PVC and CMP

My husband had frequent PVC (20000/day) since at least his late 30s. His EF was initailly normal and then dropped to about 45% in 2006.  No other cause was found for his cardiomyopathy.  His heart was enlarged (5.8 to 6 cm), as well as left atrium (4.0 cm). He underwent succesful ablation in fall of 2006. Focus was found in the base of right ventricle (posterolateral) in easily ablated (procedure lasted 3 hours only).  Mapping of the heart, left and right, showed no evidence of scar. Two MRIs were normal.  Innitially (3 months post ablation) his EF dropped to 40%, however, in 1year his EF was back to 50% and heart was smaller (5.3 to 5.6 cm, depending on the echocardiogram). 1.5 year later EF is still low normal (50%) and heart borderline enlarged.  He has only 100 PVCs per day. He is on coreg and lisinopril.
1. Is cardiomyopathy caused by PVCs ?
2. I cannot find any literature on these types of PVC (only RVOT type or ARVD). Have you had any cases where only one  focus was found in other areas of right ventricle? What was the diagnosis?
3. Could this still be ARVD despite two negative MRIs?
4. Would you expect EF to improve, decrease or remain stable in the future? We were told that often in cardiomyopathy EF will fluctuate.
5. Would you suggest any further studies or treatment? (supplements, such as carnitine, selenium...)

Thank you very much

[Michael J. McWilliams, M.D.]

1. Is cardiomyopathy caused by PVCs ?

Decreased heart function that improved after a successful PVC ablation suggests that the mechanism was PVC related, but that is as conclusive as you can be.

2. I cannot find any literature on these types of PVC (only RVOT type or ARVD). Have you had any cases where only one  focus was found in other areas of right ventricle? What was the diagnosis?

I have not had a case like that. Typically it is RVOT.  At this point, the best you can say it was likely a PVC induced cardiomyopathy.  Searching the internet for answers, in my opinion, for answer to questions that cannot be answered only adds to the anxiety.  I am sure you are trying to figure out if there is another problem or if it was only PVC induced.  Unfortunately, I do not think you will find that answer.

3. Could this still be ARVD despite two negative MRIs?

It is unlikely but still can't be completely ruled out.  At his age, one would expect it to be manifest by now if present.

4. Would you expect EF to improve, decrease or remain stable in the future? We were told that often in cardiomyopathy EF will fluctuate.

If it was PVC induced and the PVC is gone, I would expect it to say about the same +/- 5%.

5. Would you suggest any further studies or treatment? (supplements, such as carnitine, selenium...)

If you have had echo, MRI, stress test, EP study and ablation, I do not think there are many other tests that can be ordered.  A signal averaged EKG might help if they thought it was ARVD, but if they do not suspect ARVD, I wouldn't do the test.

I hope this helps.  Thanks for posting.

[mary2]

By the was he is 47 and otherwise healthy

[Momto3]

Hi Mary,

Sorry to hear your husband is dealing with heart issues, especially at such a young age.  I was 46 when I had 2 successful ablations for PVC-induced cardiomyopathy.  It is a rare cause for CM, but it can occur in the setting of very frequent PVCs.

My first ablation was for RVOT and the second was for LVOT.  At the time of the first ablation, my EF was 40% (prior to that it was normal).  Six to twelve months after the second ablation, my EF was back to 55%.  Last report said 60%.  I take a low dose of lisinopril, but no Coreg.

Not sure about ARVD.

Does the doctor feel your husband will experience further improvement in EF?  Glad to hear he is otherwise healthy : )

Connie

[mary2]

Thank you both.
I forgot that he had a signal averaged EKG which was normal. Where he was treated, they have not had a case like it. Therefore, they are causious to say it is PVC induced only. One of the EP specialist who recommended ablation said that by removing PVCs one will hopefully be able to tell if it is cardiomyopathy causing PVC or PVC causing cardiomyopathy.  The cardiologists involved in his care seem to be causious.
Even if it is PVC induced cardiomyopathy I wonder if the has had PVCs longer that 6-7 years we have know and they have caused irreversible damage to the heart?

Connie, how many years has it been from your ablation?

[Momto3]

Hi Mary,

I had my ablations in August and November, 2003.  It took nearly a year for my EF to return to 55%.  Last check, in November 2007, I was back at 60%.  

So, his ablation was not for RVOT?  My doctor was also cautious to confirm that the PVCs caused the cardiomyopathy.  It was highly suspect, but not completely confirmed until after the procedures and some normalizing of my EF.

Does your husband have any symptoms from the slightly decreased EF?  How long has he been taking the Coreg?  Lisinopril?  I've heard that Coreg can be helpful with improving EF.

I had a signal averaged EKG many years ago, and like your husband, everything was normal.  

Connie

[mary2]

Thank you Connie.
No, it is not RVOT, therefore it is so unusual and rare.  They have not had a case like it. Initally, they were worried about ARVD but two MRIs were negative for it and he has had no recurrence of PVCs since the ablation 1.5 year ago.

He has had no symptoms at all.  It was pciked up because of the irregular hert beat, which lead to stress test and echo.
He has been on medication for probably two year. Some doc question the need for coreg since EF is only mildly down.

We will keep hoping for the best