nikolaos fragakis - livemedia.gr · case presentation ii 43 year-old female symptoms: no...

Nikolaos Fragakis

Assistant Professor, FESC

3rd University Cardiology DepartmentHippokration Hospital, Thessaloniki

When to ablate patients with prematureventricular complexes?

Case presentation I• 58 – year-old female

• Symptoms: palpitations associated with dizziness either in exercise orat rest

• Holter: frequent monomorphic PVC’S and episodes of short runs ofNSVT

• Echo: normal

• Ex. Test: negative for ischeamia

• Medications: Failure of various antiarrhythmic drugs: b-blocker,verapamil, sotalol

Case presentation ITherapeutical Options

• Amiodarone

• RF ablation

• Nothing

• Referral to someone else

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

RF catheter

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

Case presentation II

Options

• Nothing

• follow-up in 6/12 or 12/12?

• RF ablation

• Referral to someone else

Critical Questions raised from this case

• Does PVCs induced cardiomyopathy exist?

• Is it reversible?

• Is ablation an effective therapy in this groupof patients?

• How long should we wait before we applytherapy?

J Am Coll Cardiol 2001;38:364 –70

PVC- Induced Cardiomyopathyepidemiology

v PVC-induced cardiomyopathy was proposed by Duffee et al (1998)when pharmacological suppression of PVCs in pts with presumedidiopathic dilated cardiomyopathy subsequently improved LV systolicdysfunction.

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

Putative mechanisms of PVCsinduced Cardiomyopathy

Circ Arrhythm Electrophysiol. 2012;5:229-236

2

>20.000/day

5.000-200001000-5000

n=289 pts

Heart 2009;95:1230–1237.

Heart 2009;95:1230–1237.

Heart Rhythm 2010;7:865–869

Circulation. 2005;112:1092-1097

Other Predisposing Factors ofVPC-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;22:791-8Yokokawa M, et al. Heart Rhythm 2012;9:1460-4Olgun H, et al. Heart Rhythm 2011;8:1046-9

European Journal of Heart Failure 2012;14:112–1120

Proposed electrocardiogram algorithm forpredicting VPC-induced pulmonarycapillary wedge pressure augmentation


Europace 2013;15:735–741

Studies Demonstrating Improvement ofLV Function after VPC treatments with

RFA

Chen T et al. J Cardiac Fail 2013;19:40-49

controls

Heart Rhythm 2007;4:863– 867

Heart Rhythm 2013;10:172–175

PVC-induced cardiomyopathy resolves within 4 months of successful ablationin most patients

Heart Rhythm 2012;9:92–95

Am J Cardiol 2012;110:852– 856

Heart Rhythm 2012;9:1465–1472

J Am Coll Cardiol 2005;46:1288 –94

Europace 2009;11:771–817

Conclusions I• PVC ablation efficacy and safety are reasonably

good but limitations should be respected

• The majority of pt with high density PVC do notdevelop cardiomyopathy

• PVC induced cardiomyopathy is usually

reversible

Conclusions IIv the suppression of PVCs is indicated for symptomatic pts with

frequent PVCs and those with overt LV dysfunction

v no evidence for the treatment of asymptomatic patients withnormal LVEF to prevent PVC induced cardiomyopathy

v In pts with decreased LVEF, a follow-up period of 3 to 12months after RF is suggested to allow for recovery of LVfunction

v Further research is needed to identify the risk predictors fordeveloping PVC induced cardiomyopathy and to make arecommendation on the need and frequency of echo follow-up

nikolaos fragakis - livemedia.gr · case presentation ii 43 year-old female symptoms: no...

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