly.
VT ablation.
PVC-induced cardiomyopathy.
Circulation 2004;109:2924
ICDs: the UGLYinfection
ICDs: the UGLYinfection
Closed pocket infection
Eroding ICD pocket
HF and Arrhythmias
ICDs: the good, the bad, and the ugly.
VT ablation.
PVC-induced cardiomyopathy.
NEJM 2008; 359:1009-17
Das et al. Cardiol Clin 2008; 26:459-479
Classification of Ventricular Arrhythmias
Zipes et a. Circulation 2006; 114:e385-484
0 20 40 60 80 100 120 140 160 180 200 220
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
VT Ablations (UPENN) 1999 -2008 ( N = 1176 ablation procedures)
YEAR
Number of VT Ablations
221
1993-1997 (N=65)
2004-2005 (N=65)
P value
Male 59 (91%) 58 (89%) ns
Age 67 ± 9.2 yrs 67 ± 8.9 yrs ns
LVEF 27 ± 7% 23 ± 9% < 0.01
Previous ICD
35 (54%) 61 (94%) < 0.01
Amiodarone 32 (49%) 51 (79%) < 0.01
Post MI patients referred for VT ablation
Marchlinski et al Circulation 2008
0102030405060708090100
Number with ICD "VT Storm" orIncessant
VT/Daily VT
Frequent but notdaily episodes or
shocks
<5 shocks orepisodes/month
Clinical presentation in 100 consecutive patients referred for VT ablation (Sick Patients – Unstable)
93%
68%
18% 14%
%
704047
176116
47
279
0
50
100
150
200
250
300
VT CAD VTRVCM*
VTLVCM
RVOT LVOT Idio LVVT
Other
UPENN VT Ablations (N= 775) 1999- 2006
Tet, Sarcoid, Non OT VT, etc
512 (66%)
263 (34%)
Recurrence vs. clinical benefit
Segal OR: Heart Rhythm 2005
0.03 0.46
Circulation Arrhyth Electrophysiol 2008; 1:153-161
Circulation 2007; 116:1998
*Low bipolar voltage surrounding the valves*Low voltage abnormalities extending toward more apical segments of the RV or LV.
Assomull et al. JACC 2006;48:1977
Electrical storm: definition
• Occurrence of 3 or more distinct episodes of VT and/or VF within a 24-hour period resulting in device intervention.– Incidence: 10-28% over 1-3 year (secondary prevention)
–Prognosis: 2-7-fold higher risk of death
Electrical stormin patients with ICDs implanted earlier
AVID
MADIT II
Huang and Traub Prog Cardiov Dis 2008; 51(3): 229-236
Eur Heart J 2006; 27: 3027
Electrolyte imbalanceIschemiaHeart failure exacerbationMedication non-compliance
identified cause in 13% !!!
Electrical storm in the ICD era.
Huang and Traub Prog Cardiov Dis 2008; 51(3): 229-236
HF and Arrhythmias
ICDs: the good, the bad, and the ugly.
VT ablation.
PVC-induced cardiomyopathy.
Circulation 2005; 112:1092-1097
J Interv Card Electrophysiol 2007; 20:9-13
University of Pennsylvania Medical CenterUniversity of Pennsylvania Medical Center