Presentación del tema: "¿Es imprescindible un EEF antes de indicar un marcapasos a pacientes con síncope y bloqueo bifascicular? Good morning, Ladies and gentlemen Dr. Alboni,"— Transcripción de la presentación:
1 ¿Es imprescindible un EEF antes de indicar un marcapasos a pacientes con síncope y bloqueo bifascicular?Good morning,Ladies and gentlemenDr. Alboni, Dr. MoyaMiguel Álvarez, Luís Tercedor, Antonio Arrebola, Juan Jiménez, Sebastián Galdeano, Pablo Santiago, Rafael Melgares.Servicio de CardiologíaHospital Universitario Virgen de las NievesGranada
2 IntroducciónEn pacientes con síncope de origen desconocido (SOD) y bloqueo bifascicular (BFB) el bloqueo AV (BAV) es la causa más frecuente de las recurrencias.El estudio electrofisiológico (EEF) está indicado en pacientes con SOD y BFB.Si el EEF es positivo es necesario el implante de un marcapasosSi es negativo podría emplearse un registrador de eventos para llegar al diagnóstico.El BAV paroxístico es la causa más frecuente de las recurrencias sincopales en pacientes con SOD y EEF negativo.Los tipos de síncope se pueden predecir por los síntomas
3 An electrophysiological study is indicated in patients with syncope and BBB when non-invasive tests have failed to make the diagnosis.Pacing is indicated in patients with BBB and positive EPS (Class I, Level B)Pacing should be considered in patients with unexplained syncope and BBB (Class IIa, Level C)The most recent guidelines for the management of syncope have stated that an electrophysiological study is indicated in patients with syncope and bundle branch block when non-invasive tests have failed to make the diagnosis. Pacing is indicated in patients with BBB and positive EPS (Class I, Level B). Pacing should be considered in patients with unexplained syncope and BBB (Class IIa, Level C)A Moya, et al. Eur Hear J 2009
4 ObjetivoEvaluar si el tipo de síncope puede predecir los resultados del EEF en pacientes con BFB.The main objective of our study was to evaluate whether the type of syncope predicts the results of electrophysiological study in patients with bifascicular block.
5 Inclusión Exclusión Pacientes remitidos a UA Bloqueo bifascicular Síncope origen desconocidoBloqueo bifascicularBloqueo de rama izquierda oBloqueo de rama derecha yHemibloqueo anterior izdo oHemibloqueo posterior izdoFunción ventricular preservadaNo CardiopatíaCardiopatía HipertensivaMasaje seno carotídeo: NegativoCardiopatía estructuralCI, MD, MH, DAVDICCFEVI deprimida (<45%)Cardiopatía “eléctrica”Síndrome Brugada,SQTL,Síndrome WPWFármacos antiarrítmicosClase IAmiodarona, sotalolBloqueo de rama alternanteHipotensión ortostáticaContraindicación para EEFPatients with U O S referred to our AU were included if they reached the inclusion criteria: BFB on ECG, preserved LVSF in patients with no SHD or HCD and a negative CSM. Patients were not included if they had any SHD, HF, depressed LVSF, electrical cardiac disease, current treatment with AAD, orthostatic hypotension, alternating BBB or contraindication for EPS.
6 Métodos Análisis retrospectivo Anamnesis y exploración física previa a EEFMasaje seno carotídeoTA decúbito y bipedestaciónClasificación de síncopeSospecha BAV paroxístico Grupo ANeuromediado Grupo BOrigen incierto Grupo CIndicación posterior de MP en función del resultado del EEF, tilt test y registrador insertable de eventos: Cardiólogo referidorThe data analysis was retrospective.Clinical history and physical examination (CSM and BP measure) were performed prior the EPS; In regard the non-invasive test ssyncope was catalogued in three groups: A, suspected AVB; B, neurally mediated and C, unexplained syncopePM, ILR and TT were indicated by their cardiologist
7 Estudio Electrofisiológico V1ADaHisaVDThree or two tetrapolar 5-french-catheters were inserted in high right atrium, His bundle region and right ventricle. Intervals were measured in basal state. incremental atrial pacing was then performed. Programmed stimulation was performed to induce atrial and ventricular tachyarrythmias. Procainamide infusion was administered if necessary. The infusion was stopped because of systemic hypotension.An EPS was considered positive if:……..These positive criteria were the same as those published on the recent guidelines.
8 Enfermedad del Sistema His-Purkinje Atrial Pacing (AP) +HV>70 msTest de Procainamida(PA) +
9 Resultados 50 pacientes incluidos Diagnóstico clínico Grupo A. Sospecha BAV:No pródromos: (84,5%)Pródromos < 5 sec: (15,5%)Grupo B. Neuromediado:Pródromos típicos (100%)Grupo C. Origen incierto:No pródromos (27%)Náusea/fatigaPródromos > 5 sec (73%)Mareo, visión borrosaFifty patients were included. Absence of prodromes was the main symptom to distinguish between the types of syncope. 27 were classified into the group A, 22 of them had no prodromes and five had prodromes lasting less than 5 seconds. Twelve patients had neurally mediated syncope with typical autonomic prodromes. Eleven patients had unknown syncope. Three had no prodromes but during the recovery they had symptoms typical of neurally mediated syncope. Eight had prodromes lasting more than 5 seconds but there were not typical autonomic prodromes.S Sud, et al. Heart Rhythm 2009
10 Características basales Grupo ASospecha- BAVGrupo BNeuromediadoGrupo COrigen inciertoHombres (%)625045Edad72±5.668±865±11*RS (%)93100No cardiopatía (%)637383Diabetes (%)15188Presíncope (%)29‡Nº síncope-2 a.2.7±2.23.4±3.38.8±10.4#Evolución meses10.2±20‡43.4±61.346.5±43.1TCE (%)4417†55Características basalesThe patients of group C were younger than the patients of group A. The majority of patients was in NSR, and had no SHD. Patients of group A had a lower percentage of presyncope and a lower evolution time. The patients of group C had more syncopal episodes in the 2 previous years. The patients of group B had a lower percentage of head trauma related to syncope.
11 ECG 12 derivaciones Grupo A Sospecha- BAV Grupo B Neuromediado Grupo C Origen inciertoBRIBRD+HAIBRD+HPI13 (48)1 (4)6 (50)5 (45,5)6 (55,5)QRS ms150±19145±26146±13PR ms194±30179±29182±30QTc ms455±45445±45455±25There were no differences in the 12-lead ECG. QRS-width, length of PR and corrected-QT intervals.
12 Resultados del EEF 73±12 55±11* 66±12 (n=9) HV ms HV interval was equal to or longer than 70 ms in 67% of patients of group A, in 33% in group C and in only 8% of patients of group B (HV was 70 ms). Two patients of group C suffered complete AVB due to injury on right bundle branch, one transient and other permanent. Basal AP was positive in 4 patients of group A (2 patients with long HV interval and 2 with normal HV conduction time) and in one patient of group C. PA test was not performed in patients with AP+ and HV interval longer than 90 ms. PA test was positive in 7 patients of group A. PA test was positive in one patient of group C who had an HV>70 ms. PA was negative in all patients of group C who had a normal HV conduction time. No patients with neuromediated syncope had an AP positive response or a positive PA test.AP= Estimulación auricular progresivaPA= Test Procainamida
13 BAVt: Bloqueo AV traumático AP= Estimulación auricular progresiva A PM was indicated and was implanted in 23 patients of group A with a positive EPS. An ILR was implanted in two patients and no device was implanted in another two. A PM should have been implanted in one patient of group B but it was not implanted in this patient. An ILR was implanted in two (one of them with HV=70 ms). In group C a PM should have been implanted in 4 patients with a positive EPS, but it was implanted in one patient more who had an spontaneous 2nd degree suprahisan AVB, an ILR was implanted in four patients and no device in 2 patients.BAVt: Bloqueo AV traumáticoAP= Estimulación auricular progresivaPA= Test ProcainamidaRIE: Registrador Insertable de eventos
14 Syncope recurrence and AVB or asystolic pause in AF were registered in five patients with an ILR. In one-group B patient NSR was rgisterd during a presyncope episode. ILR was explanted because battery in two patients.
15 Medio PlazoA PM was implanted in all patients in group A with a positive EPS. An ILR was implanted in two patients and no device was implanted in another two. PM was not implanted in any patient of group B. An ILR was implanted in two (one of them with HV=70 ms). In group C a PM was implanted in 5 patients with a positive EPS, an ILR was implanted in four and no device in 2 patients.
16 ConclusionesLas características clínicas del síncope pueden predecir los resultados del EEF en pacientes con bloqueo bifascicular y cardiopatía no significativa.Pacientes con sospecha de BAV paroxístico tienen una elevada probabilidad de enfermedad del sistema His-Purkinje.La indicación de MP podría realizarse sin EEF previoUn EEF o un RIE podrían ser la primera estrategia en pacientes con síncope de origen incierto tras historia clínica.Los pacientes con síncope neuromediado tienen una casi nula probabilidad de enfermedad del sistema His-Purkinje.El seguimiento podría ser la mejor estrategiaISSUE 2Clinical features of syncope can predict the results of EPS in patients with bifascicular block and no significant SHD.Patients with AV-block suspected syncope have a high probability of His-Purkinje system disease.Pacemaker indication could be performed independently of EPSAn EPS or an ILR could be the first strategy in patients with unexplained syncope after clinical historyPatients with neurally-mediated syncope have a near null probability of His-Purkinje system disease.Observation could be the best strategyOther strategy could be that proposed in ISSUE 2