Rehabilitation foRehabilitation fo arrhythmia Dearrhythmia, … · 2012-11-23 · Rehabilitation foRehabilitation fo arrhythmia Dearrhythmia, De valvular hevalvular he Asst. Prof.

Rehabilitation foRehabilitation foRehabilitation foarrhythmia De

Rehabilitation foarrhythmia Dearrhythmia, De

valvular hearrhythmia, De

valvular hevalvular hevalvular heAsst. Prof. Visal Kanta

Director RehabAsst. Prof. Visal Kanta

Director RehabDirector, RehabSamitivej S

k @

Director, RehabSamitivej S

k @ravkn@yaravkn@ya

or patients withor patients withor patients withefibrillator andor patients withefibrillator andefibrillator and art diseaseefibrillator and art diseaseart disease art disease aratanakul, MD., FIMSbilitation Centeraratanakul, MD., FIMSbilitation Centerbilitation CenterSrinakarinh

bilitation CenterSrinakarinhahoo.comahoo.com

CircuCircu

PumpingPumpingp gp g

ulatoryulatory

ElectricityElectricityElectricityElectricity

rhythmiasrhythmias

Exercise induced a

Arrhythmia that coyexercise

arrhythmiay

ntradicted for

e-threatening arrhythe-threatening arrhythLethal

Long QTg

Burgadag

VF, VT,

Non Lethal

exercise induced

Too fast or too s

hmiahmia

d arrhythmiay

slow

nciples of Arrhythmia Renciples of Arrhythmia Re

Treat or look at the pa

Evaluation the patients

ventilation

Oxygenation

HR, BP

Signs of inadequate

ecognition and Mxecognition and Mx

atient.... not monitor

s

e organ perfusion

art with simple oart with simple o

Is there any P ?

Is there any too long

Is there any bizarre Q

Is there other part tha

Is there any abnorma

Is there any abnorma

Is there any change d

onesones

for PR ?

QRS ?

at too long ?

al on ST ?

al T ?

during exercise ?

ercise considerationsercise considerationshythmic patient y p

Need EST and moNeed EST and mo

No contraindicationNo contraindication

No exercise-induceNo exercise induce

Fixed percentage oFixed percentage oCeiling < 10-20 be

RPE might not wor

s fors for

onitoringonitoring

nn

ed arrhythmiased arrhythmias

of MHR withof MHR with eats of arrhythmia

rk well

o contraindicatioo contraindicatio

Uncontrolled HR >

HIgh ST depression

High grade PVC

2nd or 3rd degree b

VT

onsons

120 BPM

n

block

li t PVCalignant PVCs

• Frequent PVCsq

• Multiform PVCs

• Runs of consecutiv

• R on T phenomenop

• PVC during AMIg

ve PVCs

on

acemakersacemakers

Single or dual chamber

Pacemakers now store lotsreviewed at follow up eg %reviewed at follow-up eg %

Now extremely programmaNow extremely programmaalgorithms

Rate responsiveness (HR i

AF suppression (pacing the

Rate drop acceleration resp

s of information that can be% time spent in AF% time spent in AF

able with many features &able with many features &

n response to activity)

e atria)

ponse

ventricular paceventricular pacelso known as Cardiac Resynchronization

herapy (CRT)herapy (CRT)

May be patients for whom chronic RV pacy p pbecoming problematic

leads usually (atria, RV and LV)

acing both ventricles in a timed manneracing both ventricles in a timed manner lowing resynchronisation

Optimises cardiac output by allowing ppropriate ventricular filling and co-ordinontraction

emakersemakersn

cing g

nated

plantable Cardiac Deplantable Cardiac DeAbilit to DC shock for VF VTAbility to DC shock for VF, VT

700-800 Volts or 30-40 Joules700-800 Volts or 30-40 Joules

Most now can also deliver ATP (anti-tach(pacing) to attempt to reduce need for shoherapy

Extremely complex devices that have maprogrammable featuresprogrammable features

Set-up and management is often quite triSet up and management is often quite trieg in the presence of AF

Most devices are also able to pace althoumost patients do not have a primary paci

efibrillators (ICDs)efibrillators (ICDs)

hy yock

any

ckycky

ugh ng

ication for device impication for device imp

PacemakersSSS AVB CHB CI CSSS, AVB, CHB, CI, Cbradycardia, Symptomy , y pTrifasicular block, Neu(CSS VVS situationa(CSS, VVS, situationa

Biventricular pacemaBiventricular pacemaCHF with LBBB & lowCHF with LBBB & lowon echo, long PR withNYHA class IV

plantplant

Ch i AF i hChronic AF with matic Bifasicular block / urally mediated syncope al syncope)al syncope)

kers (CRT P)kers (CRT-P)w EF(<35%) dysynchronyw EF(<35%), dysynchrony h poor haemodynamics,

ication for device impcat o o de ce pImplantable Cardiac DImplantable Cardiac D

Primary indication; sigy ; garrhythmia eg Long QTwith NSVT & poor EFwith NSVT & poor EF

Secondary indication;Secondary indication;

Biventricular ICD (CRBiventricular ICD (CR

CHF with LBBB & lCHF with LBBB & ldysynchrony on echaemodynamics, N

plantp a tDefibrillators(ICDs)Defibrillators(ICDs)nificant risk of life threateniT, Brugada, DCM, Post MI

survival of a VT or VF arresurvival of a VT or VF arre

T-D)T D)

ow EF(<35%)ow EF(<35%), ho, long PR with poor

NYHA class III or IV, prio

Psychological ChaPsychological ChaExercise in Patiente c se at e t

racters and racters andts with AICDts t C

Please close youPlease close you

What do you think if youWhat do you think if you it/accident badly ????/ y

Then next several mfire and you

ur eye and thinkur eye and think

sit in a car thatsit in a car that 

minutes that car gou struck inside

ychological compychological compPatientPatient

– DepressionDepression– AnxietyRelatives

– AnxietyFear– Fear

ponentsponents

actshere are both sides of st

actshere are both sides of stfference/ no difference/etween patient with/witore spouse anxiety if thain problems with type

tudies: there aretudies: there are e in psychologcal variablp y gthout AICDhere is/are shock storm(e D personality(distresse

people experience?

ACUTE PHASE  (Hosp

Initial Euphoria – I’ve sInitial Euphoria  I ve s

Increased anxiety andIncreased anxiety and 

Mi tiMisconceptions

pital)

survivedsurvived

depressiondepression

“You will be alricaref

Interp

?

“If I am not careIf I am not care

ight if you are g yful”

reted

eful I will die”eful I will die

“You were lucYou were luc

InterpInterp

“I won’t betim

cky this time”cky this time

pretedpreted

??

e lucky next me”

“It i l“It is only a

I tInterpr

??

“Something terri

i ”a warning”

t dreted

ble is yet to come”

OOR DISCHARGEOOR DISCHARGE

DepressedDepressed

AnxiousAnxious

Misattribution of somatic s

Physical Deconditioned – fe

Over/under involvement sp

Sexual difficulties

Time off work / lifestyle cha

symptomsy p

ear avoidance

pouse/partners

anges

46% reduction non‐fatal cardiac events

41% reduction in mortality

years follow up (Ref: Linden et al 199 years follow up  (Ref: Linden et al 199

xercise based interventions may have

ositive effect of patients – physical abi

mprove some physiological measures o

but do not impact onbut do not impact on

ood lipids

orbidity

ll t litverall mortality

sufficient evidence re psychological ap y g

s

96)96)

ility to exercise

of cardiac disease

nd social outcomes

xercise in Patientxercise in Patient 

Important thing is to clah l i l blpsychological problems

as you couldas you could

with AICDwith AICD

arify state of d fi h hs and fix them as much 

ercise considerationsercise considerationsCD patient Fixed VS. adjustable ratej

Monitor systolic pressures

Extended warm-up and co

ICD: ECG monitoring/pulse

Rate modulated pacemakeMHRR method of Karvonen

Fixed percentage of MHRFixed percentage of MHR

RPE

s for pacemakers for pacemaker

ool down

e to titrate intensity

ers intensity:

Cardiac Rehabbilitation in VHD

it ti f E /mitation of Ex/a

overprotected by thp y

overprotected by thp y

Physical conditionsy

ti itctivity

heir parentsp

heir environment

s

ormalized of exeormalized of exepacitypacity

Age of surgeryg g y

Pulmonary hypertey yp

Method of correctio

erciseercise

ension

on

Left-to-right shuntsAtrial septal defectVentricular septal defec

V l l h t l i dValvular heart lesions and Aortic stenosisAortic stenosisPulmonary valve diseasPulmonary valve diseasCoarctation of the aorta

Cyanotic congenital heart dTetralogy of FallotTransposition of the gre

ctb t ti liobstructive anomalies

seseadisease

eat arteries

i l t l d frial septal defecright volume overload

increased pulmonary b

resulting in pulmonary

normal or only slightly i

exercise capacity

the age at surgery has influenceinfluence

th i it

t (ASD)ct (ASD)

blood flow

hypertension

impaired aerobic

been shown to

entricular septalentricular septalleft ventricular volume ovl ft t i l dil t tileft ventricular dilatationhigher pulmonary to systehigher pulmonary to systeThe relative shunt fractioThe relative shunt fractioto decrease with the increexerciseexerciseExercise performance haExercise performance habe slightly decreased whage-matched controls

defect defectverload resulting in

emic flow ratioemic flow ration has been shownn has been shown easing intensity of

ave been shown toave been shown to en compared with

onditions the decronditions the decrpacitySpacityAS

Pulmonary valve diseaPulmonary valve disea

Tetralogy of Fallotgy

Transposition of the gre

rease Ex.rease Ex.

asease

eat arteries

Any QuestionAny Questionnsns