Ventricular tachycardia is a fast heart rhythm originating from the ventricles with a rate over 100 bpm. It is classified based on duration (sustained vs non-sustained), morphology (monomorphic, polymorphic, sinusoidal), and symptoms. Causes include structural heart disease, electrolyte abnormalities, drugs, and prolonged QT interval. Diagnosis involves ECG criteria showing ventricular origin. Treatment depends on hemodynamic stability and may include antiarrhythmic drugs, implantable cardioverter-defibrillator, catheter ablation, or surgery. Recurrent ventricular tachycardia is managed long term with devices, drugs, and treatment of underlying causes.

1. VENTRICULAR TACHYCARDIA
Dr. Y. Sridhar M.D.
Consultant Intensivist
Dept. of Critical Care Medicine
Apollo Health City, Hyderabad

2. Definition
• Wide complex rhythm QRS>0.12s
• Rate > 100 (or120) bpm
• Origin: from one of the Ventricles i.e., distal to
the bundle of His.
• Three or more consecutive beats on a ECG.

4. Classification
• Duration of Episodes
• Morphology
• Symptoms

5. 1.Duration of Episodes
• Three or More beats on an ECG at a rate
>100bpm originating from Ventricles
• Non Sustained VT : If rhythm self-terminates
spontaneously in less than 30seconds
• Sustained VT : If rhythm lasts > 30seconds
(Even if it self-terminates spontaneously after
30s)

6. 2.Morphology
• Monomorphic VT : same configuration beat to
beat.
• Polymorphic VT : Continually changing QRS
morphology
• Sinusoidal VT :sinusoidal appearance of
rhythm
• Accelerated idioventricular rhythm (AIVR)

7. Monomorphic VT
• Most common cause : circuit through a region
of old MI.
• Idiopathic VT (less common) No identifiable
cause.
• Right Ventricular outflow tract (RVOT)
tachycardia: MC Idiopathic VT
LBBB Morphology with inferior axis.

9. Polymorphic VT
Causes
• Active cardiac Ischemia
• Electrolyte Disturbances
• Drug Toxicity
• Familial
Torsade de pointes (twisting of points)
• Waxing and waning QRS amplitude during
tachycardia associated with prolonged QT interval

11. • Sinusoidal VT: seen in severe electrolyte
disturbances
• Hyperkalemia
• Hypocalcemia
• Hypomagnesemia
• AIVR
» Wide complex ventricular rhythm at a rate of
40-120bpm
» Usually hemodynamically stable
» MC cause :reperfusion arrhytmia in first 12hrs
after acute MI or during periods of elevated
sympathetic tone.
» Typically preceded by sinus slowing
» No treatment necessary. Self terminates.

13. Pathophysiology
• Monomorphic VT :
• Increased automaticity of a single point in
either left or right ventricle
• Reentry circuit within the ventricle
• Polymorphic VT :
• Abnormalities in ventricular muscle
repolarization

14. Etiology
• Structural Heart Disease : MI, Cardiomyopathies
(HCM), Myocarditis
• Electrolyte Abnormalities : Hypokalemia,
Hyperkalemia, Hypocalcemia, Hypomagnesemia
• Sympathomimetic agents : Ionotropes.
• Drug toxicity : Digitalis, Methamphetamine,
Cocaine
• Systemic diseases : Sarcoidosis, RA, SLE.
• Structural Congenital Disorders : Right ventricular
dysplasia, TOF

15. Etiology
Prolonged QT Interval
• Acquired :
• K Channel blocking medication : Quinidine,
Erythromycin, Clarithromycin,Haloperidol,
Droperidol
• Type 1A antiarrythmics : sotalol, amiodarone,
• Congenital :
• Brugada syndrome
• Congenital long and short QT syndromes
• Catecholamingeric polymorphic VT

16. Diagnosis
• “All WCT is VT until proven otherwise”
• AV dissociaton : Dissociation of P wave from QRS
complex.
• QRS Concordance : Absence of rS or Rs complex in
any precordial lead
• RS > 100ms
• Capture beats : Supraventricular beat conducts to
ventricle depolarising ahead of the next
tachycardia beat
• Fusion beats : Depolarisation simultanously with
excitation from a ventricular focus.

21. BRUGAGADA CRITERIA

23. Ultra simple Brugada Criteria
• In 2010 Joseph Brugada published simplified
criteria
• Measuring R wave peak time (RWPT) in Lead
Ⅱ
• RWPT > 50ms
• It measures duration of onset of QRS to first
change in polarity

25. Differential Diagnosis
• SVT with aberrant intraventricular conduction
• Preexcited Tachycardia (associated with or
mediated by accessory pathway)
• BBB
• Ventricular paced rhythms

26. Symptoms
• Chest Pain
• Light headedness
• Palpitations
• Syncope
• Sudden Cardiac Death (SCD) :
• Ambulatory ECG records at SCD have shown 50-
60% at sustained monomorphic VT as the initial
event.

27. Treatment
Depends on Hemodynamics
• Unstable VT
• Stable VT

28. ACLS Cardiac Arrest Algorithm.
Neumar R W et al. Circulation 2010;122:S729-S767
Copyright © American Heart Association

29. Stable VT
• Anti arrhythmic drug (AAD) therapy
• Implantable Cardioverter-Defibrillator (ICD)
• Catheter Ablation Therapy (CAT)
• Antiarrhythmic surgery

30. Tachycardia Algorithm.
Neumar R W et al. Circulation 2010;122:S729-S767
Copyright © American Heart Association

33. AMIODARONE
• Large volume of distribution & long half life
• Contraindications
• Iodine sensitivity
• Sinus bradycardia
• Heart block
• Precautions
• Incompatible with NS
• Preferable via CVC
• Adverse effects
– Short term : Skin reactions,Brady, hypotension,
corneal microdeposits.

34. AMIODARONE
– Long term :
• Pulmonary fibrosis, alveolitis, pneumonitis
• Liver dysfunction..monitor LFT
• Hypo or Hyperthyroidism (check TFT before
starting)
• Peripheral neuropathy, myopathy, Cerebellar
dysfunction.
• Concomitant Beta and Calcium channel
Blockers: Increased risk of bradycardia, AV Block
• Potentiates effect of Digoxin, Theophylline and
Warfarin– Reduce dose

35. Implantable cardioverter-
defibrillator (ICD)
• ICD therapy compared with conventional AAD
associated with mortality reduction of 23-55%
depending on risk group.
• Current ICD options:
– Single chamber
– Dual chamber
– Biventricular cardiac resynchronization
– Multilevel shock discharge for VT or VF
Complications:
Inappropriate shock discharge
Defibrillator storm
Infections
Exacerbation of HF

36. External Defibrillator
• Automated external Defibrillator
• Wearable automatic defibrillator
– Worn under the clothing
– Delivers shock whenever VF is detected.

37. • Procedure targets origin of VT
• Useful in recurrent VT or “VT storm”.
• Catheter is placed into heart chambers through
femoral vein
• Radiofrequency energy is applied which produces
a small burn of about 4 to 5mm in diameter
• Currently recommended in early treatment of VT
when AAD are not preferred or tolerated.

39. Figure 2. Mapping of VT. A 3-dimensional real-time map of the ventricle (created during the
procedure) merged with a computed tomography scan (obtained before the procedure).
Tung R et al. Circulation 2010;122:e389-e391
Copyright © American Heart Association

40. Recurrent VT : Long term
Management
• Risk of recurrence after successful
resuscitation : 30-40%
• Management of Intercurrent diseases
• Implantable Cardioverter Defibrillator
• Long term therapy on Amiodarone.

42. Antiarrhythmic surgery
• Surgical resection of arrhythmogenic focus
• Cardiac Sympathectomy
• Aneurysm resection

43. Thank you!