Permanent solutions for PVCs

[Bluewaters]

Had an abaltion May 2010 but from time to time these things come back and can be mixed with anxiety creating a real problem for a period.  Take Metropol at night and Lorazapam (Ambien).  Problem usually at night but now some "attacks" during normal hrs.  I wonder about another ablation if it would completely eliminate the charge; first time they injured it and moved it somewhere else. They have better equipment now.  A week after the procedure I had a severe anxiety episode for some reason. The veins/arteries are clear and heart is sound they say but there is a lot of nagging chest pains mostly in a vertical direction, upper adom pain, feeling of a burp stuck and shaking when it is at it's worst.  They claim a lot of med will create tiredness.  Looking for alternatives; not sure what caused all this (had Lymes twice).

Ron Tallman

[RVVq]

Wish you all the best and hope you can find some answers to your questions!

You might have to undergo another ablation, as you can see it is not uncommon. However, judging from available statistics your chances of being PVC-free or almost PVC-free after 2 ablations are quite high. I definitively advice you to share these studies with your doctor and see what he/she has to say about them. Please let us know how everything went!

[Bluewaters]

I'll show this to the next cardiologist I go to and determine if there is more info of the underlying causes and insist on some form of answers here (cardiac disease/infection).

But it did sound like around 70% had no recurrance after 3.5 yrs and 92% after a 2nd.  Right now I am in the 30 percentile.  No one has followed up with me since May 2010 but I did see the aythmia specialist last Fall.  This is an off again on again thing but lately all the time instead of just at night.

There is no history of heart disease tho my BP is a bit high and I am 230/5'11" on a larger frame.  I exercise 30 or more minutes a day, do not drink, smoke or use illegal drugs. A goal is 200 lbs.

Thanks for your info RVVq let's hope more of us can get to the bottom of these.

[RVVq]

Continued...

The analysis of the biopsy samples revealed that non of the patients
had a healtyh heart, 8 patients had chronic myocarditis, 7 patients
had focal fatty deposits in their ventricicles (presumably ARVD), 4 patients
had occute myocarditis. All non-invasive methods were insuficient in
pointing out the existance of morphological substrate for the arrhythmia.

SUMMARY:

Even though ablation is initially effective in getting rid of PVCs, the reocurrance rates are quite high. The authors of the study propose that long-term reocurrances of PVCs can be explained by the progression of the underlying latent cardiac diseases/infections which are responsible for generating frequent ventricular ectopy in patients.  

[RVVq]

"LONG-TERM OUTCOMES OF RADIOFREQUENCY ABALTION OF VENTRICULAR ECTOPIC FOCI IN PATIENTS WITHOUT STRUCTURAL HEART DISEASE" (Mamchur et al, Vestnik Aritmologii, vol. 61, 2010)

{Full text in Russian, abstract in broken English}

SUMMARY:

This study examined the long-term outcomes of ablations for idiopathic PVCs and VT in 115 subjects. The mean amount of  PVC/day/patient was 11306±7878; ventricular tachycardia was documented in 17 subjects. The success rate of initial procedure was 71% (success defined as absence of PVCs or less than 100 PVC/day on a post-ablation Holter).  After the second procedure, 92% of all patients were free of ventricular ectopy and 100% were free of ventricular tachycardia. During the follow up period (mean of 3.5 years), 8% had reocurrances of PVCs, all of them originating in the same area that was previously ablated. The development of all
recurrences in the late follow-up period, with the same location that in the case of primary radiofrequency ablation of the ectopic focus, gives evidence that the recurrence is not related to the operative technique or development of new arrhythmogenic foci, but is due to progression of the myocardial disease in the area of primary affection. The data gathered by researchers from the Federal Centre of Endocrinology confirms this hypotheses. They presented a study which examined 22 patients with structurally normal hearts who underwent RFC for frequent PVCs and had a endomyocardial biopsy preformed. Non of these patients had a normal  


The clinical and experimental data available call in question the correctness of identifi cation of so called “idiopathic ventricular
arrhythmias”. Notwithstanding the high primary effectiveness of radiofrequency ablation, the long-term follow-up of
patients is needed. Radiofrequency ablation seems to be more effective for eliminating ventricular tachycardia rather than
premature contractions.

[RVVq]

Continued:


Russian Study Number One - "«Idiopathic» arrhythmias as a symptom of latent cardiac disease: nosologic diagnostics using endomyocardial biopsy"
(Kogan et al, Kardiol serdečno-sosud hir [The Journal of Cardiovascular Surgery] 2010; 1: 56) (Full text available online in Russian, abstract in broken English)

Study Summary:

Endomyocardial biopsy of right ventricle was carried out in 16 patients with «idiopathic» rhythm disturbances (mainly paroxysmal atrial fibrillation, but also premature ventricular and atrial beats, paroxysmal ventricular and atrial tachycardias, various conduction disturbances and their combinations). Elevated levels of anti-myocardial antibodies, antibodies to antigens of endothelium, cardiomyocytes, conductive system and also (in some patients) identification of antinuclear factor with bull’s heart antigen (in absence of other laboratory markers) were considered as additional indications for biopsy. Normal histological picture was not received in any cases. Noninflammatory abnormalities were diagnosed in 87.5% of patients (myocarditis — in 10 patients, virus cardiomyopathy — in 1 patient, endomyocarditis — in 1 patient, systemic vasculitis — in 2 patients); virus genome was detected in myocardium of 3 patients (herpes simplex virus type 6, parvovirus B19); 2 patients had arrhythmogenic right ventricular dysplasia and Fabry disease respectively. Specific treatment was started.

Conclusion:
According to the results of the endomycardial biopsy of the right ventricle of patients with 'idiopathic' arrhythmias (mainly lone atrial fibrillation), who in most cases also had elevated levels of anti-myocardial antibodies, nosological diagnosis was established in all patients, with the majority of
patients (87.5%) afflicted by auto-immune inflammatory conditions. Since chronic myocarditis is not always caused by highly symptomatic acute myocarditis, it is posible to presume that acute and chronic myocarditises
are not different 'stages' of the  same disease, but rather are two separate diseases, with different symptoms, signs and
prognostic significance.
Therefore, according to the results of this study all patients with idiopathic rhythm disturbances, should be evaluated for the presence of chronic myocarditis or other inflammatory process in the myocardium.  

I will post the other two studies tomorrow

[RVVq]

continued...

I came to a disappointing realization that English language medical literature
does not contain much information on this topic. Since Russian is my first language, I began searching Russian and other European medical journals for answers. Here's a short summary of my findings up to this day:

The Italian Study: "Long-term follow-up of right ventricular monomorphic extrasystoles" (Gaita et al, J Am Coll Cardiol. 2001 Aug;38(2):364-70.) {Full text available online}

"Sixty-one patients who had been classified by noninvasive examinations as having frequent idiopathic right ventricle ectopy were contacted after 15 ± 2 years (12 to 20) and submitted to clinical examination, electrocardiogram (ECG), Holter monitoring, stress test, signal averaged ECG, echocardiography and, in 11 patients, cardiac MR. The primary end point was to ascertain the presence of cases of sudden death or progression to ARVD."

Results: "In our study after a mean follow-up of 15 years, most of the patients are asymptomatic, showing corresponding reduction and, often, disappearance of the extrasystoles. Moreover, no morphologic change suggestive of progression to ARVD was observed. Based on the data of our study, a normal 12-lead ECG, the monomorphic pattern of ectopy and the heart rate dependence at 24-h Holter monitoring, the suppression with increasing heart rate at stress test and the normal echocardiographic pattern are sufficient to pose the diagnosis of benign right ventricle arrhythmias."

The MRI results showed that "8 of the 11 patients showed localized adipose replacements, in contrast with the diffuse pattern that is observed in patients with ARVD. The study authors conclude that  "these abnormalities might be the anatomical substrate of right ventricle extrasystoles."

[RVVq]

I think you would be surprised at a lack of knowledge about causes of frequent ectopic beats in the medical community. There's very little research into the subject, to the extend that there's almost no speculative theories on the origin of frequent cardiac ectopy in individuals with 'healthy hearts.' As a sufferer of fairly frequent PVCs, I became interested in the subject and started to browse the internet for potential explanation of this puzzling electrophysiological phenomenon. In the process of my research I came to a disappointing realization that English language medical literature

The Italian study I mentioned

[Bluewaters]

I would be interested in these studies.  I went over this often with medical personnel and they offer no clues as to where these come from.

I am surprised at all the information I am getting thru this blog and it is beginning to give me hope.

Btw, the 6 hr Alation did cost the system $83,000.  Included a meal and sleepover.

[Bluewaters]

Thank you for your comments.  I think you are correct in these, certainly.  Looking for something natural that may help.  I do take Magnesium.  If not here then another pill I guess.  These attacks, tho seldom, are very uncomfortable and do feel like the end is coming.  A deep breath is not deep enough.  A cough is not really a cough.  It becomes a mixture of palps and anxiety; one cause the other and vice versa.  

[Bluewaters]

Thank you Michelle for taking the time and courtesy to send a note here.  The doctors and nurses never mentioned success rates.  I do also take some depression meds also and have wondered if they are a factor.  Actually it was the psychitrist (sorry sp) before my procedure who mentioned that ablations sometimes need to be done over.

[itdood]

Good post!  

I'm familiar with the Italian study and I think I know why they did it.  People of Italian descent are 4x more likely to develop ARVD than the general population (the fatty infiltration you are talking about in the RVOT).

Back during my flare of 2009 I was ordered a cardiac MRI for this very reason, I'm 100% Italian.

I've never heard of the Russian study but it confirms a personal suspicion I've had about viral bouts.  Viruses are nasty f*#$kers.    I can bet good money that most lingering autoimmune issues are preceded by a viral illness.  Sometimes autoimmune disorders resolve spontaneously.

I think the root cause of benign PVCs is enhanced automaticity.  You are getting into other root causes which I would say the PVCs are no longer intrinsically benign.  In other words the PVCs themselves aren't causing illness, they are a side effect of the root cause illness.

You've made me think of other root cause branches these can take, thanks!

[RVVq]

To get rid of PVCs permanently you need to find out what is causing them. As far as I know, there very few medical studies which investigated the causes of idiopathic PVCs. But there are some. For example, the Italian study I quoted in my first post on this board examined about 60 patients who had over 1000 monomorphic right venticular pvcs/day on their holter, with normal ECHO and ECG. 11 of these patient underwent MRI exams. Only 3 of them had normal MRI reports. The other 8 had focal fatty replacement and other abnormalities of the right ventricle. The authors of the study presumed that these localized abnormalities were the arrythmogenic substrate for the ventricular ectopy in this subset of patients.

I also read two Russian studies, in which a heart biopsy was preformed on patients undergoing ablation for PVCs and other idiopathic arryhthmias. All of the patients had 'structurally normal hearts', based on ECHO, MRI, and ECG. However, the biopsy resolts showed that all these patients had viral infections in their heart, vascular system and/or pericardium. The infections ranged from herpex simplex to localized myocarditis.

The point I am trying to make here is that frequent PVCs have a cause. Based on the limited evidence we have they are usually caused by some localized and subclinical autoimmune or degenrative processees in the ventricles or heart infections. Ablation destroys the heart tissue generating PVCs, but it does not address the underlying cause of frequent ventricular ectopy. That is why PVC ablations have a relatively high reocurrance rates and complete abolition of PVCs can be accomplished in roughly 30% of all ablations.

If anyone on this board is intrested in reading the above mentioned studies, I would gladly share them with you on this forum.

Good luck and good health!

[itdood]

Lymes is notorious for PVCs.  The only way to stop PVCs would be to get rid of the cell structures that are causing them.  

That's inherently very difficult to do. First off how do you get rid of them?  

They currently burn them away and in the process burn healthy tissue I'm sure.  That's the first problem with trying to get rid of benign PVCs.  In the process of trying to kill off defective muscle you may damage more muscle.

If the PVCs are originating in multiple locations you'd be chasing your tail trying to burn those away.  Some surgeons will go after the most troubling spots in those cases to at least attempt to lessen them.

Anyways, like michellepetkus said already, it's a mixed bag of results trying to get rid of them permanently.

[MichelleP_3811]

From what I understand ablations for PVCs are met with mixed results as you have found out.  I am not sure a second ablation would be a success or if you will continue to have problems so in my opinion another ablation is risky.  The more burns you put in your heart the more trouble you may be asking for but it is your body and you have to go by what feels right to you.  I generally base my decisions on how well I can function.  If I were you though, I would get your stomach checked out.  Stomach issues are a big trigger for pvcs and it sounds like you may have some stomach issues.  Stress is also a big trigger, anything you can do to eliminate stress will reduce the amount of pvcs as well.  Good luck with whatever you decide to do.  Take care.