Permanent TachyPermanent Tachyccardiardiasas
JJ.. JanouJanouššekek
Klinik f. KinderkardiologieKlinik f. Kinderkardiologie
UniversitUniversitäät Leipzig, Herzzentrumt Leipzig, Herzzentrum
MMechanismsechanisms
Ectopic activityEctopic activity
»» FocalFocal (e(ectopicctopic) ) atrialatrial tachycardiatachycardia (FAT(FAT,, AEAET)T)
»» Junctional ectopic (His bundle) Junctional ectopic (His bundle) tachycardiatachycardia(JET) (JET)
ReentryReentry
»» Permanent junctional reciprocating Permanent junctional reciprocating tachycardia (PJRT)tachycardia (PJRT)
Rationale of therapeutic approachRationale of therapeutic approach
Natural historyNatural history
Severity of symptoms Severity of symptoms
Risk Risk of tachycardiaof tachycardia--induced induced cardiomyopathycardiomyopathy
versusversus
Benefits and rBenefits and riskiskss of drug therapy of drug therapy and catheter ablationand catheter ablation
Indications forIndications for RF RF catheter ablationcatheter ablationin childernin childern: : ClassClass II
Resuscitated cardiac arrest in WPW
Syncope in WPW
» Min. preexc. RR <250 msec during AFib
» AC ERP <250 msec
Incessant SVT with ventriculardysfunction
Friedman RA et al., PACE 2002NASPE Expert Consensus Conference
Recurrent symptomatic SVT refractory to drug therapy, age >4 yrs
Cardiac surgery prohibiting furtherapproach to arrhythmogenic substrate (TCPC)
Incessant SVT with normal ventricular function
Indications forIndications for RF RF catheter ablationcatheter ablationin childernin childern: : ClassClass II AII A
Friedman RA et al., PACE 2002NASPE Expert Consensus Conference
Focal Focal ((ectopicectopic) ) atrial tachycardiaatrial tachycardia
AET originating from septal focusAET originating from septal focus
Main featuresMain features
P wave of first beat identical to P wave of first beat identical to subsequent beatssubsequent beats
WarmingWarming--up and coolingup and cooling--down down phenomenonphenomenon
May have AV block during running May have AV block during running tachycardiatachycardia
No induction by pacingNo induction by pacing
AET / adenosineAET / adenosine
EAT – heart rate profileBefore ablation
After ablation
Tachycardia induced CMPTachycardia induced CMP
Prior to therapy 1 year after ablation
Natural history and therapeutic Natural history and therapeutic responseresponse
Tachycardia induced CMPTachycardia induced CMP
»» Higher risk with higher heart rates and Higher risk with higher heart rates and permanent tachycardiapermanent tachycardia
Spontaneous resolutionSpontaneous resolution11
»» <3 yrs.: 78 %, <3 yrs.: 78 %, ≥≥3 yrs: 16 % (p<0.001)3 yrs: 16 % (p<0.001)
Pharmacological controlPharmacological control11
»» <3 yrs.: 91 %, <3 yrs.: 91 %, ≥≥3 yrs: 37 % (p<0.001)3 yrs: 37 % (p<0.001)
Recurrence possible!Recurrence possible!1 1 SalernoSalerno JCJC et al., JACC 2004et al., JACC 2004
AETAET Sinus r.Sinus r.
AET from right upper pulm. veinAET from right upper pulm. vein
AET from right upper pulm. veinAET from right upper pulm. vein
RAO
LAO
JunctionalJunctional ectopic tachycardiaectopic tachycardia (JET)(JET)
1 s
ECGECG
1 s
Main featuresMain features
Congenital, adult and postoperative formCongenital, adult and postoperative form
Congenital formCongenital form»» FamilyFamily history (up to 55.6 %)history (up to 55.6 %)11
»» Progression into CAVBProgression into CAVB2,62,6
»» Spontaneous rate accelerationSpontaneous rate acceleration11
»» High incidence of heartHigh incidence of heart failure (up to 60 %)failure (up to 60 %)11
»» Therapy:Therapy:
–– PropafenonePropafenone33, Amiodarone, Amiodarone11, Amiodarone+IC, Amiodarone+IC44
–– Cave: digoxinCave: digoxin11, proarrhythmia, proarrhythmia44
–– AblationAblation55
Adult formAdult form»» Later in life, betterLater in life, better tolerated, lowertolerated, lower HRsHRs
1Villain E et al. Circulation 1990, 2Henneveld H et al. Heart 1998, 3Paul T et al. J Am Coll Cardiol 1992,4Sarubbi B et al. Heart 2002, 5Fishberger SB et al. PACE 1998, 6Dubin AM et al. HeartRhythm 2004
Permanent Permanent junctional reciprocatingjunctional reciprocatingtachycardia tachycardia (PJRT)(PJRT)
Main featuresMain features
Posteroseptal pathwayPosteroseptal pathway
Retrograde conduction Retrograde conduction onlyonly
Decremental propertiesDecremental properties
IncessantIncessant
Tachycardia induced Tachycardia induced CMPCMP
Adapted using MazgalevTN et al., Circulation 2001
LLong RP, short PRong RP, short PRI
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
1 s 1 s
Diagnostic clueDiagnostic clue
300 360 360
180 200 220
PJRT PJRT –– multicenter multicenter studystudy
N = 85N = 85
Age at diagnosis Age at diagnosis 00--20 20 yrs yrs ((median median 3 3 momo))
FollowFollow--up median up median 8.2 8.2 yrsyrs
CHF 28 %CHF 28 %»» resolved with medical Txresolved with medical Tx inin allall
Success of medical TxSuccess of medical Tx: 94 %: 94 %»» amioamiodaronedarone//verapamilverapamil + digoxin+ digoxin
Spontaneous resolution: 22 %Spontaneous resolution: 22 %
Death: 2 pts with persistent LV dysfunctionDeath: 2 pts with persistent LV dysfunction
Vaksmann G et al., Heart 2005
PJRT mapping and ablationPJRT mapping and ablation
354 ms 329 ms
Ventricular extrastimulus
RF energy application
Retrograde block
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