KATA: Σ όλος ος ασθνίς μ σύνρομο ... - Livemedia.gr · 6 basic studies on EP...
Transcript of KATA: Σ όλος ος ασθνίς μ σύνρομο ... - Livemedia.gr · 6 basic studies on EP...
Άννα ΚωστοπούλουΑναπλ. Διευθύντρια
Ωνάσειο Καρδιοχειρουργικό ΚέντροΤμήμα Ηλεκτροφυσιολογίας και Βηματοδότησης
KATA: Σε όλους τους ασθενείς με σύνδρομο BRUGADA και θετική ηλεκτροφυσιολογική
μελέτη θα πρέπει να εμφυτεύεται απινιδωτής
6 basic studies on EP
• Brugada J, Brugada R, Brugada P. Determinants of sudden cardiac death in individuals with the electrocardiographic pattern of Brugada syndrome and no previous cardiac arrest.
Circulation. 2003; 108: 3092-3096.
• Paul M et al. Role of programmed ventricular stimulation in patients with Brugada syndrome: a meta-analysis of worldwide published data.
Eur Heart J. 2007; 28: 2126-2133.
• Probst V et al. Long-term prognosis of patients diagnosed with Brugada syndrome: Results from the FINGER Brugada Syndrome Registry.
Circulation. 2010 Feb 9;121(5):635-43.
• Priori SG et al. Risk stratification in Brugada syndrome: results of the PRELUDE (Programmed ELectrical stimUlation preDictive valuE) registry.
J Am Coll Cardiol. 2012; 59: 37-45.
• Sieira et at. Prognostic Value of Programmed Electrical Stimulation in Brugada Syndrome 20 Years Experience Circ Arrhythm Electrophysiol. 2015;8:777-784
• Juan Sieira, MD; Giulio Conte,Sroubek J et al. Programmed Ventricular Stimulation for Risk Stratification in the Brugada Syndrome: A Pooled Analysis.
Circulation. 2016;133(7):622-30.
Circulation. 2003;108:3092-3096
EPS
FU mean of 24+33 months (1 to 160)
Patients with BS and
survived SCA show
the highest chance
for VT/VF occurrence
during follow-up.
No significant role
of PVS with regard
to arrhythmic
events during
follow-up
• 1036 patients (85%) underwent EP-53% were inducible
• highest in SCA patients (66%)• 55% of with syncope • 25% of asymptomatic pts
Specific analysis of asymptomatic pts
11 European centres, 1.029 pts median follow-up of 32 months.
Symptoms and a
spontaneous type 1 ECG
are the only independent
predictors of arrhythmic
events.
Gender, family history of
SCD, inducibility of VT/VF
and presence of a mutation
in the SCN5A gene have
no predictive value.
Event rate in asymptomatic patients was
0.5% per year.
J Am Coll Cardiol 2012;59:37–45
308 consecutive individuals 247 men (80%) median age 44 years (18 -72) EPS at enrollmentFU Median follow-up of 34 months
(A) entire PRELUDE cohort
B) inducible with 1 or 2 extrastimuli
Overall, of the 126 inducible
patients, 5.5% were induced
with 1 premature beat, 44.5%
with 2 premature beats, and
50% with 3 premature beats.
Τhe number of inducible
patients is higher when more
aggressive protocols are used.
ECG type, syncope, QRS-f VRP <200msec have higher sensitivity and specificity than EP
Asymptomatic patients:lower sensitivity but neg predictive value 98.3%
▲▲ risk Syncope spontaneous type 1 and positive EPS HR 2.7
Circulation 2016
1,312 patients with a median follow-up of 38 months and heterogeneous stimulation protocols. 53% spontaneous type 1
incidence 0.27%/per year for (asymptomatic
individuals + drug-induced type 1) 3.22% /year (syncope and spontaneous type 1
the incremental prognostic value of abnormal PES beyond solely clinical parameters, syncope, and a spontaneous type 1 ECG pattern is small.
EP reserved for patients who are not clearly stratified by clinical features.
Why are there so many differences???
Is the debate justified???
Circardian pattern:
Eur Heart J. 1999;20:465–470. Heart Rhythm, Vol 5, No 11, November 2008J Cardiovasc Electrophysiol, Vol. pp. 1-7
SD in Brugada
Typically a polymorphic ventricular tachycardia, that evolves into VF during rest -sleep
• Monogenetic????
• Genetics involved in -30-40% 30 SCN5A loss of function a subunit sodium, 5%Ca
and K channels
• No hereditary pattern is evident in most index patients-
• Complex, locus heterogeneity, incomplete penetrance, and variable expressivity
• Changes in definitions
• Complex substrate has been documented
Europace (2011) 13, 1077–1109
SD in Brugada
Mechanism of VF in BrS multifactorial
Hormones age & sex
Dynamic and autonomic changes changes
THE ENVIRONMENT
Wilde et al J Mo Cell Cardiol 2010Conte et al J Cardiovasc Electrophysiology 2014
EP
Details of the protocol Site of pacing –Drive- cycle length extra stimuli >=200msec- time between runs -number of extras –med provocationIncrease in sensitivity looses in specificityMore specific for reentry tachycardias
No usefulness in other channelopathiesand idiopathic VFIn patients with idiopathic VF yields inconsistent inducibility (50-60%).
Wellens HJ, Schuilenburg RM, Durrer D. Electrical stimulation of the heart in patients with ventricular tachycardia. Circulation. 1972; 46: 216-226.
Reasons for diversity in results
1) Different populations in the studies
• Bias in risk estimation
• First populations identified were the high risk
• True incidence of asymptomatic pts unknown
2) EP limitations
• Different protocols in the studies
• Different ECG at the time of the study
• EP looses specificity when the protocol is aggressive
3) mechanisms of VF multifactorial that cannot be predicted by EP
J Am Coll Cardiol 2015;65:879–88
spontaneous or drug-induced Brugada type 1 with ICDs 176 ptsFU 83.8 +- 57.3 months
You cannot reassure pts of being 100% safeRisk stratification in VF has no absolute standards
Personalize
Conclusion
• SCA –ICD
• Symptoms high risk clinical -ICD
• Asymptomatic BrS pts EP does not add much
• Stratification is still a challenge –
• EP is a tool for intermediate risk patients
• Individualize
Circulation 2016;133:619-621
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