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

Osservazioni cliniche nei pazienti aritmie ed insufficienza cardica Clinical Observations in the Arrhythmic Heart Failure Patients. Mariell Jessup MD Professor of Medicine University of Pennsylvania Philadelphia, Pennsylvania. HF and Arrhythmias. ICDs: the good, the bad, and the ugly.

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

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  1. Osservazioni cliniche nei pazienti aritmie ed insufficienza cardicaClinical Observations in the Arrhythmic Heart Failure Patients Mariell Jessup MD Professor of Medicine University of Pennsylvania Philadelphia, Pennsylvania

  2. HF and Arrhythmias • ICDs: the good, the bad, and the ugly. • VT ablation. • PVC-induced cardiomyopathy.

  3. HF and Arrhythmias • ICDs: the good, the bad, and the ugly. • VT ablation. • PVC-induced cardiomyopathy.

  4. Magnitude of SCA in the US SCA claims more lives each year than these other diseases combined 167,366 Stroke3 450,000 SCA 4 Lung Cancer2 157,400 Breast Cancer2 40,600 #1 Killer in the U.S. 42,156 AIDS1 1 U.S. Census Bureau, Statistical Abstract of the United States: 2001. 2 American Cancer Society, Inc., Surveillance Research, Cancer Facts and Figures2001. 3 2002Heart and Stroke Statistical Update, American Heart Association. 4 Circulation. 2001;104:2158-2163.

  5. Severity of Heart Failure and Modes of Death 12% 26% 24% 59% 64% 15% 33% NYHA Class III n = 103 NYHA Class II n = 103 56% 11% MERIT-HF Study Group. LANCET 1999; 353:2001-2007 NYHA Class IV n = 27

  6. Underlying Arrhythmias of Sudden Cardiac Arrest Polymorphic VT 13% Bradycardia17% Monomorphic VT62% Primary VF8% Bayés de Luna A. Am Heart J. 1989;117:151-159

  7. MUST-T ICD ICD’s and survival in CHF 100 -- 90 -- 80 -- 70 -- 60 -- 50 -- MADIT- II ICD COMPANION ICD DEFINITE ICD Survival MUST-T No ICD MADIT- II No ICD COMPANION No ICD DEFINITE No ICD 0 1 2 3 Year Buxton AE, at al. (MUST-T) NEJM 1999;341:1882-90 Bristow MR, et al. (COMPANION) NEJM 2004;350:2140-50 Moss AJ, et al. ( MADIT-II) NEJM 2002;346:877-83 Kadish A, et al. (DEFINITE) NEJM 2004;350:2151-8

  8. Exner, Klein. J Cardiovasc Electrophysiol 2003; 14:574

  9. ICD Implant Procedures-UPENN 662 541 502 473 431 414 411 395 356 342

  10. MADIT-II Greenberg et al. JACC 2004;43:1459

  11. Post MI Hohnlosser et al. NEJM 2004; 351:2481

  12. All-cause mortality at 36 months by treatment group and risk-stratification criteria in IRIS The IRIS trial Steinbeck G. American College of Cardiology 2009 Scientific Sessions; March 31, 2009; Orlando, FL.

  13. JACC 2009; 53:e1-90

  14. JACC 2009; 53:e1-90

  15. HF and Arrhythmias • ICDs: the good, the bad, and the ugly. • VT ablation. • PVC-induced cardiomyopathy.

  16. Circulation 2004;109:2924

  17. ICDs: the UGLYinfection

  18. ICDs: the UGLYinfection

  19. Closed pocket infection Eroding ICD pocket

  20. HF and Arrhythmias • ICDs: the good, the bad, and the ugly. • VT ablation. • PVC-induced cardiomyopathy.

  21. NEJM 2008; 359:1009-17

  22. Classification of Ventricular Arrhythmias Das et al. Cardiol Clin 2008; 26:459-479

  23. Zipes et a. Circulation 2006; 114:e385-484

  24. VT Ablations (UPENN) 1999 -2008 ( N = 1176 ablation procedures) 221 YEAR Number of VT Ablations

  25. Post MI patients referred for VT ablation Marchlinski et al Circulation 2008

  26. Clinical presentation in 100 consecutive patients referred for VT ablation (Sick Patients – Unstable) 93% 68% % 18% 14%

  27. UPENN VT Ablations (N= 775)1999- 2006 512 (66%) 263 (34%) Tet, Sarcoid, Non OT VT, etc

  28. Recurrence vs. clinical benefit 0.03 0.46 Segal OR: Heart Rhythm 2005

  29. Circulation Arrhyth Electrophysiol 2008; 1:153-161

  30. *Low bipolar voltage surrounding the valves *Low voltage abnormalities extending toward more apical segments of the RV or LV. Circulation 2007; 116:1998

  31. Assomull et al. JACC 2006;48:1977

  32. 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

  33. Electrical stormin patients with ICDs implanted earlier AVID MADIT II Huang and Traub Prog Cardiov Dis 2008; 51(3): 229-236

  34. Electrolyte imbalance Ischemia Heart failure exacerbation Medication non-compliance identified cause in 13% !!! Eur Heart J 2006; 27: 3027

  35. Electrical storm in the ICD era. Huang and Traub Prog Cardiov Dis 2008; 51(3): 229-236

  36. HF and Arrhythmias • ICDs: the good, the bad, and the ugly. • VT ablation. • PVC-induced cardiomyopathy.

  37. Circulation 2005; 112:1092-1097

  38. J Interv Card Electrophysiol 2007; 20:9-13

  39. University of Pennsylvania Medical Center

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