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Tahiaritmii ventriculare

Extrasistolele ventriculare
Tahicardia ventriculara
Fibrilatia ventriculara
RIVA

Extrasistolele ventriculare
Def. Depolarizari ventriculare premature.
Clasificare:
1. Dupa forma: monomorfe/polimorfe
2. Dupa tendinta la sistematizare /fen repetitive :
-nesistematizate sau sistematizate: bigeminism/ trigeminism/
quadrigeminism/
-izolate/ cuplate (duplete, triplete)
1. Dupa moment aparitie: precoce (fen. R/T)/ tardive (complexe de fuziune)/
interpolate
2. Dupa frecventa: cls. 0, I (<1/h), II (1-9/h), III (9-29/h), IV (>30/h)
Etiologie:
-

la individ normal, frecventa creste cu varsta

cond patologice: ischemie, infectii (mai ales miocardita, pericardita), febra,


diselectrolitemii (hipoK, hiperCa), medicamente, exces alcool

Clinic: asimptomatici/ palpitatii


-

semne : batai precoce; dedublare paradoxala/larga zg II; accentuare sufluri


ejectionale postextrasist.

EKG
ritm nereg dat ESV
unda P nu este in relatie cu ESV, exc cond retrograda
QRS precoce, larg (> 0.12 sec), deformat, aspect BRD/BRS atipice
modif. sec de faza terminala

cuplaj fix (exc. parasistolie/ polimorfe)


pauza postextrasistolica compensatorie, completa (maj)
DD: extrasistole A cu conducere aberanta
Consecinte ESV
-

consecinte hemodinamice (daca sunt frecvente)

pot determina tulburari maligne de ritm

prognosticul si semnificatia diferite in functie de boala cardiaca de fond si


unele caracteristici lae extrasistolelor (salve, polimorfism, durata QRS)

Tratament
-

cord normal :
-

identificare si indepartare agent cauzal (medicam, cafea, alcool,


nicotina, diselectrolitemii, infectii)

asimptomatici: fara

simptomatici: BBl doze mici, anxolitice, daca nu raspunde BBl doze


uzuale/Ca Bl, linie III: amiodarona

cord patologic: tratam bolii de fond


-

IMA, BCI: BBl, Xilina, Amiodarona

Tahicardia ventriculara
Def. clasic: > 3 complexe QRS consecutive cu origine ventriculara,
frecventa > 100/min.
Clasificare:
Dupa durata :
nesustinuta < 30 s
sustinuta >30 s/degr hemodinamica
Dupa morfologie:
Monomorfa
Polimorfa
Forma speciala: torsada varfurilor

Dupa prezenta/absenta cardiopatie:


1. Pe cord normal
2. Pe cord patologic

Tahicardia ventriculara monomorfa


Def. Aritmie regulata cu origine exclusiv ventriculara, cu morfologie QRS
unica, uniforma, diferita de cea secundara activarii normale sinusale.
Etiologie:
1. Idiopatica (10% TV)- pe cord normal
2. Post IMA, BCI
3. Alte b. cardiace: CMP (H/D/R), miocardite acute, BCC mai ales
postop, valvulopatii, tumori cardiace, displazia aritmogena VD
4. Diselectrolitemii (hipoK, hiper Ca, hipoMg)
5. Ef. secundare terapie: catecolamine, digitala, xantine,
glibenclamid

Tahicardia cu origine in tractul de ejectie VD si variante

mec: postpotentiale tardive prin oscilatii potent. de mb. dependent


de acumularea de Ca intracel

majoritatea progn bun

caract. clinice:
-

predom. femei, tineri

simptome usoare legate de ef/stress

2 forme de prezentare clinica:


repetitiva monomorfa/TV in salve

Aspect ECG TV cu origine in tract de ejectie VD TV repetitiva monomorfa

TV idiopatica VS

mecanism: reintrare cu circuit situat in terit fasc. postero-inferior

fasc antero-superior
apical

caractere clinice
-

predom. barbati, tineri

simptome usoare, in repaus

forme de prezentare clinica:

TV paroxistica/sustinuta
forma incesanta

Aspectul ECG al TV idiopatica VS

Aspect ECG TV cu origine in tract de ejectie VD- TV paroxistica sustinuta

Tahicardia ventriculara monomorfa


EKG:
- ritm regulat/ usor neregulat
- frecventa cardiaca > 100/min
- unda P: disociatie A-V sau condusa retrograd
- QRS larg (> 0.12 sec), morfologie modificata, dar constanta
- capturi ventriculare (complexe inguste pe fond TV) / batai de
fuziune
-aspecte morfologice care nu pot apare in BR

Tahicardia ventriculara monomorfa-tratament


Acces: tratament de urgenta!
TV instabila hemodinamic (EPA, angina, TA<90 mmHg): SEE sinc,
100-360 J
TV stabila hemodinamic:

Procainamida, amiodarona, sotalol i.v sunt cele mai eficace;


alternativa xilina, se poate asocia dc. nu rasp la
monoterapie

SEE in caz de esec

In TV idiopatica:

TV infundibulara dr: Adenozina, Verapamil

TV fasciculara stg: Verapamil

Tratamentul afectiunii de fond si a cond favorizante

Tahicardia ventriculara monomorfa-tratament

Cronic:
-------Tratamentul bolii de baza (!CI )
------- Tratamentul specific antiaritmic
Antiaritmice: amiodarona / sotalol
Defibrilator implantabil:
Indicatii :
-

tulburari maligne de ritm ventricular care nu au cauza


reversibila

TVS in prezenta cardiopatie organica

post IM dc. FE <30% sau < 35% NYHA II sau III%

CMD cu FE <35%

TVNS FE < 40% si TV declansabila la efi

Sincopa cauza neclara cu TV declansabila la efi

Ablatie (radiofrecventa)
Indicatii:

TV recurente sub tratam medicam/ ICD

TV idiopatica simptomatica

TV prin reintrare pe ramuri (forma maligna de TV


monomorfa, care apare in b. cardiace severe)

Indicatii DEF in general


1. Stop cardiac resuscitat prin VF/ TV
2. TV sustinut cu degradare hemodinamica
3. Pacienti postIM dupa >40 zile de la acesta, cu
1. FEVS <35%
2. FEVS <40% si aritmie ventriculara indusa la SEF

3. CMD cu FEVS <30% si ICC cls II, III


4. CMHO, ARVD cu >1 factor risc MS
5. S. QT lung cu istoric sincopa / TV / FV
6. S. Brugada cu istoric sincopa
CI majora durata supravietuire estimata < 1 an

Tahicardia ventriculara polimorfa.


Def. Tahicardie ventriculara cu modificare morfologie QRS permanenta
in orice derivatie.
Torsada varfurilor = forma speciala de TV polimorfa, cu aspect
tipic EKG si asociata cel mai frecvent cu QT prelungit.
Clasificare:
Cu QT lung/ fara QT lung
QT= 0.44 sec
QTc= QT/radical(RR)
Etiologie:
-TV fara QT lg.: b.cardiace (mai ales ischemia ac.)
- TV cu QT lg: congenital/dobandit

Sd. QT lung
Poate fi:
Congenital ( alungire QT, +/- modif morfo ST-T, + sincope/MS),
- mutatii genice la niv gene ce codifica unele

canale

ionice)
Mecanism TV : hipersimpaticotonie la majoritatea
Dobandit:
1. Medicamente (antiaritmice Ia, III, adenozina, ADT,
fenotiazine, haloperidol, antihistaminice nesedative,
cisaprid, papaverina, eritromicina, antifungice)
2. Diselectrolitemii (hipoK, hipoMg)
3. Bradiaritmii (BAV, BNS)
4. B. cerebrovasc (hemoragie subarahnoidiana, AVC)

5. Hipotiroidism

Tahicardia ventriculara polimorfa


Clinic:
-frecvent cu degradare hemodinamica
-rar stabili (TVNS)
Tratament: in functie de prezenta/absenta QT lg.
forme fara QT lung

in urgenta pt TVS: SEE+ tratamentul agresiv al bolii de fond


(ischemie). Tratament medicamentos: amiodarona, BBl

de fond: ICD cand cauza nu poate fi controlata

LQTS
anomalii repolarizare + tahiaritmii ventriculare severe prin
postpotentiale precoce

transmitere genetica, 13 subtipuri


Tip

% cazuri

Mutation

Notes

LQT1

The current through the heteromeric channel (KvLQT1 + minK) is known as IKs.
alpha subunit of the slow delayed
rectifier potassium channel (KvLQT1 amount of repolarizing current. This repolarizing current is required to terminate t
or KCNQ1)
action potential duration (APD). These mutations tend to be the most common ye

LQT2

alpha subunit of the rapid delayed


rectifier potassium channel (hERG +
MiRP1)

Current through this channel is known as IKr. This phenotype is also probably ca

LQT3

alpha subunit of the sodium channel


(SCN5A)

Current through this channel is commonly referred to as INa. Depolarizing curren


thought to prolong APD. The late current is due to the failure of the channel to rem
bursting mode, during which significant current enters abruptly when it should no
common.

LQT4
LQT5
LQT6
LQT7

anchor protein Ankyrin B


beta subunit MinK (or KCNE1),
which coassembles with KvLQT1
beta subunit MiRP1 (or KCNE2),
which coassembles with hERG

LQT4 is very rare. Ankyrin B anchors the ion channels in the cell.
-

potassium channel KCNJ2 (or Kir2.1) The current through this channel and KCNJ12 (Kir2.2) is called IK1. LQT7 leads

LQT8

alpha subunit of the calcium channel


Cav1.2 encoded by the gene
CACNA1c.

LQT9

Caveolin 3

LQT10

SCN4B

LQT11

AKAP9

LQT12

SNTA1

LQT13

GIRK4

Leads to Timothy's syndrome.

Torsada varfurilor
EKG:
-apare pe fond bradicardic, precedata frecvent de bigeminism si de
modif morfologice unda T , QT
prelungit (frecvent
>0.5 sec)
-salve de cate 6-10 QRS largite, cu/fara interval liber, cu varful orientat
alternativ sus-jos; frecventa 200-250/min
Tratament:
Acces:
intrerupere medicatie cu potential de alungire QT

sulfat Mg IV

antiaritmice clsIb;

In caz de esec: cresterea AV (overdrive/isoprenalina)/ SEE


Terapia pe termen lung:
Sd. QT congenital: BBl/simpatectomie ggl cervicotoracici

evtl ICD
Sd. QT dob: trat cauza

Fibrilatie ventriculara
Def. Activare cardiaca rapida, nesistematizata, haotica, asincrona,
ineficienta hemodinamic.
Clasificare:

FV pe cord normal

FV pe cord normal patologic

Etiologie:

FV pe cord normal- exista si sd. caracterizate : Brugada, QT scurt,


Tahicardia catecolergica familiala
IMA, sechele IM (cel mai frecvent)

Alte conditii: HVS, antiaritmice, hipoxie, FiA in WPW, dupa


cardioversie, dupa traumatism cardiac

Clinic:
- frecvent debut brutal cu lipotimie-sincopa
- TA si puls nedecelabil
- zg cardiace absente
- teg reci, cianotice
EKG:

FV: ondulatii neregulate, fara a se observa complexe QRS; cu


unde mari / mici
Tratament:

manevre de RCP

EKG- FV- SEE asincron , 300-360 J

pe termen lung: tratam b. fond + ICD

RIVA
Def. > 3 complexe QRS cu origine ventriculara, cu frecventa 50-100/min,
frecvent cu interval lung de cuplare (in reperfuzie)
Etiologie:
1. Reperfuzie
2.

Necroza miocardica

3.

Toxicitate digitalica

4.

Abuz cocaina
Clinic:
de obicei bine tolerate hemodinamic, autolimitat

EKG:
- ritm regulat/ neregulat
-frecventa > decat ritm idioventricular, dar < decat TV
-disociatie A-V, cu fuziuni (frecvente), capturi
-QRS largi, deformate
- instalare gradata, cu interval lung de cuplare
- terminare gradata
Tratament:
RIVA de reperfuzie: fara tratament
rar: Instabilitate hemodinamica: tahicardizare
(pacing atrial/ atropina)

RIVA nelegat de reperfuzie/digitala: trat ca TV

Toxicitate digitalica: intrerupere tratam, evtl digibind