DISPOSITIVI MEDICI IMPIANTABILI ED ESPOSIZIONE A CAMPI ELETTROMAGNETICI IN AMBITO LAVORATIVO - AUSL Modena

DISPOSITIVI MEDICI IMPIANTABILI ED ESPOSIZIONE A CAMPI ELETTROMAGNETICI IN AMBITO LAVORATIVO

14 Dicembre 2021

Sala Hotel RMH MODENA DES ARTS
Via Luigi Settembrini, 10 - Baggiovara MO

 Indicazioni all’impianto del defibrillatore nel paziente cardiopatico e problematiche connesse

                                   Mauro Zennaro, Cardiologo, Nuovo Ospedale Civile Sant’Agostino Estense

ICD

JACC Vol. 58, No. 10, 2011

               PMs and ICDs as a Percentage of all CIED Implantations: 1993 Versus 2008

Causes of sudden cardiac death in different age groups
 the SCD rate is estimated to range                 Cardiac diseases associated with SCD
 from 1.40 per 100 000 person-years in women to     differ in young vs. older individuals.
 6.68 per 100 000 person-years in men.              In the young there is a predominance of
                                                    channelopathies and, cardiomyopathies
 SCD in younger individuals has an estimated         myocarditis and substance abuse
 incidence of 0.46–3.7 events per 100 000 person-
 years
                                                    In older populations, chronic
                                                    degenerative diseases predominate (CAD,
 CLASSIFICAZIONE - EZIOLOGICA                       valvular heart diseases and HF).

                                                        CARDIOMIOPATIA
                                                             90%

IDIOPATHIC VT
No
No Obvious
   Obvious Structural
           Structural Heart
                      Heart Disease
                            Disease

                           Right Ventricular Tachycardia
                           Repetitive Monomorphic VT
                             Adenosine-sensitive VT
                              Verapamil-sensitive VT
                            Catecholamine-sensitive VT
                                Exercise-induced VT

TACHICARDIE DAL TRATTO DI EFFLUSSO
 FORMA PIU’ FREQUENTE  ADENOSINA SENSIBILE

 EPISODI DI TV TICORRENTI SPESSO INDOTTI DA STRESS PSICOFISICO
E/O AD ESERCIZIO

 CARDIOPALMO E RARAMENTE SINCOPI

 PROGNOSI: BENIGNA (5-20% REMISSIONE SPONTANEA)

                      RVOT                                        LVOT

Structural
Structural Heart
           Heart Disease
                 Disease

                             •• Cardiopatia
                                Cardiopatia Ischemica
                                            Ischemica
                           •• Cardiomiopatia
                              Cardiomiopatia Dilatativa
                                             Dilatativa
                           •• Cardiomiopatia
                              Cardiomiopatia Ipertrofica
                                             Ipertrofica
                             •• Displasia
                                Displasia Aritmogena
                                          Aritmogena
                             •• Sindrome
                                Sindrome di
                                         di Brugada
                                            Brugada
                            •• Sindrome
                               Sindrome del
                                        del QT
                                            QT lungo
                                               lungo

CARDIOMIOPATIA IPERTROFICA

                             Malattia genetica caratterizzata da una sproporzionata
                             ipertrofia del ventricolo sinistro e, occasionalmente,
                             anche di quello destro.
                             Il setto interventricolare è tipicamente coinvolto in
                             modo più evidente rispetto alla parete ventricolare
                             sinistra libera, ma si può osservare anche un'ipertrofia
                             concentrica e apicale.

CARDIOMIOPATIA IPERTROFICA

                             Le caratteristiche alterazioni istologiche
                             comprendono:
                             - DYSARRAY DELLE FIBBRE
                             - FIBROSI MIOCARDICA
                             - ALTERAZIONI DELLE ARTERIE INTRAMURALI
                             Anomalie che non sempre corrispondono alle
                             aree di maggiore ipertrofia.

CARDIOMIOPATIA IPERTROFICA

DISPLASIA ARITMOGENA DEL VENTRICOLO DESTRO

DISPLASIA ARITMOGENA DEL VENTRICOLO DESTRO

DISPLASIA ARITMOGENA DEL VENTRICOLO DESTRO

            ICD therapy should be used in patients with HCM who have
            sustained VT and/or VF and who are receiving chronic
            optimal medical therapy and who have reasonable
            expectation of survival with a good functional status for
            more than 1 y.           CLASSE IIA LIVELLO DI EVIDENZA C

             ICD implantation can be effective for the prevention of SCD
             in patients with ARVC with extensive disease, including
             those with LV involvement, 1 or more affected family
             member with SCD, or undiagnosed syncope when VT or VF
             has not been excluded as thecause of syncope, who are
             receiving chronic optimal medical therapy, and who have
             reasonable expectation of survival with a good functional
             status for more than 1 y.
                                             CLASSE IIA LIVELLO DI EVIDENZA C

CHANNELOPATHIES - BRUGADA

Brugada syndrome is a hereditary primary electrical
disease which is associated with right ventricular
conduction abnormalities.

Clinically, the syndrome is characterized by syncope
and premature sudden death due to ventricular
fibrillation. The ECG pattern may be dynamic with
ECG features varying from diagnostic type I Brugada
ECG to a nondiagnostic type II or III ECG or an even
normal baseline ECG. The ECG pattern may be
accentuated by administration of sodium channel
blocker or by environmental influences such as an
increased vagal tone or fever.

In 20–40% of the affected patients, underlying
mutations in the SCN5A gene can be identified which
cause a loss of function of the sodium current INa.

CHANNELOPATHIES - LQTS

Congenital LQTS is a cardiac channelopathy marked by
a variable degree of QT prolongation and by episodes
of syncope and sudden death due to ventricular
tachyarrhythmias.

The QT prolongation and susceptibility to ventricular
tachyarrhythmia result from ion channel dysfunction
with prolongation of repolarization abnormalities
predominantly by decreased outward potassium
current, IKs (LQT1, LQT5) or IKr (LQT2, LQT6), or by
enhanced activity of mutant inward sodium current
INa (LQT3). Genetic testing in LQTS can detect an
underlying mutation in 60–70% of patients

CARDIOPATIA ISCHEMICA CRONICA

Il rischio

        HF                              PCI                               CABG
Rischio maggiore nei primi 30   Rischio maggiore nei primi 90   Rischio maggiore nei primi 90
giorni post-IM                  giorni post-PCI                 giorni post-GABC

Bauer A et al. Eur Heart J, 2009, 30, 576–583

6J A C C V O L . 6 7 , NO . 2 5 , 2 0 16

European Heart Journal (2000) 21, 2071–2078

Arrhythmic death was rather dramatically reduced, with a relative risk reduction of 50%
                      in favour of ICD compared to amiodarone.

Patients with better preserved left ventricular function appeared to obtain little or no benefit
from the ICD, whereas those with moderate to severe left ventricular dysfunction obtained a
                               significant benefit from the ICD.

J Am Heart Assoc. 2020
                                                    31 701 patients, 3631 (11.5%) with ICD

Fixed-effects Risk Ratio for Sudden Cardiac Death

Fixed-effects Risk Ratio for All-Cause Death

lower risk of all-cause death in patients with ICD compared to patients without ICD, highlighting
the complementarity of pharmacological therapy with devices in patients with HFrEF

BMJ Open 2017
2573 patients

ICD is associated with lower all-cause mortality

ICD is potent in reducing SCD, but it cannot modify other competing non-cardiac death events.

Primary prevention ICD therapy in patients with NICM was
associated with 21% relative risk reduction and 3% absolute risk
reduction in all-cause mortality (number needed to treat=33)

            There was a suggestion of possible effect modification by age, with more benefit
            in patients

ICD for the secondary prevention of
sudden cardiac death and ventricular
tachycardia

OMT

5485 patients were included : 2181 (39.8%) with NICM and 3304 (60.2%) with ICM.

Cox proportional hazards analysis for baseline characteristics associated with all-cause mortality

J Am Heart Assoc. 2021

4296
patients

 The overall cumulative incidence of
 appropriate ICD therapy was:

 14% (95% CI, 13%–15.2%) at 1 year,

 26% (95% CI, 24.7%–27.7%) at 3 years

 36% (95% CI, 34.4%– 38.2%) at 6 years

J Am Heart Assoc. 2021

The cumulative incidence of
all-cause death was:
5% (95% CI, 4%–6%) at 1 year

13% (95% CI, 12%–14%) at 3 years

25% (95% CI, 24%–26%) at 6 years

In the multivariate analysis, sex, increasing age, previous AF, chronic kidney disease, diabetes
mellitus, and impaired LVEF emerged as independent predictors of all-cause death

European Heart Journal (2019)

                           Cumulative lifetime risk of device-related infection

significant host-related risk factors
for device-related infection

procedure- and device-related risk
factors for device-related infection

Wearable cardioverter defibrillator

Journal of Arrhythmia 32 (2016)

                                  Independent associates of psychological
                                          characteristics scores

GRAZIE