MANAGEMENT OF PVCS AND VT IN ADV HF:

THERAPEUTIC OPTIONS AND NOVEL

APPROACHES MARCH 16, 2015

Melissa R. Robinson, MD FACC FHRS CCDS Assistant Professor of Medicine

Director of the Complex Arrhythmia Service

University of Washington, Seattle

CASE: 27 Y.O. WOMAN WITH “PPCM”

• NICM for five years

• on optimal GDT for 1 year

• NYHA Class III, being considered for LVAD/Tx

• Referred for primary prevention ICD for EF < 30%

CASE: 27 Y.O. WOMAN WITH “PPCM”

• TTE – frequent ectopy,

•LVEF est. 23%, LVEDD 71 mm

• de MRI was normal

• Holter monitor showed 38% monomorphic PVCs, rare NSVT

•Antiarrhythmic?

•ICD?

•PVC Ablation?

PRIMARY ELECTRO-CARDIOMYOPATHY

• Frequent ventricular ectopy itself can cause a cardiomyopathy

• Mechanism

•Dyssynchrony

•Decrease in Ito and IK1 currents

•Δs in spatial relationship of L-type Ca2+ channels and ryanodine receptors

• Increasing data that it is often reversible with abolition of PVCs.

Bogun, et al. Heart Rhythm 2007;4:863 Wang Y, Heart Rhythm 2014:11;2064

PVC INDUCED CARDIOMYOPATHY

Baman T, Heart Rhythm 2010:7(7);865 Baman T, Heart Rhythm 2010:7;865

35%

54%

LVEF IMPROVES WITH PVC RFA IN ICM

Sarrazin J, Heart Rhythm 2009:6(11);1543

• 30 pts with ICM referred

for ICD with frequent

PVCs

• Randomized to PVC

ablation + ICD or ICD

alone

• Control group saw no

change in EF

38%

51%

• 30 pts with NICM, scar on MRI, >5% PVCs

• Pleomorphic PVCs

• Most localized to scar – not idiopathic regions

• 60% overall ablation success

• EF improvement 34 to 46%

PVC ABLATION IN NICM PTS

El Kadri M, Heart Rhythm 2015; in press

CASE: RCC PVC ABLATION

Gami AS, JICE 2011;30:5

PVC ABLATION IN ADV HF

• Morphology is important – idiopathic regions

(outflow tract, annular, papillary m) are more

favorable ablation outcome

• Medical therapy less effective than ablation

• CRT pts with high PVC burden (>22%) improve

EF, LV size with RFA of PVCs

• Safe, well tolerated procedures

Zhong L, Heart Rhythm 2014;11:187

Lakkireddy D, JACC 2012;60:1531

CASE: 60 Y.O. MAN NICM AND VT

• LVEF 20%

• Bi-v ICD

• Carvedilol 12.5mg 2

• Amiodarone 200mg1

• Aldactone, Losartan

• Presyncopal

• β Blockers

•Dose should be maximized

• Amiodarone

•Caution with β blockers, digoxin, warfarin

•May slow VT below detection zone

•Can increase DFT

• Sotalol

•Can have neg inotropy

• Mexiletine

ANTIARRHYTHMICS

Vassallo P, JAMA 2007;298:1312

Connelly S, JAMA 2006;294:165

• Dofetilide

• Class Ic agents

•Non-ischemic CM pts

•Added to amiodarone

• ICD should be present

• Ranolazine

•Small series show decreased VT burden

•Added to Class III agents

• Ischemic and non-ischemic CM pts

NOVEL ANTIARRHYTHMIC STRATEGIES

Bunch J, PACE 2011;34:1600

Pinter A, JACC 2011;57:380

Note: These are all

off label uses for

these drugs

VT ABLATION SHOULD NOT BE A RX OF LAST RESORT

Frankel D, JCE 2011;22:1123

Early Group

Late Group

• Late referrals – ≥2 episodes separated by one month

• 2/3 pts were late referrals

• More likely to be in VT storm, on high dose amiodarone, slightly older

• LVEF same

VT ABLATION BENEFIT IN LOWER EF PTS

Bunch J, Heart Rhythm 2014;11:533

Tung R, JCE 2010;21:799

• SMASH-VT analysis, benefit of ablation was independent of EF.

• Trend towards more recurrences in Class III – IV patients, however

• Bunch, et al, evaluated a registry of device and ablation patients

• 102 pts after VT ablation for ICD shock

• 2088 pts without ICD shock

• 817 pts with shock, but no ablation

HEMODYNAMIC SUPPORT DURING VT ABLATION

Miller M, Heart Rhythm 2012;9:1168

• Dilated pts with faster VTs

• Normal PAP, RV ƒ(x)

• General anesthesia

• Impella CP

•Better support

•Less EAM interference

• 14F CFA access

BENEFITS OF PLVAD DURING VT ABLATION

Aryana A, Heart Rhythm 2014;11:1122

• Longer mapping times in VT

• Decreased post-ablation hemodynamic embarrassment

• Possibly increase success of VT ablation

CASE: 60 Y.O. MAN NICM AND VT

• LVEF 20%

• Bi-v ICD

• Carvedilol 12.5mg 2

• Amiodarone 200mg1

• Aldactone, Losartan

• Presyncopal

• Underwent pVAD

supported ablation

• Discharged next

day

• VT free for 14 mo

later off of

amiodarone

LIMITATIONS OF THE PERCUTANEOUS

APPROACH TO VT RFA

• Recurrent/refractory VT

• Inability to access the pericardium (prior CABG or valve surgery)

• Location near phrenic nerve or coronary artery

• Inaccessible area for ablation

•septum*

•midmyocardial

•Epicardial fat

• Insulated 0.014”

wire used for

mapping

• Coil or alcohol

injection after

testing for effect

INTRACORONARY MAPPING FOR VT

Tholakanahalli V, Heart Rhythm

2013;10:292

NEEDLE ABLATION FOR VT

Sapp J, JCE 2006;17:65 Sapp J, Circ 2013;128:2289

SURGICAL ABLATION

Soejima K, Circ 2004;110:1197

• Cardiac Electrophysiologist

• Device Clinic Staff

• Advanced Heart Failure/Transplant

• Cardiac Anesthesiologists

• Interventional Cardiologists

• Cardiac Surgeons

• Pharmacists

• Psychiatrists

• Palliative Care Team

MANAGEMENT OF VT IN ADVANCED HF

mrrw@uw.edu