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PVCs Revisited: Etiology, Significance and Management
Edward P Gerstenfeld MD Twitter: @ed_gerst Professor of Medicine University of California, San Francisco
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PVCs Revisited: Etiology, Significance and Management Edward P - - PDF document
PVCs Revisited: Etiology, Significance and Management Edward P - - PDF document
12/7/19 PVCs Revisited: Etiology, Significance and Management Edward P Gerstenfeld MD Twitter: @ed_gerst Professor of Medicine University of California, San Francisco 2.0 1 Conflicts Biosense-webster: research grant, honoraria
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ECG Localization
Enriquez et al. Heart Rhythm 2019, in press
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Aorta RVOT
RV or LV Outflow Tract?
RVOT
posterior anterior
LVOT (LCC)
R L A P
V2 V1
Superior view
V3 V6 V5 V4
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The V2 Transition Ratio: A New ECG Criterion for Distinguishing LV From RV Outflow Tachycardia Origin
I II III R L F I II III R L F V1 V2 V3 V4 V5 V6 V1 V2 V3 V4 V5 V6
RVOT LVOT
Betensky … Gerstenfeld. JACC 2011;57:2255-62
Patient 1 Patient 2
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PVC ECG Localization
Enriquez Heart Rhythm 2019, in press
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Prognosis
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Association Between Baseline PVCs and 5-Year Reduction in EF
Dukes J … Marcus G. J Am Coll Cardiol 2015;66:101–9.
Ø 1,139 CHS participants with normal EF and no prior CHF randomly assigned to 24-hour Holter Ø Echocardiogram at baseline and 5 years
Adjusted for age, sex, race, BMI, HTN, DM, CAD, BB use, AF, NSVT
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Population Risk for Incident CHF
Dukes J … Marcus G. J Am Coll Cardiol 2015;66:101–9.
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Lee AKY, et al. Heart 2019;0:1–6.
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Frequent PVC Evolution
Ø 44 pts (44%) had PVC resolution (<1%) over 15.4m [2.6-64.3] Ø 52 pts (52%) had a ≥80% reduction in PVCs over 14.1m Ø 4 pts (4.0%) reduced LVEF <50% over 60.9m [52.7-74.8]
Lee AKY, et al. Heart 2019;0:1–6.
Ø 9 of the 44 patients (20.5%) had a subsequent increase in PVC burden to ≥1%
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PVCs in Underlying Structural Heart Disease – GISSI-2 Trial
Maggioni AP. Circulation. 1993;87:312-322.
Patients with LV Dysfunction
No PVCs 1-10 PVCs/h > 10 PVCs/h
0.88 0.90 0.92 0.94 0.96 0.98 1.00 30 60 90 120 150 180
Days
Survival p log-rank 0.0001
0.86
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Idiopathic PVC’s/VT When to worry
Ø History of syncope Ø Frequent ectopy (>20,000 PVCs over 24hours) Ø Fast sustained RVOT VT (>230 bpm) Ø Short coupled PVCs or Torsade Ø Abnormal right or left ventricular function Ø Multiple VT/PVC morphologies or unusual morphology
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PVC Burden and Cardiomyopthy
Baman TS et al. Heart Rhythm 2010;7:865-869.
N=174 pts with frequent PVCs 57/174 (33%) with decreased EF Pre-RF Post-RF
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When to Worry:
Tachy-Induced Cardiomyopathy
Ø 24 patients with tachy induced cardiomyopathy Ø Etiology: AF, AFL, AT, PJRT, PVCs Ø 5 patients with recurrent tachycardia Ø 3/24 (12.5%) with sudden death
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When to Worry: Short Coupled PVCs
Viskin S et al. JCE 2005;16:912-916.
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PVCs: When to Worry
52 yo man with palpitations and presyncope
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Lightheadedness During Exertion
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32 yo with PVCs
Ø Arrhythmogenic RV Cardiomyopathy
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Mechanism: Idiopathic PVCs
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A port V port
pacing sensing
Swine PVC Model
PM
AV delay=coupling interval
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0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 W 2 W 4 W 6 W 8 W 1 W 1 2 W 1 4 W PVC Control 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 W 2 W 4 W 6 W 8 W 1 W 1 2 W 1 4 W PVC (LVDD) Control (LVDD) PVC (LVSD)
LV ejection fraction LV end-diastolic dimension LV end-systolic dimension
Effect of 50% PVCs on LV Function
n=5 n=10
Tanaka et al. Heart Rhythm. 2016 Feb;13(2):547-54
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5 10 15
1 2 3 4
Control mild CMPY CMPY
2 4 6 8 10
1
BL AL Control mild CMPY CMPY AS BS
% fibrosis % fibrosis
A
Control (basal-lateral): 1.8% fibrosis Cardiomyopathy (basal-lateral): 4.7% fibrosis
Fibrosis in LV CMPY
*
Tanaka et al. Heart Rhythm. 2016 Feb;13(2):547-54
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Recovery of LVEF After PVC Cessation
PVCs Off
Control LV PVC Recovery
LVEF (%)
40 50 60 70 80
Weeks
0 2 4 6 8 10 12 14 16
F-statistic 31.5, p<0.001
n=5 n=5 n=5
Walters T et al. J Am Coll Cardiol. 2018;72:2870-2882.
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LV Fibrosis Persist after PVC Cessation
Walters T et al. J Am Coll Cardiol. 2018;72:2870-2882.
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Management
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PVC Evaluation
Ø 12-lead ECG + rhythm strip morphology Ø 7 or 14-day continuous monitor Ø Echocardiogram Ø Cardiac MRI if – non-OT morphology, multiple morphologies, abnormal echo
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Daily Variation in PVC Burden With 14-day Monitor
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Treatment Options for Idiopathic PVCs
Ø Reassurance (if asx, normal EF, low PVC burden) Ø Beta-blockers (consider acebutolol, bisoprolol) Ø Class IB antiarrhythmics (mexiletine) Ø Class IC antiarrhythmics (flecainide, propafenone) if no SHD Ø Class III antiarrhythmics (sotalol, amiodarone) if EF significantly reduced Ø Catheter ablation
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Before ablation I II III
200 100 1 sec 50
After ablation I II III
200 100 50
Hemodynamics of Ventricular Ectopy
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PVC Burden LV EF N=20
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Catheter Ablation of PVCs
Success rates 90-95% for OT PVCs
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Treatment of PVCs in LV Dysfunction
Ø Guideline-directed medical therapy:
- B-blockers, ace inhibitor, aldactone
Ø If PVC burden > 10,000 -> Rx suppression or catheter ablation Ø IF EF<35% despite PVC suppression -> ICD Ø IF LBBB and persistent EF<35% -> BiV ICD
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Penela et al. Heart Rhythm 2015;12:2434–2442
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Ø 13% BiV nonresponders (n=65) with PVC burden > 10%
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How Much PVC Reduction is Enough?
Follow-up Data No or rare VPDs (N=44) > 80% VPD reduction (N=15) No VPD Reduction (N=8) p Follow up (months) 7.5 ± 7.0 7.5 ± 7.0 8.3 ± 7.4 0.290 VPD/24hrs 320±540 2,826±782 23,768±10,183 <0.001 %VPD 0.4 ± 0.6% 2.5 ± 0.7% 22.8 ± 9.7% <0.001 EF(%) post RF 49 ± 10 45 ± 9 31 ± 11 0.002 Change in EF (%) +13 ± 9 +12 ± 9
- 2 ± 7
0.003 LVEDD (mm) 53 ± 8 56 ± 6 62 ± 9 0.040
Mountantonakis et al. Heart Rhythm 2011;8:1608-14.
Ø Reduction of PVC burden 80% or <5% PVCs is sufficient
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PVCs in Asymptomatic Patients
Asymptomatic patients with frequent (>20k) PVCs?
1) Monitor yearly with echo/Holter for LV dilatation, drop in EF 2) Beta-blocker, if tolerated?
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Predictors of PVC Cardiomyopathy
Parameter Univariate analysis Multivariate analysis OR 95% CI p-value OR 95% CI p value NSVT 6.19 2.8–15.2 <0.001 5.26 2.09 – 13.23 <0.001 Coupling Interval >500ms 4.67 2.4–9.0 <0.001 4.73 2.19 – 10.21 <0.001 Superiorly-directed axis 2.27 1.4–4.8 0.004 2.70 1.25 – 5.81 0.01 PVC burden 10 – 20%* 2.20 1.1 – 4.6 0.04 3.50 1.39 – 8.82 0.01 PVC burden > 20%* 3.47 1.2 – 10.5 0.03 4.40 1.17 – 16.49 0.03 Broad PVC QRS (>160ms) 2.03 1.0 – 4.4 0.07
- LBBB morphology
0.60 0.3 – 1.2 0.12
- Age
1.00 1.0–1.0 0.98
- Male gender
1.93 1.0 – 3.7 0.05 Atrial fibrillation 1.93 0.9 – 4.1 0.08
- Body mass index
1.02 1.0 – 1.1 0.56
- Hypertension
1.13 0.6 – 2.1 0.69
- Coronary artery disease
1.48 0.8 – 2.8 0.24
- >1 PVC morphology
1.72 0.9 – 3.3 0.10
- Ventricular bigeminy
0.72 0.4 – 1.4 0.30
- PVC coupling interval SD
15.2 0.9 – 258.3 0.06
- Voskoboinik et al, submitted.
N=204
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PVC Risk Score – ABC-VT
Voskoboinik et al, submitted.
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Freedom From Adverse Events
Cardiovascular mortality, absolute LVEF decline by 10%
- r CHF hospitalization) over 3.3±1.8 years
Voskoboinik et al, submitted.
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Are all PVCs the Same?
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PVC’s
Ø Most outflow tract PVCs in the setting of a structurally normal heart are benign! Ø History: syncope/SHD Ø Check ECG, echo and 7-14 day TTM Ø Tw inversions>V2, ”R on “T PVC, multiple/unusual PVCs, Torsade – consider referral Ø If PVC burden <5% and EF normal - reassurance Ø If PVC burden>10% & EF normal: recheck 1 year Ø If PVC burden>10% & EF reduced: medical therapy and consider referral Ø Bothersome symptoms: referral for RFA
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Thank you
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