icd terapija kod dece i adolescenata goran milašinović pmc, kcs

ICD terapija kod dece i adolescenata

Goran Milašinović

PMC, KCS

Disclosure

Receive mild to moderate compensation for lectures andclinical studies from Medtronic, St Jude Medical, Biotronik and BioControl Co.

Receive no grant from any company.

ICD terapija: prevencija iznenadne srčane smrti

Arrhythmia PVCs; VT-NSVT-S; VF

Heart Disease Absent PresentPresent Present

LV Dysfunction Absent AbsentAbsent PresentPresent Present

Potential Risks for SCD

Minimal IntermediateIntermediate High

PVCsPVCs

VT-NSVT-NS

Risk-Stratification for Sudden Cardiac Death

PVC=premature ventricular complexes; VT-NS=nonsignificant ventricular tachycardia;VT-S=significant ventricular tachycardia; VF=ventricular fibrillation.

Prystowsky EN. Am J Cardiol. 1988;61:102A-107A.

CAST: Survival

CAST Investigators. N Engl J Med. 1989;321:406-412.

P=0.0003

Sur

viva

l (%

)

100

95

90

85

0 400 450 50050 100 150 200 250 300 350

Days After Randomization

Placebo (N=725)

Encainide or flecainide (N=730)

Julian DG, et al. Lancet. 1997;349:667-674.

EMIAT: All-Cause Mortality LVEF and by Group

Months Since Randomization Months Since Randomization

Pro

bab

ility

of

Su

rviv

al

Pro

bab

ility

of

Su

rviv

al

Amiodarone

PlaceboEjection fraction < 30%

Ejection fraction 31%-40%

CAMIAT: All-Cause Mortalityand Nonarrhythmic Death

Cairns JA, et al. Lancet. 1997;349:675-682.

Months Since Randomization

Cu

mu

lati

ve

Ris

k (

%)

Months Since Randomization

Cu

mu

lati

ve

Ris

k (

%)

P=0.072

P=0.130

Amiodarone

Placebo

Primary Prevention Post-MI Trials

1. Buxton AE, et al. N Engl J Med. 1999;341:1882-1890.2. Moss AJ, et al. N Engl J Med. 1996;335:1933-1940.3. Moss AJ, et al. N Engl J Med. 2002;346:877-882.

0

10

20

30

40

50

60

70

80

MUSTT1

27 MonthsMADIT2

27 MonthsMADIT-II3

20 Months

Mo

rtal

ity

Red

uct

ion

w/IC

D R

x (%

)

55 54

31

MUSTT Randomized Patients:Total Mortality

Eve

nt-

Fre

e R

ate

P<0.001

EP ICD

Control

Months After Enrollment

EP no ICD

Buxton AE, et al. N Engl J Med. 1999;341:1882-1890.

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60

MADIT: Survival by Treatment Groups

Moss AJ, et al. N Engl J Med. 1996;335:1933-1940.

Months After Enrollment

Pro

bab

ility

of

Su

rviv

al

ICD

Conventional Therapy

P=0.009

0.0

0.2

0.4

0.6

0.8

1.0

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60

MADIT-II: Survival byTreatment Group

Moss AJ, et al. N Engl J Med. 2002;346:877-882.

0.78

0.69

P=0.007

0 1 2 3 4

Defibrillator Group

Conventional Group

Pro

bab

ilit

y o

f S

urv

ival

Years

0.5

0.6

0.7

0.8

0.9

1.0

Secondary Prevention Trials:AVID, CASH, CIDS

1. AVID Investigators. N Engl J Med. 1997;337:1576-1583.2. Kuck KH, et al. Circulation. 2000;102:748-754.3. Connolly SJ, et al. Circulation. 2000;101:1297-1302.

0

10

20

30

40

50

60

70

80

AVID1

3 YearsCASH2

3 YearsCIDS3

3 Years

Mo

rtal

ity

Red

uct

ion

w/IC

D R

x (%

)

31

2820

AVID: Overall Survival

0 1 2 3Years After Randomization

Defibrillator Group

Antiarrhythmic Drug Group

Pro

po

rtio

n S

urv

ivin

g

P<0.02

AVID Investigators. N Engl J Med. 1997;337:1576-1583.

0.0

0.2

0.4

0.6

0.8

1.0

CIDS Update: 11-Year Follow-Up

ICDAmiodarone

100

80

60

40

20

020 40 60 80 100 120 140

P=0.021

Months

Act

uar

ial S

urv

ival

(%

)

Bokhari FA, et al. Circulation. 2002;106(19 suppl II):II-497.

Primarna prevencija iznenadne srčane smrti kod dece

• Hipertrofična ili Dilatativna CMP

Faktori rizika: 1. Istorija sinkopa u porodici 2. Značajna hipertrofija LK 3. NSVT na holteru 4. Pad TA prilikom testa opterećenjem

2 od 4 ICD

From SURGERY for CONGENITAL HEART DEFECTS, 3rd Ed., Editors J STARK, M. de LEVAL and VT TSANG


• Long QT sy. (LQTS), koji ne reaguje na beta-blokatore ili ne mogu da se uzimaju.



• Long QT sy. (LQTS) = Polimorfna VT



• CPVT (kateholamin-senzitivna (ili zavisna) polimorfna VT).



• Brugada sy.


Genetska bolest koju karakteriše abnormalan EKG i povišen rizik za iznenadnu srčanu smrt. Celularna električka aktivnost izmenjena zbog izlaska natrijuma iz ćelija.

ISS kod adolescenata i mladih sportista

• CardiomyopathiesDilatedHypertrophicRight ventricular dysplasia

• Electrical abnormalities• Long-QT syndromes• Brugada syndrome• W-P-W syndrome

Viral myocarditisAbnormal coronary arteriesDrug-induced arrhythmiasInflammatory/infiltrative diseasesIdioventricular fibrillationDiseases of heart valves

From Ventricular Arrhythmias and Sudden Cardiac Death. Edited by Paul J. Wang, Chapter 17, Epidemiology and etiologies of sudden cardiac death, Keane K. Lee et al, 2008

0–1 d 94–155

1–3 d 92–158

3–7 d 90–166

7–30 d 107–182

1–3 mo 120–179

3–6 mo 106–186

6–12 mo 108–168

1–3 yr 90–152

3–5 yr 73–137

5–8 yr 64–133

8–12 yr 63–130

12–16 yr 61–120From Davignon A, Rautaharju P, Boisselle E, et al: Normal ECG standards for infants and children. Pediatr Cardiol 1:123-152, 1979.

Normalna srčana frekvenca kod dece

An ICD should be implanted in pediatric survivors of a cardiac arrest when a thorough search for a correctable cause is negativeand the patients are receiving optimal medical therapy and have reasonable expectation of survival with a good functional status formore than 1 year.

Hemodynamic and EP evaluation should be performed in the youngpatient with symptomatic, sustained VT.

ICD therapy in conjunction with pharmacological therapy is indicated for high-risk pediatric patients with a genetic basis (ion channel defects or cardiomyopathy) for either SCD or sustainedventricular arrhythmias. The decision to implant an ICD in a childmust consider the risk of SCD associated with the disease, the potential equivalent benefit of medical therapy, as well as risk of device malfunction, infection, or lead failure and that there is reasonable expectation of survival with a good functional status for more than 1 year.

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII



VA & SCD in Pediatric Patients

ICD therapy is reasonable for pediatric patients with

spontaneous sustained ventricular arrhythmias associated

with impaired (LVEF of 35% or less) ventricular function who

are receiving chronic optimal medical therapy and who have

reasonable expectation of survival with a good functional

status for more than 1 year.

Ablation can be useful in pediatric patients with symptomatic

outflow tract or septal VT that is drug resistant, when the

patient is drug intolerant or wishes not to take drugs.




Pharmacological treatment of isolated PVCs in pediatric

patients is not recommended.

Digoxin or verapamil should not be used for treatment of

sustained tachycardia in infants when VT has not been

excluded as a potential diagnosis.

Ablation is not indicated in young patients with

asymptomatic NSVT and normal ventricular function.





Epikardno ili transvenskiIndikacije za permanentu epikardnu

stimulaciju u dece.

• < 8 kg• Desno-levi šant• Problem sa venama• Više tipova hirurških rešavanja srčanih mana

podrazumevaju prethodnu implantaciju pejsmejkera• Opstrukcija VCS • Težak pristup DK• Mehanička trikuspidna valvula• Neuspeli transvenski pristup


Epikardno vs. Endokardno

EpicardialAdvantages• Avoiding concerns of

Venous Thrombus

Disadvantages• Having to enter the chest

cavity• Poor pacing and sensing

thresholds

TransvenousAdvantages• Avoid Thoracotomy• Lower Pacing Thresholds• Lower incidence of Exit

Block

Disadvantages• Higher Dislodgement Rates• Potential for Venous

Occlusion• Risk for Embolic Vascular

Event• Risk of Subclavian Crush• Endocarditis• Potential for Tricuspid Valve

damage

From presentation on Pediatric Pacing by Christine Youngs.

Comparison of epicardial with endocardial electrode use in children. Note the gradually increasing use of endocardial electrodes.

(Data from the Midwest Pediatric Pacemaker Registry.)

• White ring on 4968 identifies cathode leg

• Suture-down holes

4968

4965

Surgical Approacha. Subxiphoidb. Left Lateral Thoracotomy*c. Median Sternotomyd. Other approaches include:• Subcostal• Right Thoracotomy

38303830 4.1 french lumen-less 4.1 french lumen-less

catheter-delivered leadcatheter-delivered lead

C315 delivery catheters for 3830 leadsInner diameter 5.5 FrOuter diameter 7.0 Fr“Pacemaker leads with smaller

body design may help in preservationof venous patency in children.”Implantation of SelectSecure Leads in Children, PACE 7/07VOLKAN TUZCU, M.D.

• Extra lead slack is usually left in the pediatric patient’s atrium to allow for growth

• Adhesions can still form preventing lead slack from helping

• Following slides show slack being taken up as patient grows

Graphic From SURGERY for CONGENITAL HEART DEFECTS, 3rd Ed., Editors J STARK, M. de LEVAL and VT TSANG

From Cardiac Pacing, Defibrillation, and Resychronization: A Clinical Approach,2008, 2nd Ed., pg. 187, Daniel L. Hayes and Paul A. Friedman

From Extracardiac ICD implantation in an infant, T. Kriebel et al., Zeitschrift für Kardiologie, Band 94, Heft 6 (2005)

Chest radiograph showing placement of a single-coil transvenous defibrillator system with the lead tunneled down the lateral chest wall to the device, which also serves as the second defibrillation electrode and is placed in a left upper quadrant abdominal pocket.

Use of Use of Transvenous Transvenous Lead Lead tunneled to tunneled to abdominally abdominally placed ICDplaced ICD

Programiranje ICD u dece

• ICD VR, zbog veličine

• Jedna zona detekcije, jer su najčešće indikacije kod dece VF, a ne VT (re-entry) “Pain-free” studija nije studirana kod dece.

• Max. SVT diskriminator

• Jedan elektrodni vodič da se izbegne venska opstrukcija

Case Report: 2001

• 14 god, ženski pol

• Abdominalni ICD sa 10 god.

• Indikacija: VT 170, operisana ToF sa 2 god.

• Intravenska lektroda + subkutani “pač” u aksili

Age 10

ICD

Subcut. patch

On the age 14

Age 14

Subcutaneous lead

Pg

Jap. Circulation, 2005

Zaključak

• Najčešća indikacija primarna prevencija

• Sekundarna prevencija kod operisanih USM

• ICD na tržišitu primenjivi za decu

• Često korišćenje epikardnih i supkutanih elektroda

• Programiranje drukčije nego kod odraslih

icd terapija kod dece i adolescenata goran milašinović pmc, kcs

Documents

n engl j

j cardiol

flecainide n

randomizationplacebo

editors j stark

arrhythmiapvcs vtnsvt

ventricular fibrillation

monthsactuarial survival