Management of pv cs and ventricular tachycardia in advanced heart failure
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Transcript of Management of pv cs and ventricular tachycardia in advanced heart failure
MANAGEMENT OF PVCS AND VT IN ADV HF:
THERAPEUTIC OPTIONS AND NOVEL
APPROACHES MARCH 16, 2015
Melissa R. Robinson, MD FACC FHRS CCDS Assistant Professor of Medicine
Director of the Complex Arrhythmia Service
University of Washington, Seattle
CASE: 27 Y.O. WOMAN WITH “PPCM”
• NICM for five years
• on optimal GDT for 1 year
• NYHA Class III, being considered for LVAD/Tx
• Referred for primary prevention ICD for EF < 30%
CASE: 27 Y.O. WOMAN WITH “PPCM”
• TTE – frequent ectopy,
•LVEF est. 23%, LVEDD 71 mm
• de MRI was normal
• Holter monitor showed 38% monomorphic PVCs, rare NSVT
•Antiarrhythmic?
•ICD?
•PVC Ablation?
PRIMARY ELECTRO-CARDIOMYOPATHY
• Frequent ventricular ectopy itself can cause a cardiomyopathy
• Mechanism
•Dyssynchrony
•Decrease in Ito and IK1 currents
•Δs in spatial relationship of L-type Ca2+ channels and ryanodine receptors
• Increasing data that it is often reversible with abolition of PVCs.
Bogun, et al. Heart Rhythm 2007;4:863 Wang Y, Heart Rhythm 2014:11;2064
PVC INDUCED CARDIOMYOPATHY
Baman T, Heart Rhythm 2010:7(7);865 Baman T, Heart Rhythm 2010:7;865
35%
54%
LVEF IMPROVES WITH PVC RFA IN ICM
Sarrazin J, Heart Rhythm 2009:6(11);1543
• 30 pts with ICM referred
for ICD with frequent
PVCs
• Randomized to PVC
ablation + ICD or ICD
alone
• Control group saw no
change in EF
38%
51%
• 30 pts with NICM, scar on MRI, >5% PVCs
• Pleomorphic PVCs
• Most localized to scar – not idiopathic regions
• 60% overall ablation success
• EF improvement 34 to 46%
PVC ABLATION IN NICM PTS
El Kadri M, Heart Rhythm 2015; in press
PVC ABLATION IN ADV HF
• Morphology is important – idiopathic regions
(outflow tract, annular, papillary m) are more
favorable ablation outcome
• Medical therapy less effective than ablation
• CRT pts with high PVC burden (>22%) improve
EF, LV size with RFA of PVCs
• Safe, well tolerated procedures
Zhong L, Heart Rhythm 2014;11:187
Lakkireddy D, JACC 2012;60:1531
CASE: 60 Y.O. MAN NICM AND VT
• LVEF 20%
• Bi-v ICD
• Carvedilol 12.5mg 2
• Amiodarone 200mg1
• Aldactone, Losartan
• Presyncopal
• β Blockers
•Dose should be maximized
• Amiodarone
•Caution with β blockers, digoxin, warfarin
•May slow VT below detection zone
•Can increase DFT
• Sotalol
•Can have neg inotropy
• Mexiletine
ANTIARRHYTHMICS
Vassallo P, JAMA 2007;298:1312
Connelly S, JAMA 2006;294:165
• Dofetilide
• Class Ic agents
•Non-ischemic CM pts
•Added to amiodarone
• ICD should be present
• Ranolazine
•Small series show decreased VT burden
•Added to Class III agents
• Ischemic and non-ischemic CM pts
NOVEL ANTIARRHYTHMIC STRATEGIES
Bunch J, PACE 2011;34:1600
Pinter A, JACC 2011;57:380
Note: These are all
off label uses for
these drugs
VT ABLATION SHOULD NOT BE A RX OF LAST RESORT
Frankel D, JCE 2011;22:1123
Early Group
Late Group
• Late referrals – ≥2 episodes separated by one month
• 2/3 pts were late referrals
• More likely to be in VT storm, on high dose amiodarone, slightly older
• LVEF same
VT ABLATION BENEFIT IN LOWER EF PTS
Bunch J, Heart Rhythm 2014;11:533
Tung R, JCE 2010;21:799
• SMASH-VT analysis, benefit of ablation was independent of EF.
• Trend towards more recurrences in Class III – IV patients, however
• Bunch, et al, evaluated a registry of device and ablation patients
• 102 pts after VT ablation for ICD shock
• 2088 pts without ICD shock
• 817 pts with shock, but no ablation
HEMODYNAMIC SUPPORT DURING VT ABLATION
Miller M, Heart Rhythm 2012;9:1168
• Dilated pts with faster VTs
• Normal PAP, RV ƒ(x)
• General anesthesia
• Impella CP
•Better support
•Less EAM interference
• 14F CFA access
BENEFITS OF PLVAD DURING VT ABLATION
Aryana A, Heart Rhythm 2014;11:1122
• Longer mapping times in VT
• Decreased post-ablation hemodynamic embarrassment
• Possibly increase success of VT ablation
CASE: 60 Y.O. MAN NICM AND VT
• LVEF 20%
• Bi-v ICD
• Carvedilol 12.5mg 2
• Amiodarone 200mg1
• Aldactone, Losartan
• Presyncopal
• Underwent pVAD
supported ablation
• Discharged next
day
• VT free for 14 mo
later off of
amiodarone
LIMITATIONS OF THE PERCUTANEOUS
APPROACH TO VT RFA
• Recurrent/refractory VT
• Inability to access the pericardium (prior CABG or valve surgery)
• Location near phrenic nerve or coronary artery
• Inaccessible area for ablation
•septum*
•midmyocardial
•Epicardial fat
• Insulated 0.014”
wire used for
mapping
• Coil or alcohol
injection after
testing for effect
INTRACORONARY MAPPING FOR VT
Tholakanahalli V, Heart Rhythm
2013;10:292
• Cardiac Electrophysiologist
• Device Clinic Staff
• Advanced Heart Failure/Transplant
• Cardiac Anesthesiologists
• Interventional Cardiologists
• Cardiac Surgeons
• Pharmacists
• Psychiatrists
• Palliative Care Team
MANAGEMENT OF VT IN ADVANCED HF