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NON SUSTAINED VENTRICULAR TACHYCARDIA AND APICAL CARDIOMYOPATHY

Israel Aeromedical Center. NON SUSTAINED VENTRICULAR TACHYCARDIA AND APICAL CARDIOMYOPATHY. Dan Carter MD , Bela Azaria MD, Liav Goldstein MD,MHA. Case Presentation. 49 yo A-4 (Skyhawk) weapon system operator (WSO). Medical history: Hepatitis 1983.

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NON SUSTAINED VENTRICULAR TACHYCARDIA AND APICAL CARDIOMYOPATHY

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  1. Israel Aeromedical Center NON SUSTAINED VENTRICULAR TACHYCARDIA AND APICAL CARDIOMYOPATHY Dan Carter MD, Bela Azaria MD, Liav Goldstein MD,MHA

  2. Case Presentation • 49 y\o A-4 (Skyhawk) weapon system operator (WSO). • Medical history: Hepatitis 1983. • 1999- Inverted T waves in routine E.C.G.(V1-V6) Stress test: ST depression. Echocardiography: Concentric hypertrophy. Septal-basal Hypertrophy. No SAM. No outflow obstruction. (septum 12 mm)

  3. Case Presentation • 2002: Cardiac catheterization: Normal coronaries. Spade shape on ventriculography. 24 h ECG recording: Normal. • 2004: 24 h ECG recording: 15 sec NSVT 160 beats\minute (asymptomatic). Stress test: No evidence of arrhythmia.

  4. Diagnosis NSVT and Apical Cardiomyopathy Should we grant a waiver?

  5. Apical Cardiomyopathy • A subtype of HOCM. • More common in the far east. • Symptoms: Atypical chest pain, effort dyspnea, palpitations. (57% of patients). • Usually good prognosis. Ventricular cariomyopathy with ventricular septal hypertrophy localized to the apical region of the left venticle. Maroon et al. Am J Cardiol 1982.

  6. Risk factors for sudden death in HOCM Major risk factors: Cardiac arrest ( ventricular fibrillation) Spontaneous sustained ventricular tachycardia Family history of sudden death Minor risk factors: Left ventricular wall thickness > 30 mm Abnormal blood pressure on exercise Non sustained ventricular tachycardia Left ventricular outflow obstruction Microvascular obstruction High risk genetic defect

  7. NSVT and HOCM • EPS and AICD implantation- Not needed.

  8. Waivers • USAAF: VT associated to cardiomyopathy is permanently disqualifying. • USA NAVY: Permanent grounding. • USA ARMY: Permanent grounding.

  9. Aeromedical consideration • What are the chances for a catastrophic event during flying? • What will be the result of such an event? • Does the flying environment enhance the risk for a catastrophic event?

  10. Factors in favor for grounding • Idiopathic NSVT -0.33% annul hemodynamic compromise. • MR and NSVT- 2.3% annul hemodynamic compromise. • NSVT and IHD or cardiomyopathy- the worst prognosis. Non sustained ventricular tachycardia in 193 u.s. military aviators: long term follow up. ASEM 2000.

  11. Exposure to G is arrythmogenic. • There is worsening is the disease pattern.

  12. Factors in favor for granting a waiver • The total risk for sudden death is HOCM is less then 1%. • NSVT in HOCM is associated with more 1.9 increase in the risk for sudden death (which is less then 1% annually). • The aviator is a WSO. • The aviator is exposed to 2-3G. • The aviators wants to continue his aviation duties.

  13. Decision • A waiver was granted for low performance platforms. • Subsequently, he developed atrial fibrillation after an exercise. Converted to sinus rhythm with propafenone. • Grounded. • Now treated with ß-blockers and aspirin. • 24-rhythm monitoring X 4- normal

  14. Returned to operation as a instructor on low performance platforms.

  15. Thank You

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