When to ablate patients with premature ventricular complexes?

Transcription

1 When to ablate patients with premature ventricular complexes? Nikolaos Fragakis Assistant Professor, FESC 3rd University Cardiology Department Hippokration Hospital, Thessaloniki

2 58 year-old female Case presentation I Symptoms: palpitations associated with dizziness either in exercise or at rest Holter: frequent monomorphic PVC S and episodes of short runs of NSVT Echo: normal Ex. Test: negative for ischeamia Medications: Failure of various antiarrhythmic drugs: b-blocker, verapamil, sotalol

3 Case presentation I Therapeutical Options Amiodarone RF ablation Nothing Referral to someone else

4 Short term success rate 70-90% Limited data on long term success rate

5 RF catheter

6 Case presentation II 43 year-old female Symptoms: No disturbing, occasionally palpitations Holter: Monomorhic PVC S>25000/24hr single or couples Echo: mildly abnormal LV function (EF= 45-50%) Ex. Test: negative for ischeamia MRI : No evidence of ARVC, no other abnormalities Medications: Failure of various antiarrhythmic drugs: b-blocker, amiodarone

7 Case presentation II Options Nothing follow-up in 6/12 or 12/12? RF ablation Referral to someone else

8 Critical Questions raised from this case Does PVCs induced cardiomyopathy exist? Is it reversible? Is ablation an effective therapy in this group of patients? How long should we wait before we apply therapy?

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10 J Am Coll Cardiol 2001;38:364 70

11 PVC- Induced Cardiomyopathy epidemiology v PVC-induced cardiomyopathy was proposed by Duffee et al (1998) when pharmacological suppression of PVCs in pts with presumed idiopathic dilated cardiomyopathy subsequently improved LV systolic dysfunction. Duffee DF et al. Mayo Clin Proc. 1998;73:430-3 v 22 year old female symptomatic pt, > 25000PVCs/24hr, LBBB inferior axis 6 months after ablation EF 43% 58% LVEDD 65mm 57mm Chugh SS et al. JCE 2000;11:328-9

12 Putative mechanisms of PVCs induced Cardiomyopathy Circ Arrhythm Electrophysiol. 2012;5:

13 2 n=289 pts >20.000/day Heart 2009;95:

14 Heart 2009;95:

15 Heart Rhythm 2010;7:

16 Circulation. 2005;112:

17 Other Predisposing Factors of VPC-Induced Cardiomyopathy VPC QRS width (>140 ms) burden of interpolated VPCs presence of NSVT multiform VPCs VPCs of right ventricular origin del Carpio Munoz F, et al. J Cardiovasc Electrophysiol 2011;22:791-8 Yokokawa M, et al. Heart Rhythm 2012;9: Olgun H, et al. Heart Rhythm 2011;8:1046-9

18 European Journal of Heart Failure 2012;14:

19 Proposed electrocardiogram algorithm for predicting VPC-induced pulmonary capillary wedge pressure augmentation European Journal of Heart Failure 2012;14:

20 European Journal of Heart Failure 2012;14:

21 Europace 2013;15:

22 Critical Questions raised from this case Does PVCs induced cardiomyopathy exist? Is it reversible? Is ablation an effective therapy in this group of patients? How long should we wait before we apply therapy?

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24 Critical Questions raised from this case Does PVCs induced cardiomyopathy exist? Is it reversible? Is ablation an effective therapy in this group of patients? How long should we wait before we apply therapy?

25 Studies Demonstrating Improvement of LV Function after VPC treatments with RFA Chen T et al. J Cardiac Fail 2013;19:40-49

26 controls Heart Rhythm 2007;4:

27 PVC-induced cardiomyopathy resolves within 4 months of successful ablation in most patients Heart Rhythm 2013;10:

28 Critical Questions raised from this case Does PVCs induced cardiomyopathy exist? Is it reversible? Is ablation an effective therapy in this group of patients? How long should we wait before we apply therapy?

29 Heart Rhythm 2012;9:92 95

30 Am J Cardiol 2012;110:

31 Heart Rhythm 2012;9:

32 J Am Coll Cardiol 2005;46:

33 Europace 2009;11:

34 Conclusions I PVC ablation efficacy and safety are reasonably good but limitations should be respected The majority of pt with high density PVC do not develop cardiomyopathy PVC induced cardiomyopathy is usually reversible

35 v v Conclusions II the suppression of PVCs is indicated for symptomatic pts with frequent PVCs and those with overt LV dysfunction no evidence for the treatment of asymptomatic patients with normal LVEF to prevent PVC induced cardiomyopathy v In pts with decreased LVEF, a follow-up period of 3 to 12 months after RF is suggested to allow for recovery of LV function v Further research is needed to identify the risk predictors for developing PVC induced cardiomyopathy and to make a recommendation on the need and frequency of echo follow-up

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