PVCs: Benign nuisance or wake up call?

PVCs: Benign nuisance or wake up call?

PVCs: Benign nuisance or
wake up call?
Brian Jaffe MD
Traverse Heart and Vascular
October 10, 2015
Are they Nefarious or “Sometimes a cigar is
just a cigar…”
• Marker of VT?
• Marker of Structural Heart
Disease?
• Marker of Electrical Heart
Disease?
• Cause of Cardiomyopathy?
• Benign Automatic Focus
• LV Function/Valves/RV normal?
• Patient Asymptomatic?
• Remember the lesson of CAST–
antiarrhythmics can kill
Figure 3
EF Improved 35% to 54% post-ablation in CMP patients
Heart Rhythm 2010 7, 865-869DOI: (10.1016/j.hrthm.2010.03.036)
Copyright © 2010 Heart Rhythm Socie
Baman et al. (U of M)
Heart Rhythm
Volume 7, Issue 7, Pages 865-869 (July 2010)
Figure 1
Rough Correlation between PVC Burden and EF
Baman et al. (U of M)
Heart Rhythm
Volume 7, Issue 7, Pages
865-869 (July 2010)
Heart Rhythm 2010 7, 865-869DOI: (10.1016/j.hrthm.2010.03.036)
Assessment of the PVC
• Symptomatic?
• Cardiac Function Assessment
•
•
•
•
LVEF, wall motion; RV function
Ischemia Assessment
Valve Function
Be wary of nuclear imaging EF with beat averaging
• PVC Morphology
• 12- Lead Rhythm Strip
• Outflow Tract Focus? Inferior QRS Axis
• PVC Burden
• Holter
History for PVCs
• Chronicity
• Triggers
• Stimulants & Stress
• Caffeine
• Night Shift
• Illicit Drugs
• Family history of arrhythmias, Sudden Death, RV Dysplasia
L Coronary Cusp VT
OutFlow Tract or RV Dysplasia?
• Classic Outflow Tract
• Unifocal PVCs: LBBB, Inferior Axis
• Normal intrinsic QRS
• Smooth PVCs
• No notching
• Gradual Transition across Precordium
• Arrhythmic RV Dysplasia
• Often Multifocal
• LBBB, variable axis
• Abnormal intrinsic QRS
• T inversion V1-V3
• Abnormal PVCs
• Notching
• Late transition
Figure 2
RVOT PVCs,
Normal Heart
RVOT PVCs,
ARVD
*T Inversion V1-V3
*Notching I, III, L
*QRS=120 in I
*Transition V5
Heart Rhythm 2013 10, 477-482DOI: (10.1016/j.hrthm.2012.12.009)
Hoffmayer, Kurt S. et al.
Heart Rhythm , Volume 10 , Issue 4 , 477 - 482
Outflow Tract PVCs/VT
Treatment of PVCs
• Reassurance and NO Therapy if benign
• If symptomatic/Significant
•
•
•
•
•
Ca++ Blockers > Beta Blockers
Exercise
Mg Supplement
Suppression Trial (Mexilitene)
Ablation
• Structural Heart Disease
• ? Suppression with Amio/ Tikosyn/ ?Sotalol
• Ablation
PVC Ablation
• Law of 80’s
• 80% Success, 80% no recurrence
• RVOT/LVOT
• RV:
• Moderator Band
• Scar in ARVD
• LV:
•
•
•
•
Aortic Cusps
Aortic-Mitral Continuity
LV Scar
Papillary Muscle
• IntraVentricular
• Epicardial
• Outpatient
• 2-4 hours duration
• Cath-like sedation
• Fem Venous/?Arterial Access
• Risks
• <10% Pericarditis
• <2% AV Block
• Minimal stroke risk if R sided; <1%
if Arterial
Questions?
• Excellent review- Callans article