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Indications to ablation of ectopic beats from the outflow tract: the role of LV
enlargement, symptoms and arrhythmia burden
Dr. Gerardo Rodriguez DiezArrhythmias and pacing Unit
CMN 20 de Noviembre. ISSSTEMéxico D.F.
4 years old girl - with PVC’s since born
PVC’s from the Outflow
Tract
» Why do we performed ablation in this patient?
• Because her symptoms?
• Because decrease Ejection Fraction?
• Because she has dilated cardiomiopathy?
Before ablation
After ablation
Post Ablation - LVEF 60%
Pre Ablation – LVEF 35%
Mountantonakis S et al Heart Rhythm. 2011,8(10):1608-1614
61 (88%)success
↑↑EF by 14%
8 pts with VPDsNo EF ∆ on Max HF meds
2 pts (3%)recurrence
Reversal of PVC Induced LVCM
63 (91% success)
6 pts (9%)Close to coronary or Intramural
RF ablation
69 pts (EF-35 ±9%; LVDD
5.8 ± 0.7cm; 61 % -LVOT)
Role of ventricular enlargement
» Ventricular enlargment is very important in this pathology
» What is first?
• Cardiomiopathy becuase PVC’s
• PVC’s worsening a previous dilated heart
• Can we identify patients with PVC’s at risk for cardiomyopathy ?
• 43/57 - VPDs >24%
• 14/57 - VPDs < 24%• 16 +/-4% (10 - 21%)
• 25/117 with Normal EF with VPDs >24%
57 n = 174 pts117
U of Michigan Group(Bogun) Heart Rhythm, Vol 7 July 2010
PVC Burden and LV Function
•Sensitivity: 79%•Specificity: 78%
If exclude pts with PVCs < 10,000 then difficult to distinguish risk between 10-35%
• Can one identify patients with PVC’s at risk for cardiomyopathy/with reversible cardiomyopathy?
JACC 2013; 62(13)
25% of patients went out of ICD
Class 1 indication
80 pts34% Structural Heart Disease
PVC QRS Duration – Relationship to LV CM (90pts)
No LV Dysfunction (n=66)
Reversible LV Dysfunction(N=24)
Deyell M, Park K et a Heart Rhythm 9:1465-1472 2012
No difference in PVC amount(all >10,000/day) or location (RV/LV)
P<0.001158
135
PVCs may unmask some baseline fiber disruption and cause depressed function in predisposed patients?
VPD QRS Duration - >151ms 79% sensitivity; 91% specificity for LVCM
Deyell M, Park K et a Heart Rhythm 9:1465-1472 2012
QRS duration >15382% Sensitivity 75% specificity
Carballeira L et al. Heart Rhythm 2014; 11:299-306
Stress system with RVA Pacing – QRS duration with pacing to improve specificity?
Can this information be applied prospectively to identify risk and ablate prophylactically?
QRS with RVA pacing >170ms
Park K, Deyell M et al Heart Rhtyhm 2012 abstract
Could we can identify patients with irreversible cardiomyopathy?
PVC QRS Duration – Outcome After Ablation (103pts)
No LV Dysfunction (n=66)
Reversible LV Dysfunction(N=24)
Partially reversible/Irreversible LV Dysfunction(N=13)
No difference in PVC amount(all >10,000/day) or location
P<0.002
P<0.001158
173
135
Deyell M, Park K et a Heart Rhythm 9:1465-1472 2012
Best VPD Duration Cutoff for identifying irreversibility of PVC induced CM
Deyell M, Park K et a Heart Rhythm 9:1465-1472 2012
JACC 2013 60(21) 2194-2204
SCAR
Normal Bipolar Electrogram
Synchronous depolarization
Normal
Infarcted
Low Amplitude Fractionated Electrograms
Discontinuous conduction with poor cell to cell coupling → Reentry
Bipolar Voltage Mapping - Identify Gross Scar (VT Substrate)
EndocardiumBipolar
EndocardiumUnipolar
EpicardiumBipolar
>1.0 mV
<0.5 mV
>8.3 mV
<0.7 mV
>1.5 mV
<0.5 mV
Normal6pts
NICM +VT
Endo Unipolar Egs to Identify Epicardial Scar
Hutchinson et al Circ Arrhythm Electrophysiol. 2011 Feb:4(1):49-55.
Normal Heart(17pts)
Anticipated Reversible VPD induced CM(14pts)
Irreversible CM (24pts)
No scar or small macro scar which was excluded
Campos B et al JACC 2013; 60:2194-2204
3 Patient Groups studied
1.2%
9.8%
58.8%
Bipolar vs Unipolar maps
Percent Area of Unipolar Abnormality Predicts Reversibility of LV Dysfunction
• Risk assessment?• Response to drug tx?• Response to bi V
pacing?
Campos B, et al JACC 2013 60(21) 2194-2204
• Frequent VPDs/NSVT• Common /under-recognized cause of reversible CM• Association with risk of reversible CM
> 13 000 PVCs threshold ? (13%)>153 QRS duration during PVC>170 ms QRS duration during RVA pacing
Identify risk - early ablation – Need prospective validation• Recognition of Irreversible CM
• QRS with PVC > 170ms• 190 RVA pacing(preliminary)• Unipolar Mapping – Uni Egs > 32% of LV surface area
Identifying Reversible Nonischemic Cardiomyopathy
Conclusion
Thank you very much for your attention!
¡Grazie Mille!
