Premature Ventricular Contraction:: Treat It or Leave It
Premature Ventricular Contraction:: Treat It or Leave It
Premature Ventricular Contraction:: Treat It or Leave It
VENTRICULAR
CONTRACTION :
Treat it or Leave it
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
ICD and
Ablation
Sudden Cardiac Death
• 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)
10%
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
Transition Ratio:
< 0.6 = RVOT
> 0,6 = LVOT
Diagnostic Algorit
With Lead V3 P
• 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)
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
• 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
• 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
• Beta blocker and non dihydropirydine CCB are almost fit for all cases