Significant Premature Ventricular Complex Burden Causing Dilated Cardiomyopathy/Heart Failure: A Case Report

AimCurrent literature lacks a definitive threshold of idiopathic premature ventricular complex (PVC) burden for predicting cardiomyopathy (CMP). The main objective of the present study was to evaluate relationship between the PVC burden and left ventricular ejection fraction (LVEF).MethodThis multicenter, cross‐sectional study included 341 consecutive patients with more than 1,000 idiopathic PVC in 24 hr of Holter monitoring admitted to the cardiology clinics between January 2019 and May 2019 in the nineteen different centers. The primary outcome was the LVEF measured during the echocardiographic examination.ResultOverall, the median age was 50 (38–60) and 139 (49.4%) were female. Percentage of median PVC burden was 9% (IQR: 4%–17.4%). Median LVEF was found 60% (55–65). We used proportional odds logistic regression method to examine the relationship between continuous LVEF and candidate predictors. Increase in PVC burden (%) (regression coefficient (RE) −0.644 and 95% CI −1.063, –0.225, p < .001), PVC QRS duration (RE‐0.191 and 95% CI −0.529, 0.148, p = .049), and age (RE‐0.249 and 95% CI −0.442, −0.056, p = .018) were associated with decrease in LVEF. This inverse relationship between the PVC burden and LVEF become more prominent when PVC burden was above 5%. A nomogram developed to estimate the individual risk for decrease in LVEF.ConclusionOur study showed that increase in PVC burden %, age, and PVC QRS duration were independently associated with decrease in LVEF in patients with idiopathic PVC. Also, inverse relationship between PVC burden and LVEF was observed in lower PVC burden than previously known.

The long-term outcome of athletes with frequent ventricular premature complexes (VPCs) and apparently normal heart has not been fully clarified. To evaluate the clinical and prognostic significance of VPCs and the influence of continuing sports activity during follow-up, we studied 120 healthy athletes (96 men; median age 16 years) in whom frequent VPCs (>100 VPCs/24 hours) were discovered by chance during preparticipation screening. All athletes were followed up for a median of 84 months. During follow-up, 96 underwent serial 24-hour Holter recording and 62 underwent serial echocardiography. The median number of VPCs/24 hours on basal Holter was 3,760. During follow-up, 81 athletes continued sports activity, whereas 39 did not. No athlete died or developed overt heart disease. The median number of VPCs/24 hours decreased in both athletes who continued sports activity and those who did not (from 3,805 to 1,124, p <0.0001 and from 5,787 to 1,298, p <0.0001, respectively). During follow-up, left ventricular ejection fraction slightly decreased to <55% in 9 of 62 athletes who, in respect to the remaining 53, had more VPCs/24 hours both in the basal state (12,000 vs 3,880) and during follow-up (10,702 vs 1,368), and a longer follow-up (95 vs 36 months). In conclusion, (1) frequent VPCs in athletes without heart disease have a long-term benign prognostic significance, (2) sporting activity does not modify this benign outcome, (3) during follow-up, the burden of VPCs decreases whether or not subjects continue sports activity, and (4) in 14.5% of athletes, ejection fraction slightly decreases over time.

The role of interpolation in PVC-induced cardiomyopathy

Recovery from left ventricular dysfunction after ablation of frequent premature ventricular complexes

PO-02-143 RAP1 AND CAMP SIGNALING PATHWAY ARE ASSOCIATED WITH HIGHER BURDEN OF PREMATURE VENTRICULAR COMPLEX

Premature ventricular complexes (PVC) may cause ventricular dyssynchrony and lead to left atrium and ventricle mechanical abnormalities. Although ventricular cardiomyopathy due to PVCs has been well studied, little is known about atrial adaptation to PVCs. To assess atrial and ventricular responses to PVC therapy. All patients with PVC burden > 5000 beats/day on Holter monitoring were enrolled. Baseline demographics, comorbidities, social habits, Holter parameters, and echocardiography profiles were recorded. Follow-up Holter electrocardiography (ECG) and echocardiography data were compared between PVC-treated and non-treated patients. Two hundred and eighty-six patients were enrolled, of whom 139 received PVC treatment. Among the treated patients, 125 who underwent follow up Holter ECG or echocardiography were included in the final analysis. The mean follow-up times of Holter ECG and echocardiography were 9.40 ± 6.70 and 9.40 ± 5.52 months, respectively. Ventricular arrhythmic burden was significantly reduced in the treatment group (16.46% vs. 13.41%, p = 0.041) but was significantly increased in the observation group (7.58% vs. 14.95%, p = 0.032). A significant increase in left atrial (LA) diameter (36.94 mm vs. 39.46 mm, p = 0.025) and reduction in left ventricular ejection fraction (LVEF) (57.26% vs. 53.8%, p = 0.040) were noted in the observation group. There were no significant differences in supraventricular arrhythmic burden in the observation group and LA diameter and LVEF in the treatment group. PVC therapy effectively reduced ventricular arrhythmic burden in the treatment group on follow-up. Our data suggest that PVC treatment may prevent LA dilation and LVEF decline.

Transcutaneous Electrical Vagus Nerve Stimulation to Suppress Premature Ventricular Contractions: A Crossover, Randomized Clinical Trial (NoVa-PVC).

Premature ventricular complex (PVC) has been regarded as benign; however, when frequent, the arrhythmia can induce left ventricular (LV) systolic dysfunction. Meanwhile, the influence of PVCs on cardiac structural remodeling and functional change before occurrence of overt systolic heart failure has not been fully described. In this study, we attempted to identify early cardiac structural/functional manifestations of frequent PVCs in patients with normal LV systolic function. A total of 146 patients (age: 55 ± 15 years, 48 males) with frequent PVCs observed on 24-hour Holter monitoring (>10/h) and normal LV ejection fraction (LV EF ≥ 55% on echocardiography) were enrolled. Clinical characteristics and echocardiographic parameters of the patients were compared with those of an age-/sex-matched control group (n = 292, age: 55 ± 15 years, 96 males). Patients with frequent PVCs had significantly larger left atrial volume index (LAVI [28 ± 9 mL/m(2) vs. 24 ± 7 mL/m(2) ]), along with larger LV end-diastolic dimension (49.4 ± 4.4 mm vs. 48.5 ± 3.9 mm), lower LV EF (63 ± 7% vs. 66 ± 6%), and lower peak systolic mitral annular velocity (7 ± 2 cm/s vs. 8 ± 2 cm/s; P < 0.05 for all), whereas other clinical characteristics were similar. In particular, in patients with frequent PVCs, LAVI showed linear correlation with PVC burden (R = 0.30, P < 0.001), and, in a multiple regression model, PVC burden independently estimated LAVI, even after controlling for age, sex, comorbidities, and systolic function (β = 0.309, P < 0.001). Frequent PVC is associated with LA enlargement in patients with normal LV EF. Atrial anatomical remodeling may precede LV geometry change and systolic dysfunction in patients with frequent PVCs.

Truncating titin variants (TTNtvs) are the most prevalent cause of inherited dilated cardiomyopathy. Occurrence of different ventricular arrhythmia (VA) subtypes, including premature ventricular complexes (PVCs), nonsustained ventricular tachycardia (NSVT), and sustained monomorphic VT (SMVT), has been reported. The aim of this study was to analyze the prognostic relevance of distinct VA subtypes among TTNtv carriers and their underlying arrhythmogenic substrates. Twenty-two TTNtv carriers referred for ablation of SMVT (n = 14) or frequent PVCs (n = 8) from 5 centers were included (mean age 56 ± 11 years; left ventricular ejection fraction 38% ± 13%; 77% male). Detailed phenotyping was performed, including Holter monitoring, cardiac imaging, and electroanatomical mapping. Patients were followed up for a median of 44 months. Demographic characteristics, including age, comorbidities, and left ventricular ejection fraction, were similar. NSVTs were frequent in both groups but faster in patients with SMVT (cycle length: 350 milliseconds [Q1-Q3: 315-403 milliseconds] vs 427 milliseconds [Q1-Q3: 395-469 milliseconds]). Although substrates for SMVT extended in a basal ring-like fashion with septal predominance, PVC sites of origin were limited to the basal anterior left ventricular segment. In the SMVT group, acute complete procedural success was achieved for 36%; during follow-up, 86% had recurrent VT, and 50% died of progressive heart failure. In the PVC group, complete abolition of PVCs was achieved in only 13%; at 3 months, median PVC burden was 1%, and there were no deaths or sustained VT during follow-up. VA subtype and NSVT cycle length were associated with mortality and poor VT-free survival. In TTNtv carriers, SMVTs but not frequent PVCs are associated with high mortality due to heart failure. Occurrence of SMVT may identify a subgroup at risk for rapid, progressive adverse remodeling. The prognostic significance of different VA subtypes needs to be confirmed in a larger cohort.

Background/Introduction Activation mapping is the “gold standard” for localisation of the site of origin during mapping and ablation of symptomatic premature ventricular complexes (PVC). In case of suppression of PVCs during the procedure, the origin of the PVC can be located using a pace mapping technique. The PASO module is an addition in the CARTO3 mapping system that calculates the correlation between the induced and observed 12-lead ECG PVC morphology, and visualises this correlation on an isochronal 3D colour map. Purpose The aim of this study was to compare the follow-up success rate of pace mapping using the PASO module and activation mapping and to determine cut-off values for clinical success. Methods Seventy-six consecutive ablation procedures of symptomatic PVCs were included in this single-center retrospective study. Mapping and ablation parameters were derived from the CARTO3 mapping system. Ablation success was defined as a ≥95% reduction in PVC burden on 24-hour Holter recordings or absence of the clinical PVC on multiple ECGs in case of multiple PVC morphologies. Logistic regression analysis was performed to evaluate the relationship between applied mapping methods and ablation parameters. Optimal cut-off values of ablation characteristics for successful ablation were determined using ROC curves. Results Thirty-five (46%) patients were male and 39 (51%) patients had a reduced left ventricular ejection fraction. Pace mapping was used in 36 (47%) patients. Baseline PVC burden was lower in patients when pace mapping was applied (18% vs. 28%, p&amp;lt;0.001). The use of either mapping technique was influenced by PVC localisation (p=0.004). Pace mapping was used predominantly in the right ventricular outflow tract (n=21/31) whereas activation mapping was used predominantly in the left ventricle (n=14/22) and left ventricular outflow tract (n=7/7). Ablation success did not differ between activation mapping (77.5%) and pace mapping (77.8%). Median [IQR] maximum PASO correlation was 98.2% [97.1–98.6] for successful ablations and 96.5% [92.9–97.5] for unsuccessful ablations (p=0.030). The optimal cut-off value for successful ablation of the PASO correlation was 97.6% (AUC 0.754, sensitivity 68%, specificity 88%). There were no significant differences in other ablation parameters between both groups. Conclusion This study indicates that pace mapping using PASO is a good alternative for activation mapping for localisation of the PVC. A minimum PASO correlation coefficient of 97.6% is the optimal cut-off value for successful PVC ablation. ROC of maximum PASO coefficient Funding Acknowledgement Type of funding source: None

Objective To investigate the characteristics and associated factors of ventricular arrhythmias in patients with chronic heart failure. Methods Two hundred and forty two heart failure patients with reduced left ventricular ejection fraction (HF-REF) without hemodynamic disorder were consecutively enrolled in Armed police general hospital from January 2014 to October 2016. Left ventricular diastolic ending internal diameter, left ventricular ejection fraction (LVEF) and E/A values were assessed by cardiac ultrasound. Premature ventricular contractions (PVCs), ventricular bigeminy, frequent PVCs, nonsustained ventricular tachycardia (NSVT) and average heart rate were assessed by 24 hour ambulatory electrocardiogram (AECG). Results AECG showed the presence of PVCs, ventricular bigeminy, frequent PVCs, and NSVT was 80.2% (194/242), 58.3% (141/242), 28.1% (68/242) and 16.1% (39/242), respectively. Of whom, 35 patients had monomorphic NSVT and 4 patients had polymorphism NSVT. Multiple logistic analysis showed that the association between the etiology of heart failure and the presence of ventricular arrhythmias was not significantly different (all P<0.05). LVEF (OR=0.777, 95% CI =0.662-0.912, P=0.002) was associated with the presence of PVCs. LVEF (OR=0.670, 95% CI =0.555-0.809, P<0.001) and average heart rate (OR=1.047, 95% CI =1.006-1.090, P=0.024) were associated with the presence of frequent PVCs. LVEF (OR=0.659, 95% CI =0.529-0.822, P<0.001) and E/A values (OR=6.845, 95% CI =1.563-9.979, P=0.011) were associated with the presence of NSVT. Conclusion The prevalence of ventricular arrhythmias was frequent in patients with HFREF. LVEF was associated with the presence of different types of ventricular arrhythmias. Key words: Heart failure; Arrhythmias, cardiac; Associated factors

Efficacy of advanced pace mapping technology for idiopathic premature ventricular complexes ablation: Usefulness of pace mapping

Catheter ablation of parahisian premature ventricular complexes in patients with and without cardiac scar

Background Premature ventricular complexes (PVCs) constitute a commonly encountered arrhythmia. Catheter ablation has emerged as a safe and effective therapeutic modality. However, long term follow-up data are still lacking. Purpose We conducted long term follow-up of patients who underwent catheter ablation for frequent PVCs, defined as more than 10.000, during at least two 24- hour ambulatory ECG- monitoring. Methods This retrospective cohort study included 152 patients (34.2% female; median age 58.4, IQR 24.1 years) who underwent catheter ablation at a single center from 2015 to 2022. PVC burden ranged from 10 to 30% in 113 patients (74.34%) and over 30% in 39 patients (25.6%). We sought to evaluate the following factors: Patient demographics, procedural characteristics and outcomes, complication rates and long-term clinical outcomes. There were 37 (24.3%) patients with already diagnosed structural heart disease (27 with ischemic heart disease, 7 with dilated cardiomyopathy, 1 with valvular heart failure, 1 with hypertensive heart failure and 1 with non- dilated left ventricular cardiomyopathy). A diagnosis of PVC induced cardiomyopathy, prior to ablation, was established in 21 (13.8) % of cases. Prior to catheter ablation, 142 patients had received beta-blockers and 22 had received class IC or III antiarrhythmics, without PVCs suppression. Results Acute procedural success was achieved in 139 (91.4 %) of patients. In the long term follow up of the successful cases (mean follow up 3.6 ± 2.3 years), 6 recurrences were observed (among them, a new origin of PVCs was noted in one patient, 4 years after the index procedure). Patients with PVCs originating from sites other than the outflow tracts were more likely to experience arrhythmia recurrence (log- rank test, p = 0.029). PVC induced cardiomyopathy resolved in 18 out of 21 patients, post catheter ablation. Among the failed cases, one procedure was discontinued due to intraprocedural tamponade. The rest of the failed cases were attributed to inaccessible site of origin, mainly left ventricular summit (n= 4) and papillary muscle (n = 5). No procedure-related mortality was recorded. Cardiac tamponade occurred interprocedurally in two patients (1.32%) and was successfully treated with pericardiocentesis. Both were attributed to the use of non- contact force technology. Temporal conduction system disturbances (less than 24 hours duration) were noted in 6 patients (3.9%). One patient suffered intraprocedural ischemic stroke, which was successfully treated with thrombectomy. One patient suffered vascular access-related complication, namely femoral hematoma, which required vascular surgery. Mean procedural duration was 134.7 ± 48 minutes. Conclusion In the long term follow up, catheter ablation of frequent PVCs demonstrates safety and effectiveness, and requires multidisciplinary approach of complications management.Long Term follow-up

Transcutaneous Electrical Vagus Nerve Stimulation to Suppress Ventricular Premature Complexes (TREAT-PVC): A Randomized Clinical Trial.