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transcript
ICD terapija kod dece i adolescenata
Goran Milašinović
PMC, KCS
Disclosure
Receive mild to moderate compensation for lectures andclinical studies from Medtronic, St Jude Medical, Biotronik and BioControl Co.
Receive no grant from any company.
ICD terapija: prevencija iznenadne srčane smrti
Arrhythmia PVCs; VT-NSVT-S; VF
Heart Disease Absent PresentPresent Present
LV Dysfunction Absent AbsentAbsent PresentPresent Present
Potential Risks for SCD
Minimal IntermediateIntermediate High
PVCsPVCs
VT-NSVT-NS
Risk-Stratification for Sudden Cardiac Death
PVC=premature ventricular complexes; VT-NS=nonsignificant ventricular tachycardia;VT-S=significant ventricular tachycardia; VF=ventricular fibrillation.
Prystowsky EN. Am J Cardiol. 1988;61:102A-107A.
CAST: Survival
CAST Investigators. N Engl J Med. 1989;321:406-412.
P=0.0003
Sur
viva
l (%
)
100
95
90
85
0 400 450 50050 100 150 200 250 300 350
Days After Randomization
Placebo (N=725)
Encainide or flecainide (N=730)
Julian DG, et al. Lancet. 1997;349:667-674.
EMIAT: All-Cause Mortality LVEF and by Group
Months Since Randomization Months Since Randomization
Pro
bab
ility
of
Su
rviv
al
Pro
bab
ility
of
Su
rviv
al
Amiodarone
PlaceboEjection fraction < 30%
Ejection fraction 31%-40%
CAMIAT: All-Cause Mortalityand Nonarrhythmic Death
Cairns JA, et al. Lancet. 1997;349:675-682.
Months Since Randomization
Cu
mu
lati
ve
Ris
k (
%)
Months Since Randomization
Cu
mu
lati
ve
Ris
k (
%)
P=0.072
P=0.130
Amiodarone
Placebo
Primary Prevention Post-MI Trials
1. Buxton AE, et al. N Engl J Med. 1999;341:1882-1890.2. Moss AJ, et al. N Engl J Med. 1996;335:1933-1940.3. Moss AJ, et al. N Engl J Med. 2002;346:877-882.
0
10
20
30
40
50
60
70
80
MUSTT1
27 MonthsMADIT2
27 MonthsMADIT-II3
20 Months
Mo
rtal
ity
Red
uct
ion
w/IC
D R
x (%
)
55 54
31
MUSTT Randomized Patients:Total Mortality
Eve
nt-
Fre
e R
ate
P<0.001
EP ICD
Control
Months After Enrollment
EP no ICD
Buxton AE, et al. N Engl J Med. 1999;341:1882-1890.
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60
MADIT: Survival by Treatment Groups
Moss AJ, et al. N Engl J Med. 1996;335:1933-1940.
Months After Enrollment
Pro
bab
ility
of
Su
rviv
al
ICD
Conventional Therapy
P=0.009
0.0
0.2
0.4
0.6
0.8
1.0
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60
MADIT-II: Survival byTreatment Group
Moss AJ, et al. N Engl J Med. 2002;346:877-882.
0.78
0.69
P=0.007
0 1 2 3 4
Defibrillator Group
Conventional Group
Pro
bab
ilit
y o
f S
urv
ival
Years
0.5
0.6
0.7
0.8
0.9
1.0
Secondary Prevention Trials:AVID, CASH, CIDS
1. AVID Investigators. N Engl J Med. 1997;337:1576-1583.2. Kuck KH, et al. Circulation. 2000;102:748-754.3. Connolly SJ, et al. Circulation. 2000;101:1297-1302.
0
10
20
30
40
50
60
70
80
AVID1
3 YearsCASH2
3 YearsCIDS3
3 Years
Mo
rtal
ity
Red
uct
ion
w/IC
D R
x (%
)
31
2820
AVID: Overall Survival
0 1 2 3Years After Randomization
Defibrillator Group
Antiarrhythmic Drug Group
Pro
po
rtio
n S
urv
ivin
g
P<0.02
AVID Investigators. N Engl J Med. 1997;337:1576-1583.
0.0
0.2
0.4
0.6
0.8
1.0
CIDS Update: 11-Year Follow-Up
ICDAmiodarone
100
80
60
40
20
020 40 60 80 100 120 140
P=0.021
Months
Act
uar
ial S
urv
ival
(%
)
Bokhari FA, et al. Circulation. 2002;106(19 suppl II):II-497.
Primarna prevencija iznenadne srčane smrti kod dece
• Hipertrofična ili Dilatativna CMP
Faktori rizika: 1. Istorija sinkopa u porodici 2. Značajna hipertrofija LK 3. NSVT na holteru 4. Pad TA prilikom testa opterećenjem
2 od 4 ICD
From SURGERY for CONGENITAL HEART DEFECTS, 3rd Ed., Editors J STARK, M. de LEVAL and VT TSANG
Primarna prevencija iznenadne srčane smrti kod dece
• Long QT sy. (LQTS), koji ne reaguje na beta-blokatore ili ne mogu da se uzimaju.
From SURGERY for CONGENITAL HEART DEFECTS, 3rd Ed., Editors J STARK, M. de LEVAL and VT TSANG
Primarna prevencija iznenadne srčane smrti kod dece
• Long QT sy. (LQTS) = Polimorfna VT
From SURGERY for CONGENITAL HEART DEFECTS, 3rd Ed., Editors J STARK, M. de LEVAL and VT TSANG
Primarna prevencija iznenadne srčane smrti kod dece
• CPVT (kateholamin-senzitivna (ili zavisna) polimorfna VT).
From SURGERY for CONGENITAL HEART DEFECTS, 3rd Ed., Editors J STARK, M. de LEVAL and VT TSANG
Primarna prevencija iznenadne srčane smrti kod dece
• Brugada sy.
From SURGERY for CONGENITAL HEART DEFECTS, 3rd Ed., Editors J STARK, M. de LEVAL and VT TSANG
Genetska bolest koju karakteriše abnormalan EKG i povišen rizik za iznenadnu srčanu smrt. Celularna električka aktivnost izmenjena zbog izlaska natrijuma iz ćelija.
ISS kod adolescenata i mladih sportista
• CardiomyopathiesDilatedHypertrophicRight ventricular dysplasia
• Electrical abnormalities• Long-QT syndromes• Brugada syndrome• W-P-W syndrome
Viral myocarditisAbnormal coronary arteriesDrug-induced arrhythmiasInflammatory/infiltrative diseasesIdioventricular fibrillationDiseases of heart valves
From Ventricular Arrhythmias and Sudden Cardiac Death. Edited by Paul J. Wang, Chapter 17, Epidemiology and etiologies of sudden cardiac death, Keane K. Lee et al, 2008
0–1 d 94–155
1–3 d 92–158
3–7 d 90–166
7–30 d 107–182
1–3 mo 120–179
3–6 mo 106–186
6–12 mo 108–168
1–3 yr 90–152
3–5 yr 73–137
5–8 yr 64–133
8–12 yr 63–130
12–16 yr 61–120From Davignon A, Rautaharju P, Boisselle E, et al: Normal ECG standards for infants and children. Pediatr Cardiol 1:123-152, 1979.
Normalna srčana frekvenca kod dece
An ICD should be implanted in pediatric survivors of a cardiac arrest when a thorough search for a correctable cause is negativeand the patients are receiving optimal medical therapy and have reasonable expectation of survival with a good functional status formore than 1 year.
Hemodynamic and EP evaluation should be performed in the youngpatient with symptomatic, sustained VT.
ICD therapy in conjunction with pharmacological therapy is indicated for high-risk pediatric patients with a genetic basis (ion channel defects or cardiomyopathy) for either SCD or sustainedventricular arrhythmias. The decision to implant an ICD in a childmust consider the risk of SCD associated with the disease, the potential equivalent benefit of medical therapy, as well as risk of device malfunction, infection, or lead failure and that there is reasonable expectation of survival with a good functional status for more than 1 year.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
VA & SCD in Pediatric Patients
ICD therapy is reasonable for pediatric patients with
spontaneous sustained ventricular arrhythmias associated
with impaired (LVEF of 35% or less) ventricular function who
are receiving chronic optimal medical therapy and who have
reasonable expectation of survival with a good functional
status for more than 1 year.
Ablation can be useful in pediatric patients with symptomatic
outflow tract or septal VT that is drug resistant, when the
patient is drug intolerant or wishes not to take drugs.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
VA & SCD in Pediatric Patients
Pharmacological treatment of isolated PVCs in pediatric
patients is not recommended.
Digoxin or verapamil should not be used for treatment of
sustained tachycardia in infants when VT has not been
excluded as a potential diagnosis.
Ablation is not indicated in young patients with
asymptomatic NSVT and normal ventricular function.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
VA & SCD in Pediatric Patients
Epikardno ili transvenskiIndikacije za permanentu epikardnu
stimulaciju u dece.
• < 8 kg• Desno-levi šant• Problem sa venama• Više tipova hirurških rešavanja srčanih mana
podrazumevaju prethodnu implantaciju pejsmejkera• Opstrukcija VCS • Težak pristup DK• Mehanička trikuspidna valvula• Neuspeli transvenski pristup
From SURGERY for CONGENITAL HEART DEFECTS, 3rd Ed., Editors J STARK, M. de LEVAL and VT TSANG
Epikardno vs. Endokardno
EpicardialAdvantages• Avoiding concerns of
Venous Thrombus
Disadvantages• Having to enter the chest
cavity• Poor pacing and sensing
thresholds
TransvenousAdvantages• Avoid Thoracotomy• Lower Pacing Thresholds• Lower incidence of Exit
Block
Disadvantages• Higher Dislodgement Rates• Potential for Venous
Occlusion• Risk for Embolic Vascular
Event• Risk of Subclavian Crush• Endocarditis• Potential for Tricuspid Valve
damage
From presentation on Pediatric Pacing by Christine Youngs.
Comparison of epicardial with endocardial electrode use in children. Note the gradually increasing use of endocardial electrodes.
(Data from the Midwest Pediatric Pacemaker Registry.)
• White ring on 4968 identifies cathode leg
• Suture-down holes
4968
4965
Surgical Approacha. Subxiphoidb. Left Lateral Thoracotomy*c. Median Sternotomyd. Other approaches include:• Subcostal• Right Thoracotomy
38303830 4.1 french lumen-less 4.1 french lumen-less
catheter-delivered leadcatheter-delivered lead
C315 delivery catheters for 3830 leadsInner diameter 5.5 FrOuter diameter 7.0 Fr“Pacemaker leads with smaller
body design may help in preservationof venous patency in children.”Implantation of SelectSecure Leads in Children, PACE 7/07VOLKAN TUZCU, M.D.
• Extra lead slack is usually left in the pediatric patient’s atrium to allow for growth
• Adhesions can still form preventing lead slack from helping
• Following slides show slack being taken up as patient grows
Graphic From SURGERY for CONGENITAL HEART DEFECTS, 3rd Ed., Editors J STARK, M. de LEVAL and VT TSANG
From Cardiac Pacing, Defibrillation, and Resychronization: A Clinical Approach,2008, 2nd Ed., pg. 187, Daniel L. Hayes and Paul A. Friedman
From Extracardiac ICD implantation in an infant, T. Kriebel et al., Zeitschrift für Kardiologie, Band 94, Heft 6 (2005)
Chest radiograph showing placement of a single-coil transvenous defibrillator system with the lead tunneled down the lateral chest wall to the device, which also serves as the second defibrillation electrode and is placed in a left upper quadrant abdominal pocket.
Use of Use of Transvenous Transvenous Lead Lead tunneled to tunneled to abdominally abdominally placed ICDplaced ICD
Programiranje ICD u dece
• ICD VR, zbog veličine
• Jedna zona detekcije, jer su najčešće indikacije kod dece VF, a ne VT (re-entry) “Pain-free” studija nije studirana kod dece.
• Max. SVT diskriminator
• Jedan elektrodni vodič da se izbegne venska opstrukcija
Case Report: 2001
• 14 god, ženski pol
• Abdominalni ICD sa 10 god.
• Indikacija: VT 170, operisana ToF sa 2 god.
• Intravenska lektroda + subkutani “pač” u aksili
Age 10
ICD
Subcut. patch
On the age 14
Age 14
Subcutaneous lead
Pg
Jap. Circulation, 2005
Zaključak
• Najčešća indikacija primarna prevencija
• Sekundarna prevencija kod operisanih USM
• ICD na tržišitu primenjivi za decu
• Često korišćenje epikardnih i supkutanih elektroda
• Programiranje drukčije nego kod odraslih