SVT: What's important to Know & New Treatment Update

SVT: What’s important to Know& New Treatment UpdateEric D. Good, D.O., F.A.C.O.I.69th ANNUAL CONVENTION ANDSCIENTIFIC SESSIONS

Disclosures:• Speaking honoraria for CME programs & research:– Medtronic– Boston Scientific (Guidant)– Biosense-Webster• Research/grant support:– Medtronic– Boston Scientific (Guidant)– Biotronik– Atritech

GOALS OF PRESENTATION• Utilize a case-based approach to identify keyfeatures of the patient history, clinical presentationand ECG that help diagnose the mechanism ofcommon SVTs.• Relate general concepts about EP studies and theablation of supraventricular arrhythmias.• Discuss new technologies utilized in diagnosis andtreatment of SVTs.

Supraventricular TachycardiaSinus tachycardia (ST)Inappropriate sinus tachycardia (IST)Sinoatrial nodal reentrant tachycardia (SNRT)Atrial tachycardia (AT)Multifocal atrial tachycardia (MAT)Atrial fibrillation (AF)Atrial flutter (AFl)Junctional ectopic tachycardia (JET)Nonparoxysmal junctional tachycardia (NPJT)Atrioventricular nodal reentrant tachycardia (AVNRT)Atrioventricular reentrant tachycardia (AVRT)

CASE: DE• 27 y/o female with c/o palpitations & “racingheart” for “years”• Sudden-onset, termination• Sometimes break with straining• Associated SOB, dizziness• Normal labs (TSH), stress echo & 24 hr holter 3yrs ago• Dx with “anxiety” & Rx prn alprazolaml• Now more frequent episodes, pre-syncope• No significant other PMHx

Clinical Clues• Absence of stuctural heart disease• Sudden or gradual onset• Precipitating it ti factors• Regularity of rhythm• Frequency, duration• Termination: Vagal Maneuvers• Severity of symptoms: Syncope

CASE: DEWhat Do You Do Next?1. Order repeat echocardiogram2. Tell her: “it’s all in your head, you just need torelax more” & increase alprazolam to TID3. Treat empirically with BBl4. Send for EP study5. Order an event monitor

External Event Monitor:• Worn for extended period(21-28 days)• Office or home hook-up• Manual & auto-triggertiactivation• Cell transmission, internetaccessibility• Acute alert notifications• Pt can mail back• $$$ (may be costly)

External Event Monitor:CPT Codes:• 93270 ECG Memory Looping Recorders (hook up)• 93272 ECG Memory Looping Recorders (review andinterpretation)• 93014 ECG Non-Looping Recorders (review andinterpretation)t ti • 93225 ECG Digital Holter Recorders (hook up)93227 ECG Di i l H l R d ( i d• 93227 ECG Digital Holter Recorders (review andinterpretation)

Implantable Loop Recorder:

CASE: DE

CASE: DENCT 12-lead in ED:

CASE: DESinus 12-lead in ED:

PSVT-Most Common Mechanisms• AV node reentry 70%• AP-mediated 25%• Atrial tachycardia 5%

Electrocardiographic Clues:• Narrow QRS tachycardia (usually)• Characterize short-RP, long-RP• Onset, termination• Effect premature beatsSVT

Typical, Atrioventricular Nodal Reciprocating Tachycardia(AVNRT)Washington Heart Rhythm Associates, LLCUpToDate, 2005

A1A2: 500/320 ms- Block in FP, ConductionThrough SP, Induction of AVNRTAH 260

Typical AVNRT:UpToDate, 2005

Atypical AVNRT:UpToDate, 2005

Atypical AVNRT:

Treatment Strategies AVNRT:• Acute tachycardia– Vagal maneuvers– Adenosine– CV (hemodynamically unstable)• Medical therapy– AV nodal agents, particularly BBl– Sometimes class IC AARx• Catheter ablation is mainstay– Efficacy approaches 98% in many centers– Complications

New Ablation Technologies:Indian Pacing Electrophysiol. J. 2008; 8 (Suppl. 1): S75-S91

CASE: MW• 28 y/o G1P0 female at 20 wks gestationpresents to ED with c/o sudden-onsetpalpitations, i “racing heart” & chest pain• Normal prenatal exams, otherwise healthy• Taking only prenatal multivitamin• No prior PMHx• Rapid irregular HR & BP 95/56 on exam• Following ECG obtained

CASE: MW

1. Immediate CV 360JCASE: MW2. Bolus 150 mg IV Amiodarone3. Call for stat Cards/EP consult4. Bolus & IV qtt procainamide5. Exclaim “I remember this was on the boards,but I never thought I’d ever really see it!,” thenimmediately go buy a Mega-Millions Lotteryticket

CASE: MW

VentricularPreexcitation

Accessory AV Connection

Orthodromic Reciprocating TachycardiaAVNAP

ECG Clues Suggestive ofOrthodromic Reciprocating• Rate >200 bpmTachycardia• P wave in ST segment• QRS alternans• AV or VA block during tachycardiaexcludes ORT as mechanism

Orthodromic ReciprocatingTachycardia

PW Wave in STS Segment tin V2

Orthodromic ReciprocatingTachycardia:QRS Alternans240 bpm

Antidromic Tachycardia

Antidromic Tachycardia: Left-Sided AP220 bpm

Sinus with Pre-excitation,PAC initiating i i i ORT

Orthodromic Reciprocating Tachycardia:Drug TherapyFlecainidePropafenoneQuinidineProcainamideDisopyramideSotalolAmiodaroneAVNAPAdenosineBeta-blockersCalcium channel blockersDigitalisSotalolAmiodarone

Pre-excited AFib After 12 mg Adenosine225 bpm

CASE: MW1. Keep in hospital on IV Procainamide2. Take emergently to C-section3. Transition to quinidine & monitor throughpregnancy4. Transition to amiodarone & monitor throughpregnancy5. Transition to beta-blocker & monitor throughpregnancy

Pregnancy: Class IA Drugs• Quinidine• Longest record of safe use in pregnancy (60y)• Secreted in breast milk but ok to nurse (AAP)• Case reports of thrombocytopenia, premature labor,CN VIII toxicity• Disopyramide – initiation of premature labor• Should not use• Procainamide• No teratogenic effectsec • Acute treatment of arrythmia• Not as much experience as quinidine• No longer available orally

Pregnancy: Class IC• Limited experience• Relatively safe• Cross placenta• Flecanide used for fetal SVT• Ok to breast feed

Pregnancy: Beta Blockers• Used extensively for HTN and hyperthyroidismyand are well tolerated• Reports of IUGR, bradycardia in fetus,hypoglycemia• Mechanistic risk of decreased uterine relaxation(beta 2)decreased placental flowincreasedfetal PVR• no firm evidence that non-selective ect e agents areworse but use of selective agents recommended• Not first line treatment for arrhythmia

Pregnancy: CCB• 1stst line for AVNRT and Idiopathic VT• Verapamil• May impair i uterine contractions ti if used longterm• Diltiazem• Not as much experienceMaternal hypotension may occur with IV dosing

CASE: MW• Managed on quinidine SR 324 mg twice daily• No recurrence AFib or SVT, only palpitations• Intrauterine pregnancy at 37-1/7th weeks'gestation• Footling breech presentation and spontaneousrupture of membranes• C-section, delivered healthy 2640-gm maleinfant• Taken to EPS-RFA 9 mos later• Post-Lat AP successfully ablated, no recurrencey ,to date

Radiofrequency Ablationof an Accessory PathwayRF on

CASE: MW

RF Ablation of AP’s in 1,242 PatientsUniversity of Michigan• Mean Age-• Acute Success 96%• Procedure Time37 ± 15 yrs100 ± 35 min• Fluoro Time40 ± 30 min• Recurrence 3%• Long term Success 95%

Complications of RFA of AP’s• Death 0.08% *• Cardiac Tamponade0.5%• AV Block 0.5%• Femoral artery complication 0.5%• Coronary artery spasm 0.2%• Pericarditis 01% 0.1%• TIA 0.1%*3 of 4000 pts at 5 centers

“New” Anatomical Relationships:Septal AP, close to HIS

“New” Anatomical Relationships:Better timing from NCC Aorta

28 y/o man with WPW, Hx of AF, rate 250/min

Coronary Sinus Venogram

Transpericardial Access:

Position o of Effective Pericardial Target SiteRelative to Right Coronary Artery0° AP 40° LAO

Delivery of RF Energy in Pericardial Space(4-mm tip, 40 watts, temp 55-60)* *

SVT: Re-entrant mechanism• AV Nodal Re-entryentry• AP-mediated Re-entry (ORT, ART)• Atrial Tachycardia (Automatic)

CASE: JH• 20 y/o female with no PMHx presents withasymptomatic, incessant tachycardia to PCPfor evaluation of dysuria/UTI• Echocardiogram with LVEF = 20%• Negative ischemic, congenital w/u• No CHF Sx

CASE: JH12-lead ECG

CASE: JH1. Start BBl, ACEi/ARB, spironolactone and orderf/u echocardiogram 6 mos2. Schedule TEE-CV3. Initiate appropriate Rx & Send for EPS ± RFA4. Order event monitor5. Send for ICD evaluation

CASE: JH

Tachycardia-Induced Cardiomyopathyy• Incessant SVTs • abnormal calciumhandling• Afib• depletion of myocardial• AflutterATP• PVCs• downregulation of β-1• VTreceptors• Myocardial stunning fromoxidative stress*** HIGH INDEX OF SUSPICION is key to diagnosis ***

Transseptal Puncture with ICERALA

Focal Atrial Tachycardia (FAT)

Termination FAT during RF

Incidence of FAT by site:(independent d of LA RFA)Kistler et al. JACC 2006(48)5:1010-1017.Series of 126 consecutive patientsTang C, Scheinman M, et al.JACC 1995(26)5:1315-13251325.Series of 31 consecutive patients

IIIBase of RAA:IIIaVRaVLFATSinusaVFV1V2V3V4V5V6AT/48M

Focal atrial tachycardia originating from the epicardialleft atrial appendageYamada et al. Heart Rhythm 2008;5:766 –767.

SVT after AFib RFA:

Macro-reentrant SVT post-Afib RFA:(Atypical atrial flutter)• Large circuit (>2-3 cm)• Bound by anatomic orfunctional barriers toconduction• Frequently multi-looped• Atrial conduction timeaccounts for most of thecycle length AT (90%)• Target is critical isthmusof conductionChae et al. JACC 2007. (50)18:1781-1787.

Focal Atrial Tachycardia post-Afib RFA:(FAT)• Isoelectric segment between p-waves• 1:1 atrial conduction?• Adenosine sensitivity?• Centrifugal activation awayfrom small area• Atrial conduction time does notaccount for entire cycle lengthAT• Target earliest activation• Focal application terminatestachycardia abruptly at SOO

Left Atrial Focal TachycardiaPA projectionRSPVLSPVLIPVRIPVMitral AnnulusIIAblCS

Atrial Tachycardia After CircumferentialPulmonary Vein Ablation of Atrial FibrillationChae et al. JACC 2007. (50)18:1781‐1787.• Incidence:– 10‐30% PAF ablations– 25‐50% CAF ablationsMicro-re-entry(14%)FAT(12%)Macro-re-entry(75%)• 155 ATs mapped, 78 pts– 88% Re‐entry– 12% Focal

Mapping of Atrial Tachycardia AfterAblation of Atrial FibrillationChae et al. JACC 2007 (50)18:1281‐1287.Critical isthmus in 96% LA reentrant ATs traversed a priorablation line, consistent with a gap-related mechansim

SVT after CAF RFA:JB/63M

Treatments for AT post AF RFA:• AV nodal blocking agents may not help• Class IC anti-arrhythmics may make things worse• Patients t often feel worse than Afib• Early, repeated CV probable benefit (unpublisheddata)• Early repeat ablation?

Chugh et al. Heart Rhythm (2008). Pub Pending.JB/63M

Chugh et al. Heart Rhythm (2008). Pub Pending.JB/63M

CASE: DO• 56 y/o male with hx of OHT 20 yrs prior (bi-atrialanastamosis)• Multiple co-morbidities, including CRF• Presents with tachycardia & hypotension duringHD, stable BP otherwise• Following ECG obtained

CASE: DO12-lead ECG

CASE: DO1. Administer adenosine with 12-lead ECG2. Immediate 360J unsynchronized CV3. Bolus & start on IV lidocaine4. Submerge patient’s head in a bucket of ice-waterand tell them “it’s for your own good!”5. Do nothing, sign-out patient to your partner oncall& let him/her make the decisions for once

Case DO:12 mg IVP Adenosine

Two Heart Beat As One:RECIPIENT’S ATRIUMTRANSPLANTED ATRIUM

Two Hearts Joined As One:SuperiorVena CavaPurple: New HeartMulti-colors:Old HeartTricuspidValveInferiorVena CavaView of Right Atria

Biatrial Orthotopic Heart Transplant:Recipient’s Heart(Atrium)Donor Heart(Transplanted Atrium)Suture LineMorgan and Edwards. J CARD SURG. 2005;20:103

Catheter Ablation:

Summary• Identified most common SVTs & theirmechanisms as presented in unique clinical casevignettes– AV Nodal Re-entrant– AP-mediated– Atrial Tachycardia/ Atrial Flutters• Discussed various treatment t t options, focus onemerging diagnostic & ablative therapies• Identified “Novel” SVTs (LA AT/AFL) as a product• Identified Novel SVTs (LA AT/AFL) as a productof AFib ablation procedures & discussedtreatment options

ACC/AHA/ESC 2003 Practice Guidelines:Management SVT

Ei Eric D. Good, DOD.O.Assistant Professor,Interventional Cardiac ElectrophysiologyDepartment of Internal MedicineDivision of Cardiovascular MedicineUniversity of MichiganContact t information:•Office: 734-763-7392•Fax: 734-936-7026•Email: dogood@umich.edu