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MMD6500
Dr Blandine MondésertElectrophysiology service, Medicine department
Adult Congenital Heart Disease Center Montreal Heart Institute, Université de Montréal
26 octobre 2016
Cours résidents anesthésie
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• 4.3.1.3 ElectrophysiologyDescribe the normal anatomy of the cardiac conduction systemDescribe the phases of cellular action potentials, including the major associated ion currentsDescribe the automaticity of the cardiac conduction system, understanding the differences between the SA node, AV node, Bundle of His and Purkinje fibresDescribe excitation-contraction coupling, and how electrical activation of the myocyte leads to contraction and relaxation
• 4.3.2 Clinical assessmentHolter monitors
• 4.3.3 PathophysiologyAnti-dysrryhthmicsAberrant conduction including: Wolf Parkinson White (WPW)), dysrhythmia, ablationprocedures (procedures in the Electrophysiology (EP) labSudden acute and sub-acute ventricular and supra-ventricular arrhythmia
Plan
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Anatomie
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• <iframe width="560" height="315" src="https://www.youtube.com/embed/SegeRP2KXSY" frameborder="0" allowfullscreen></iframe>
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11h54
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13h
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Après 24h d’arrêt
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Le potentiel d’action
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Classification de Vaughan et Williams
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Classification de Vaughan et Williams
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Cas clinique
• Patient 76 ans MCAS: sténose 70% CD Sao serrée, AVA 0.8cm2
• En attente de chirugie cardiaque
• Transfert en urgence d’un hopital périphériquepour mort subite
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Cas clinique
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Cas clinique
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Cas clinique
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Cas clinique
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Cas clinique
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Europace (2013) 15, 1389–1406
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Traitement?
• Aigu: CVE Troubles hydroélectrolytiques (Mg++, K+) Tx allongeant QT? www.qtdrugs.org Isuprel ou pacing atrial Tx facteur déclenchant
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• Long cours: Tx facteur déclenchant BB ICD selon clinique et recommandations Dépistage génétique si non aquis Dépistage familial
Traitement?
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36 y.o. woman with palpitations
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• CVE+++
• Pas d’amio, pas d’AA
• Adénosine
Traitement?
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36 y.o. woman with palpitationsPost Adenosine 12…
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36 y.o. woman with palpitationsPost Adenosine 12…
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Sinus rhythm Tachycardia
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Manifest Accessory Pathways(Pre-excitation)
• Accessory Pathways that are able to conduct anterogradely
• Result in WPW Short PR interval
(<120ms) Delta Wave
(ventricular pre-excitation)
Prolonged QRS duration
SVT’s
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Accessory AV Connections
Left Free Wall = 45-60%Postero-septal = 25%
Right Free Wall = 13-21%Antero-septal = 2%
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Concealed Accessory Pathways(Non pre-excited)
• Capable of only retrograde VA conduction No ventricular
pre-excitation PR interval Normal QRS duration
Normal Typical display
non-decrementalconduction
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Characterize the delta wave…
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Right or Left?
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An algorithm for the electrocardiographic localization of accessory pathways in the Wolff-
Parkinson-White syndrome.
Milstein, Sharma, Guiraudon, and KleinPACE, Vol. 10, May, 1987
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V1
Right Ventricle Left Ventricle
Negative delta wave and QRS
Positive delta wave and QRS
Negative delta and
QRSII, III, avF
Isoelectric or negative
deltaI, avL, V5,
V6
Posteroseptal Lateral
Negative delta and
QRSII, III, avF
Posteroseptal
Right free wall
Anteroseptal
Inferior axis
Left axis
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PGG
EPS
HRA
HIS
RAO LAO
CS
RVA
HRA
HIS
CSRVA
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Post Ablation
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Cas clinique
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Facteurs prédictifs BAV post TAVI
- 75 patients TAVI, EPS pré et post TAVI, median follow-up de 1.4 ans (IQ 0.6-2.1)
- 11 (14.7%) BAV per hospitalisation et 3 (4%) après congé 83.3% BBD pré-procédure 26.7% nouveau BBG14.3% BBG pré-existant
- Analyse ROC- delta-HV ≥13 ms prédictif de BAV (100% de sensibilité, 84.4% de
spécificité)- HV-interval ≥65 ms (83.3% sensibilité et 81.6% spécificité)
Electrocardiographic and Electrophysiological Predictors of Atrioventricular Block Following Transcatheter Aortic Valve Replacement☆
Lena Rivard, MD, MSc, Gernot Schram, MD, PhD, Anita Asgar, MD, Paul Khairy, MD, PhD, Jason G. Andrade, MD, Raoul Bonan, MD, Marc Dubuc, MD, Peter G. Guerra, MD, Reda Ibrahim, MD, Laurent Macle, MD, Denis Roy, MD, Mario Talajic, MD, Katia Dyrda, MD, Azadeh Shohoudi, PhD, Jean-Benoit le polain de Waroux, MD, PhD, Bernard Thibault,
MDDepartment of Cardiology at the Montreal Heart Institute and the Université de Montréal, Montreal, Canada
Published Online: October 31, 2014
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Tous les patients avec QRS ≥ 120ms, EPS pré-TAVI :-Les patients avec BBG (10% des TAVI): mesure de HV pré-TAVI et PMT-Les patients avec BBD PMT (90% de risque de BAV).
Tous les autres patients (QRS<120 ms), pas d’EPS
En post-TAVI:
- Implantation PMP quand trouble conductif de haut-degré persistent
- Chez les patients avec nouveau BBG: projet de recherche si Corevalveou EPS +/- PM si HV>70ms pour les autres
- EPS chez tous les patients avec BBG ancien (pre-TAVI) avec mesure du HV et implantation PMP si delta HV ≥ 13 ms
- Pas d’EPS et retrait du PMT sur l’étage si QRS reste fin
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Protocole ICM
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Patient avec BBG post Corevalve
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Projet de recherche
Protocole Monitoring: Implantation Reveal linq
Protocole EPS: EPS pour mesure HVSi >70 ms implantation PMSi < suivi
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Monitoring
• ECG• Télémétrie• Holter 24 ou 48h• Iphone• King of heart• Cardiomémo• Moniteur implantable
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• Jeune homme 17 ans• Trauma post chute en vélo• Pas de syncope• Trauma du fémur• Bradycardie per opératoire• -> holter
Cas clinique
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Holter ECG
Courtoisie du Dr Andrade
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Courtoisie du Dr Andrade
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Courtoisie du Dr Andrade
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Courtoisie du Dr Andrade
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Courtoisie du Dr Andrade
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Courtoisie du Dr Andrade
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Merci!