PVC induced Cardiomyopathy

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Raja Selvaraj, JIPMER

Introduction

Tachycardia induced Cardiomyopathy?

  • Heart failure
  • Systolic dysfunction
  • Due to prolonged elevated heart rate (> 100)
  • Reversible on control of arrhythmia

PVC induced cardiomyopathy

  • First reported in a small series in 1998
  • Less well understood
  • "Tachycardia" / Repetitive dyssynchronous activation / irregularity of rhythm

Duffee DF, Shen WK, Smith HC. Suppression of frequent premature ventricular contractions and improvement of left ventricular function in patients with presumed idiopathic dilated cardiomyopathy. Mayo Clinic Proc 1998;73:430–3. 10.1016/S0025-6196(11)63724-5

Canine models

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Huizar JF.. Ellenbogen KA, Wood MA. Left ventricular systolic dysfunction induced by ventricular ectopy: a novel model for premature ventricular contraction-induced cardiomyopathy. Circ Arrhythm Electrophysiol 2011;4:543–549.

Patient with PVCs - Clinical scenarios

  • Symptomatic PVC - treat to reduce symptoms
  • Asymptomatic PVC, normal LV
  • PVCs, LV dysfunction, no heart disease
  • PVCs, LV dysfunction and heart disease

PVCs, LV dysfunction and no other heart disease

Causation and recovery

  • Cardiomyopathy with PVC or PVC with cardiomyopathy ?
  • Around 80% recover
  • Markers for recovery
    • No heart disease on evaluation
    • High PVC burden
    • Morphology consistent with idiopathic PVCs

Dont miss treatable heart disease

  • Coronary artery disease
  • Sarcoidosis
  • Tuberculosis
  • CAG / Cardiac MRI

Higher PVC burden in those with LV dysfunction

  • Related to burden / frequency
  • Frequency - 16 (1) to 24 % (2)
  • Burden - 10000 (3)
  1. Hasdemir C et al. Tachycardia-induced cardiomyopathy in patients with idiopathic ventricular arrhythmias: the incidence, clinical and electrophysiologic characteristics, and the predictors. J Cardiovasc Electrophysiol. 2011 Jun;22(6):663-8.
  1. Baman TS, .. Oral H, Morady F,Bogun F. Relationship between burden of premature ventricular complexes and left ventricular function. Heart Rhythm. 2010 Jul;7(7):865-9.
  1. Kanei et al. Frequent premature ventricular complexes originating from the right ventricular outflow tract are associated with left ventricular dysfunction. Ann Noninvasive Electrocardiol. 2008 Jan;13(1):81-5.

PVC burden

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Baman et al. Relationship between burden of premature ventricular complexes and left ventricular function. Heart Rhythm. 2010 Jul;7(7):865-9.

PVC duration as marker of recovery ?

  • In patients with frequent PVCs and successful ablation, QRS duration was associated with recovery of LV function (1)
  • Very long QRS may indicate permanent scarring
  • Cut off of 150 ms suggested by others (2, 3)
  1. Deyell MW .. Marchlinsky. Predictors of recovery of left ventricular dysfunction after ablation of frequent ventricular premature depolarizations. Heart Rhythm 2012;9:1465–72.
  1. Yokokawa M, Kim HM, Good E, et al. Impact of QRS duration of frequent premature ventricular complexes on the development of cardiomyopathy. Heart Rhythm 2012;9:1460–4.
  1. Del Carpio Munoz F, Syed FF, Noheria A, et al. Characteristics of premature ventricular complexes as correlates of reduced left ventricular systolic function: study of the burden, duration, coupling interval, morphology and site of origin of PVCs. J Cardiovasc Electrophysiol 2011;22:791–8.

QRS duration and reversibility of LV dysfunction

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  1. Deyell MW .. Marchlinsky. Predictors of recovery of left ventricular dysfunction after ablation of frequent ventricular premature depolarizations. Heart Rhythm 2012;9:1465–72. DOI: 10.1016/j.hrthm.2012.05.019; PMID: 22640894

Role of medical management

  • Ablation superior to Metoprolol or Propafenone (1)
  • Flecainide may be a good option (2)
  • Amiodarone effective in heart failure and improves EF (3)

  1. Ling Z et al. Radiofrequency ablation versus antiarrhythmic medication for treatment of ventricular premature beats from the right ventricular outflow tract: prospective randomized study. Circ Arrhythm Electrophysiol 2014;7:237–3.
  1. Capucci et al. A double-blind crossover comparison of flecainide and slow-release mexiletine in the treatment of stable premature ventricular complexes. Int J Clin Pharmacol Res. 1991;11:23–33
  2. Singh SN, Fletcher RD, Fisher SG, Singh BN, Lewis HD, Deedwania PC, Massie BM, Colling C, Lazzeri D. Amiodarone in patients with congestive heart failure and asymptomatic ventricular arrhythmia. Survival Trial of Antiarrhythmic Therapy in Congestive Heart Failure. N Engl J Med. 1995;333:77–82.

PVCs, LV dysfunction and other heart disease

Heart disease / LV dysfunction / frequent PVCs

  • PVCs may contribute to LV dysfunction
  • Higher PVC burden may suggest significant contribution
  • Treatment may result in partial improvement of LV dysfunction

Non ischemic Cardiomyopathy

  • LV dysfunction preesxistent in 20, diagnosed simultaneously in 49
  • Improvement also seen in those with preexisting cardiomyopathy
  • More modest improvement in these patients
  • less response when initial EF was lower

Mountantonakis SE, Frankel DS, Gerstenfeld EP, et al. Reversal of outflow tract ventricular premature depolarization–induced cardiomyopathy with ablation: effect of residual arrhythmia burden and preexisting cardiomyopathy on outcome. Heart Rhythm 2011;8:1608–14. DOI: 10.1016/j.hrthm.2011.04.026; PMID: 21699837

Ischemic Cardiomyopathy

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Sarrazin .. , Morady F, Bogun F. Impact of radiofrequency ablation of frequent post-infarction premature ventricular complexes on left ventricular ejection fraction. Heart Rhythm . 2009;6:1543–1549.

Important consideration in patients eligible for ICD / CRT

  • LV dysfunction, eligible for device implant, with frequent PVCs
  • Consider ablation before CRT or ICD
  • Indication removed in 64% after successful ablation (1)
  • Wait 3-12 months for potential recovery

  1. Ablation of frequent PVC in patients meeting criteria for primary prevention ICD implant: Safety of withholding the implant. Heart Rhythm 2015;12:2434–2442

Reversal of ICD indication after ablation

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Penela D, .. M, Brugada J, Mont L, Berruezo A. Ablation of frequent PVC in patients meeting criteria for primary prevention ICD implant: Safety of withholding the implant. Heart Rhythm. 2015 Dec;12(12):2434-42.

PVCs with normal LV function and no symptoms

PVCs are not uncommon

  • 40 to 75% in 24 to 48 hour Holter recordings (1)
  • Only a fraction of them are at risk
  • General cardiologists tend to under treat
  • Electrophysiologists seem to over treat
  1. Ng GA. Treating patients with ventricular ectopic beats.Heart. 2006;92:1707–1712.
  2. David Callans. Premature Ventricular Contraction-induced Cardiomyopathy. Arrhythmia & Electrophysiology Review 2017; 6(4):153–5

PVC burden and risk

  • Higher burden seen in those presenting with cardiomyopathy
  • Does not directly translate to risk of future development of LV dysfunction

Burden is not only factor

  • Very variable relationship
  • Small, early series of 8 patients with LV dysfunction and PVCs (7 improved after successful ablation) (1)
  • Mean ct > 17k pvcs, but 2/8 has < 6k pvcs

Yarlagadda et al. Reversal of cardiomyopathy in patients with repetitive monomorphic ventricular ectopy originating from the right ventricular outflow tract. Circulation 2005;112:1092–7. DOI: 10.1161/CIRCULATIONAHA.105.546432; PMID: 16103234

PVCs and LV dysfunction - factors other than PVC burden

  • Site of origin - RV PVCs more prone to produce LV dysfunction compared to LV PVCs ?
  • PVC QRS duration > 140 ms / 150 ms (1, 2)
  • PVC coupling interval < 600 ms (3)
  • Interpolation (4)
  1. Del Carpio Munoz .. Asirvatham SJ. Characteristics of premature ventricular complexes as correlates of reduced left ventricular systolic function: study of the burden, duration, coupling interval, morphology and site of origin of PVCs. J Cardiovasc Electrophysiol. 2011 Jul;22(7):791-8.
  1. Yokokawa M .. , Morady F, Bogun F. Impact of QRS duration of frequent premature ventricular complexes on the development of cardiomyopathy. Heart Rhythm. 2012 Sep;9(9):1460-4.
  1. Sun Y et al. The influence of premature ventricular contractions on left ventricular function in asymptomatic children without structural heart disease: an echocardiographic evaluation. Int J Cardiovasc Imaging. 2003 Aug;19(4):295-9.
  1. Olgun H, Yokokawa M, Baman T, et al. The role of interpolation in PVC-induced cardiomyopathy. Heart Rhythm 2011;8:1046–9.

What is actual rate of development of cardiomyopathy ?

  • Only one prospective study
  • 249 patients with > 1000 PVCs / 24 h, mean FU > 5 yrs
  • 13 patients developed fall in EF > 6%

Niwano S et al. Prognostic significance of frequent premature ventricular contractions originating from the ventricular outflow tract in patients with normal left ventricular function. Heart 2009;95:1230–7. DOI: 10.1136/hrt.2008.159558; PMID: 19429571

Prospective follow up for 4 years

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Niwano S et al. Prognostic significance of frequent premature ventricular contractions originating from the ventricular outflow tract in patients with normal left ventricular function. Heart 2009;95:1230–7. DOI: 10.1136/hrt.2008.159558; PMID: 19429571

An argument for a conservative approach

  • No good markers to identify those at risk of developing LV dysfunction
  • Patients prone to develop LV dysfunction often present with same
  • Those presenting with normal LV function only infrequently develop LV dysfunction
  • Conservative management may suffice for most
  • Guidelines recommend conservative management and follow up imaging

ACC guidelines

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Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Heart Rhythm 2017; DOI: 10.1016/j.hrthm.2017.10.036;

Summary

  • Symptomatic patients need treatment
  • Large number of PVCs in presence of LV dysfunction - trial of therapy warranted
  • PVCs may contribute to / worsen LV dysfunction in underlying heart disease and trial of therapy is warranted
  • Ablation often is preferable to medical management in these patients
  • Treatment of frequent PVCs in absence of symptoms or LV dysfunction - decision in discussion with patient, observation suffices for most
  • Follow up is the preferred option for these patients