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 Ø Biosense-webster: research grant, honoraria Ø Medtronic: research grant, donated devices, leads Ø St Jude medical: research grant, honoraria Ø Boston Scientific: research grant, honoraria Ø Rhythm Diagnostic Systems: Board of Directors 2 1

12/7/19 Outline Ø ECG Localization Ø Prognosis Ø When to Worry Ø Mechanism of PVC Cardiomyopathy Ø Management Ø Conclusions 3 27 yo with palpitations Ø LBB/inferior axis V4 transition 4 2

12/7/19 ECG Localization Enriquez et al. Heart Rhythm 2019, in press 5 RV or LV Outflow Tract? RVOT A LVOT (LCC) posterior anterior L R P V2 V1 V3 V4 V5 V6 RVOT Aorta Superior view 6 3

12/7/19 The V2 Transition Ratio: A New ECG Criterion for Distinguishing LV From RV Outflow Tachycardia Origin Patient 1 Patient 2 RVOT LVOT I V1 V1 I V2 V2 II II V3 V3 III III V4 V4 R R V5 V5 L L V6 V6 F F Betensky … Gerstenfeld. JACC 2011;57:2255-62 7 PVC ECG Localization Enriquez Heart Rhythm 2019, in press 8 4

12/7/19 Prognosis 9 Association Between Baseline PVCs and 5-Year Reduction in EF 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 Dukes J … Marcus G. J Am Coll Cardiol 2015;66:101–9. 10 5

12/7/19 Population Risk for Incident CHF Dukes J … Marcus G. J Am Coll Cardiol 2015;66:101–9. 11 Lee AKY, et al. Heart 2019;0:1–6. 12 6

12/7/19 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] Ø 9 of the 44 patients (20.5%) had a subsequent increase in PVC burden to ≥1% Lee AKY, et al. Heart 2019;0:1–6. 13 PVCs in Underlying Structural Heart Disease – GISSI-2 Trial Patients with LV Dysfunction 1.00 0.98 0.96 Survival 0.94 0.92 p log-rank 0.0001 0.90 0.88 0.86 0 30 60 90 120 150 180 Days No PVCs 1-10 PVCs/h > 10 PVCs/h Maggioni AP. Circulation. 1993;87:312-322. 14 7

12/7/19 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 15 PVC Burden and Cardiomyopthy N=174 pts with frequent PVCs 57/174 (33%) with decreased EF Pre-RF Post-RF Baman TS et al. Heart Rhythm 2010;7:865-869. 16 8

12/7/19 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 17 18 9

12/7/19 When to Worry: Short Coupled PVCs Viskin S et al. JCE 2005;16:912-916. 19 PVCs: When to Worry 52 yo man with palpitations and presyncope 20 10

12/7/19 Lightheadedness During Exertion 21 32 yo with PVCs Ø Arrhythmogenic RV Cardiomyopathy 22 11

12/7/19 Mechanism: Idiopathic PVCs 23 Swine PVC Model A port sensing V port pacing PM AV delay=coupling interval 24 12

12/7/19 Effect of 50% PVCs on LV Function LV end-diastolic dimension LV ejection fraction LV end-systolic dimension 90.0 40.0 80.0 n=5 35.0 70.0 30.0 60.0 25.0 50.0 n=10 20.0 40.0 15.0 30.0 10.0 20.0 PVC (LVDD) PVC 5.0 Control (LVDD) 10.0 Control PVC (LVSD) 0.0 0.0 W W W W W W W W W W W W W W W W 0 2 4 6 8 0 2 4 0 2 4 6 8 0 2 4 1 1 1 1 1 1 Tanaka et al. Heart Rhythm. 2016 Feb;13(2):547-54 25 Fibrosis in LV CMPY A Control (basal-lateral): 1.8% fibrosis 10 % fibrosis 8 6 * 4 2 0 Control mild CMPY 1 CMPY Cardiomyopathy (basal-lateral): 4.7% fibrosis 15 Control % fibrosis mild CMPY CMPY 10 5 0 1 2 3 4 AL BL AS BS Tanaka et al. Heart Rhythm. 2016 Feb;13(2):547-54 26 13

12/7/19 Recovery of LVEF After PVC Cessation 40 50 60 70 80 F-statistic 31.5, p<0.001 n=5 LVEF (%) Control LV PVC Recovery n=5 PVCs Off n=5 0 2 4 6 8 10 12 14 16 Weeks Walters T et al. J Am Coll Cardiol. 2018;72:2870-2882. 27 LV Fibrosis Persist after PVC Cessation Walters T et al. J Am Coll Cardiol. 2018;72:2870-2882. 28 14

12/7/19 Management 29 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 30 15

12/7/19 Daily Variation in PVC Burden With 14-day Monitor 31 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 32 16

12/7/19 Hemodynamics of Ventricular Ectopy Before ablation I II III 200 100 50 1 sec After ablation I II III 200 100 50 33 PVC Burden LV EF N=20 34 17

12/7/19 Catheter Ablation of PVCs Success rates 90-95% for OT PVCs 35 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 36 18

12/7/19 Penela et al. Heart Rhythm 2015;12:2434–2442 37 Ø 13% BiV nonresponders (n=65) with PVC burden > 10% 38 19

12/7/19 How Much PVC Reduction is Enough? No or rare > 80% VPD No VPD Follow-up Data VPDs reduction Reduction p (N=44) (N=15) (N=8) Follow up 7.5 ± 7.0 7.5 ± 7.0 8.3 ± 7.4 0.290 (months) 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 Ø Reduction of PVC burden 80% or <5% PVCs is sufficient Mountantonakis et al. Heart Rhythm 2011;8:1608-14. 39 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? 40 20

12/7/19 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 2.03 1.0 – 4.4 0.07 - - - (>160ms) 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 - - - N=204 Voskoboinik et al, submitted . 41 PVC Risk Score – ABC-VT Voskoboinik et al, submitted. 42 21

12/7/19 Freedom From Adverse Events Cardiovascular mortality, absolute LVEF decline by 10% or CHF hospitalization) over 3.3 ± 1.8 years Voskoboinik et al, submitted. 43 Are all PVCs the Same? 44 22

12/7/19 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 45 Thank you 46 23

12/7/19 47 Validation Cohort Ø Freedom from adverse events (CV mortality,LVEF decline >10% or CHF hospitalization) over 4.0 ± 3.4 years Ø Follow-up data from Korean validation cohort with baseline LVEF > 45% and PVC burden >5%): 48 24