RVOT VT or Vasovagal Syncope?

[416340]

I'm a 24 year old female who has been diagnosed with RVOT PVC’s with LBBB and inferiorly directed axis (one holter monitor shows over 28,000 PVC’s and another holter shows 35,000 PVC's).  I do not feel those constant PVC’s however, I do have episodes where I get extremely dizzy, weak and have chest pain and palpitations.  I have passed out a few times. These episodes use to happen once a month, but since February they began to happen about 3-4 times a week.  These episodes happen when standing, sitting and even while lying down. Twice, I have woken up from sleep violently gasping for air. My cardiologist first said my episodes were due to RVOT VT, but now believes that these episodes are not related to the PVC’s and believes that they are vasovagal episodes. I had a tilt table test preformed, but it was negative, likely because I am now on Sotalol to help suppress the PVC’s and reduce my symptoms.

I do have a brother that passed away suddenly when only a few months of age, so a cardiac MRI is being booked to rule out Cardiomyopathy(ARVC).  My cardiologist said that ARVC can look a lot like ARVC.  How concerned should i be about this? Do you feel that these episodes could possibly be due to vasovagal sycope, or should I be trying to push my cardiologist for a more firm diagnosis and analysis?  Also on a more recent holter, 60 escape beats were found and couplets.  Are these of any signifance?  These were not found on previous holters, is this a sign, that my condition is progressing?

I was considering getting ablation done to reduce the PVC’s and frequency/severity of the episodes because I have been having some side effects of the medication and do not what to take beta blockers for the rest of my life.  But I also hesitate to do the ablation if the PVC’s are not the cause of my episodes.  

Any advise or suggestions would be great.  

[416340]

Thank you for the info and the links!

[101705]

If your interested in reading deeply on RVOT VT/PVC versus ARVD differential diagnosis; I found this like to be an interesting read:
http://www.grupoakros.com.ar/pipermail/arvd-forum/2005-April/000119.html

[101705]

Yes, week 1 good means virtually no PVCs (maybe 5 or 10 all day/night), week 2, 3 and 4 bad means return of near constant PVCs, next 3 weeks very good means again virtualy none - some days none felt at all (and I always feel them) and this week - well their at it again so I am taking the BB again (when I am having my good weeks I am not using any medications).  I have never had dizziness from them just a little mild left sided chest pain which might be from them or may be unrelated.  Hopefully you wont have to wait to much longer to get your MRI.  As far as you question goes respecting BB's and MRIs; I am no expert but doubt that it will affect the MRI protocol for Dx of ARVC as the main thing they are looking for are structural abnormalities of the RV, RV dysfunction and fatty tissue deposition within the RV myocardium - all of that stuff should show whether or not you are on BB's but you should check with the MRI people before you go in for all specific instructions including use of medications

[416340]

Sorry to hear about your health issues, it's tough not having a firm diagnosis.  When you say that post ablation week 1 was good and the next three bad, i'm just wondering good/bad in what way. Did you have a return of constant PVC's, palpitations, dizzyness? I am on a waiting list for an MRI and just hope that i don't have too wait to much longer to get in.  Were you on Beta blockers at the time of the MRI?  Do you know if Beta blockers can alter the MRI results?  

[101705]

I am very interested in your case as it is very similiar to mine.  I had no Hx of PVCs until an acute onset in Oct 2005 and since that time I have had them virtually constant at about the same frequency as you (32,000 on one halter, 18,468 on another) and all coming from the same place as you RVOT.  I found that BB's are not effective but unfortunately the only thing that can give some very temporary relief.  I got fed-up and went for an ablation on July 20, 2007 - 1st week very good, next 3 weeks bad, next 3 very good and last week (this one) bad again.  I dont know if I made the right decision or not - my reasoning was noting could be worse that virtially constant bi and trigem.  Anyhow more interseting stuff - back in spring of 2006 they did the MRI - I was supprised when I was called in and told "not normal" showed multiple small right V aneurisms and hypokin of the right apex - prvisional Dx - "Probabable ARVC" - No other stuff all other ECG and signal ave., etc. negative except for very frequent PVCs (which is one of the diagnostic criteria).  Whether or not I have ARVC remains unknown - a second MRI at a different center was negative (they were using diffiernt machine settings - its not that the 1st was wrong - pity). I know all my heart problems started after a case of the flu which I feel was accompanied by a mild care of viral myocarditis = damage/scars = PVCs as I had a sinus tach of over 100 for about 10 days just as I was recovering from the flu - then all the fun with PVCs started a few months later - never had a lick of trouble from the old ticker before that time and doubt I ever had a PVC.  Anyway as far as the ARVC goes I am told to just sit and wait and if it is what it is - well then it will manifest itself - oh wonderful I just cant wait for v-tach to start and for by ECg to show episolon waves.  Hope your MRI is a resounding negative and you can proudly claim to be a RVOT-PVCer and nothing more - PS you might want to make sure you have all the health coverage you need before you go for the MRI - if you dont and are a positve you might have trouble - good luck - keep me (and us all posted).

[Cleveland Clinic]

Escape beats and PVC's are very similar.  Couplets are PVC's in a row.  I am not sure that we can tell for sure that your conditions is getting worse.  You did have 35000 PVC's previously reported.  That's quite advanced already.

[416340]

Thank you for all of the detailed information!  I am still wondering about the following: on a more recent holter, 60 escape beats were found and couplets.  Are these of any signifance?  These were not found on previous holters, is this a sign, that my condition is progressing?

[Cleveland Clinic]

RBBB VT with inferior axis may be associated with a benign form known as RVOT trachycardia.  Most patients with this conditions do well on medical therapy.  Ablation can be curative in up to 80 to 100% of cases.  Unfortunately, that same arrhythmia may be related to ARVD. Getting an MRI is important.  This will point your doctors in the right direction as far the underlying pathology.  The fact that you brother died suddenly and that you have passed out before and are passing more fequently now really worries me.  I wouldn't put it all on vasovagal syncope, especially that your Tilt table test was negative.  I would definitely seek an opinion of an experienced cardiac electrophysiologist.  Given you history, they are likely to suggest putting in an ICD (defibrillator) and considering further medical therapy for the arrhythmia.  Sotalol is a good option for ARVD patients.  Depending on the morphology/origin of the PVC's, meaning how many different types are there, one should consider performing an ablation.  The reason is that with the amount of ectopy that you are having (35,000) there is a risk of developing a cardiomyopathy (low heart function).  Overall, I think you should be concerned about all this and I think you should seek a second opinion from an experience cardiac electrophysiologist regarding your condition.