Η δοκιμασία κόπωσης στην καθημερινή πρακτική Ενδιαφέροντα περιστατικά προς συζήτηση

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1 ΣΕΜΙΝΑΡΙΑ ΟΜΑ ΩΝ ΕΡΓΑΣΙΑΣ ΚΑΡ ΙΟΛΟΓΙΑΣ 2011 Η δοκιμασία κόπωσης στην καθημερινή πρακτική Ενδιαφέροντα περιστατικά προς συζήτηση Εμ. Μπαντόλας Νοσοκομείο «Άγιος Παύλος» Θεσσαλονίκη

2 ΓΕΝΙΚΑ ΣΤΟΙΧΕΙΑ Έφηβη, 14 ετών Παραπομπή για εμφάνιση συχνών κοιλιακών έκτακτων συστολών σε ΗΚΓ επιφανείας κατά τον έλεγχο για έκδοση πιστοποιητικού για το σχολείο Ασυμπτωματική Φυσιολογική ανάπτυξη Μέτρια σωματική δραστηριότητα ΕΡ Φυσιολογικός έλεγχος θυρεοειδικών ορμονών Ελεύθερο ατομικό αναμνηστικό Ελεύθερο οικογενειακό ιστορικό

3 ΗΚΓ

15 οκιμασία κόπωσης ΛΟΓΟΣ ΙΑΚΟΠΗΣ ΕΞΕΤΑΣΗΣ: φυσική εξάντληση ΙΑΡΚΕΙΑ: 12 min10 s ΜΕΤS: 13,4 ΜΕΓ ΣΥΧΝΟΤΗΤΑ: 196 ( 95 %ΠΡΟΒΛΕΠΟΜΕΝΗΣ) ANΟΧΗ ΣΕ ΚΟΠΩΣΗ: άριστη ΙΝΟΤΡΟΠΗ ΑΠΑΝΤΗΣΗ: κφ ΧΡΟΝΟΤΡΟΠΗ ΑΠΑΝΤΗΣΗ: κφ ΑΡΡΥΘΜΙΟΓΕΝΕΣΗ: συχνές μονόμορφες κοιλιακές έκτακτες συστολές, που υφέθηκαν στο 7 ο min της άσκησης και επανεμφανίσθηκαν στο 2 ο min της ανάνηψης. εν εισήχθη VT

16 MRI

17 MRI

19 Premature ventricular contractions Premature ventricular contractions have been described in 1% of clinically normal people as detected by a standard ECG and 40 75% of apparently healthy persons as detected by hour ambulatory (Holter) ECG recordings. Kennedy et al demonstrated that frequent (>60/h or 1/min) and complex PVCs could occur in apparently healthy subjects (with an estimated prevalence of 1 4% of the general population) and that could be associated with a benign prognosis. Both the incidence and complexity of PVCs is increased in almost all heart disease, and could be 90% in coronary artery disease and dilated cardiomyopathy. In the presence of heart disease, frequent and repetitive extrasystoles are an independent predictive factor of total mortality and sudden death N Engl J Med 1985;312:193 7.

20 Ventricular ectopy with LBBB morphology Very frequent monomorphic ventricular complexes and even bursts of ventricular tachycardia in subjects without evidence of heart disease are generally considered benign. In 1922, Gallavardin first described this kind of arrhythmia. In 1969, Rosenbaum defined ventricular ectopy with left bundle branch block (LBBB) morphology and the main QRS forces directed inferiorly as typical for normal subjects. The site of origin is most often the right ventricular outflow tract and, to a lesser extent, the interventricular septum In the majority of these patients, echocardiography does not identify structural cardiac abnormalities Using cardiac MRI a high prevalence of fatty replacement and other anatomic and functional abnormalities has been demonstrated in patients with apparently idiopathic right outflow tract tachyarrhythmias Am J Cardiol 1984;54:31 6. Arch Mal Coeur 1922;15: J Electrocardiol 1969;2: Cardiac Electrophysiology and Arrhythmias. Orlando, FL: Grune & Stratton, 1985: J Am Coll Cardiol 1994;24:720 7.

21 AVRD vs IDIOPATHIC RVOT VT ARVC ( dysplasia ) is suspected in patients, typically a young man, with RV arrhythmias or in relatives of individuals with known ARVC. Syncope, presyncope, and, less frequently, biventricular failure are also observed. The ventricular arrhythmias have LBBB morphology that spans the spectrum of simple ventricular ectopy, sustained and NSVT, or VF. ARVC needs to be considered along with idiopathic RV outflow VT in the individual with ventricular ectopy and VT coming from the RV outflow region. In contrast to ARVC, idiopathic RV outflow VT is usually not associated with the ECG abnormalities seen with ARVC, is more common in women, and is initiated by isoproterenol infusion instead of by EP testing. The ECG in ARVC frequently shows precordial T-wave inversion, usually over V1 to V3, and QRS duration greater than 110 ms. Low voltage potentials following the QRS (epsilon waves) are characteristic but seen relatively infrequently, and late potentials are observed on the SAECG in greater than 50% of individuals.

22 ιαφορές μεταξύ V.T. από RVOT και ARVD Πρόγνωση SAECG ΗΚΓ ηρεμίας RVOT ARVD καλή πτωχή αρνητικό % παθολογικό ηρεμίας κ.φ. παθολογικό MRI κ.φ % παθολογικό Ablation άριστα ποικίλα ADO (απάντηση) θετική αρνητική Εξέλιξη σε μυοκαρ. Εισαγωγή σε ΗΦΜ Ηλ. Μηχανισμός Σπάνια συνήθης burst PES με iso-epi epi-phenyl phenyl extra stimulus Trig. Activity reentry

23 AVRD: echo - MRI Echo findings: inflow and outflow tract dilatation of the RV in genotyped ARVC patients (normal up to 39 and 32 mm, respectively). RVOT >32 mm specificity97% sensitivity 56% RVIM >39 mm specificity 97%, sensitivity 42% RV segmental wall abnormalities present a sensitivity and specificity >95%. Excessive trabeculation and hyper-reflectivity of the moderated band may also contribute to the diagnosis. LV involvement, in the absence of aneurysms, may not be seen at echo and misdiagnosed MRI: investigates abnormal morphology and function as well as tissue characterization through abnormal signal intensity and late-enhancement information on RV enlargement, regional motion abnormalities/aneurysms and presence of fat and fibrosis. Investigating the LV for fat infiltration and fibrosis, considering that LV involvement is present in at least 2/3 of cases. The discovery of gene mutations allows genetic screening in first degree relatives

24 The major finding of the study is that ARVD and RVOT tachycardia are different electrophysiological syndromes

25 AVRD risk factors for SCD risk factors for SD in ARVC/D history of syncope-cardiac arrest, family history of SD-ARVC/D, extensive RV dysfunction- LV involvement, polymorphic VT, refractory anti-arrhythmic drug therapy, epsilon wave, late potentials, QRS dispersion).

When faced with right ventricular premature contractions in an otherwise normal ECG, we have to decide whether it represents a benign pattern or a possible early form of ARVD a normal 12-lead ECG,

26 When faced with right ventricular premature contractions in an otherwise normal ECG, we have to decide whether it represents a benign pattern or a possible early form of ARVD a normal 12-lead ECG, the monomorphic pattern of ectopy and the heart rate dependence at 24-h Holter monitoring, the suppression with increasing heart rate at stress test and the normal echocardiographic pattern are sufficient to pose the diagnosis of benign right ventricle arrhythmias.

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