PREMATURE

VENTRICULAR
CONTRACTION :
Treat it or Leave it

Dr. Ardian Rizal, SpJP

Arrhythmia and Electrophysiology Division
Cardiology and Vascular Medicine
Faculty of Medicine, Brawijaya University
Introduction
 PVCs in Numbers

40–75%
In General
1.39 3.5%
incidence of
Mostly
Only need
Population Male compared sustained
to female reassurance
VT or SCD
 Ventricular Arrhythmia
Clinical Spectrum

Reassurance
Asymptomatic and Benign

Frequent and Symptomatic

ICD and
Ablation
Sudden Cardiac Death

Heart Rhythm, Vol 11, No 10, October 2014

 Ventricular Arrhythmia
Diagnosis Work UP

12 Lead ECG & Specific Morphology

Structural heart disease ?
Echocardiography
inherited and acquired cardiomyopathies?
Holter Monitoring
myocardial ischemia ?
Other imaging
 Expert Consensus EHRA/HRS/APHRS
Diagnosis Work UP
• All patients should have a resting ECG and echocardiogram to detect underlying
heart disease including inherited and acquired cardiomyopathies. Especially in
patients in whom the arrhythmia morphology suggests such a specific etiology
(II a ; LOE B)

• A test for myocardial ischemia should be considered in all patients with VAs in
whom the clinical presentation and/or the type of arrhythmia suggests the
presence of coronary artery disease. (II a ; LOE C)

• Prolonged ECG monitoring by Holter ECG, prolonged ECG event monitoring, or

implantable loop recorders should be considered when documentation of
further, potentially longer arrhythmias would change management. (II a ; LOE C)

Heart Rhythm, Vol 11, No 10, October 2014

VT Classification
 VT Etiology

10%

• Ischemic Cardiomyopathy • Outflow Tract VT (80-90 %)

• Non – Ischemic Cardiomyopathy • ILVT
• Hypertrophic Cardiomyopathy • Idiopathic Propanolol VT
• Arrhythmogenic Right • Cathecolaminergic Polymorphic
Ventricular Dysplasia VT
• Sarcoidosis • Inherited Channelopathies
(Brugada and Long QT
Syndrome)
90%

structurally normal heart

structural heart diasese
SUPPLEMENT OF JAPI • APRIL 2007 •
VT/PVC in Structurally Normal Heart

SUPPLEMENT OF JAPI • APRIL 2007 •

VT / PVC in Structurally Normal
Heart
Also called Idiopathic VT
Outflow tract VT (RVOT/LVOT) 90 %
Manifest at a relatively early age
Female à RVOT ; Male à LVOT
Symptoms :
• Most patients (48% to 80%) experience palpitations
• Presyncope and lightheadedness may also be observed
(28% to 50%)
• True syncope à rarely seen

Huang et all, 2011

Am Heart J 1992; 124: 746
 ECG Presentation

Inferiror Axis

LBBB Type
VT localization : General Principle
VT Localization: General ECG Principle
1. —LVRBBB/LBBB morphology:
free wall VT shows RBBB
— RBBB: origin in the left ventricle
configuration, while VT
exiting from IVS or RV
— LBBB: origin in the right ventricle
displays LBBB configuration.
2. Inferior/superior axis (lead II, III and
—Septal exits are associated
aVF):
with narrower QRS
consistent with synchronous
— Inferior axis (positive in lead II, III and aVF):
rather than sequential
origin superior wall
ventricular activation.
3. — Superior axis (negative in lead II, III and aVF):
Basal sites show positive
origin inferior wall
precordial concordance,
while negative concordance
—is Basal/apical (lead V5-V6):
seen in apical sites of
— Positive concordance in V5-6: basal origin
origin.
— Negative concordance in V5-6: apical origin
8
Differentiate LVOT and RVOT
 Distinguish LVOT from RVOT : V2 transition ratio

• Measure R and S waves in V2 of SR QRS and PVC QRS

• Transition ration is (R/R+S) VT / (R/R+S) SR

Transition Ratio:
< 0.6 = RVOT
> 0,6 = LVOT

Betensky et al. JACC 2011

Transition of PVC and SR

PVC after SR = RVOT 100% PVC at/before SR = LVOT 71%

Betensky et al. JACC 2011

 V2 Transition Ratio
Diagnostic Algorithm for Outflow tract VT

Diagnostic Algorit
With Lead V3 P

Betensky et al. JACC 2011

Idiopathic Left Ventricular Tachycardia
(Fasicular VT)

• Reentry (Verapamil-sensitive)
• 3 Types :
• Left posterior type
(RBBB+LAD, common form)
• Left Anterior type
(RBBB+RAD, uncommon form)
• Left Upper Septal type
(Narrow QRS+IA, rare form)
Substrate and Anatomy
“Slow-Fast” Type “Fast-Slow” Type (Upper septal)

False Tendon or Fibromuscular band

Posterior Fasicular VT

RBBB morphology with Left axis deviation

Anterior Fasicular VT

RBBB morphology with Right axis deviation

Left Upper septal VT

• Narrow QRS complex (100 msec)

• R/S transition between V3-V4
• Inferior axis
Specific ECG Finding
Cardiac Channelopathies
Specific
ECG
Finding
Cardiac
Channel
opathies
Specific ECG Finding
Cardiac Channelopathies
Patophysiology
Patophysiology and Classification

Substrate

Arrhythmia
Trigger
Mechanism
Pathophysiology
heightened
adrenergic
state

Anaerobic myocardial
glycolysis Ectopic ischemia

Automatic
Focus
Sympathomi Acid-base
metic agent disorders

Automaticity
Pathophysiology

Re - entry

• two parallel conducting pathways connected

proximally and distally
• reentrant circuits arise in areas in which normal
cardiac tissue becomes interspersed with patches of
fibrous (scar) tissue
• Such as after a myocardial infarction or with
cardiomyopathic diseases
Pathophysiology
Triggered activity
• Abnormal fluxes of positive ions into cardiac
cells
• Trigger the rapid sodium channels (which are
voltage dependent) and cause another
action potential to be generated
• triggered activity appears to be the dominant
mechanism in reperfusion injury

abnormal fluxes of positive ions

Substrate : Long QT Syndrome
Trigger : PVC
Arrhythmia Mechanism :
Triggered Activity
Management
 PVC
Induced Cardiomyopathy
• Several studies have demonstrated an association
between PVCs and a potentially reversible
cardiomyopathy

• Risk predictors :
• high-frequency PVCs
• longer duration of PVCs
• epicardial or broad QRS complex PVCs
• interpolated PVCs
• male sex
Rev Esp Cardiol. 2016;69(4):365–369
Management of PVCs
 Treatment
In Structural Normal Heart
• The first step is education of the benign nature of
this arrhythmia and reassurance

• The most common indication for treating PVCs

remains the presence of symptoms

• Medical tx :
• Beta – blocker and non-dihydropyridine calcium
antagonists
PVC/NSVT Management
in Normal Heart
 PVC/NSVT Management
in Structural Heart Disease
 Catheter Ablation
• catheter ablation should only be considered for patients who are markedly symptomatic
with very frequent PVC

• Multiple studies indicate high efficacy of ablation with PVC elimination in 74 – 100% of
patients

• Procedural success may be dependent on site of origin and number of PVC morphology

• Although complete PVC elimination is the goal of ablation, it should be noted that partial
success may still be associated with significant improvement in LV systolic function

• Catheter ablation for idiopathic ventricular tachycardia For focal VT (esp RVOT VT) à
highly successful and carries low procedural risk
Management of SMVT
Intra Cardiac Defibrillator (ICD) Indications
 Treatment
In Structural Heart : Ischemic VT
• ICD first
• most agree that ablation therapy is palliative
and adjunctive to ICD therapy
• The typical patient considered for VT
ablation has frequent VT episodes resulting
in multiple ICD shocks due to rapid VT

Huang et all, 2011

Am Heart J 1992; 124: 746
Take Home Messages
• Not all the PVC are the same

• Most PVC in normal structural heart only need reassurance

• Beta blocker and non dihydropirydine CCB are almost fit for all cases

• Idiopathic PVC Ablation have high success rate and dr

Matur Nuwun Rawuhipun