Ventricular Arrhythmias in Dilated Cardiomyopathy JOHANNES BRACHMANN, THOMAS HILBEL, EKKEHARD GRiJNIG, ANDREAS BENZ, MARKUS HAASS, and WOLFGANG KIJBLER From the Department of Cardiology, University Hospital, Heidelberg, Germany BRACHMANN, J., ET AL.: Ventricular Arrhythmias in Dilated Cardiomyopathy. Although prognosis of di- lated cardiomyopathy (DCM) has improved due to advances in diagnosis and therapy, still too many sud- den cardiac deaths occur in DCM. Spontaneous ventricular ectopy is a very common finding in patients with DCM, but the prognostic significance of Holter monitoring remains controversial. Other noninvasive methods, e.g., late potentials and QT dispersion, have not yet contributed to the evaluation of prognosis for arrhythmogenic events in DCM. Programmed ventricular stimulation has been repeatedly used to strat- ify long-term prognosis, yet satisfactory data are still missing as many deaths occur in patients without in- ducible arrhythmias. Several prognostic studies are still in progess, and preliminary data for the use of ICDs already appear to be promising. In patients with poor left ventricular function and ICDs in situ, prog- nosis is determined by progression of heart failure. Heart transplantation may be the ultimate therapeu- tic instrument for end-stage heart failure patients. For patients with advanced DCM and increased risk for malignant arrhythmias who are unsuitable for orthotopic heart transplantation, the combined therapy with an ICD and dynamic cardiomyoplasty may be an alternative treatment. (PACE 1997; 20[Pt. II] :2714-2718} ventricular arrhythmias, dilated cardiomyopathy, prevalence, therapy Introduction Recent studies in dilated cardiomyopathy (DCM] have extended the present state of knowl- edge and provided new insights into a disease en- tity associated with significant morbidity and mortality. Continuous efforts in molecular analy- sis of families with inherited DCM are promising to give better understanding of this disease. Prog- nosis of DCM is generally poor. Survival statistics exhibit mortality rates of up to 25%-30% after 1 year and up to 50% after 5 years of follow-up.^"^ However, more recent observations may suggest substantially better survival with an average 5- year mortality as low as 20%.* This reduction in mortality probably reflects a shift to population- based studies, earlier detection of the disease, and improved treatment strategies. Address for reprints: Johannes Brachmann, M.D, Innere Medi- zin III, Dept. of Cardiology, Bergheimer Str. 58, 69115 Heidel- berg, Germany. Fax: 49-6221-565447; E-mail: Johannes brachmann@krzmail.krz.uni-heidelberg.de Received December 11, 1996; revised January 27, 1997; ac- cepted January 29, 1997. Ventricular Arrhythmias and Sudden Cardiac Death in DCM Ventricular arrhythmia (VA) and sudden cardiac death (SCD) are common in DCM, although the prognostic significance of VA re- mains unclear. Presence of nonsustained ventricu- lar tachycardia (VT) is associated with more advanced state of the disease and increased total cardiac mortality. In a recent meta-analysis of prospective studies, 12% of DCM patients died suddenly, accounting for 28% (8%-51%) of all deaths.^ A 7-year follow-up survival analysis by Chen et al.^ in patients with DCM demonstrated that total mortality is almost exclusively due to cardiac causes during the first 5 years of follow-up with a majority dying suddenly. Non- cardiac causes from a significant proportion of overall mortality occurred only from the fifth year onwards. In the study of Sugrue et al.,^ age > 53 years and left ventricular ejection fraction (LVEF) < 36% at the time of diagnosis was associated with a significantly reduced prognosis. In the survival curves of DCM patients with high and low ejection fractions there was no dissociation of the survival 2714 October 1997, Part II PACE, Vol. 20