PVCs - Saudi Heart Association

PVCs: Do they cause
Cardiomyopathy?
Raed Abu Sham’a, M.D.
Cardiologist and Electrophysiologist
No conflict of interest related to this
presentation
Objectives
1. PVCs are benign. What is the Evidence?
2. Effects of PVCs on Mechanical Function of the Heart
3. Hemodynamic effects of PVCs
4. Risk of LV dysfunction from frequent PVCs
5. Is it reversible or non-reversible CMP?
6. PVCs in ischemic and non-ischemic CMP
7. What the guidelines tell us to do?
Case presentation
• Mrs. L.J is a 56 YOFP with DM and HTN.
• C/O atypical chest pain and fatigue. There was no
dyspnea, palpitations or syncope.
• Coronary Angiogram: normal in 2013.
• Echocardiogram:
• 2013: LVEF 60%
• 2014: LVEF 55%
• 2015: LVEF 30%
• She was referred for ICD implant
ECG in the clinic
24-hours Holter
What the next step should be?
A. Proceed for ICD implantation
B. Wait for 9 months on medical therapy
C. Start Amiodarone
D. Referral for EP Study
Objectives
• PVCs are benign. What is the Evidence?
• Effects of PVCs on Mechanical Function of the Heart
• Hemodynamic effects of PVCs
• Risk of LV dysfunction from frequent PVCs
• Is it reversible or non-reversible CMP?
• PVCs in ischemic and non-ischemic CMP
• What the guidelines tell us to do?
The first recorded description of PVCs
• It was described as intermittent
perturbations interrupting the regular
pulse. It was from the early Chinese
physician Pien Ts’Io, around 600 BC.
• He
was
pulse
the
master
palpation
diagnosis.
in
and
Pien Ts’Io . . . 600 years BC
• He noted that:
these irregularities did not interfere
with normal lifespan when they were
occasional but an ominous prognosis
was implied if they were frequent.
Idiopathic PVCs are usually
associated with a benign
course from the standpoint
of arrhythmic death.
What is the Evidence?
• 71 subjects with frequent PVCs, [13.4% ]
• Followed for 3.0 – 9.5 yrs, [mean 6.5 yrs]
• 2 death: 1 SCD, 1 cancer
the long-term prognosis in asymptomatic
healthy subjects with frequent and complex
ventricular ectopy is similar to that of the
healthy U.S. population and suggests no
increased risk of death.
• 61 pts who having frequent RV PVCs contacted
after 15 ± 2 years (12 to 20)
• The primary end point was to ascertain the
presence of cases of sudden death and
development of ARVD.
• At the end of the follow-up, 55 pts were alive
• six died, none of sudden death
• 47 pts had normal ECG
• In 24 patients (51%) extrasystoles were no
longer present at Holter monitoring
1. No patient died of sudden death
2. No patient developed ARVC
3. Two-thirds of the patients were asymptomatic
4. in half of the patients, ectopy disappeared
Objectives
• PVCs are benign. What is the Evidence?
• Effects of PVCs on Mechanical Function of the Heart
• Hemodynamic effects of PVCs
• Risk of LV dysfunction from frequent PVCs
• Is it reversible or non-reversible CMP?
• PVCs in ischemic and non-ischemic CMP
• What the guidelines tell us to do?
• 2-D echo was used to quantitate LV
function during and immediately after
single PVC in dogs.
12 successive beats during NSR
UCHIYAMA, Am J Cardiol 1981
PVC with Long Coupling Interval
CI = 600 ms
UCHIYAMA, Am J Cardiol 1981
PVC with Short Coupling Interval
CI = 400 ms
UCHIYAMA, Am J Cardiol 1981
Objectives
• PVCs are benign. What is the Evidence?
• Effects of PVCs on Mechanical Function of the Heart
• Hemodynamic effects of PVCs
• Risk of LV dysfunction from frequent PVCs
• Is it reversible or non-reversible CMP?
• PVCs in ischemic and non-ischemic CMP
• What the guidelines tell us to do?
PVC with Long Coupling Interval
11%
UCHIYAMA, Am J Cardiol 1981
PVC with Short Coupling Interval
57%
UCHIYAMA, Am J Cardiol 1981
PVC with Short Coupling Interval
Relative Bradycardia
Objectives
• PVCs are benign. What is the Evidence?
• Effects of PVCs on Mechanical Function of the Heart
• Hemodynamic effects of PVCs
• Risk of LV dysfunction from frequent PVCs
• Is it reversible or non-reversible CMP?
• PVCs in ischemic and non-ischemic CMP
• What the guidelines tell us to do?
• 239 pts with frequent, RVOT or LVOT
PVCs (>1000 beats/ day).
• No heart disease by echo and MRI.
• Follow up for 5.6 ± 1.7 years
• No patients exhibited any serious cardiac
events.
Change in the LVEF and LVDd over the time
course with a different PVC prevalence
Time course of changes in LVEF and
LVDd in 13 pts developed LV dysfunction
Is normal Ejection Fraction
means normal heart?
• 13 dogs were implanted PMs to pace in bigeminy for 12
wks.
• The PVC group developed CMP
– LVEF 40±5% versus 61±4%; P=0.0001
• PVC-induced CMP resolved within 2 to 4 weeks after
discontinuation of PVCs.
LV Dysfunction Induced by Frequent PVCs
• No inflammation, fibrosis, or changes in apoptosis and
mitochondrial oxidative phosphorylation were observed
Huizar F et al. Circ Arrhythm Electrophysiol. 2011;4:543-549
PVC myocytes had prolonged APDs with
exaggerated beat-to-beat variations
Wang Y. et al. Heart Rhythm 2014; 11:2064–2072
Objectives
• PVCs are benign. What is the Evidence?
• Effects of PVCs on Mechanical Function of the Heart
• Hemodynamic effects of PVCs
• Risk of LV dysfunction from frequent PVCs
• Is it reversible or non-reversible CMP?
• PVCs in ischemic and non-ischemic CMP
• What the guidelines tell us to do?
1998 vol. 73 no. 5 430-433
• 14 pts with more than 20,000 PVCs/24 h
• LVEF ≤ 40%
• Started on Antiarrhythmics
After 3 to 6 months . . .
• Five patients had a reduction (≥75%) in PVCs.
– Four
patients
had
significant
improvement
clinical functional status and the LVEF:
From 27 ± 10% to 49 ± 17%, (P = 0.04)
in
• 26 year old woman
baseline after (6m)
VPCs
25-56K
~1600
LVd
65/48
57/39
LVEF
43%
58%
LVEF before and after
catheter ablation
Successful ablation
Control
Bogun F, Heart Rhythm 2007;4:863– 867
Objectives
• PVCs are benign. What is the Evidence?
• Effects of PVCs on Mechanical Function of the Heart
• Hemodynamic effects of PVCs
• Risk of LV dysfunction from frequent PVCs
• Is it reversible or non-reversible CMP?
• PVCs in ischemic and non-ischemic CMP
• What the guidelines tell us to do?
Assessment of LV Function
LVEF
LVEF
• 30 patients (mean age 59±12)
• Mean EF 38%±15%
• structurally abnormal hearts based on:
• scar on CMR, or
• history of CMP before the presence of frequent
PVCs.
Heart Rhythm 2015;12:706–713
c
c
When Do We Ablate?
• Frequent PVCs > 10,000/24 hours
• Symptomatic
• LV dysfunction
• Monomorphic
• Accessible
• Associated VT
Objectives
• PVCs are benign. What is the Evidence?
• Effects of PVCs on Mechanical Function of the Heart
• Hemodynamic effects of PVCs
• Risk of LV dysfunction from frequent PVCs
• Is it reversible or non-reversible CMP?
• PVCs in ischemic and non-ischemic CMP
• What the guidelines tell us to do?
Back to our patient
•
Mrs. L.J is a 56 YOFP with DM and HTN.
•
C/O atypical chest pain and fatigue. There was no dyspnea, palpitations or
syncope.
•
Coronary Angiogram: normal in 2013.
•
Echocardiogram:
•
•
2013: LVEF 60%
•
2014: LVEF 55%
•
2015: LVEF 30%
She was referred for ICD implant
•
Successful ablation was done on October 13, 2015 in the RVOT.
•
Echo was done before discharge and showed LVEF 40%!
•
24-hour Holter was done and showed <1% PVCs (non-OT)
•
Three months Echo is pending.
Take home message
1. Persistent bigeminy halves pulse rate.
2. High burden PVC associated with reversible
form of LV dysfunction.
3. Radiofrequency Catheter Ablation is effective
therapy for PVC-induced CMP.
Characteristics of Patients who may
Develop CMP
1. If PVCs are frequent (≥10/min), (≥ 24%)
2. Long duration [older patients]
3. Lack of palpitations
4. Have a short coupling interval
5. Coupling Interval Dispersion
6. Epicardial origin
7. Increased BMI
8. The presence of a retrograde P-wave following a PVC
In press: Heart Rhythm 2015; 0:0–8
Kawamura M et al. J Cardiovasc Electrophysiol. 2014 Jul;25(7):756-62.
Ban J et al. Europace (2013) 15, 735–741
Predictors of reversibility of LV systolic
dysfunction in patients with PICMP
1. Longer PVC duration
2. Absence of myocardial scar
3. Effective elimination of PVCs (>80% reduction
in PVC burden)
4. Early improvement in LVEF at 1-week
Del Carpio Munoz F et al. J Cardiovasc Electrophysiol 2011; 22:791–798.
Yokokawa M et al. Heart Rhythm 2012; 9:1460–1464.
Deyell MW et al. Heart Rhythm 2012; :1465–1472.
Hasdemir C et al. Pacing Clin Electrophysiol 2012; 35:465–470.
PVCs + depressed LV function:
PVCs Resulting from
Cardiomyopathy
PVCs-Induced CMP
Patient
Characteristics
Older patients with CAD
Healthy Individuals
Comorbidity
HTN, IHD, Myocarditis,
Family Hx of Structural
HD
Often no prior history
or family history
Frequency of
PVCs
< 5000/24 hr
> 10,000/24 hrs
Pattern of PVCs
Polymorphic
Monomorphic
QRS Morphology
Non-specific
RVOT, LVOT
morphology
Response to AA
Therapy
No improvement in LV
function
If PVCs suppressed,
LV function improves
Response to RFA
Required to reduce the
ICD shocks
Curative