Mariell Jessup MD Professor of Medicine University of Pennsylvania Philadelphia, Pennsylvania

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