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 developedSudden death increased

All P ＜ 0.05

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

Takemoto M, et al. J Am Coll Cardiol, 2005;45:1259–65

Risk of very frequent PVCs

Prognostic significance of frequent PVCs with normal LV function

• 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

The proportion of asymptomatic patients was significantly higher in the presence of cardiomyopathy (36/76, 47%) than in normal LV function (25/165, 15%)

PVC-CMP more easily attacked in asymptomatic patients

Yokokawa M, et al. Heart Rhythm, 2012;9:92–95

• 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

Incidence of PVC-CMP

Hasdemir C, et al. J Cardiovasc Electrophysiol, 2011,22:663-668

• 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)

Sudden death increased

Abdalla IS, et al. Am J Cardiol, 1987, 60:1036 -1042

Cheriyath P, et al. Am J Cardiol, 2011, 107:151-155

Baseline examination from 1987 to 1989, 2-minute rhythm strip of EKGfollow-up data collected until December 200214,574 subjects,130 incident cases of SCDParticipants 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

• 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

Characteristics of PVC-CMP

Huizar JF, et al. Circ Arrhythm Electrophysiol, 2011;4:543-549

Takemoto M, et al. J Am Coll Cardiol, 2005;45:1259–65

Huizar JF, et al. Circ Arrhythm Electrophysiol, 2011;4:543-549

• a short PVC coupling

• LV dyssynchrony during PVCs

• postextrasystolic potentiation (Which could increase in intracellular Ca2+ and

myocardial oxygen consumption)

Mechanism of PVC-CMP

Huizar JF, et al. Circ Arrhythm Electrophysiol, 2011;4:543-549

• PVC burden?

• QRS width?

• NSVT?

• Duration?

• Symptom or absence of symptom?

• Gender?

• ….........

Determinants of PVC-CMP

All P ＜ 0.05

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

Takemoto M, et al. J Am Coll Cardiol, 2005;45:1259–65

Carpio Munoz, FD, et al. J Cardiovasc Electrophysiol, 2011, 22,791-798

PVC burden

reduced LVEF (n = 17) vs normal LVEF (n = 53) burden of PVCs: (29.3 ± 14.6% vs 16.7 ± 13.7%, P = 0.004)

• 57Pts with reduced LVEF(0.37 ±0.10)• 117Pts with normal LVEF• PVC burden:33% ± 13% VS 13 ± 12%

Baman TS, et al. Heart Rhythm, 2010;7:865–869PVC burden

PVC burden ＞ 24% was independently associated with PVC-CMP sensitivity :79% , specificity :78%, under curve:0.89

Hasdemir C, et al. J Cardiovasc Electrophysiol, 2011,22:663-668

PVC burden

PVC burden ＞ 16% was independently associated with PVC-CMP sensitivity :100% , specificity :87% ,under curve:0.96

• 17Pts with reduced LVEF• 227Pts with normal LVEF• PVC burden:29% ± 9% VS 8 ± 7%

QRS duration Yokokawa M, et al. Heart Rhythm, 2012, 9:1460-1464

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)

Deyell MW, et al. Heart Rhythm, 2012;9:1465–1472QRS duration

Carpio Munoz, FD, et al. J Cardiovasc Electrophysiol, 2011, 22,791-798

QRS duration and NSVT

Yokokawa M, et al. Heart Rhythm, 2012;9:92–95

.

...

Others: male, asymtomatic status

Does VPCs ablation

reverse LV function?

• 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

implication of medical therapy

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)

Sekiguchi Y, et al. J Cardiovasc Electrophysiol, 2005,16:1057-1063

GROUP1

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

• 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 functionfollowing 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