Ventricular Arrhythmia (Drs Saliba&Wazni 6 28 13)
Friday, June 28, 2013 - Noon
Ventricular arrhythmias are abnormal heart rhythms that originate in the bottom chambers of the heart called the ventricles. These rhythms can occur as a result of damage to the heart muscle from a heart attack or cardiomyopathy – or can occur in patients with hearts that seem structurally normal. Dr. Walid Saiba and Dr. Oussama Wazni answer your questions about ventricular arrhythmias, including diagnosis and treatment.
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Ventricular Tachycardia (v-tach)
petesuszc: I am a 65 y.o. male, lifelong jogger, been having arrhythmia for four years. Cath in 11/12 showed normal coronary arteries. Monitors and ecg's over time have shown pac, psvt, junction rhythm, atrial couplet and the last mobile cardiac outpatient telemetry system (MCOT) (which is why I am writing) showed 15 beats @ 120 bpm of ventricular tach. My cardiologist didn't think that it was anything to panic about. I would like your opinion on this last vtach/ possible options/ treatment. With these extra beats the last few years, I sometimes think instead of eating properly and exercising my whole life, I should have just smoked, relaxed and ate sausage everyday! Thanks, Pete
Oussama_Wazni,_MD: I agree with your cardiologist that you should not be concerned about these rhythms. The most important prognostic factors are your normal coronaries; as long as your ventricular function is normal and you are feeling well. If these arrhythmias are causing you symptoms then it may be worthwhile to consider suppressive treatment either with medications or if needed ablation. You should keep eating right and exercising and maintaining a healthy lifestyle as you are doing.
dolltree: Can you actually get an ablation and cure your v tach?
Walid_Saliba,_MD: Some v tachs are cured with an ablation, however, if you have structural disease such as MI (heart attack), ablation of the VT may not eliminate the potential for future VT to occur.
JimmyFla: I have had PVCs for years. Recently had an almost pass out episode and had a holter monitor. My doctor said I am having runs of V tach. When they did the echo they said I have no heart disease - so why would I get the v tach. Can you talk about the ways to treat this? I am thinking medications because I don't want to get any procedures. Is that possible?
Walid_Saliba,_MD: You need further evaluation with possibly cardiac MRI to rule out other structural heart disease that are not usually seen on echo. The treatment of the VT can be with medications and/or ablation depending on the nature of the underlying heart disease if any.
Oussama_Wazni,_MD: Even if the echo and MRI reveal no heart problems, patients may still have what we refer to as normal heart VT, which also may be treated with medications or ablation.
Thorner: I was just diagnosed with vtach and my doctor put me on a beta blocker and told me he wants to see me again in 3 months. Does that sound ok to you? How often do you follow up with newly diagnosed vtach?
Walid_Saliba,_MD: We need to know if you have any underlying heart disease by testing such as echocardiography, stress testing and possibly cardiac MRI. Treatment of the VT depends predominantly on the underlying heart condition.
sinaihospital: I was diagnosed with left ventricular hypertrophy since 2004 I have had ekgs stress echoes stress test for in 2008 become sick in Toronto with very fast heart beats did an ekg it said was ventricular arrhythmia was sent to mount Sinai hospital in Toronto were they medicine for it then send to the hotel what tests and treatments for this problem thank you sirs.
Walid_Saliba,_MD: If you indeed had sustained ventricular tachycardia, then you should be considered for ICD placement or ablation therapy. You need to have further evaluation to make sure your left ventricular hypertrophy is not genetic in origin (HOCM).
indie1962: I have VT and cardiomyopathy, likely due to Sarcoidosis. Over the last few years I have developed increasingly painful and more frequent muscle spasms and cramps, first just in the lower half of my body, and now in arms, back, shoulders, neck, etc. When I took an over the counter electrolyte pak with Vitamin dosages many times the US DV, at first the muscle issues went away but then I had 29 VT's in 29 minutes. The shock occurred at approximately the 15th VT, and still had to be paced out several more times. Blood tests showed deficiencies in B2, B3, B6, B12, Vit C and Folate. Now that I'm taking small doses of B Vitamins and gradually increasing until the muscle problems go away, I'm not aware of having any VT's. Can you comment on the connection between Vitamin deficiencies, especially B's, but including Magnesium, which I also have since doubled my daily dosage. Thank you.
Oussama_Wazni,_MD: There is no known relationship between ventricular tachycardia and vitamin B deficiency. Taking magnesium supplements may lessen the burden of VT. In your case, the VT is primarily due to the sarcoidosis.
makry: Can an otherwise healthy heart experience VT?
Walid_Saliba,_MD: Yes. This is usually called normal heart VT. The reason we call it normal is because we cannot identify any disease by the various cardiac imaging that we have available.
girlz: What are the symptoms of Ventricular Arrhythmias? How would they be different from AFib?
Oussama_Wazni,_MD: Both afib and ventricular arrhythmias can have very similar symptoms of palpitations, fatigue and dizziness; although, VT is more likely to cause more profound symptoms such as dizziness, syncope or sudden death.
TerryB: I feel pvcs sometimes where I feel them in my throat and get dizzy. I wore a halter it showed pvcs and pacs and a couple runs of 3 pvcs in a row but mostly single pvcs. The doctor said everyone has this but he is doing an echo next week. He said if the echo is normal don't worry about the pvcs. But what do you do about pvcs that are untreatable but make you freak out and you have dizziness when they occur?
Oussama_Wazni,_MD: Treatment of frequent PVCs is dictated by the patient's symptoms. If you feel that these PVCs are altering your lifestyle and your quality of life then it is reasonable to consider suppressive treatment with medications or ablation. Otherwise, as long as your left ventricular function is normal, you can be reassured that these are not detrimental for your health.
Atrial Fibrillation and Ventricular Arrhythmias
az1435t: Is there any relationships between a history of atrial flutter and afib progressing to VT? EF fraction are normal and no blockages confirmed via cardiac cath procedure.
Walid_Saliba,_MD: Under certain situations such as taking anti-arrhythmic medications (example flecainide) atrial fibrillation with rapid ventricular rate can lead to ventricular tachycardia. Alternatively, atrial fibrillation can look like ventricular tachycardia in certain instances.
bradma: I have been diagnosed with severe mitral regurgitation with a mildly dilated left ventricle and severely dilated left atrium. I'm scheduled to come to Cleveland Clinic in August to have the valve repaired. I took a stress test a few months ago and the doctor saw a short run of a few beats of vtach and it repeated with an 8 beat run on a Holter monitor report (no symptoms in either case). Should I be concerned by this and is it likely to be related to the MV problem and cured by the repair? Two weeks ago I started having AFib. Again, I'm wondering if this is related to the MV problem and if the surgery is likely to change it.
Oussama_Wazni,_MD: The atrial fibrillation is related to the mitral valve problem and should probably be addressed with a concomitant Maze procedure during the time of mitral valve surgery. The VT can be a manifestation of mitral valve prolapse and fixing the valve does not necessarily eliminate the ventricular arrhythmia. Nevertheless, in the setting of near normal heart function, the VT does not need to be specifically treated beyond medications such as beta blockers.
bradma: The repair was being done by Dr. Gillinov using the DaVinci. Do you know if he can do the Maze procedure with the robot or will it take a different type of procedure?
Walid_Saliba,_MD: Please let Dr. Gillinov know that you have atrial fibrillation so he can address this appropriately.
johnknuth: How do you recommend getting out of A-Fib?
Walid_Saliba,_MD: As we had discussed in our afib web chat (see the transcript) recently there are different ways to get out of afib. This includes medications and cardioversion. The problem is how to maintain normal rhythm which is a more difficult issue and can be done with medications as well as ablation.
Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)
az1435t: I was diagnosed with CPVT based on one Holter Monitor recording that occurred post spinning class in Aug 2012. I am female, 59 years old and previous rhythm issues were diagnosed as Aflutter/Afib which were treated with 2 ablations. Subsequently received an ICD in Nov 2012 and started atenolol (25 mg daily). In Feb 2013 afib symptom reoccurred and was put on digoxin (.25mg daily). I get really tired after exercise and find my self winded when HR gets in 120 range. Question 1: is a CPVT diagnosis a given with only one event and no genetic testing and no prior family history, other than apparent atrial issues? Would it be prudent to just install a loop recorder to try to get more data to confirm CPVT or some other possibilities? I have a fairly uncomfortable ICD because I am thin and also suffered through a partially collapsed lung after the ICD was implanted. Question 2: can I stop cut back or possibly take any different drugs? I take the atenolol and other drugs in evening, but just hate being so tired/winded. I run low BP so to tolerate the atenolol I was put on Florinef (0.1mg daily) which upsets my stomach so I also take protonix. Thanks for you thoughts.
Oussama_Wazni,_MD: Question1. Yes CPVT may be diagnosed with one episode if the episode had a very specific appearance on the holter monitor. It can be confirmed by genetic testing however given the high mortality with CPVT, an ICD is reasonable, especially if you plan to remain active. Now that you have an ICD, a loop recorder would not add any information.
Walid_Saliba,_MD: Question 2. You may stop digoxin. But consider other medication if your heart rate remains elevated during episodes of atrial fibrillation. Atenolol may be switched to metoprolol which may have a better blood pressure profile precluding the need for florinef and protonix.
[Note: Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT) is a ventricular tachycardia that causes syncope or passing out during times of intense stress, emotion or exercise in a person whose heart is structurally normal.]
Ventricular Fibrillation and Sudden Cardiac Death
virginiagal: My dad died last year of sudden death. My mom found him and tried cpr with no help. The doctor said it was ventricular fibrillation. I want to know what causes that. Was there risk factors or things that we should have seen before to prevent it? He seemed healthy I think before. Are my brothers and I at risk if he died from that? He was 57 years old.
Walid_Saliba,_MD: In the USA, the most common cause of ventricular fibrillation is coronary artery disease and acute heart attack. An autopsy usually will give you the information.
Oussama_Wazni,_MD: If this was a heart attack, then your risk depends mostly on your medical condition, for example the presence of diabetes, hypertension, coronary disease. However, if this was a heart attack you may have a higher propensity of developing coronary artery disease and will need evaluation.
If this was not a heart attack, then it would be important to review any previous ECGs your father may have had or you have had to detect other forms of heart diseases that may predispose you to sudden cardiac arrest.
Evaluation of Arrhythmia
TerriLynn: If you have multiple PVCs, how many is enough for treatment. I had surgery (not heart) last month and the anesthesiologist said I had a lot. I knew I had them but the doctor said they don't usually treat. Should I get another opinion?
Oussama_Wazni,_MD: This will depend on whether your heart function is normal or not. If your heart function is normal and you are not aware of these PVCs with symptoms, then no treatment is indicated. Sometimes, when being under general anesthesia PVCs may be more prevalent.
Mark2254: For the past few months, if I am lying down to go to sleep I get a feeling of a run in my chest and sometimes a painful skipped beat - I can feel it in my chest. My doctor put me on a beta blocker which seems to help but should I have a cardiologist do a bigger exam?
Walid_Saliba,_MD: Yes - we would recommend at least some form of monitoring to evaluate the mechanism of these palpitations.
Jerzie: 2 weeks ago, I woke up from sleep and felt like my heart was racing. I felt my pulse and felt fast and then it slowed down and then felt like a skipped beat every 2 or 3 beats and then went away. Since then I feel a skipped beat every now and then but not like what I had that night. Do you think I need to see a doctor for this?
Oussama_Wazni,_MD: Yes. These symptoms need to be evaluated with monitoring - either with a cardiac event monitor or a holter monitor to determine the mechanism of these racing heart and skipped beats.
charSC: For medications for ventricular arrhythmias. My doctor told me about three options amiodarone, sotalol and tikosyn. Amiodarone has really bad side effects I think long term so thinking of one of the others. Can you talk about the three drugs and risk and benefits. How do you know what drug to put someone on?
Walid_Saliba,_MD: Amiodarone has many extra cardiac side effects (thyroid, lung, liver, eyes, skin, and CNS). Sotalol and Tikyosn are cousins and their main side effect is pro-arrhythmia, which means they can cause serious and potentially fatal arrhythmias such as torsades des pointes, which is a specific form of ventricular fibrillation.
Tikosyn is generally not used for ventricular arrhythmias and is mostly used for atrial fibrillation. Both of these medications should be initiated on an inpatient basis.
May2283: I had a procedure 6 months ago to control my arrhythmia and there was a complication; puncture of some sort; weeklong hospital stay. I am still having many PVCs about 300 an hour. I cannot tolerate a lot of medications. Would you suggest another procedure? Very worried.
Walid_Saliba,_MD: If these PVCs are symptomatic, then another attempt at ablation can be worthwhile. We would be happy to evaluate you.
jh987: What is the long term success rate for radiofrequency ablation for numerous PVC'S?
Oussama_Wazni,_MD: If acutely successful (at the time of procedure), after an ablation, the long term success rate is more than 95%.
az1435t: Are there any procedures ( like ablation, or maze) for VT, specifically CPVT, so that drug therapy could be discontinued and possibly an ICD could be removed?
Oussama_Wazni,_MD: There are procedures (ablation) for ventricular tachycardia but not for CPVT. CPVT is cathecholaminergic polymorphic ventricular tachycardia, which implies that it happens during strenuous physical activity and may not be originating from one specific site in the ventricle, making it difficult to localize and ablate. Given, we would not recommend removal of an ICD if already implanted.
Lariat and Left Atrial Appendage
Fran: How many Lariat Procedures has the Cleveland Clinic done?
Walid_Saliba,_MD: None so far. There is no scientific evidence at this time that exclusion of the left atrial appendage using the lariat system does indeed reduce the risk of stroke. Alternatively there is enough evidence (and we are currently part of a study) that occlusion of the left atrial appendage with a simpler procedure using the Watchman device does reduce the stroke and long term mortality in patients with atrial fibrillation when compared with taking Coumadin. However, we are certified in the lariat procedure which is ideal for patients who are unable to take Coumadin and plan to perform more of these procedures in the future.
ICD (Implantable Cardioverter Defibrillator)
Melissa-MI: I have hypertrophic cardiomyopathy and after wearing a monitor for a day, the doctor said I had multiple PVCs and three 4 or 5 beat runs of VT. I am scheduled for an ICD. I have a lot of reluctance to get one, but he said I need one. Would this be the criteria for an ICD? How do you know when you need one? Should I get another opinion?
Walid_Saliba,_MD: Having PVCs and NSVT (nonsustained VT) on the holter monitor is not enough criteria to warrant an ICD. The need for ICD also depends on the thickness of your heart muscle and whether you had dizziness or passing out spells, or a family history of sudden death as well as cardiac MRI criteria.
johnknuth: I had a Heart Attack on October 1, 2011 (extensive myocardial infarction, coma 4 days, 5 stents with no re-flow). I was released from hospital with a life vest and had an ICD placed in on January 3, 2012, I maintained a healthy lifestyle (before and after my heart attack) I have A-Fib problems about twice a month with pulse rate in 70’s. My normal heart rate before and after HA is 52 BPM. My EF from an echocardiogram on 1/4/2013 was 25-30%. No Ventricular Arrhythmia. My medicines are the following: 1000 mg Niacin, 150mg Pradaxa, 20mg Coreg Cr, 5mg Altace, 25mg Aldactone, 81 mg Aspirin, 10 mg Lipitor. Do I need my ICD? Who specializes in leads removal at CC? How do I get out of A-Fib? Your thoughts about using Multaq on a need bases. Taking more of a Beta Blocker— Propranolol or metoprolol or more Coreg? Currently, I lie down or exercise to return to rhythm.
Walid_Saliba,_MD: Given that your heart function is less than 30% in the setting of having an MI, you do need an ICD.
- Do I need my ICD? Who specializes in leads removal at CC?
You do not need removal of the ICD.
- How do I get out of A-Fib?
We can treat afib with medications (tikosyn or amiodarone) or with ablation depending on how much symptoms it is causing you.
- Your thoughts about using Multaq on a need bases:
it is relatively face but not very potent drug to treat atrial fibrillation.
Marcus22: If you go into vtach in the ep lab how likely is that to go into vfib and do you then require an ICD?
Walid_Saliba,_MD: If you go into VT in the lab, we are in control of your rhythm and we can put you into normal rhythm whether or not you go into ventricular fibrillation. The decision to have an ICD is a clinical decision that is not exclusively based on VT/VF in the ep lab.
Electrolytes and Arrhythmias
Rickie93: I am on diuretics and last week my potassium was out of wack. the doctor put me on potassium because he said my heart can go out of rhythm. what electrolytes in the blood have an impact on heart rhythm?
Oussama_Wazni,_MD: Mostly potassium and magnesium and calcium.
Ventricular Arrhythmia Treatment at Cleveland Clinic
Moderator: Drs., can you tell us about any recent developments in your area?
Oussama_Wazni,_MD: We have recently instituted a rapid response team for patients who present with ventricular tachycardia whereby a comprehensive and individualized approach is implemented and ablation is performed when needed in a timely manner. Our VT Center handles all types of ventricular arrhythmias in a multidisciplinary fashion with excellent outcomes in terms of minimizing the risk and optimizing success rates.
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