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Ventricular Arrhythmias (Dr Lindsay 10 4 10)

Monday, October 4, 2010 - Noon

Bruce Lindsay, MD
Section Head, Electrophysiology & Pacing

Description

Ventricular arrhythmias, or abnormal heart beats, begin in the lower chambers of the heart. There are different types of ventricular arrhythmias including, premature ventricular contractions, ventricular tachycardia and ventricular fibrillation. These arrhythmias can be life threatening so it is important for you to learn more about the diagnosis, symptoms and treatment for each. Get your questions answered by joining Cleveland Clinic cardiologist, Bruce Lindsay, MD in a free online chat on ventricular arrhythmias.

More information

Cleveland_Clinic_Host: Welcome to our Ventricular Arrhythmias online health chat with Bruce Lindsay, MD. Dr. Lindsay will be answering a variety of question on the different type or arrhythmias. We are very excited to have him here today!

Cleveland_Clinic_Host: Thank for joining us Dr. Lindsay, let's begin with the questions.

Dr__Lindsay: Thank you for having me today. Let's begin answering questions.


Premature Beats: Premature Ventricular Contractions (PVCs) and Premature Atrial Contractions (PACs)

sugarleaf4: I have PVC's on a daily basis and thought that when I got a pacemaker, that would have eliminated them. I recently read a post on the Pacemaker Club site that taking Magnesium and decreasing caffeine intake might lessen the PVC's. What effect (if any) does Magnesium and caffeine have on the frequency of PVC's? Why hasn't my pacemaker eliminated them?

Dr__Lindsay: A pacemaker has no effect on PVCs. Treatment with medications or possibly an ablation procedure would help to alleviate them. Some patients are sensitive to caffeine but that is not predictable.

Nubianspirit: I started having PVC's 11 years ago right after the birth of my last child. Could I have always had them but only noticed them after she was born. I don't understand where they came from all of a sudden. They scare me.

Dr__Lindsay: PVCs can occur in the absence of any heart disease. In such cases, they are not dangerous but they can be very annoying. The explanation for why they occur is complex and beyond the scope of this discussion. Treatment with medications or an ablation procedure can be helpful to patients with significant symptoms

dbranden: Is it common to have an increase in PVC's and PAC's several months after having a baby? My son is now 9 months old and my skipped beats have increased quite a bit. At the very end of my pregnancy and for several weeks after delivery, I had nearly zero palpitations. As time goes by I seem to get more and more. Is this common?

Dr__Lindsay: It is not common to have more premature beats after pregnancy but I have seen that problem. It would be important for your doctors to confirm that your heart function remains normal - I would recommend an echocardiogram if you have not already had one.

diane43: Hello Dr Lindsay, I have two arrhythmias, premature and svt's. I also have three heart valves that have gurgitation (aortic, mitral and the tricuspid) which are either mild or med. I also have a DES in my LAD. I just had an angiogram to check for blockages and to see if the stent was okay. I am still having angina symptoms. What kind of symptoms would the arrhythmias cause other than feeling them when they happen? Thanks Diane

Dr__Lindsay: Premature beats are annoying but generally would not account for any severe symptoms. Sustained SVT lasting several minutes can cause chest pain, shortness of breath or lightheadedness. One way to clarify the cause of your symptoms is to wear an event monitor which documents your rhythm when you are having symptoms.


Supraventricular Tachycardia (SVT)

frank1947: I have had 2 ablations for supraventricular tachycardia. The first one was good for about 3 years then it came back. The second one did not help at all. Finally I was put on 25mg of Metoprolol once a day and 50mg of Flecainide Acetate twice a day. I have been on these for about 1 year. I have palpitations daily and I have what I call mild tachycardia attacks because I can stop theses by coughing. I limit myself to activities because of this. I am now retired and will be 63 this week. I hate having to take these medications. Is there anything that you think can help me deal with this?

Dr__Lindsay: Most tachycardias that can be terminated by coughing involve a mechanism that should be curable by an ablation procedure. It would be worthwhile to take another look at this option at an experienced center. Other medications might be helpful but I cannot be more specific without knowing exactly what you have.

Kitty: Just wondering if svts can occur in healthy normal individuals with no connection to heart ventricles, valves, etc. I am in menopause and seem to get a lot of extra beats, premature, and svts. Lots of times the premature beats come during a hot flash. Can puberty and menopause cause these symptoms to occur more often?

Dr__Lindsay: As a point of clarification physicians use the term "SVT" to identify supraventricular tachycardia, or tachycardia coming from the top chambers of the heart. Ventricular tachycardia refers to tachycardias arising from the lower chambers.

Premature atrial and ventricular beats can be influenced by hormones. Many women notice that they are worse during the premenstrual phase of their cycle and others seem to have more trouble during menopause.

P235777149603: I had a PFO closure on 10/29/2009 at Hopkins, after a cryptogenic stroke on 10/6/2008. Since the closure, I have developed arrhythmias, intermittent at first (occurring once in 11/09, then twice in 2/10), but since May 2010 they've gotten progressively worse. I’ve been hospitalized once and to the ER many times over the past few months. I'm currently taking Multaq 400 mg 2x a day, as well as Metoporol 25 mg 3x a day. I'm tolerating the drugs ok, but am considering ablation (an EP at Hopkins thinks it’s mainly SVT, after I wore a 30-day event monitor). I have a Helex septal occluder in my atrium now, and that presents greater risks with catheterization when looking at the left side of my heart. What are my options? Is this a viable, albeit risky, surgery? I can't seem to find many doctors who have done it this way.....I'm a 47-year-old male who is otherwise very healthy!! I prefer not to take an unproven, new (2009) drug like Multaq the rest of what I hope to be a long life.

Dr__Lindsay: One question is whether you have SVT as opposed to atrial fibrillation. The approach to these could be quite different. There is limited experience in trans-septal puncture in patients with occlusion devices, but we have done a few successfully.

P235777149603: If I were to consider having my ablation done (trans-septal puncture) at Cleveland Clinic (I live near Washington DC) would that be an option? Whom should I contact to get things going?

Dr__Lindsay: You can send the information to me and I will review it with appropriate members of our group. Please call my office at 216-444-4293 or toll free 800-223-2273, extension 44293.


Ventricular Tachycardia

mlolander: I had an ICD implanted 2 years ago. I have been on every antiarhythmic medication out there. The only one that really controlled the device from firing was amiodorone. Obviously, my doctors don't want me on that long term. I was on it for a year and started having pulmonary issues. Are there other surgical options out there to control this once and for all? Is there something relating to denervation type surgery? My device seems to act up when I am stressed, anxious and/or my adrenaline is high?

Dr__Lindsay: There is no effective procedure for denervation, however ablation procedures for ventricular tachycardia are successful in about 75 to 80 percent of patients like you. I would need further information to make a more specific recommendation.

drbhaiya: sir, can a young pt presenting in cardiac arrest to emergency room with ventricular tachycardia be labeled as congenital long QT syndrome as in his post resuscitation ecg there is prolonged QT almost 850 milliseconds, my question is because after C P R there are wide varieties of arrhythmias depending on them is it wise to make such diagnosis.

Dr__Lindsay: There are a number of changes in the electrocardiogram following prolonged resuscitation that can confuse this issue. A QT interval of 850 msec is extraordinarily long. I could not make the diagnosis of long QT without seeing all the electrocardiograms.

MM: Dr. Lindsay, I have A-tach and V-tach. It seems I am experiencing many more episodes of Vtach. I cannot tolerate medicines and have a pacemaker. My EP will be doing another ablation once the Vtach becomes more sustained. Is there anything I can and or should do prior to ablation that could help during one of the tach episodes?

Dr__Lindsay: Ventricular arrhythmias are caused by damage to the heart in most patients. Other than leading a healthy lifestyle, there is not much you can do that would affect your risk for the arrhythmias.

AnjelicaJones: Can healthy hearts sometimes experience ventricular arrhythmias i.e non sustained vt?

Dr__Lindsay: Premature ventricular beats and non-sustained ventricular arrhythmias can occur in patients with no evidence of other heart disease. In such cases, they are generally benign and the need for treatment is determined primarily by the severity of symptoms.

mlolander: I will probably be contacting you with my records. I know that the arrhythmia’s have been determined to be VT and I feel since I haven't handled/responded well to the meds out there, I would like to know what other options are available- even if surgical as I don't want to be taking the amount of meds I have been for the last 2 years. Thank you for all your help.

Dr__Lindsay: Ablation procedures are the best option for patients with symptomatic ventricular arrhythmias that cannot be controlled with medications. In some cases, patients elect to undergo an ablation procedure as an alternative medical therapy.


Ventricular Fibrillation

elvia: Are you aware of anything regarding an increased risk with ventricular fibrillation associated with a bicuspid aortic valve? my husband had a mildly dilated ascending aorta (3.9 CM) mild aortic stenosis moderate aortic insufficiency moderate regurgitation and left ventricular enlargement with normal systolic function (EF 55 - 60%) and severe left atrial enlargement. He was a semi pro elite bicycle racer who died after he collapsed after a bike race on 6/8 from VT from what I'm aware and despite immediate CPR from on site medics (defibrillator came within 8 minutes) Pathology found some myocyte fibrosis which I've learned can be related to either HCM (although his fibers were not in disarray) and I've learned could be due to the regurgitation. Curious to know if you have a BAV if you're at an increased risk for VT or fatal arrhythmia.

Dr__Lindsay: Severe aortic stenosis caused by a bicuspid valve could lead to sudden death. If the stenosis was not severe then I think it was unlikely to be the cause of ventricular fibrillation.


Idioventricular Rhythm

kobiheidi: Good Morning, we have a 20 yr old son who was diag. with Idioventricular Rhythm four years ago, it was found when he was having a procedure for an endoscope and the heart monitor showed something, he went though numerous test, stress test holter monitors saw the 'electrical heart Dr, cardio Dr he continues to be seen yearly by the cardiologist, we are told he is fine no need to worry , but we do, my son does not, he is a soccer player @ college very athletic and has always been, we were told this seems to happen in very well conditioned athletes?????????? Hard to believe but, non the less we as parents are concerned and need to know if we should do anything else to be sure our son is ok. Thank you so very much for any information you may provide, if you think we should come to your clinic for any thing we would. Thanks again sheri and bob

Dr__Lindsay: Accelerated idioventricular rhythms are benign. They typically have a rate less than 100 beats per minute and are not associated with sudden death. Assuming that he has no other evidence of heart disease there is no cause for concern.


Diagnosis of Arrhythmias

albertv182: About a full disclosure of a diagnosis of arrhythmia. Can a patient request a full explanation based on EKG of the nature of arrhythmia using concepts of origin of pacemakers, ectopic rhythms, reentrance and ways of stimuli, possible blocks, escape beats. It is important for making decision of my second radio ablation, how the doctor is going to correct the first unsuccessful one.

Dr__Lindsay: The origin of a ventricular arrhythmia can be estimated from the ECG (electrocardiogram). But, there are limitations. We are currently investigating a new technology to determine if it will help us do this more accurately.

DAVIDRANDOLPH: Periodically I have bouts of very fast heart beats which lasts less than an hour is this atrial fibrillation and what should I do

Dr__Lindsay: In order to determine the cause of your symptoms you would need to wear a monitor while you are having the symptoms. You can discuss this with your doctor.


Ablation Treatment

pattihanselman: How successful are ablations in treating irregular heartbeats on the outside of the heart

Dr__Lindsay: We often receive referrals for patients who have had unsuccessful ablation procedures. Sometimes the origin is on the inner aspect of their heart or arising near the aortic valve. Occasionally they do arise from the outer surface of the heart. Ablation procedures using special techniques can eliminate 80 - 90 percent of these arrhythmias.

Lavinia: What is the long term success rate for radiofrequency ablation for numerous PVC'S?

Dr__Lindsay: The success rate depends on where they arise and on the experience where the procedure is performed. The success rate at the Cleveland Clinic is in the range of 90 percent or more. A more specific comment would require further review of your records.

Dory: I have fascicular ventricular tachycardia and am considering an ablation in the left ventricle. How difficult and successful is this procedure due to the thickness of the left ventricle wall?

Dr__Lindsay: Fascicular tachycardia can be ablated with a high degree of success (greater than 90%) at experienced centers. The Fascicles are located near the inner surface of the heart so the thickness of the muscle should not be a problem.

msmike: I have cardiomyopathy and while my EF has improved to 40-50% I still have a lot of pvcs. I'm told I'm not a candidate for ablation and there are no meds that will help with pvcs. Do you agree?

Dr__Lindsay: There is no way for me to pass judgment on this without a thorough review of your records. It might be feasible to adjust your medicines or perform an ablation procedure successfully.

mlolander: I have had two different EP's tell me that because of the chaotic rhythms, that ablation isn't an option. Anything else out there as an option?

Dr__Lindsay: The treatment of arrhythmias is determined by which arrhythmia you have - I would need more specific information to advise you.

gebsr: Dr. Lindsay: I don't want you to second guess another doctor, but do you have an idea why a cardiologist would schedule a ventricular ablation at the same time of pacemaker implant, but elect not to do the procedure?

Dr__Lindsay: I really cannot answer the question without knowing more specifics about your evaluation or the reasons that he or she made this decision.

mike714: can you use ablation for the lower chambers for V tach?

Dr__Lindsay: We commonly perform ablation procedures for ventricular arrhythmias.


Medications Treatment

pattihanselman: How effective are drugs in treating irregular heartbeats

Dr__Lindsay: The effectiveness of drugs depends on why patients have these premature beats. In some cases, beta blockers can be quite effective. But in other cases, they are not. I would need to review your medical history and electrocardiogram to make a more specific recommendation.

sweetc: There is a new drug called Multaq. How effective is it in treating ventricular arrhythmias?

Dr__Lindsay: Multaq was recently approved for treatment of atrial fibrillation. There are no published studies evaluating its effectiveness in patients with ventricular arrhythmias. We have used it with mixed results.


Devices Treatment: Pacemakers and Implantable Defibrillators (ICDs)

b_black: how does the pacemaker/defibrillator combination regulate ventricular tachycardia/ What activities should someone with ventricular tachycardia avoid, ie; lifting, shoveling. what would a good exercise be for someone with ventricular tachycardia, if any?

Dr__Lindsay: ICDs do not prevent ventricular arrhythmias but they do terminate them. In order to prevent the arrhythmias you might benefit from medications or some patients benefit from catheter ablation of the tachycardia.

Most patients can engage in their usual activities unless their underlying heart disease is a limitation. For most patients moderate exercise such as walking helps to maintain their energy and exercise capacity.


General Questions about Arrhythmias

shirleym: what is the difference in arrhythmias whether it is top or bottom of your heart

Dr__Lindsay: This is a complex question. Most arrhythmias arising from the upper chambers of the heart are not life-threatening but they can cause substantial symptoms. Some but not all arrhythmias arising from the lower chambers (ventricles) are extremely dangerous. Even those that are not life-threatening can cause annoying symptoms.

shirleym: what symptoms can these arrhythmias cause?

Dr__Lindsay: Symptoms associated with arrhythmias commonly include: the sensation of a rapid or irregular heart beat; sometimes patients have chest discomfort or lightheadedness; more severe symptoms include loss of consciousness.

P235777149603: Is there any clinical correlation between arrhythmias and obesity?

Dr__Lindsay: there is a higher incidence of atrial fibrillation in patients who are obese.

Nubianspirit: Are Palpitations considered to be a heart problem?

Dr__Lindsay: Palpitations are symptoms related to an abnormal heart beat. They are common and are not always associated with significant heart disease. Most patients with these symptoms undergo a careful evaluation to make certain there is no underlying heart disease.

shirleym: I get sore in the mornings in my rib area and lung area could this be from an arrhythmia

Dr__Lindsay: You may simply have a musculoskeletal source of your chest discomfort, but I think it would be appropriate to discuss this with your doctor.


Other Rhythms: Atrial Fibrillation, Bradycardia, WPW

lrpryor: Have had stem cell implants for nonischemic cardiomyopathy (left bundle branch block) with nearly a tripling of EF in the first year post-procedure. The second year the decline left me about where I was (before implant) and with atrial fibrillation (taking Sotalol). If the recurrence was caused by a virus; how would I confirm that and what are the treatment alternatives.

Dr__Lindsay: Stem Cell research is still in its early stages of investigation and is extremely complex. The treatment alternatives would depend on a detailed review of your records. Dr. Ellis will discuss stem cell research in another session next week.

wisdom: Is A Fib. under the topic of Ventricular Arth.

Dr__Lindsay: We generally cover atrial fibrillation under a separate discussion. Please see the transcripts for previous questions and answers. my.clevelandclinic.org/heart/webchat/transcripts.aspx

Joanne: Someone asked about bradycardia - is it serious?

Dr__Lindsay: Bradycardia refers to a slow heart rhythm. Many patients have a heart rhythm that is slower than average, but that is not necessarily serious. The need to treat bradycardia depends primarily on whether it causes any symptoms. In such cases, we might be able to alter medications that cause the bradycardia or in some cases a pacemaker might be indicated. Many patients do not require any treatment.

bonjoursylvia: Which chamber would be affected with posteriorseptal WPW? If a chamber did not completely fill or empty for many years and then the WPW was ablated, would the heart function remain somewhat inefficient? Would mild tricuspid regurg noted a year later be something that should be repaired?

Dr__Lindsay: WPW is related to a microscopic muscle fiber that crosses from the atrium to the ventricle. It would not affect the contraction of either chamber. Nor would it cause valve dysfunction. the only time that ablation of WPW improves the heart is when patients have so many arrhythmias that it begins to effect the function of the heart. In most cases, this does not occur.


Hypertrophic Cardiomyopathy (HCM)

AnjelicaJones: Hello Dr. Lindsay, I have HCM, and I'm concerned about my children who are 12 and 8. They get yearly echos. All fine so far. Other than a holter monitor, is there any other test or sign indicating that a child is experiencing non-sustained ventricular tachycardia?

Dr__Lindsay: Genetic testing often identifies patients who carry the genes associated with HCM. You might consider this if it has not been done already. The only way to detect non-sustained arrhythmias is to perform monitoring.

shirleymahoney: My son has HCM and his son which is 10 has had an irregular heart beat in the past, do we need to worry

Dr__Lindsay: I think it would be appropriate for the 10 year old to be evaluated by a pediatric cardiologist to determine whether he has HCM or an arrhythmia. This might include an ECG, monitor recordings, echocardiogram, or possibly genetic testing.

AnjelicaJones: I have HOCM. My brother does not (yet). How often should he get himself and his get his kids checked out? (once a year?)

Dr__Lindsay: Probably every year or two. I believe Dr. Lever addresses follow up in previous chats on hypertrophic cardiomyopathy - see my.clevelandclinic.org/heart/webchat/transcripts.aspx for transcripts.

mike714: thank you for doing the chat line, I hope you can do more of them

Dr__Lindsay: You are welcome.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Lindsay is now over. Thank you again Dr. Lindsay for taking the time to answer our questions about Ventricular Arrhythmias.

Dr__Lindsay: Thank you for having me.

Reviewed: 10/10

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

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