2016 The Arrhythmic Patient in the Emergency Department 2
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2016 The Arrhythmic Patient in the Emergency Department 2
Acute Management of Arrhythmias in Patients with Known Congenital Heart DiseaseFrancesca Bianchi and Stefano Grossi7.1Focusing on the IssueSurgical ad 2016 The Arrhythmic Patient in the Emergency Department 2dvances for congenital heart disease (CHD) allow long-term survival for a unique group of patients who would otherwise have died during early childhood. Improved longevity had eventually exposed to late complications, atrial and ventricular arrhythmias contributing to sudden cardiac death (SCD) 11]. 2016 The Arrhythmic Patient in the Emergency Department 2 Arrhythmias are the consequences of both native abnormalities and surgical procedures. It seems that the arrhythmic burden is the price paid to survi2016 The Arrhythmic Patient in the Emergency Department 2
val and mostly occurs in adults with CHD. It is now estimated that there are over 1.8 million of adult patients with CHD in Europe [2] and one millionAcute Management of Arrhythmias in Patients with Known Congenital Heart DiseaseFrancesca Bianchi and Stefano Grossi7.1Focusing on the IssueSurgical ad 2016 The Arrhythmic Patient in the Emergency Department 2ective surgical solution and large number of patients surviving into middle age: this is the case of tetralogy of Fallot that has been studied more extensively than other conditions and so arrhythmic mechanisms and risks are best known [ I ]: other conditions, less common or with a more recent impro 2016 The Arrhythmic Patient in the Emergency Department 2vement of survival, are less known.The entire spectrum of arrhythmias may be encountered in adults with CHD. with several subtypes often coexisting. F2016 The Arrhythmic Patient in the Emergency Department 2
or some conditions, arrhythmias are intrinsic to the structural malformation itself, as is the case with Wolff-Parkinson-White syndrome in the settingAcute Management of Arrhythmias in Patients with Known Congenital Heart DiseaseFrancesca Bianchi and Stefano Grossi7.1Focusing on the IssueSurgical ad 2016 The Arrhythmic Patient in the Emergency Department 2 of the great arteries (L-TG.A). For most other CHD patients, arrhythmias represent an acquired condition related to the unique myocardial substrateF. Bianchi (E3) • s. GrossiCardiology Unit. Department of Cardiovascular Diseases, Azienda Ospedaliera Ordine Mauriziano. Turin. Italye-mail: fbianchi@m 2016 The Arrhythmic Patient in the Emergency Department 2auriziano.it: sgrossi@mauriziano.it© Springer International Publishing Switzerland 2016109M. Zecchin. G. Sinagra (eds.). The Arrhythmic Patient in the2016 The Arrhythmic Patient in the Emergency Department 2
Emergency Department: A Practical Guide for Cardiologists and Emergency Physicians. nni in mm/mc 1 -Ỉ1O 0/iioe 1 1noF. Bianchi and s. Grossicreated bAcute Management of Arrhythmias in Patients with Known Congenital Heart DiseaseFrancesca Bianchi and Stefano Grossi7.1Focusing on the IssueSurgical ad 2016 The Arrhythmic Patient in the Emergency Department 2t is peculiar for any CHD, but some general principles can be identified, and recently international scientific boards have provided evidence-based recommendations on best practice procedures for the evaluation, diagnosis, and management of arrhythmias [5, 6].Arrhythmia management is strictly connec 2016 The Arrhythmic Patient in the Emergency Department 2ted to anatomical native and surgical substrate and to hemodynamic status. Classification of CHD complexity (simple, moderate, and great/severe) propo2016 The Arrhythmic Patient in the Emergency Department 2
sed by the ACC7AHA task force (7] reported in Table 7.1 is used to orientate management.7.2What Physicians Working in ED Should KnowFacing acute arrhyAcute Management of Arrhythmias in Patients with Known Congenital Heart DiseaseFrancesca Bianchi and Stefano Grossi7.1Focusing on the IssueSurgical ad 2016 The Arrhythmic Patient in the Emergency Department 2lar fibrillation resulting in pulseless arrest requires management according to AHA/ACC/ESC guidelines for Adult Cardiac Life Support (ACLS) [8]. When direct current cardioversion is required, paddles or patches have to be positioned taking into account cardiac location in the chest [6].In tolerated 2016 The Arrhythmic Patient in the Emergency Department 2 arrhythmias, 12-lead electrocardiogram (ECG) of the event should be registered. Knowledge of anatomical defect and collection of surgical reports are2016 The Arrhythmic Patient in the Emergency Department 2
also fundamental for best acute and long-term management and should be obtained as soon as possible.Hemodynamical ly tolerated tachycardia should be Acute Management of Arrhythmias in Patients with Known Congenital Heart DiseaseFrancesca Bianchi and Stefano Grossi7.1Focusing on the IssueSurgical ad 2016 The Arrhythmic Patient in the Emergency Department 2(AAD) are frequently poorly tolerated due to negative inotropic and other side effects, and few data exist on their safety and efficacy [6].For atrial arrhythmias the thromboembolic risk must be assessed before cardioversion. reminding that in moderate and severe complexity CHD. it is high even when 2016 The Arrhythmic Patient in the Emergency Department 2 onset is <48 h [6].Unexplained syncope in adults with CHD is an alarming event that may have several potential etiologies, including conduction abnor2016 The Arrhythmic Patient in the Emergency Department 2
malities and bradyarrhythmias, atrial and/or ventricular arrhythmias, and nonarrhythmic causes [6].In patients with CHD. the majority of sudden cardiaAcute Management of Arrhythmias in Patients with Known Congenital Heart DiseaseFrancesca Bianchi and Stefano Grossi7.1Focusing on the IssueSurgical ad 2016 The Arrhythmic Patient in the Emergency Department 2ilure, and aortic or aneurysmal rupture [5]. SCD is responsible for approximately one-fifth of the mortality in adult's CHD. with a greater risk observed in certain malformations (tetralogy of Fallot. Ebstein's disease, left-sided obstructive disease). However, the annual mortality rates are low com 2016 The Arrhythmic Patient in the Emergency Department 2pared with adult population (0.1-0.3 C7c per patient-year) [ I ].7 Acute Management of Arrhythmias in Patients with Known Congenital Heart Disease 1112016 The Arrhythmic Patient in the Emergency Department 2
Table 7.1 Complexity of diagnosis in adult patients with congenital heart diseaseSimpleModerate complexityGreat/severe complexityNative disease: IsolaAcute Management of Arrhythmias in Patients with Known Congenital Heart DiseaseFrancesca Bianchi and Stefano Grossi7.1Focusing on the IssueSurgical ad 2016 The Arrhythmic Patient in the Emergency Department 2ed small ventricular septal defect (no associated lesions) Mild pulmonary stenosis Small patent ductus arteriosus Repai red conditions: Previously ligated or occluded ductus arteriosus Repaired secundum or sinus venosus atrial septal defect without residua Repaired ventricular septal defect without 2016 The Arrhythmic Patient in the Emergency Department 2residuaAorto-left ventricular fistulas Anomalous pulmonary venous drainage, partial or total Atrioventricular septal defects, partial or complete Coar2016 The Arrhythmic Patient in the Emergency Department 2
ctation of the aorta Ebstein's anomaly Infundibular right ventricular outflow obstruction of significance Ostium primum atrial septal defect Patent duAcute Management of Arrhythmias in Patients with Known Congenital Heart DiseaseFrancesca Bianchi and Stefano Grossi7.1Focusing on the IssueSurgical ad 2016 The Arrhythmic Patient in the Emergency Department 2 aneurysm Sinus venosus atrial septal defect Subvalvular or supravalvular aortic stenosis Tetralogy of Fallot Ventricular septal defect with: Absent valve or valves Aortic regurgitation Coarctation of the aorta Mitral disease Right ventricular outflow tract obstruction Straddling tricuspid or mitral 2016 The Arrhythmic Patient in the Emergency Department 2 valve Subaortic stenosisConduits, valved or nonvalved Cyanotic congenital heart disease (all forms) Double-outlet ventricle Eisenmenger syndrome Font2016 The Arrhythmic Patient in the Emergency Department 2
an procedure Mitral atresia Single ventricle (also called double inlet or outlet, common, or primitive) Pulmonary atresia (all forms) Pulmonary vasculAcute Management of Arrhythmias in Patients with Known Congenital Heart DiseaseFrancesca Bianchi and Stefano Grossi7.1Focusing on the IssueSurgical ad 2016 The Arrhythmic Patient in the Emergency Department 2entricular or ventriculoarterial connection not included above (e.g.. crisscross heart, isomerism, heterotaxy syndromes, ventricular inversion)Adapted from Warnes et al. |7|; with permission7.3What Cardiologist Should KnowAtrial tachyarrhythmias (ATs), the most frequent in CHD. have been identified 2016 The Arrhythmic Patient in the Emergency Department 2as a risk factor for SCD. The mechanism has been attributed to rapid AV conduction, most notably at times of exertion, with hemodynamic instability ca2016 The Arrhythmic Patient in the Emergency Department 2
used by the atrial112F. Bianchi and s. Grossitachyarrhythmia itself or by its degeneration into a secondary ventricular tachyarrhythmia [71.PrevalenceAcute Management of Arrhythmias in Patients with Known Congenital Heart DiseaseFrancesca Bianchi and Stefano Grossi7.1Focusing on the IssueSurgical ad 2016 The Arrhythmic Patient in the Emergency Department 2of a 55-year-old women without CHI): patients with Gill) are young with aged hearts [91; atrial fibrillation (AF) is less common than atrial flutter accounting for 20-30 % of all A Is [10, I I J.The most common mechanism of tachycardia seen in the adult CHD patient population is macro-reentry within 2016 The Arrhythmic Patient in the Emergency Department 2 the atrial muscle. It is defined as intra-atrial reentrant tachycardia (IART) [71.Illis arrhythmia usually is a late postoperative disorder, and it m2016 The Arrhythmic Patient in the Emergency Department 2
ay arise after nearly all procedures involving a right alriotomy (even simple closure of an atrial septal defect): the incidence is clearly highest afAcute Management of Arrhythmias in Patients with Known Congenital Heart DiseaseFrancesca Bianchi and Stefano Grossi7.1Focusing on the IssueSurgical ad 2016 The Arrhythmic Patient in the Emergency Department 2ends to be slower than typical flutter, with atrial rates in the range of 170-250 beats per minute. In the selling of a healthy AV node, these rates will frequently allow a pattern of I: I AV conduction that may result in hemodynamic instability, syncope, or possibly death [3. 7]. Rate control shoul 2016 The Arrhythmic Patient in the Emergency Department 2d be achieved as soon as possible. Beta-blocking drugs and nondi hydropyridine calcium channel antagonists can be used to achieve ventricular rate con2016 The Arrhythmic Patient in the Emergency Department 2
trol with insufficient evidence to recommend one agent over another; since beta-blockers are associated with a decreased incidence of ventricular tachGọi ngay
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