Ventricular Arrhythmias in Heart Failure

20 Pages·2012·12.18 MB·English

10/4/12
Ventricular Arrhythmias in Heart Failure:
Pharmacotherapies and Ablation
Edward P Gerstenfeld MD
Associate Professor of Medicine
University of California, San Francisco
Role of Ventricular Ectopy and LV Dysfunction in
SCD Risk – GISSI-2 Tria l
Patients withou t Patients with
LV Dysfunction LV Dysfunction
1.00 1.00
0.98 0.98
0.96 p log-rank 0.96
0.002
Survival 00..9924 Survival 00..9924 p0 .l0o0g0-r1a nk
0.90 0.90
0.88 0.88
A B
0.86 0.86
0 30 60 90 120 150 180 0 30 60 90 120 150 180
Days Days
No PVBs
1-10 PVBs/h
> 10 PVBs/h
Maggioni AP. Circulation. 1993;87:312-322.
Ventricular Arrhythmias in CHF –
Background Therapy
Ø Beta-blockers
Ø ACE/ARB
Ø Aldactone
Ø BiV pacing if LBBB
Ø ICD if EF<35%
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Outline
Ø Idiopathic PVCs/VT
RVOT, LVOT, AoCusp
Ø VT in ischemic cardiomyopathy
Ø VT in non-ischemic Dilated Dardiomyopathy
Baseline ECG
Typical RVOT VT/PVC Origin
Ao
PV
HIS
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Coronal View of Outflow Tract
Location of Typical RVOT VT
RVOT
Aorta
Aortic
Valve
cusps
Anatomy of Aortic Cusps
603 autopsied hearts
57% myocardial sleeves above aortic valve
Gami AS et al. JICE 2011;30:5-15.
Evaluation for Idiopathic PVCs
Ø History (family history VT, sudden death)
Ø Physical Exam (cardiomyopathy)
Ø 12-lead ECG (ARVC, prior MI, HCM, other)
Ø 24-hour Holter monitor (PVC burden
Ø Echocardiogram
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PVC Burden and Cardiomyopthy
N=174 pts with frequent PVCs
57/174 (33%) with decreased EF
Baman TS et al. Heart Rhythm 2010;7:865-869.
Treatment Options for
Idiopathic PVCs
Ø Reassurance (if asymptomatic, normal EF, PVC burden <5%)
Ø Beta-blockers
Ø Class IC antiarrhythmics (flecainide, rhythmol) if preserved EF
Ø Class III antiarrhythmics (sotalol, amiodarone) if EF reduced
Ø Catheter ablation
Hemodynamics of Ventricular Ectopy
Before
 abla*on

I
II

III

200

100

50

1
 sec

A4er
 abla*on

I
II

III

200
 200

mmHg

100
 100

mmHg
 50

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Outcome in Outflow Tract VT Ablation
Ø RVOT – 81-92%
Ø LVOT, Ao Cusp 752-100%3
Ø Epicardial VT 39%- 96%4
1 Krittayaphong Europace 2006;8;^01-606.
2 Daniels et al. Circulation 2006;113:1659-66.
3 Kanagaratnam et al JACC 2001;37:1408-14
4 Schweikert et al Circulation 2003;108:1329-35.
PVCs in Patients with LVCM
Ø 69 pts with non-ischemic CMPY (EF<50%) and PVCs (>10K/24)
Ø 24-hour Holter and echo at baseline and ~ 6 mos post ablation
Epicardial
AMC
RVOT
R/LCC
LCC RCC
!
Mountantonakis Heart Rhythm 2011;8:1608-14.
Baseline Characteristics
Age (yrs) 51 ± 16
Gender (M/F) 42/26
Preexisting LVCM 20 (29%)
Medical Therapy
B-blockers 58 (85%)
ACE inhibitors 49 (72%)
Antiarrhythmic Agents 12 (16%)
LVEF (%) 35 ± 8
LV Diastolic Diameter (mm) 58 ± 7
VPD/24hrs 31,816 ± 17,365
%VPD 29 ± 13%
Mountantonakis Heart Rhythm 2011;8:1608-14.
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PVC Ablation Improves LV EF
55
CI) 50
%
5 45
9
F (
E 40
V
L
%
35
30
Pre Post
!
Mountantonakis Heart Rhythm 2011;8:1608-14.
Results
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
Mountantonakis Heart Rhythm 2011;8:1608-14.
Chronic PVC Ablation Outcome
CI)
%
5
9
F (
E
V
L
n
e i
g
n
a
h
C
None or >80% No change
rare reduction
Mountantonakis Heart Rhythm 2011;8:1608-14.
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Results in Patients with
Preexisting Cardiomyopathy
CI)
%
5
9
F (
E
V
L
n
e i
g
n
a
h
C
No Yes
Ø Patients (n=20) with preexisting LV CMPY still had a modest
improvement in EF (+8%) after ablation
Predictors of LV EF
Improvement
Hazard
95% CI p
Ratio
EF Prior to Ablation 1.51 1.05 to 3.12 <0.001
Absence of Preexisting LV
6.67 1.69 to 11.77 0.011
Cardiomyopathy
Ablation Outcome 6.99 3.99 to 9.92 <0.001
Mountantonakis Heart Rhythm 2011;8:1608-14.
Conclusions
Ø  Reduction in VPD burden of >80% to a residual VPDs of
<5,000/24hrs is comparable to complete VPD elimination
in improvement of LVEF in patients with VPD-related
LVCM. This implies that in patients with multiple VPD
morphologies, targeting the dominant focus (foci) may
suffice as an endpoint.
Ø  Elimination of VPDs is beneficial even in patients with
preexisting LVCM.
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PVC Burden and Cardiomyopthy
N=174 pts with frequent PVCs
57/174 (33%) with decreased EF
Baman TS et al. Heart Rhythm 2010;7:865-869.
Objective
Ø The purpose of this study was to identify
clinical and electrophysiologic predictors of
recovery of LV function after successful
ablation of frequent VPDs
Deyell M et al. Heart Rhythm 2012;9:1465-1472.
Study Population
Ø Subjects undergoing ablation between 2007
and 2011 with:
- ≥10% VPDs over
 24
 hours
 on
 Holter
 monitoring

-­‐
 LVEF
 of
 <50%
 by
 echocardiography

Ø Only
 pa*ents
 with
 successful
 abla*on
 included

(≥80%
 reduc*on
 in
 VPD
 burden
 on
 follow-­‐up
 Holter)

Ø A
 reference
 group
 of
 pa*ents
 with
 ≥10%
 VPDs
 but

LVEF
 ≥55%
 were
 also
 iden*fied
 for
 comparison

Deyell M et al. Heart Rhythm 2012;9:1465-1472.
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Subject Classification
≥10%
 VPDs
 and

LVEF
 <50%

Par6ally

Reversible
  Irreversible

reversible

ΔLVEF
 ≥10%
  ΔLVEF
 ≥10%
  ΔLVEF
 <10%

and
  and
  and

Final
 LVEF
 ≥50%
  Final
 LVEF
 <50%
  Final
 LVEF
 <50%

Deyell M et al. Heart Rhythm 2012;9:1465-1472.
Clinical Characteristics
Characteristic Normal LV Reversible Irreversible/ P
EF (N=24) partially
(N=66) reversible
(N=13)
Age – mean±SD 48.3±15.4 56.5±15.0 53.2±15.8 0.044
Female gender– N (%) 34 (51.5) 8 (33.3) 5 (38.5) 0.297
History of CHF – N (%) 0 (0.0) 2 (8.3) 1 (7.6) 0.044
Holter monitoring
% VPDs – mean±SD 26.6±12.0 31.6±11.5 24.0±8.1 0.077
Echocardiography
LV EF- mean±SD 58.5±6.0 38.2±6.8 35.8±8.9 0.001
Deyell M et al. Heart Rhythm 2012;9:1465-1472.
Electrophysiologic Characteristics
Characteristic Normal Reversible Irreversible/ P
(N=66) (N=24) partially
reversible
(N=13)
ECG parameters
Sinus QRS width
84.7±10.6 90.7±16.0 102.8±25.6) 0.018
(ms) – mean±SD
VPD QRS width (ms)
134.7±12.3 158.2±8.6 173.2±12.9 0.001*
– mean±SD
VPD site of origin – N(%)
RVOT/ Right CC/PA 24 (36.4) 6 (25.0) 3 (23.1) 0.520
Left CC/ AMC/
25 (37.9) 7 (29.2) 7 (53.9) 0.340
L/R CC/AIV
Multiple VPDs 5 (7.6) 3 (12.5) 0 (0.0) 0.482
LV site (vs. RV) 41 (62.1) 18 (75.0) 10 (76.9) 0.214
Deyell M et al. Heart Rhythm 2012;9:1465-1472.
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VPD QRS Duration Gradient
200
p<0.001
180
VDPuDra QtioRnS 160
(ms)
140
120 p=0.002
100
Normal LV function Reversible Partially reversible/
irreversible
Deyell M et al. Heart Rhythm 2012;9:1465-1472.
VPD QRS Duration – Septal RVOT/RCC
200
n (ms) 180 p=0.003
o
urati 160
d
RS 140
Q
VPD 120 p=0.070
100
Normal LV function Reversible Partially reversible/
irreversible
Deyell M et al. Heart Rhythm 2012;9:1465-1472. N=33
VPDs
 Arising
 From
 the
 Le4/Right
 Coronary
 Cusp

Part. reversible/
Normal LV function Reversible irreversible
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
142 ms 119 ms 159 ms 161 ms 180 ms 171 ms
10