The role of aortic valve anatomy in determining the site of origin of ventricular ectopic beats: correlation between echocardiographic and electrophysiologic data

Abstract

Purpose: In presence of premature ventricular complexes (PVCs) arising from both Ventricular Outflow Tracts (RVOT and LVOT) it's often difficult to determine the origin before intracardiac mapping, due to smooth different ECG features for adiacent sites (posteroseptal RVOT, anteroseptal LVOT, Aortic Cusps). The aim of our study was to determine if the aortic valve anatomy as assessed by transthoracic echocardiography (TTE) is correlated with the origin site of the PVCs in patients with no evidence of Structural Heart Disease (SHD) and uncertain ECG features who undergo ablation with Radio-Frequency (RF) of monomorphic PVCs. Methods and materials: Thirty-one consecutive patients (mean age 52.5±18 yrs, 19 males) with no evidence of SHD who underwent RF ablation of PVCs were enrolled in our study. In all patients the 24 h Holter monitoring showed that at least 20% of the total heart beats was represented by monomorphic PVCs arising from RVOT or LVOT. Ablation was performed using electro-anatomic mapping and image-integration provided by intracardiac echo. The site of origin of the PVCs was determined according to the site of effective ablation. A complete standard TTE was performed before the ablation procedure, including an emphasized study of the aortic valve; aortic valve sclerosis (AVS) was defined by the presence of enhanced echogenicity/thickness (>2mm) of the aortic cuspids or the presence of focal calcifications. Results: The systolic left ventricular function expressed as ejection fraction (%) was normal in all patients (58.5±7.2). AVS was found in 11 pts, in 10 being associated with trivial valvular regurgitation. The ablation procedure was acutely successful in all patients. PVCs were originating from the LVOT in 12 pts (38%). All patients with PVCs originating from RVOT had normal aortic valve, instead AVS was present in 92% of patients with PVCs from LVOT and all 3 patients with PVCs from the Aortic Cusps. Conclusions: The presence of the aortic valve sclerosis assessed by transthoracic echocardiography was correlated with the LVOT origin of the premature ventricular complexes and it could help the preoperative management of the patients without structural heart disease who undergo RF ablation of monomorphic PVCs in presence of ambiguous ECG features.