Dealing with Sudden Cardiac Death: Who Deserves Device Implantation

Sudden cardiac death is one of the leading causes of death in the western industrial nations. Most people are affected by coronary heart disease (coronary heart disease, CHD) or heart muscle (cardiomyopathy). These can lead to life-threatening cardiac arrhythmias. If the heartbeat is too slow due to impulse or conduction disturbances, cardiac pacemakers will be implanted. High-frequency and life-threatening arrhythmias of the ventricles (ventricular tachycardia, flutter or fibrillation) cannot be treated with a pacemaker. In such cases, an implantable cardioverter-defibrillator (ICD) is used, which additionally also provides all functions of a pacemaker. The implantation of a defibrillator is appropriate if a high risk of malignant arrhythmias has been established (primary prevention). If these life-threatening cardiac arrhythmias have occurred before and are not caused by a treatable (reversible) cause, ICD implantation will be used for secondary prevention. The device can stop these life-threatening cardiac arrhythmias by delivering a shock or rapid impulse delivery (antitachycardic pacing) to prevent sudden cardiac death. Another area of application for ICD therapy is advanced heart failure (heart failure), in which both main chambers and / or different wall sections of the left ventricle no longer work synchronously. This form of cardiac insufficiency can be treated by electrical stimulation (cardiac resynchronization therapy, CRT). Since the affected patients are also at increased risk for sudden cardiac death, combination devices are usually implanted, which combine heart failure treatment by resynchronization therapy and the prevention of sudden cardiac death by life-threatening arrhythmia of the heart chambers (CRT-D device). An ICD is implanted subcutaneously or under the pectoral muscle in the area of the left collarbone. Like pacemaker implantation, ICD implantation is a routine, low-complication procedure today

Predictors of Appropriate Shocks and Ventricular Arrhythmia in Indonesian with Brugada Syndrome

Background : Brugada syndrome is an inherited disease characterized by an increased risk of sudden cardiac death owing to ventricular arrhythmias in the absence of structural heart disease. It has been reported that this syndrome is more prevalent in South-East Asia than in Western countries. Furthermore, genetic studies showed important contributions of several gene mutations to the phenotype of BrS. These suggest that ethnic difference play significant roles in the pathogenesis of BrS. In addition, ICD implantation remains the cornerstone management with a low rate of appropriate shocked. Therefore, it is important to investigate patients’ characteristics for risk stratification. Our objective to investigate the clinical, electrocardiography (ECG) and electrophysiological characteristics that can be used as predictor of appropriate shock due to ventricular arrhythmia (VA) in Indonesian patients with BrS. Methods : We analyse data from Brugada syndrome registry at National Cardiovascular Centre Harapan Kita since January 2013. Total 22 patients were included. Characteristics of BrS that we analysed were baseline characteristics (age and sex), Clinical finding (syncope, cardiac arrest), ECG finding (spontaneous type 1 or drug induced) and Electrophysiology study result (inducible VA and RV ERP). We also added some new ECG characteristic (S wave in lead 1, S wave duration in V1, Fragmented QRS, Junction ST elevation and early repolarization pattern in infero-lateral) to  be analysed. Our end point are appropriate shock during ICD interrogation for those who have been implanted an ICD, and documented VA for those who didn’t receive ICD. Result : We found high incidence of  appropriate ICD’s shock in our population (50% in our study vs 5-11.5% in real world). Predictors of appropriate shock and documented VA are history of syncope (p = 0.045; OR 2.57 [1.44-4.59]), spontaneous type-1 ECG (p = 0.005) and right ventricular effective refractory period (RV ERP) of <200 ms (p=0.018). Other parameters that have been reported to correlate with the occurrence of VA (S Wave in lead 1 (p = 0.530), early repolarization pattern (p = 0.578), fragmented QRS (p = 0.601), S Wave duration (p = 0.365) and J Point STE (p = 0.800) were found to be not correlated to appropriate shock in our populations. Conclusion : History of syncope, spontaneous type-1 Brugada ECG and RV ERP of <200 ms have predictive values for risk stratification of Indonesian patients with Brugada syndrome.    Keywords : Brugada Syndrome, Ventricular arrhythmia, ICD shock      &nbsp

Mobitz Type II Second-Degree Atrioventricular Block in a Pilot : To Pace or Not to Pace?

Background: Atrioventricular (AV) block is a threatening condition that caused sudden loss of consciousness and death, notably if happened to aircraft pilot will compromise the reliability of flight operations and safety. Cardiac arrhythmia is well known as one of the main disqualifier for loss of flying license, and discriminating between benign and potentially significant rhythm abnormalities remains a challenge. The present case describes the electrophysiological feature of a high-grade AV block in an aircraft pilot. Case illustration: A 60-year-old male worked as commercial aircraft pilot presented with asymptomatic high-grade AV block during inflight Holter monitoring. He had never experienced any remarkable symptoms nor history of near syncope, but had a history of percutaneous coronary intervention (PCI) with one stent at left circumflex (LCx) coronary artery. Electrophysiology (EP) study revealed AH interval of 105 ms, HV interval of 50 ms, AV node effective refractory period of 280 ms and Weckenbach point of 330 ms, suggesting a normal EP study. Stimulation with atrial pacing and ATP showed prolongation of AH interval without changes in HV interval, showing the presence of a supra-Hisian AV node dysfunction. The highly demanding physiological environment in aircraft elucidate the likelihood of vagotonic cause of his condition and pacemaker implantation was not warranted. Conclusion: Atrioventricular (AV) block is an AV conduction disorder that can manifests in various symptoms and severity. Electrophysiology study is considered as a modality to locate the site of block that allows the avoidance of unnecessary permanent pacing and the appropriate prophylactic pacing

Tindakan Ablasi pada Fibrilasi Atrium Berasal dari Vena Kava Superior

Latar Belakang: Fibrilasi atrium (FA) merupakan aritmia yang paling sering ditemukan. Fibrilasi atrium membutuhkan adanya pemicu untuk inisiasi dan substrat untuk mempertahankan aritmia. Fokus tunggal atau multipel sebagai pemicu, paling sering di vena pulmonal tetapi dapat juga berasal dari selain vena pulmonal, seperti di vena kava superior. Patofisiologi aritmia di vena kava superior masih belum dapat dipahami. Ilustrasi Kasus: Seorang perempuan, 72 tahun, datang ke poliklinik Pusat Jantung Nasional Harapan Kita (PJNHK) dengan keluhan utama sering berdebar-debar. Pasien pertama kali mengeluh berdebar-debar pada tahun 2000, namun baru pada tahun 2007 pasien melakukan pemeriksaan dan terapi dengan obat-obatan serta dilakukan tindakan ablasi FA. Pada tahun 2010, pasien mengeluh berdebar-debar kembali dan dapat dikontrol dengan terapi medikamentosa. Pada tahun 2016, pasien menjalani tindakan ablasi kedua dengan hasil berhasil dilakukan isolasi vena pulmonal dan angiografi koroner memperlihatkan arteri koroner normal. Pasien sempat datang ke UGD PJNHK bulan Mei 2017 dengan keluhan berdebar dan hasil pemeriksaan EKG saat di UGD menunjukkan irama FA. Dilakukan tindakan ablasi ketiga dengan hasil berhasil dilakukan isolasi vena kava superior. Kesimpulan: Vena kava superior dapat berperan sebagai pemicu atau substrat fibrilasi atrium. Sebagai fokus, selain vena pulmonal, yang paling sering menjadi sumber fibrilasi atrium, vena kava superior menjadi target penting saat tindakan ablasi fibrilasi atrium

2021 Asia Pacific Heart Rhythm Society (APHRS) practice guidance on atrial fibrillation screening

In this paper, the Asia Pacific Heart Rhythm Society (APHRS) sought to provide practice guidance on AF screening based on recent evidence, with specific considerations relevant to the Asia-Pacific region. A key recommendation is opportunistic screening for people aged >= 65 years (all countries), with systematic screening to be considered for people aged >= 75 years or who have additional risk factors (all countries)

Exploring Clinical and Echocardiographic Factors in EHRA Type 2 Atrial Fibrillation for Predicting Ischaemic Stroke: A Search for Unrevealed Insights

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults. Valvular heart diseases (VHD), regardless of the arrhythmic problems, increase the risk of thromboembolism, which are even higher in those with associated atrial fibrillation. The EHRA (Evaluated Heartvalves, Rheumatic or Artificial) classification categorised AF patients with significant VHD into type 1 and type 2. Unfortunately, there are currently very limited data on risk prediction in stroke-related valvular AF, particularly in the Asian population. Aims: To investigate the clinical and echocardiographic risk factors for ischaemic stroke prediction in patients with EHRA type 2 VHD. Methods: This retrospective study enrolled 695 AF patients with EHRA type 2 VHD. The data were collected from patients' medical records who met the inclusion and exclusion criteria from 2015 until 2020. The primary outcome was ischaemic strokes within observation period. Results: There were 67 ischaemic stroke events (9,6%) of the total sample. Our analysis found that none of the analysed variables proved to be statistically significant risk factors in predicting the occurrence of ischaemic stroke. The median CHA2DS2-VASc risk prediction in the sample was 3, with an accuracy of AUC 0.502 (CI 95%; 0.429 – 0.576), sensitivity 56.7% and specificity  44.7%. Conclusion: Based on the parameters analysed in this study, no factor was statistically well-predictive to predict the ischaemic stroke incidence in EHRA type 2 VHD AF. In addition, the CHA2DS2-VAS accuracy was low in this population. Further exploration is needed to build an accurate ischaemic stroke risk prediction for EHRA type 2 VHD