HF and TICM

Question 1

Tachy- cardiomyopathy

Answer 1

Persistent supra-ventricular or ventricular tachycardia leads to LV systolic impairment and dilation

Reversible with normalisation of heart rate

Question 2

Diagnosis of exclusion

Answer 2

Atrial fibrillation seen in 30% of patients with heart failure
Exclude other causes of LV dysfunction
Alcohol
Drugs
Hyperthyroidism
Valvular heart disease
Ischaemic heart disease
Prior cardiac surgery

Cardiac MR – structural abnormalities/scar
ECG other abnormalities/ conduction disease

Question 3

Atrial fibrillation

Answer 3

• Most common cause of tachy-cardiomyopathy
• If haemodynamic instability – DC cardioversion (TOE guided if onset unclear)
• If haemodynamically stable initial rate control
  Beta blockers
  Digoxin
  Amiodarone
  AVOID diltiazem and verapamil
• Anticoagulation with warfarin or NOAC

Question 4

What is PVI?

Answer 4

Pulmonary vein isolation is a strategy for AF ablation. Isolate each PV independently

Castle HTx
AF ablation versus medical therapy in patients with end stage heart failure
97 patients each arm
High rates successful PVI
Reduced likelihood of death, transplant or LVAD implantation

Question 5

Who may not benefit from ablation?

Answer 5

Long duration of AF
Ischaemic aetiology
Dilated atria, atrial fibrosis on CMR

Trial of cardioversion – symptomatic benefit/improvement in LV function

Question 6

Atrial Flutter

Answer 6

25% patients with flutter have LV dysfunction
57% improve following treatment
Rate control challenging in atrial flutter
Responsive to DC cardioversion
High success rates with ablation

Atrial tachycardias well recognised tachycardiomyopathy
Ectopic atrial tachycardia most common cause of TCMP in children

Question 7

Premature ventricular complexes

Answer 7

High PVC burden associated with LV impairment
PVCs often asymptomatic
Broader ectopics, higher chance of LVSD
High burden 10- 24000 / 24 hours (>10-24% total beats)
Ablation 70-90% successful
Aim to get PVC burden <5000
1% risk of serious complications

Question 8

Suspected Tachycardiomyopathy pathway

Answer 8

SVT/AF/Frequent PVCs -> Assess rhythm burden: imaging for structural heart disease (Echo/MRI) -> Minimisation of arrhythmia by rate/rhythm control –>
AF -> Rate/ablation/Pace and AVN ablation
SVT -> Curative ablation
PVC -> Drugs/ablation
–> Resolution of LV fn: with rate/rhythm control confirms TC -> Close monitoring: Maintain SR/Optimal HR; continue B-Blocker ACE-I; Continue imaging surveillance -> (decline in LV fn-> Attempt to correct arrhythmia if this us the cause/optimise HF meds

–> No resolution of LV fn (TC unlikely)

Question 9

SUMMARY
TCMP potentially reversible cause of heart failure
Diagnosis of exclusion
Pulmonary vein isolation appears most effective in patients with HFrEF
Anticoagulate AF and HF
PVC ablation should be considered in patients with high PVC burden and left ventricular dysfunction