Download Does asymptomatic patients with very frequent ventricular ectopy

Does asymptomatic patients with very frequent ventricular
ectopy need prophylactic catheter ablation
to prevent the development of cardiomyopathy
Minglong Chen, MD
Division of Cardiology
The First Affiliated Hospital of Nanjing Medical University
Risk of very frequent PVCs
in asymptomatic patients
PVC-CMP developed
Sudden death increased
Risk of very frequent PVCs
PVC burden
≤20%
＞20%
LVEF
45±1mm
54±1mm
CTR
46±1%
52±2%
LVEF
73±2%
66±2%
MR
0.4±0.1
1.2±0.2
NYHA
1.3±0.1
1.8±0.2
All P ＜ 0.05
Takemoto M, et al. J Am Coll Cardiol, 2005;45:1259–65
Prognostic significance of
frequent PVCs with normal LV function
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239 pts with frequent PVCs (>1000 beats/day)
Structural heart disease was ruled out, FU period of 5.6 ys
no patients exhibited any serious cardiac events.
negative correlation between the PVC prevalence and DeltaLVEF
(p<0.001)
• positive correlation between the PVC prevalence and DeltaLVDd
(p<0.001).
• PVC prevalence and LVEF at the initial evaluation were
independent predicting the development of LV dysfunction (p<0.01)
Niwano S, et al. Heart, 2009, 95(15):1230-1237
PVC-CMP more easily attacked
in asymptomatic patients
The proportion of asymptomatic patients was significantly higher
in the presence of cardiomyopathy (36/76, 47%) than in normal
LV function (25/165, 15%)
Yokokawa M, et al. Heart Rhythm, 2012;9:92–95
Incidence of PVC-CMP
• Definition: LVEF of ≤50% in the absence of any detectable
underlying heart disease and improvement of LVEF≥15%
following effective treatment of index ventricular
• Incidence: 6.8% in patients with idiopathic ventricular
arrhythmias
• Predictors: gender, absence of symptoms, PVC burden,
the presence of repetitive monomorphic VT, and so on
Hasdemir C, et al. J Cardiovasc Electrophysiol, 2011,22:663-668
Sudden death increased
• prospective study,15 637 apparently healthy white men, 35
to 57 ys
• prevalence of any VPC was 4.4% (681 of 15,637)
• Over FU of 7.5 years, a total of 381 deaths occurred
• The presence of any VPC was associated with a
significantly higher risk for SCD (adjusted RR=3.0; P ＜
0.025)
• frequent (2 or more uniform VPCs every 2 minutes) or
complex (multiforms, pairs, runs, R-on-T) VPCs were at a
significantly increased risk of SCD (adjusted RR=4.2; P ＜
0.005)
Abdalla IS, et al. Am J Cardiol, 1987, 60:1036 -1042
Baseline examination from 1987 to 1989, 2-minute
rhythm strip of EKG
follow-up data collected until December 2002
14,574 subjects,130 incident cases of SCD
Participants with VPC were 2 times as likely to have SCD
compared to those without VPC (HR2.09, 95% CI1.22 to
3.56)
Cheriyath P, et al. Am J Cardiol, 2011, 107:151-155
Cheriyath P, et al. Am J Cardiol, 2011, 107:151-155
Characteristics of PVC-CMP
• Enlarged LVDd and CTR, reduced LVEF,
increased MR, and deteriorated NYHA functional
class
• PVC-CMP was resolved within 2 to 4 weeks after
discontinuation of PVCs
• No inflammation, fibrosis, or changes in apoptosis
and mitochondrial oxidative phosphorylation
Takemoto M, et al. J Am Coll Cardiol, 2005;45:1259–65
Huizar JF, et al. Circ Arrhythm Electrophysiol, 2011;4:543-549
Huizar JF, et al. Circ Arrhythm Electrophysiol, 2011;4:543-549
Mechanism of PVC-CMP
• a short PVC coupling
• LV dyssynchrony during PVCs
• postextrasystolic potentiation
(Which could increase in intracellular Ca2+ and
myocardial oxygen consumption)
Huizar JF, et al. Circ Arrhythm Electrophysiol, 2011;4:543-549
Determinants of PVC-CMP
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PVC burden?
QRS width?
NSVT?
Duration?
Symptom or absence of symptom?
Gender?
….........
≤20%
＞20%
LVEF
45±1mm
54±1mm
CTR
46±1%
52±2%
LVEF
73±2%
66±2%
MR
0.4±0.1
1.2±0.2
NYHA
1.3±0.1
1.8±0.2
All P ＜ 0.05
PVC burden
Takemoto M, et al. J Am Coll Cardiol, 2005;45:1259–65
reduced LVEF (n = 17) vs normal LVEF (n = 53)
burden of PVCs: (29.3 ± 14.6% vs 16.7 ± 13.7%, P = 0.004)
PVC burden
Carpio Munoz, FD, et al. J Cardiovasc Electrophysiol, 2011, 22,791-798
• 57Pts with reduced LVEF(0.37 ±0.10)
• 117Pts with normal LVEF
• PVC burden:33% ± 13% VS 13 ± 12%
PVC burden ＞ 24% was independently associated with PVC-CMP
sensitivity :79% , specificity :78%, under curve:0.89
PVC burden
Baman TS, et al. Heart Rhythm, 2010;7:865–869
• 17Pts with reduced LVEF
• 227Pts with normal LVEF
• PVC burden:29% ± 9% VS 8 ± 7%
PVC burden ＞ 16% was independently associated with PVC-CMP
sensitivity :100% , specificity :87% ,under curve:0.96
Hasdemir C, et al. J Cardiovasc Electrophysiol, 2011,22:663-668
PVC burden
QRS duration＞150 ms predict PVC-CMP: sensitivity 80%; specificity
52%
PVC burden for developing PVC-CMP
PVC-QRS width of ≥ 150 ms vs narrower PVC-QRS complex
(22% ± 13% vs 28% ± 12%; P＜0.0001)
QRS duration
Yokokawa M, et al. Heart Rhythm, 2012, 9:1460-1464
QRS duration
Deyell MW, et al. Heart Rhythm, 2012;9:1465–1472
QRS duration and NSVT
Carpio Munoz, FD, et al. J Cardiovasc Electrophysiol, 2011, 22,791-798
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Others: male, asymtomatic status
Yokokawa M, et al. Heart Rhythm, 2012;9:92–95
Does VPCs ablation
reverse LV function?
implication of medical therapy
• 7 pts with more than 20,000 VPCs in holter
(EF:40% or less) received additional cardiac
medical therapy, including 4 patients with
amiodarone therapy
• After medical therapeutic intervention , 75%
VPCs or more reduction from baseline in 5 pts
• 6±3m FU, EF increased from (27±10)% to 49
+/- 17% in the 5 pts
suppression of frequent VPCs
may be associated with improvement of left ventricular function
Duffee DF, et al. Mayo Clin Proc, 1998, 73(5):430-433
8pts，VPCs 17 541±11 479 per day
Before abl:LVEF39%±6%，post abl:62%±6%，P=0.017
Yarlagadda RK, et al. Circulation, 2005, 112:1092-1097
47pts
PVCs＞10000/d, average 24194±12516/d
38pts RF successfully(GROUP 1), 9 pts unsuccessfully(GROUP 2)
GROUP1
Sekiguchi Y, et al. J Cardiovasc Electrophysiol, 2005,16:1057-1063
GROUP2
Plots of BNP levels before and after RFCA in the two groups
• 22/60 Pts with reduced EF 34% ± 13%
• VPCs burden: 37% ± 13% vs. 11% ± 10%
• Patients with reduced EF: before abl vs after abl, 34% ±
13% to 59%±7%
• EF remained unchanged in control group
Bogun F, et al. Heart Rhythm, 2007;4:863– 867
Controll group
ablation group
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69 pts (51 ± 16 ys)
LVEF35% ±9%, LVDD5.8 ± 0.7 cm
Frequent outflow tract VPCs (29% ± 13%)
11 ± 6 months FU
The magnitude of LVEF improvement correlated with the decline in
residual VPD burden (r=0.475, P=.007)
Mountantonakis SE, et al. Heart Rhythm, 2011;8:1608 –1614
Predictors of recovery of LV function
following the elimination of VPCs
Mountantonakis SE, et al. Heart Rhythm, 2011;8:1608 –1614
Deyell MW, et al. Heart Rhythm, 2012;9:1465–1472
Do we need catheter ablation to prevent the
development of cardiomyopathy