Post on 02-May-2015
Dr. P. Pieragnoli
Extrasistolia nel
Cuore Sano
Firenze, 8 Novembre 2014
Università degli Studi di Firenze
D’Este et al, G Ital Cardiol 2010
Extrasistolia ventricolare che origina dal fascicolo posteriore della branca sinistra.Morfologia del QRS a tipo blocco di branca destra ed emiblocco anteriore sinistro.
Extrasistolia ventricolare dal tratto di efflusso del ventricolo
destro. Morfologia del QRS a tipo
blocco di branca sinistra con asse verticale.
D’Este et al, G Ital Cardiol 2010
Characteristic appearance of ectopy from the right ventricular outflow tract
Giles et al, Canadian Journal of Cardiology 2013
Displasia aritmogena del ventricolo destro. Morfologia del QRS a tipo blocco di branca sinistra.
Sindrome del QT lungo congenito.Allungamento dell’intervallo QT
soprattutto nei battiti post-extrasistolici.
D’Este et al, G Ital Cardiol 2010
Extrasistolia ventricolare in un caso di fibrillazione ventricolare idiopatica. Le extrasistoli sono precoci ed hanno morfologia bizzarra.
D’Este et al, G Ital Cardiol 2010
Kennedy et al. NEJM 1985
Ataklte et al, Am J Cardiol 2013
Ataklte et al, Am J Cardiol 2013
Association of VPCs with risk forSudden Cardiac Death
Ataklte et al, Am J Cardiol 2013
Association of VPCs with risk for Total Cardiac Death
Lee V et al, Heart 2012
Presence of PVCs is associated with a pooled OR of 1.72 (95% CI 1.28 to 2.31) of developing all-cause mortality, cardiovascular mortality, SCD or ischaemic heart disease when compared with patients without any PVCs.
Our paper has shown that the current evidence base on the exact prognosis of PVCs in structurally normal hearts is limited and has many flaws. Most studies on the prognosis of PVCs in normal hearts did not use advanced tests to rule out structural heart disease. Among these patients, PVCs are associated with a worse cardiovascular outcome, and this risk is correlated to the age and underlying cardiovascular risk of the patient population, suggesting that the poor prognosis studies may have inadvertently included patients with occult structural heart disease, the population in which PVCs are known to confer adverse outcomes. More studies are required.
Lee V et al, Heart 2012
Giles et al, Canadian Journal of Cardiology 2013
Biffi et al. JACC 2002
Biffi et al. JACC 2002
Frequent and complex ventricular tachyarrhythmias are common in trained athletes and are usually unassociated with underlying cardiovascular abnormalities. Such ventricular arrhythmias (when unassociated with cardiovascular abnormalities) do not convey adverse clinical significance, appear to be an expression of “athlete’s heart syndrome,” and probably do not per se justify a disqualification from competitive sports.
Biffi et al. JACC 2002
Behavior of the median number of VPCs/24 hours during followup
in subjects who continued sporting activity and in those who did not.
The number of VPCs/24 hours decreased significantly in both
groups.
Median number of VPCs in the basal condition and during follow-up in subjects who had a normal (>55%) or abnormal (55%) EF at the end of follow up.
Delise et al, Am J Cardiol 2013
The best cutoffs to predict low left ventricular EF at the end of follow-up, based on receiver operating characteristic curve analysis of the number of basal and final VPCs, were 5873 and 10436 VPCs/24 hours, respectively.
Delise et al, Am J Cardiol 2013
Basal VPCs VPCs during Follow-up
Lee et al, Am J Cardiol 2014
The relation of VPC burden to (A) LVEF and (B) left ventricular end-systolic dimension (LVESD).
Premature ventricular contraction (PVC) burden and its effect onLV function.
Lee et al, Am J Cardiol 2014
Kaplan-Meier survival estimates of PVC burdens.Significant difference among patient groups with PVC burden <1,000/24h, 1,000 to 10,000/24h, and >10,000/24h
Lee et al, Am J Cardiol 2014
Kaplan-Meier survival estimates of PVC features.
Survival rates were lower in patients with a PVC QRS duration of 150ms than those with a PVC QRS duration of <150ms (A)
Survival rates were lower in patients with a PVC coupling interval of >480 ms than those with a PVC coupling interval of 480 ms (B).
Lee et al, Am J Cardiol 2014
Kaplan-Meier survival estimates of PVC origins.
The comparison of survival rates between the VPCs originating from (A) OT and non-OT locations and (B) between the RV and the LV.
Ephrem et alAnn Noninvasive Electrocardiol 2013
Ephrem et alAnn Noninvasive Electrocardiol 2013
Time to adverse event by frequency
Time to adverse event by pattern
Qureshi W et al, Am J Cardiol 2013
All-Cause Mortality
Cardiovascular Disease Mortality
Ischemic Heart Disease Mortality
Qureshi W et al, Am J Cardiol 2013
APC
APC
APC
VPC
VPC
VPC
These findings highlight the potential use of electrocardiography as a screening tool in asymptomatic patients to detect subclinical cardiac disease.Further studies are needed to validate our findings and evaluate the mechanisms by which APCs are associated with poor outcomes.
Qureshi W et al, Am J Cardiol 2013
Heidbuchel et al, European Heart J 2003
Heidbuchel et al, European Heart J 2003
Role of SEF
PVC-INDUCED CARDIOMYOPATHY
Tachicardia Induced Cardiomyopathy
Ventricular Dyssynchrony
Increased Oxygenconsumption
Myocardial and pheripheral vascular autonomic dysregulation
Alterations in heart rate dynamics
Hemodynamic impairment
Alterations in intracellulare calcium and membrane ionic currents
Yong-Mei Cha et al, Circulation 2012
Yong-Mei Cha et al, Circulation 2012
Krittayaphong et al, Am J Cardiol 2014
Comparison of percent improvement of symptoms, PVC count, and average heart rate as measured by AECG, and QOL score be- tween the atenolol group and the placebo group (positive direction represents reduction in symptoms, PVC count, and heart rate, and an increase in QOL score)
Krittayaphong et al, Am J Cardiol 2014
Minhua Zang et al, Heart Bmj 2014
Minhua Zang et al, Heart BMJ 2014
Minhua Zang et al, Heart Bmj 2014
Change in LVEDd post-AblationChange in LVEF post-Ablation
Effect of Ablation
Miyamoto et al., Circ J 2010
Benigne PVC from RV Outflow Tract
Surface EKG Endocardial Ablation
Benigne PVC from Outflow Tract
Tanner et al., JACC 2005
Surface EKG Epicardic Ablation
Yokakawa et al., Heart Rhythm 2013
Wijnmaalen et al., Heart 2010
Conclusions: Frequent PVCs can induce subtle cardiac dysfunction detected by speckle tracking imaging analysis in patients without apparent cardiomyopathy. RFCA can successfully eliminate PVCs and improve cardiac function.
Baser et al., J Cardiovasc Electrophysiol 2014
Baser et al., J Cardiovasc Electrophysiol 2014
Preablation and 3 months postablation PVC burden in patients with an acutely effective
versus an acutely failed procedure. There was no significant difference in the PVC burden preablation. The PVC burden at 3 months
postablation was significantly reduced.
Site of origin of predominant PVCs. The numbers in parentheses indicate number of patients with success/failure at 3 months postablation.
Conclusioni 1
In assenza di una dimostrata cardiopatia di base i BPV frequenti non sembrano avere in sè una potenziale evolutività verso aritmie maligne e comportare quindi un più elevato rischio di morte improvvisa.
Un numero molto elevato di BPV nelle 24 ore (>2000) si accompagna più facilmente a polimorfismi e forme complesse, aspetti quest’ultimi caratterizzati da maggior prevalenza di cardiopatia.
È necessario che il cardiologo escluda con ragionevole sicurezza la presenza di una cardiopatia prima di assolvere i BPV dal sospetto di essere markers e spie di patologie latenti, subcliniche o molecolari.
Sotto il profilo terapeutico, solo la presenza di una cardiopatia giustifica provvedimenti farmacologici con antiaritmici, prescritti in modo personalizzato.
In casi altamente selezionati anche in questo campo risulta vantaggioso il ricorso alle tecniche di ablazione con radiofrequenza.
Per quanto riguarda gli atleti bisogna ricordare l’efficacia del detraining sul controllo dei BPV e l’importanza dell’indagine relativa all’assunzione di sostanze illecite, la cui sospensione è spesso sufficiente a risolvere il problema aritmico nei casi senza patologia cardiaca.
Conclusioni 2