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