Novel approaches to PVC

1. PVC
&
HEART FAILURE
THERAPEUTIC OPTIONS
AND NOVEL APPROACHES
Alireza Ghorbani Sharif, MD
Electrophysiologist
Tehran arrhythmia Clinic
May 2016

2. DEFINITION
• Premature ventricular contractions (PVCs) are early
depolarization of the myocardium originating in the
ventricle.
• Traditionally they have been thought to be relatively
benign in the absence of structural heart disease.
Yong-Mei Cha, MD; Glenn K. Lee, MBBS; Kyle W. Klarich, MD; Martha Grogan, MD, (Circ Arrhythm Electrophysiol. 2012;5:229-236.)

3. PVCS
Compensatory
Pause
Interpolated
PVCs

4. ETIOLOGY
• Causes:
• Hypoxia
• Myocardial Ischemia
• Electrolyte Imbalance
• Digitalis Toxicity
• Congestive Heat Failure or CHF
• Idiopathic

5. PVCS AND
VENTRICULAR TACHYCARDIA

6. EPIDEMIOLOGY
• PVCs are common with an estimated prevalence of 1% to
4% in the general population.
• In a normal healthy population PVCs have been detected in
1% of subjects on standard 12-lead electrocardiography and
between 40% and 75% of subjects on 24- to 48-hour Holter
monitoring.
• Their prevalence is generally age-dependent ranging from
1% in children 11 years 7 to 69% in subjects 75 years.
Yong-Mei Cha, MD; Glenn K. Lee, MBBS; Kyle W. Klarich, MD; Martha Grogan, MD, (Circ Arrhythm Electrophysiol. 2012;5:229-236.)

7. PVC-INDUCED CARDIOMYOPATHY
(PVCI-CMP)
• Commonly thought to be a benign entity the concept of PVC-
induced cardiomyopathy was proposed by Duffee et a in 1998
when pharmacological suppression of PVCs in patients with
presumed idiopathic dilated cardiomyopathy subsequently
improved left ventricular (LV) systolic dysfunction.
• It was only15 years ago that the term of (PVCi-CMP) emerged.
Yong-Mei Cha, MD; Glenn K. Lee, MBBS; Kyle W. Klarich, MD; Martha Grogan, MD, (Circ Arrhythm Electrophysioloy. 2012;5:229-236.)
Marie Sadron Blaye- Felice,MD et al, (Heart Rhythm2016;13:103–110)

8. MECHANISMS AND PATHOPHYSIOLOGY
Yong-Mei Cha, Circ Arrhythm Electrophysiol. 2012;5:229-236.

9. WHICH CAME FIRST
THE CHICKEN OR THE EGG?

10. CLINICAL EVALUATION
• Because a single 24-hour recording may not reflect the true PVC load due to day-to-day
variability, a strong suspicion that frequent PVCs may be the cause of LV dysfunction
may warrant extended Holter recordings of 48 to 72 hours or several 24-hour Holter
recordings.
• Echocardiographic features in PVC-induced cardiomyopathy include decreased LVEF,
increased LV systolic and diastolic dimensions, wall motion abnormalities, which are
often global as opposed to regional as well as mitral regurgitation (typically due to mitral
annular dilatation)
• Two-dimensional speckle tracking strain imaging detect subtle changes in the ventricles
function whereas the LVEF remains preserved.
Yong-Mei Cha, MD; Glenn K. Lee, MBBS; Kyle W. Klarich, MD; Martha Grogan, MD, (Circ Arrhythm Electrophysiol. 2012;5:229-236.)

11. CLINICAL EVALUATION
• Coronary angiography should be performed in every patient with
reduced LV systolic function to exclude significant coronary artery
disease except for those with a low cardiovascular risk.
• Cardiac MRI may be warranted in detecting arrhythmogenic right
ventricular cardiomyopathy with LV involvement and infiltrative
disease when clinically suspected.
Yong-Mei Cha, MD; Glenn K. Lee, MBBS; Kyle W. Klarich, MD; Martha Grogan, MD, (Circ Arrhythm Electrophysiol. 2012;5:229-236.)

12. PARAMETERS SIGNIFICANTLY RELATED
TO THE PVCI-CMP
1. PVC burden
2. Symptoms : Presence or absence of palpitation
3. Duration of symptoms
4. Age and gender
5. Morphology and Sit of origin
Marie Sadron Blaye-Felice, MD, (Heart Rhythm2016;13:103–110)

13. PVCS BURDEN
• Majority of patients with frequent PVCs have a benign course
whereas up to one third of them develop PVCi-CMP.
• The prevalence of PVCi-CMP is estimated as only 5% to 7%
among patients with a PVC burden 10%.
• Baman and Fred Morady et al suggested that a PVC burden of
24% had a sensitivity and specificity of approximately 80% in
separating the patient populations with impaired versus preserved
LV function.
Yong-Mei Cha, MD; Glenn K. Lee, MBBS; Kyle W. Klarich, MD; Martha Grogan, MD, (Circ Arrhythm Electrophysiol. 2012;5:229-236.)
Timir S. Baman, MD, Fred Morady et al, (Heart Rhythm 2010;7:865–869)

14. PVCS BURDEN
• Takemoto et al analyzed the result of ablation with relation to 3 pre
specified subgroups (<10%,10%–20%, >20%) based on the burden of
PVCs on 24-hour Holter monitoring the subgroup with >20% of PVCs
at baseline had the most benefit from ablation with significant
improvement in LVEF and LV dimensions
• When the PVC burden was expressed in the absolute number of PVCs
before RFA, the subgroup with >20 000 PVCs per day was shown to be
associated with highest risk of LV dysfunction and heart failure.
Clin. Cardiol. 38, 4, 251–258 (2015) A. Saurav et al: PVC-induced cardiomyopathy

15. SYMPTOMS
AGE AND GENDER
• Absence of symptoms are independently associated with PVCi-
CMP because diagnosis of PVCs is delayed in asymptomatic patients
often made fortuitously over the course of the developing CMP
• The duration of palpitations of 30 to 60 months specially more than
60 months
• More common with increasing age and in males
Marie Sadron Blaye- Felice, MD, (Heart Rhythm2016;13:103–110)
Fred Morady , MD, et al ,Heart Rhythm 2012;9:92–95

16. MORPHOLOGY AND SITE OF ORIGIN
• Long PVC-QRS duration
• Epicardial origin of the focus
• Interpolated PVCs
• LV origin of PVCs
• Long PVC coupling interval
• High PVC QRS amplitude
• Presence of polymorphic PVCs

17. MORPHOLOGY AND SITE OF ORIGIN
• Longer PVC-QRS duration, especially in the presence of a LBBB
participate in the alteration of LV function because of the electrical
and therefore likely associated mechanical dyssynchrony.
• Epicardial PVCs have longer PVC-QRS duration than other PVCs
probably because of the paucity of Purkinje fibers in the
epicardium.
Marie Sadron Blaye- Felice, MD, (Heart Rhythm2016;13:103–110)

18. EPICARDIAL PVCS

19. MORPHOLOGY AND SITE OF ORIGIN
• Interpolated PVCs have a longer Ventriculo-atrial block
cycle length compared with PVCs without interpolation.
• The total PVC burden increased with interpolation
Clin. Cardiol. 38, 4, 251–258 (2015) A. Saurav et al: PVC-induced cardiomyopathy

20. INTERPOLATED PVCS
Clin. Cardiol. 38, 4, 251–258 (2015) A. Saurav et al: PVC-induced cardiomyopathy

21. MORPHOLOGY AND SITE OF ORIGIN
LV origin of PVCs
Long PVC coupling interval
High PVC QRS amplitude
Presence of polymorphic
PVCs
Marie Sadron Blaye-Felice, MD, (Heart Rhythm2016;13:103–110)
Fred Morady, MD et al, (Heart Rhythm 2011;8:1046 –1049)

22. TREATMENT OPTIONS
• Medical Therapy
• Catheter Ablation

23. MEDICAL THERAPY
• Anti-Failure therapies
• Typically, in mildly symptomatic patients with mild LV dysfunction a
trial of β-blockers or a nondihydropyridine calcium channel blocker
should be considered as first-line therapy.
• Class Ic and III antiarrhythmic agents such as flecainide and sotalol
are effective but with significant adverse effect.
• These agents, with the exception of amiodarone, should not be used
in patients with sever LV dysfunction.
Fred Morady, MD et al, (Heart Rhythm 2011;8:1046 –1049)

24. CATHETER ABLATION
• There are growing evidence in favor of catheter ablation for PVCs especially in the
presence of LV dysfunction.
• Multiple studies demonstrating high efficacy of catheter ablation of PVCs with success
rates ranging from 80% to 100%.
• Procedural success may be dependent on the site of origin with lower efficacy for
epicardial foci or multiple PVC morphologies.
• Major complications occur in approximately 3% of cases including death stroke
myocardial infarction cardiac perforation with or without pericardial tamponade pericardial
effusion and blood vessel dissection or stenosis.
A. Saurav et al: PVC-induced cardiomyopathy Clin. Cardiol. 38, 4, 251–258 (2015)

25. CATHETER ABLATION
• In patients with frequent PVCs and PP-ICD indication
ablation improves LVEF and, in most cases, allows removal of
the indication.
• Withholding the ICD and reevaluating within 6 months
of ablation seems to be a safe and appropriate strategy
Ablation of frequent PVCs in patients meeting
criteria for primary prevention ICD implant:
Heart Rhythm. 2015 Dec;12(12):2434-42. doi: 10.1016/j.hrthm.2015.09.011. Epub 2015 Sep 15.

26. • Sarrazin et al considered frequent PVCs to be 5% of the beats observed on a
24-hour monitor.
• Our data suggest that despite the presence of scar tissue in post infarction
patients a component of reversible cardiomyopathy may be present in patients
with frequent PVCs.
• A low ejection fraction with a small amount of scar tissue may suggest a
potentially reversible cardiomyopathy.
Renee M. Sullivan, MD, Brian Olshansky, MD, FHRS doi:10.1016/j.hrthm.2009.08.029
CATHETER ABLATION
How many PVCs are too many in post-MI
patients:

27. PVC MEDIATED CARDIOMYOPATHY
• Ablation of PVC in patient in presence of
structural heart disease
• Reverse or stop of progression of LV dysfunction

28. CATHETER ABLATION
• Frequent PVCs to be 4-5% of the beats observed on a 24-hour monitor
• In patients with frequent PVCs and nonischemic cardiomyopathy EF and
functional class can be improved but not always normalized by
successful PVC ablation
Effect of ablation of in patients with nonischemic
cardiomyopathy:

29. EFFECTIVENESS OF ABLATION
IN PVCI-CMP
• The criterion for an effective ablation procedure was an 80%
reduction in the PVC burden.
• Improved by at least 15% or normalized (ejection fraction 50%)
after an effective ablation procedure.
Timir S. Baman, MD, Fred Morady et al, (Heart Rhythm 2010;7:865–869)

30. CONCLUSIONS
• Frequent PVCs may be the consequence of LV systolic dysfunction
or the cause of LV dysfunction.
• Reduction of frequent PVCs with antiarrhythmic drugs or by
ablation may improve LV function in patients presenting with newly
recognized depressed LV function and frequent PVCs.
• Catheter ablation appears to be more effective than antiarrhythmic
drugs in PVCs frequency reduction and LVEF normalization.
Li Zhong, MD, PhD et al Heart Rhythm2014;11:187–193

31. CASE 1
• 27 years old man with aborted SCD and previous ICD
implantation, LVEF 25%
• Dyspnea
• Palpitation
• Frequent ventricular ectopies, progressive LV dysfunction and
possibility PVC induced cardiomyopathy

32. PVCS

33. EARLY SIGNAL

34. EARLY SIGNAL

35. TERMINATION OF PVCS DURING BURN

36. LAO & RAO VIEWS

37. 3D MAPPING

38. CASE 2
• 65 years old man known case of DCM
• Severe LV dysfunction( LVEF 20%)
• Frequent PVC and ECG suggestive epicardial origin

39. EARLY SIGNAL

40. EARLY SIGNAL

41. TERMINATION OF PVCS DURING BURN

42. 3D MAPPING

43. 3D MAPPING

44. EPICARDIAL APPROACH

45. EPICARDIAL APPROACH

46. EPICARDIAL APPROACH

47. Tehran Arrhythmia Center
www.IranEP.org
info@IranEP.org