Cardiac Electrostimulation in the Light of New Guidelines

Elektrostimulacija je vrlo djelotvoran način liječenja bradiaritmija, a posljednjih desetak godina i za život opasnih tahiaritmija. U početku se elektrostimulacija rabila samo za zaštitu bolesnikova života. Napredovanjem tehnologije indikacije su proširene na poboljšanje kvalitete života. I kod kardioverter-defibrilatora indikacije se sa sekundarne šire na primarnu prevenciju nagle smrti. Elektrostimulatori i kardioverter-defibrilatori danas su vrlo sofisticirani uređaji s mnoštvom programabilnih parametara kojima se mogu dobro prilagoditi potrebama bolesnika. Istodobno to je i vrlo skup način liječenja, ali bez jednako djelotvorne alternative. Ovisno o tipu, cijena jednog kardioverter-defibrilatora kreće se od 15 000 do 30 000 eura. Radi racionalne primjene potrebno je dobro poznavati mogućnosti, indikacije i moguće nuspojave terapije. U radu su prikazani tehnički podaci i osnove terapije elektrostimulacijom, načini elektrostimulacije, indikacije i češći praktični problemi. Indikacije su sigurne ako postoji opći konsenzus baziran na dokazima da je elektrostimulacija efikasna, a vjerojatne ako mišljenje o indikaciji još nije potpuno usuglašeno. U postupnicima se navode još neke moguće indikacije za koje korist i učinkovitost za sada nisu dovoljno dokumentirane, pa u tablicama u ovom radu nisu ni navedene. Navedene indikacije ipak su samo smjernice, a konačna odluka temelji se na individualnom bolesnikovu stanju.Electrostimulation is a very efficient way of bradyarrhythmia and malignant tachyarrhythmia therapy. At the beginning, pacing was indicated only for the patient’s life protection. Along with the development of technology, indications have been expanded to the improvement of life quality. Indications for cardioverter-defibrillator implantation are also expanded from secondary to primary prevention of sudden death. Today, pacemakers and cardioverter-defibrillators are very sophisticated devices with a large number of programmable parameters, by which they can be well adjusted to the patient’s needs. At the same time, it presents a very expensive way of therapy, but without the equivalent alternative. Depending on type, the price of a cardioverter-defibrillator is 15000-30000 Euros. Thus, the rational application and good knowledge of characteristics, indications and possible adverse reactions of therapy are indispensable. In the article are described technical data, principles and modes of therapy, indications and frequent practical problems. Indications are certain if there is a general agreement based on the evidence that therapy is efficient, but probable if there is divergence of opinions about the indication. Some other possible indications are stated in various guidelines. But, because their usefulness or efficacy at this moment is not sufficiently documented, they are not stated in tables here. The described indications are still only recommendations, and definite decision is based on the individual patient’s condition

The first case of epicardial ablation of ventricular tachycardia in a patient with non-ischemic cardiomyopathy in our country

Od 2012. u nas se uspješno provode procedure endokardijalne ablacije u bolesnika sa strukturnom bolesti srca i ventrikularnim aritmijama. Riječ je o kompleksnim elektrofiziološkim procedurama kojima se koristimo u liječenju električne oluje ili pri repetitivnim uključivanjima kardioverterskog defibrilatora. Međutim, kod dijela bolesnika endokardijalna ablacija nije uspješna budući da se ključni supstrat aritmije nalazi subepikardijalno. Prikazujemo 20-godišnjeg bolesnika koji je preživio izvanbolnički arest, uzrokovan ventrikularnom fibrilacijom (VF) u sklopu preboljenog miokarditisa. Širokom kardiološkom obradom isključen je drugi uzrok aritmije, a magnetskom rezonancijom utvrđen je supstrat u obliku subepikardijalnih ožiljnih zona u lijevom ventrikulu. Bolesniku je ugrađen kardioverterski defibrilator, no usprkos većem broju linija antiaritmičke terapije i dalje su bili učestali recidivi VF-a. Stoga je učinjena kombinirana perkutana endokardijalna/epikardijalna procedura, nakon koje bolesnik više nije imao recidiva aritmije. Zbog velike kompleksnosti epikardijalne ablacije dosad smo ovakve bolesnike morali referirati kolegama u inozemnim centrima, što odsad više nije nužno.Since 2012 we have successfully implemented endocardial ablation procedures in patients with structural heart disease and ventricular arrhythmias. These are complex electrophysiological procedures that are used to treat electric storms or repetitive discharges of cardioverter-defibrillators. However, in one part of the patients endocardial ablation is unsuccessful, since the key substrate of arrhythmia is subepicardial. We report a 20-year-old patient who has survived out-of-hospital arrest, caused by ventricular fibrillation (VF) in the setting of myocarditis. Extensive cardiac work-up did not show any pathology, however cardiac magnetic resonance found subepicardial scarring zones in the left ventricle as the primary cause of arrhythmia. The patient was implanted with a cardioverter-defibrillator, but in spite of several lines of antiarrhythmic therapy there were still frequent recurrent VFs. Therefore, a combined percutaneous endo/epi procedure was performed, after which the patient had no recurrence of arrhythmia. Due to the great complexity of epicardial ablation, so far these patients have been refered to colleagues in foreign centers, which is no longer the case

THE FIRST CASE OF RADIOFREQUENT ABLATION OF VENTRICULAR TACHYCARDIA IN A PATIENT WITH ISCHEMIC CARDIOMYOPATHY IN OUR COUNTRY

Ablacija ventrikularne tahikardije kod bolesnika s ishemijskom kardiomiopatijom kompliciranija je i mnogo teža od ablacije većine supraventrikularnih tahikardija. Aritmogeni supstrat je kompleksniji, a lokalizacija mu je često nejasna. Zbog karakteristika tahikardije preciznije metode mapiranja često se ne mogu rabiti. Uz to se obično radi o bolesnicima sa slabijom sistoličkom funkcijom, zatajivanjem srca, ishemijom i brojnim komorbiditetima gdje izazivanje tahikardije i postupak ablacije mogu dovesti do naglog hemodinamskog urušavanja. Neinducibilnost kliničke aritmije postiže se kod 65–95% bolesnika, ali se recidiv javlja kod 20–44% bolesnika. Teže komplikacije bilježe se kod 8% bolesnika uz smrtni ishod kod 2,7% bolesnika. Odluku o strategiji liječenja treba stoga donositi individualno procjenjujući potencijalnu korist i rizik od intervencije. Ovaj članak prikazuje prvi slučaj uspješne ablacije ventrikularne tahikardije kod bolesnika s ishemijskom kardiomiopatijom koja je učinjena u našoj zemljAblation of ventricular tachycardia in patients with ischemic cardiomyopathy is more complicated and more difficult than ablation of most supraventricular tachycardias. Arrhythmogenic substrate is complex and its localisation is often unclear. Because of the tachycardia characteristics, more precise mapping methods often can’t be utilised. Also, patients are usually seriously ill with decreased systolic function, heart failure, ischemia and various comorbidities where tachycardia induction and ablation procedure may facilitate abrupt hemodynamic disturbance. Uninducibility of the clinical tachycardia can be achieved in 65–95% of patients, but tachycardia recurs in 20–44% of patients. Serious complications were noted in 8% of patients with lethal outcome in 2.7% of patients. Decision about therapeutic strategy should be made individually according to potential risk and procedure benefit. This paper presents the first case of the successful ablation of ventricular tachycardia in a patient with ischemic cardiomyopathy in our country

ATRIAL FIBRILLATION AND HEMODINAMICALY UNSTABLE WIDE QRS COMPLEX TACHYCARDIA – A case report

Tahikardija je aritmija karakterizirana srčanom frekvencijom > 100/minuti. Prema širini QRS-kompleksa može se podijeliti na tahikardije uskih ( 120 ms). Tahikardija uskih QRS-kompleksa uvijek je supraventrikularna, što znači da joj je izvorište proksimalno od Hisova snopa, dok tahikardija širokih QRS-kompleksa može biti ventrikularna (izvorište u ventrikulu distalno od Hisova snopa), ali i supraventrikularna. Strategija liječenja ovih dvaju poremećaja različita je pa je točna dijagnoza preduvjet optimalne terapije. Prikazujemo ovaj slučaj jer su diferencijalna dijagnoza tahikardije širokih QRS-kompleksa, a time i planiranje terapije bili posebno otežani zbog istodobno prisutne fibrilacije atrija te hemodinamske kompromitacije i akutnog ugrožavanja života bolesnice.Tachycardia is an arrhythmia characterized by heart rate > 100 / minute. According to the width of the QRS complex it can be divided into narrow QRS ( 120 ms). Narrow QRS tachycardia is always supraventricular which means that its source is proximal to the bundle of His, while wide QRS tachycardia can be ventricular (source is in the ventricle, distal to the bundle of His) or supraventricular. The strategies for treating these two conditions are different so the correct diagnosis is prerequisite for optimal therapy. We present this case because the differential diagnosis of wide QRS tachycardia and therefore the treatment planning was particularly difficult due to concurrently present atrial fibrillation with hemodynamic compromise and an acute threat to the life of the patient