1. Does asymptomatic patients with very frequent ventricular ectopy need prophylactic catheter ablation to prevent the development of cardiomyopathy Minglong Chen, MD Division of Cardiology The First Affiliated Hospital of Nanjing Medical University

2. Risk of very frequent PVCs in asymptomatic patients PVC-CMP developed Sudden death increased

3. All P ＜ 0.05 PVC burden≤20% ＞ 20% LVEF45±1mm54±1mm CTR46±1%52±2% LVEF73±2%66±2% MR0.4±0.11.2±0.2 NYHA1.3±0.11.8±0.2 Takemoto M, et al. J Am Coll Cardiol, 2005;45:1259–65 Risk of very frequent PVCs

4. Prognostic significance of frequent PVCs with normal LV function 239 pts with frequent PVCs (>1000 beats/day) Structural heart disease was ruled out, FU period of 5.6 ys no patients exhibited any serious cardiac events. negative correlation between the PVC prevalence and DeltaLVEF (p<0.001) positive correlation between the PVC prevalence and DeltaLVDd (p<0.001). PVC prevalence and LVEF at the initial evaluation were independent predicting the development of LV dysfunction (p<0.01) Niwano S, et al. Heart, 2009, 95(15):1230-1237

5. The proportion of asymptomatic patients was significantly higher in the presence of cardiomyopathy (36/76, 47%) than in normal LV function (25/165, 15%) PVC-CMP more easily attacked in asymptomatic patients Yokokawa M, et al. Heart Rhythm, 2012;9:92–95

6. Definition: LVEF of ≤50% in the absence of any detectable underlying heart disease and improvement of LVEF≥15% following effective treatment of index ventricular Incidence: 6.8% in patients with idiopathic ventricular arrhythmias Predictors: gender, absence of symptoms, PVC burden, the presence of repetitive monomorphic VT, and so on Incidence of PVC-CMP Hasdemir C, et al. J Cardiovasc Electrophysiol, 2011,22:663-668

7. prospective study,15 637 apparently healthy white men, 35 to 57 ys prevalence of any VPC was 4.4% (681 of 15,637) Over FU of 7.5 years, a total of 381 deaths occurred The presence of any VPC was associated with a significantly higher risk for SCD (adjusted RR=3.0; P ＜ 0.025) frequent (2 or more uniform VPCs every 2 minutes) or complex (multiforms, pairs, runs, R-on-T) VPCs were at a significantly increased risk of SCD (adjusted RR=4.2; P ＜ 0.005) Sudden death increased Abdalla IS, et al. Am J Cardiol, 1987, 60:1036 -1042

8. Cheriyath P, et al. Am J Cardiol, 2011, 107:151-155 Baseline examination from 1987 to 1989, 2-minute rhythm strip of EKG follow-up data collected until December 2002 14,574 subjects,130 incident cases of SCD Participants with VPC were 2 times as likely to have SCD compared to those without VPC (HR2.09, 95% CI1.22 to 3.56)

9. Cheriyath P, et al. Am J Cardiol, 2011, 107:151-155

10. Enlarged LVDd and CTR, reduced LVEF, increased MR, and deteriorated NYHA functional class PVC-CMP was resolved within 2 to 4 weeks after discontinuation of PVCs No inflammation, fibrosis, or changes in apoptosis and mitochondrial oxidative phosphorylation Characteristics of PVC-CMP Huizar JF, et al. Circ Arrhythm Electrophysiol, 2011;4:543-549 Takemoto M, et al. J Am Coll Cardiol, 2005;45:1259–65

11. Huizar JF, et al. Circ Arrhythm Electrophysiol, 2011;4:543-549

12. a short PVC coupling LV dyssynchrony during PVCs postextrasystolic potentiation (Which could increase in intracellular Ca 2+ and myocardial oxygen consumption) Mechanism of PVC-CMP Huizar JF, et al. Circ Arrhythm Electrophysiol, 2011;4:543-549

13. PVC burden? QRS width? NSVT? Duration? Symptom or absence of symptom? Gender? …......... Determinants of PVC-CMP

14. All P ＜ 0.05 PVC burden ≤20% ＞ 20% LVEF45±1mm54±1mm CTR46±1%52±2% LVEF73±2%66±2% MR0.4±0.11.2±0.2 NYHA1.3±0.11.8±0.2 Takemoto M, et al. J Am Coll Cardiol, 2005;45:1259–65

16. Carpio Munoz, FD, et al. J Cardiovasc Electrophysiol, 2011, 22,791-798 PVC burden reduced LVEF (n = 17) vs normal LVEF (n = 53) burden of PVCs: (29.3 ± 14.6% vs 16.7 ± 13.7%, P = 0.004)

19. 57Pts with reduced LVEF(0.37 ±0.10) 117Pts with normal LVEF PVC burden:33% ± 13% VS 13 ± 12% Baman TS, et al. Heart Rhythm, 2010;7:865–869 PVC burden PVC burden ＞ 24% was independently associated with PVC-CMP sensitivity :79%, specificity :78%, under curve:0.89

21. Hasdemir C, et al. J Cardiovasc Electrophysiol, 2011,22:663-668 PVC burden PVC burden ＞ 16% was independently associated with PVC-CMP sensitivity :100%, specificity :87%,under curve:0.96 17Pts with reduced LVEF 227Pts with normal LVEF PVC burden:29% ± 9% VS 8 ± 7%

22. QRS duration Yokokawa M, et al. Heart Rhythm, 2012, 9:1460-1464 QRS duration ＞ 150 ms predict PVC-CMP: sensitivity 80%; specificity 52% PVC burden for developing PVC-CMP PVC-QRS width of ≥ 150 ms vs narrower PVC-QRS complex (22% ± 13% vs 28% ± 12%; P ＜ 0.0001)

23. Deyell MW, et al. Heart Rhythm, 2012;9:1465–1472 QRS duration

24. Carpio Munoz, FD, et al. J Cardiovasc Electrophysiol, 2011, 22,791-798 QRS duration and NSVT

25. Yokokawa M, et al. Heart Rhythm, 2012;9:92–95.... Others: male, asymtomatic status

26. Does VPCs ablation reverse LV function?

27. 7 pts with more than 20,000 VPCs in holter (EF:40% or less) received additional cardiac medical therapy, including 4 patients with amiodarone therapy After medical therapeutic intervention, 75% VPCs or more reduction from baseline in 5 pts 6±3m FU, EF increased from (27±10)% to 49 +/- 17% in the 5 pts implication of medical therapy suppression of frequent VPCs may be associated with improvement of left ventricular function Duffee DF, et al. Mayo Clin Proc, 1998, 73(5):430-433

28. 8pts ， VPCs 17 541±11 479 per day Before abl:LVEF39%±6% ， post abl:62%±6% ， P=0.017 Yarlagadda RK, et al. Circulation, 2005, 112:1092-1097

29. 47pts PVCs ＞ 10000/d, average 24194±12516/d 38pts RF successfully(GROUP 1), 9 pts unsuccessfully(GROUP 2) Sekiguchi Y, et al. J Cardiovasc Electrophysiol, 2005,16:1057-1063 GROUP1

30. GROUP2

31. Plots of BNP levels before and after RFCA in the two groups

32. 22/60 Pts with reduced EF 34% ± 13% VPCs burden: 37% ± 13% vs. 11% ± 10% Patients with reduced EF: before abl vs after abl, 34% ± 13% to 59%±7% EF remained unchanged in control group Bogun F, et al. Heart Rhythm, 2007;4:863– 867

34. Controll groupablation group

35. 69 pts (51 ± 16 ys) LVEF35% ±9%, LVDD5.8 ± 0.7 cm Frequent outflow tract VPCs (29% ± 13%) 11 ± 6 months FU The magnitude of LVEF improvement correlated with the decline in residual VPD burden (r=0.475, P=.007) Mountantonakis SE, et al. Heart Rhythm, 2011;8:1608 –1614

38. Predictors of recovery of LV function following the elimination of VPCs

39. Mountantonakis SE, et al. Heart Rhythm, 2011;8:1608 –1614

40. Deyell MW, et al. Heart Rhythm, 2012;9:1465–1472

41. Do we need catheter ablation to prevent the development of cardiomyopathy