Ablation Of Premature Ventricular Contractions Research Articles

Anatomical versus Electrophysiological Approach for Ablation of Premature Ventricular Contractions Originating from the Left Ventricular Summit (ISESHIMA-SUMMIT Study).

Catheter ablation (CA) of idiopathic ventricular arrhythmias (VAs) from the epicardial left ventricular summit is challenging. The endocardial approach targets two sites: the endocardial closest site (ECS) to the epicardial earliest activation site (epi-EAS) and the endocardial EAS (endo-EAS). We aimed to differentiate between cases where CA at the ECS was effective and where CA at the endocardial EAS yielded success. Fifty-eight patients (47 men, 60±13 years) were analyzed with VAs in which the EAS was observed in the coronary venous system (CVS). Overall, VAs were successfully eliminated in 42 (72%) patients; 8 in the CVS, 8 where the ECS matched with the endo-EAS, 11 at the ECS, and 15 at the endo-EAS. Successful ECS ablation was associated with a shorter epi-EAS-ECS distance (10.2±4.7 vs. 18.8±5.3 mm; P<0.001) and shorter epi-EAS-left main coronary trunk (LMT) ostial distance (20.3±7.6 vs. 30.3±8.4 mm; P=0.005), with optimal cut-off values of ≤12.6 mm and ≤24.0 mm, respectively. Successful endo-EAS ablation was associated with an earlier electrogram at the endo-EAS (23 [18, 36] vs. 15 [0, 19] ms preceding the QRS; P<0.001) and shorter epi-EAS-endo-EAS interval (6 [1, 8] vs. 22 [12, 25] ms; P<0.001), with optimal cut-off values of ≥18 ms and ≤9 ms, respectively. Shorter anatomical distances between the epi-EAS and ECS, and between the epi-EAS and LMT ostium, predict a successful ECS ablation. The prematurity of the endo-EAS electrogram and a shorter interval between the epi-EAS and endo-EAS predicted a successful endo-EAS ablation.

Digital health in the EP lab: routine implementation of remote access and technical support for complex ablation procedures

Abstract Background Complex electrophysiological procedures are performed using three-dimensional (3D) electroanatomical mapping (EAM) systems, which are usually operated on site, by field technical engineers (FTE). Due to a lack of skilled personnel, the engineers usually must travel between different hospitals and the procedures have to be planed in advance. Remote access (RA) technologies were recently implemented in clinical practice, aiming to increase the flexibility in the EP lab and maximise healthcare resources use. Methods Electroanatomical mapping was performed remotely by means of an integrated audio-visual solution for RA. The operator and the FTE communicated exclusively using the RA system, while the latter worked only in home office. Consecutive procedures were prospectively enrolled and analysed in terms of indication, procedural characteristics, feasibility and saved travelled time by the FTA. Results Between September 2022 and July 2023, a total of 133 EP procedures were performed in a high volume, tertiary electrophysiological centre in Germany. The mean age was 67 (57.5, 75.5) years. Women represented 39.8% of the population. The median BMI was 26.2 (23.1, 30.3) Kg/m2. A total of 56 (42.1%) patients underwent an atrial fibrillation ablation procedure (37.5% paroxysmal), 22 (16.5%) an atrial tachycardia ablation, 13 (9.8%) cavotricuspid isthmus ablation, 15 (11.3%) supraventricular tachycardia ablation, 14 (10.5%) a premature ventricular contraction ablation, 12 (9%) ventricular tachycardia ablations and 1 patient an electrophysiological diagnostic study. The median time length of procedure was 130 (96.5, 168) minutes. The median number of radiofrequency applications was 63.5 (22.3, 109.5), while the median RF time was 14.2 (6.9, 25.1) minutes. The fluoroscopy time was 9.2 (6.5, 12.6) minutes, with a median radiation dose of 408.5 (233.0, 631.8) cGy x cm2. The median amount of contrast media was 40 (8.75, 50.0) ml and the median amount of heparin administered was 12000 (8000, 16000) UI. Protamine was used in 9 cases, with a median of 7000 (5000, 7000) UI. Except for one supraventricular procedure, where no arrhythmia induction was possible, all procedures were successful. One major complication was observed. In one case, the internet-based headphone connection was not stable. Therefore, the communication was established via a conventional smartphone. No change to on-site support was needed. The travel time reduction was available in 130 cases. In total, 290 travel hours could be saved. Conclusion The routine implementation of RA for complex EP procedures proved to be safe and efficient. This approach has the potential to increase the feasibility in case of emergency procedures, reduce travel times for FTE and streamline healthcare resources allocation.

3D Map Combined with Transthoracic Echocardiography for Ablation of Premature Ventricular Contractions/Ventricular Arrhythmia from Papillary Muscle: A Technical Report.

Ventricular arrhythmias originating from the papillary muscle of the ventricles are complex clinical problems. Catheter ablation has the potential to cure these arrhythmias. However, the procedure is usually challenging due to the specific anatomy, catheter instability and difficulty in localization of the origin of the arrhythmias. Intracardiac echocardiography (ICE) has been reported to be the suitable imaging method for assessing the location of focus in papillary muscles. We used transthoracic echocardiography (TTE), as a noninvasive cost-effective imaging supporting modality, in combination with 3D mapping to guide the exact localization and successful ablation of papillary muscle-originating premature ventricular contractions (PVCs).

Source Localization and Classification of Pulmonary Valve-Originated Electrocardiograms Using Volume Conductor Modeling with Anatomical Models.

Premature ventricular contractions (PVCs) are a common arrhythmia characterized by ectopic excitations within the ventricles. Accurately estimating the ablation site using an electrocardiogram (ECG) is crucial for the initial classification of PVC origins, typically focusing on the right and left ventricular outflow tracts. However, finer classification, specifically identifying the left cusp (LC), anterior cusp (AC), and right cusp (RC), is essential for detailed preoperative planning. This study aims to improve the accuracy of cardiac waveform source estimation and classification in 27 patients with PVCs originating from the pulmonary valve. We utilized an anatomical human model and electromagnetic simulations to estimate wave source positions from 12-lead ECG data. Time-series source points were identified for each measured ECG waveform, focusing on the moment when the distance between the estimated wave source and the pulmonary valve was minimal. Computational analysis revealed that the distance between the estimated wave source and the pulmonary valve was reduced to less than 1 cm, with LC localization achieving errors under 5 mm. Additionally, 74.1% of the subjects were accurately classified into the correct origin (LC, AC, or RC), with each origin demonstrating the highest percentage of subjects corresponding to the targeted excitation origin. Our findings underscore the novel potential of this source localization method as a valuable complement to traditional waveform classification, offering enhanced diagnostic precision and improved preoperative planning for PVC ablation procedures.

Multielectrode catheter-induced ectopy mapping: a novel technique for ablation of infrequent premature ventricular contractions

BackgroundAblation of infrequent premature ventricular complexes (PVC) is challenging. ObjectivesA novel mapping strategy for patients with infrequent PVCs, called “multielectrode catheter-induced ectopy mapping” (MECIE-mapping) is described, aiming at performing a hybrid activation/template matching map by taking advantage of multielectrode catheter-induced arrhythmogenicity. MethodsPatients referred to three tertiary centers for PVC ablation were prospectively enrolled if they had infrequent PVCs (less than 1 PVC per minute) at onset of procedure, preventing the realization of an accurate activation map. A detailed MECIE-map was created using the arrhythmogenic property of multielectrode catheters, corresponding to a local activation time (LAT) map generated by annotating LAT from mechanical PVCs. Selecting mechanical PVCs with ≥ 99% concordance with the clinical PVC spotted the site of origin where ablation was delivered. The primary endpoint was long-term success, defined as an > 80% reduction in PVC burden during follow-up. Results29 patients were included, with 25 [IQR 7-30] PVCs in the initial 30 minutes of procedure. During MECIE-mapping, 67 [IQR 1-332] points with ≥ 99% concordance were acquired. The best LAT was 34.0±9.5 ms before QRS onset. Pace-mapping was 97.4±3.1% compared to the clinical PVC. Ablation was locally performed. After 13.2±5.1 months of follow-up, 27 patients (93.1 %) had 80% reduction in PVC burden, and only two patients had a symptomatic recurrence. ConclusionsA detailed MECIE-map taking advantage of multielectrode catheter arrhythmogenicity may be generated to spot the origin of PVCs, a strategy resulting in a good procedural success rate.

Additional Lesion Sets in Ablation of Outflow Tract Premature Ventricular Contractions: A Randomized Clinical Trial.

Recurrence remains a challenge after ablation of outflow tract premature ventricular contractions (OT-PVCs). Although adding additional lesions next to the index effective ablation site is sometimes performed to reinforce the ablation, it remains uncertain whether this approach is effective. To test the hypothesis that additional ablation lesions would reduce the recurrence rate compared with single-point ablation at the index effective site for the ablation of OT-PVCs. This study was a multicenter, prospective, randomized clinical trial. Patients receiving their first catheter ablation for OT-PVCs were enrolled from 18 hospitals in China between October 2021 and February 2023. Scheduled follow-up duration was 3 months after the procedure. After identifying the target point and eliminating the PVC by a single-point ablation, patients were randomized 1:1 into an additional ablation group or a control group. The primary end point of the study was freedom from PVC recurrence (≥80% reduction of PVC burden, which is the number of PVCs in 24 hours/total heartbeats in 24 hours × 100%) from baseline to 3 months postprocedure. Of 308 patients enrolled in the study, 286 (mean [SD] age, 49.2 [14.6] years; 173 female [60.5%]) were randomized to the additional ablation or the control group. The additional ablation group had a mean (SD) of 6.3 (1.1) radiofrequency applications, whereas the control group (single-point ablation group) had a mean (SD) of 1 (0) radiofrequency application. After a median (IQR) follow-up of 3.2 (0) months, the rate of freedom from PVCs was significantly higher in the additional ablation group (139 of 142 [97.9%]) compared with the control group (115 of 139 [82.7%]; P < .001). Patients in the additional ablation group also had a more substantial reduction in PVC burden than the control group (mean [SD] reduction, 23.0% [10.5%] vs 19.0% [10.4%]; P = .002). There were no severe periprocedural complications in either group. This randomized clinical trial showed a benefit of additional ablation in reducing the recurrence of OT-PVCs compared with the single-point ablation strategy, without increased complication risk. Additional ablations surrounding the index effective ablation point should be considered in OT-PVC ablation. Chinese Clinical Trials Registry Identifier: ChiCTR2200055340.

Strategies for Catheter Ablation of Premature Ventricular Contractions and Ventricular Tachycardia With Intramural Origins.

Strategies for Catheter Ablation of Premature Ventricular Contractions and Ventricular Tachycardia With Intramural Origins.

Premature ventricular contraction arising from the left coronary sinus cusp: Which signal is the target of ablation?

We described a premature ventricular contraction arising from the left coronary sinus cusp, in which we discussed about the interpretations of the signals recorded there. Our case provided further insights into the interpretation of signals recorded at the coronary sinus cusp during premature ventricular contraction ablation.

Zero-fluoroscopy catheter ablation of premature ventricular contractions: comparative outcomes from the right ventricular outflow tract and other ventricular sites.

The three-dimensional electroanatomic mapping (EAM) system allows performing catheter ablation (CA) without fluoroscopy in patients with premature ventricular contractions (PVCs). The right ventricle outflow tract (RVOT) location is favorable for performing zero-fluoroscopy CA. Non-RVOT zero-fluoroscopy CA is a challenging procedure. The study aimed to evaluate the efficacy and safety of zero-fluoroscopy CA using the EAM in patients with PVCs from RVOT and non-RVOT. Completely zero-fluoroscopy CA of PVCs guided by EAM was performed in 107 patients with PVCs. 54 patients underwent zero-fluoroscopy RVOT CA. The remaining 53 patients underwent zero-fluoroscopy non-RVOT CA. Demographic and clinical baseline characteristics, procedure parameters, and follow-up were obtained from medical records. Primary outcomes were the acute and the permanent success rate (12-month follow-up), complications, and procedure time. There were no significant differences between groups regarding baseline characteristics. Acute procedural success was achieved in 52 patients (94,44%) in the RVOT zero-fluoroscopy CA group and in 45 patients (86,54%) in the non-RVOT zero-fluoroscopy CA group (ns). A long-term success rate was achieved in 50 patients (90,74%) in the RVOT zero-fluoroscopy CA group and in 44 patients (84,62%) in the non-RVOT zero-fluoroscopy CA group (ns). The median procedure time was 80.5 minutes in the RVOT group and 90 minutes in the non-RVOT group (ns). There were two complications in the non-RVOT group (ns). There were no differences in procedure time efficacy and safety zero-fluoroscopy ablation between RVOT and non-RVOT locations. Non-fluoroscopy CA of PVCs is a feasible, safe, and efficient procedure.

Clinical, Electrophysiological Characteristics and Long-Term Outcomes of Catheter Ablation of Premature Ventricular Contractions Originating From Left Coronary Cusp

Clinical, Electrophysiological Characteristics and Long-Term Outcomes of Catheter Ablation of Premature Ventricular Contractions Originating From Left Coronary Cusp

Fatty infiltration and ventricular premature beats originating from right ventricular outflow tract: association or causality?

Anatomical evidence reveals heterogeneous fat distribution in both atrial and ventricular myocardium that are considered normal, but at the same time arrhythmogenic, and numerous cardiac pathophysiological conditions are associated with myocardial fat deposits. The relationship between fatty infiltration, especially in the epicardial layer and its pathophysiological implication is not completely understood. The aim of this study was to establish a positive or negative relationship between the ventricular burden and several parameters related to right ventricle (RV) adipose tissue - the RV thickness, RV indexed mass, body mass index (BMI), age, gender. Twenty-three patients with documented premature ventricular contractions (PVCs) originating from right ventricular outflow tract based on electrocardiography (ECG) evaluation were hospitalized between January 2018-November 2022 for electrophysiological study and PVCs ablation. Data obtained after collecting the clinical characteristics, ECG, RV measurements from transthoracic echocardiography (TTE), cardiac computed tomography (CT) and magnetic resonance imaging (MRI) were analyzed. A weak positive relationship between the ventricular burden and BMI (r=0.14, p=0.49), tricuspid annular plane systolic excursion (TAPSE) (r=0.07, p=0.7), the RV thickness (r=0.03, p=0.8), epicardial adipose tissue (r=0.13, p=0.55), RV mass indexed (r=0.05, p=0.82) was observed. No clear cut-off of the PVCs burden could be established in terms related to the increase in BMI, RV thickness, epicardial adipose tissue, RV mass indexed. No significant positive or negative relationship between the ventricular burden and the RV thickness, RV indexed mass were found in individuals with a high PVCs originating from right ventricular outflow tract (RVOT) burden.

Electrophysiological characteristics and catheter ablation of ventricular arrhythmias arising from the superior septal left ventricle

Background and aimsElectrophysiological characteristics and radiofrequency catheter ablation (RFCA) of premature ventricular contractions (PVCs) originating from the superior septal left ventricle (SSLV) have not yet been fully characterized.Methods and resultsThis study included 247 patients who underwent RFCA for PVCs arising from the ventricular outflow tract between February 2020 and August 2022. The successful ablation site was on the SSLV in 37 of the 247 patients. In 12 (32.4%) of those 37 patients, a low amplitude and high frequency spiky potential (SP) was recognized. Five patients showed a narrow QRS duration (86.8 ± 4.6 ms), with a discrete SP observed in PVCs and sinus rhythm, which showed an isoelectric line with the ventricular electrogram at the earliest activation site. Seven patients showed a wide QRS duration (131.6 ± 4.5 ms), with SP observed in PVCs without an isoelectric line with the ventricular electrogram. RFCA was successful at the site of the earliest SP in all 12 patients. The time from SP onset at the successful ablation site to the QRS onset (local activation time) was 30 ± 12 ms, which differed significantly from that for the remaining 25 patients withoutSP(22.1 ± 7.1 ms, P < 0.05).ConclusionsSPs were recorded in 12 (32.4%) of the 37 patients with PVCs originating from the SSLV. The morphology of the PVCs may show a narrow or wide QRS duration and the target site for successful ablation should be identified by the earliest SP.

Real-world assessment of multipolar and point-by-point mapping for premature ventricular contraction ablation.

We aimed to assess the acute and midterm efficacy of premature ventricular contraction (PVC) ablation guided by multielectrode and point-by-point (PbP) mapping. This is a retrospective, international multicentre study of consecutive patients referred for PVC ablation in 10 hospital centres from January 2017 to December 2021. Based on the mapping approach, two cohorts were identified: the 'Multipolar group', where a dedicated high-density mapping catheter was employed, and the 'PbP group', where mapping was performed with the ablation catheter. Procedural endpoints, safety, and acute (procedural) and midterm efficacies were assessed. Of the 698 patients included in this study, 592 received activation mapping [46% males, median age of 55 (41-65) years]-248 patients in the Multipolar group and 344 patients in the PbP group. A higher number of activation points [432 (217-843) vs. 95 (42-185), P < 0.001], reduced mapping time (40 ± 38 vs. 61 ± 50 min, P < 0.001), and shorter procedure time (124 ± 60 vs. 143 ± 63 min, P < 0.001) were reported in the Multipolar group. Both groups had high acute success rates (84.7% with Multipolar mapping vs. 81.3% with PbP mapping, P = 0.63), as well as midterm efficacy (83.4% vs. 77.4%, P = 0.08), with no significant differences in the risk of adverse events (6.0% vs. 3.5%, P = 0.24). However, for left-sided PVC ablation specifically, there was a higher midterm efficacy in the Multipolar group (80.7% vs. 69.5%, P = 0.04), with multipolar mapping being an independent predictor of success [adjusted OR = 2.231 (95% CI, 1.476-5.108), P = 0.02]. The acute and midterm efficacies of PVC ablation are high with both multipolar and PbP mapping, although the former allows for quicker procedures and may potentially improve the outcomes of left-sided PVC ablation.

Automated template matching versus conventional pace-mapping during pvc ablation: results from a randomized controlled trial

Abstract Background Pace-mapping has an important role in the ablation of idiopathic premature ventricular contractions (PVC). There is a software with an automated algorithm annotating and visualizing template matching points. Automated template matching (ATM) facilitates the matching process and may thus shorten the procedure duration and potentially increase ablation success. In this randomized study we evaluate whether the use of the automated template matching (ATM) software compared to conventional pace-mapping (PM) influences outcomes and periprocedural parameters in patients undergoing PVC ablation. Methods The study was performed as a prospective randomized controlled single-center clinical trial. Patients scheduled for de-novo PVC ablation were included and randomly assigned to either PVC ablation using the ATM algorithm (ATM) or conventional pace-mapping (PM). The primary endpoint was the procedural outcome represented by the PVC burden after three and twelve months. Secondary endpoints were periprocedural parameters including procedure duration, number, and duration of radiofrequency application (RFA), fluoroscopy (FS) dose, and duration. An interim analysis was predetermined after 72 patients had completed their three-month follow-up. Results After the interim analysis, the study was prematurely ended for futility. At termination of the trial 108 patients had been included. 18 patients dropped out of the study. Out of the remaining 90 patients, 88 patients (97%) have completed the three-month follow-up, and 73 patients (81%) the twelve-month follow-up. The mean age at the time of procedure was 57.3 years [18-82] without significant differences between both groups. Before ablation, the mean PVC burden was 20.8% [0.1-55.0] (ATM: 20.8% [3.0-55.9]; PM: 20.7% [0.1-44.0]; p=0.959). At 3-month follow-up, the mean PVC burden in both groups (ATM: 4.7% [0-29.4]; PM: 3.6% [0-45.7]; p=0.512) showed no significant difference between the groups. At 12-month follow-up the mean PVC burden in both groups (ATM: 3.8% [0-31]; PM: 2.2% [0-25.6]; p=0.282) also resulted in a non-significant difference between the groups. Furthermore, the procedural parameters (table) did not differ significantly between both groups. Conclusion In this randomized trial, the use of the automated template matching software did not result in improved outcomes or procedure-related parameters. Conventional pace-mapping appeared to be equally effective compared to the automated template matching software as used in this study.Table secondary endpoints

Imaging-derived tissue visualization guides catheter ablation of premature ventricular contractions

Abstract Background The presence of myocardial scarring is associated with worse outcomes after catheter ablation of premature ventricular contractions (PVCs). Three-dimensional substrate characterization is emerging for peri-procedural ablation guidance, but its value for tissue visualization during PVC ablation is unknown. Purpose The aim of the present study was to assess the impact of imaging-derived tissue visualization on lesion planning, procedural and clinical outcomes of PVC ablation. Methods Thirteen consecutive patients (92.3% male, 62.2±12.4 years) undergoing unipolar (n=8) or bipolar (n=5) PVC catheter ablation with integrated three-dimensional imaging from multidetector computed tomography or cardiac magnetic resonance imaging were included. All patients presented with assumed myocardial scarring due to an underlying cardiomyopathy and/or after previous ablation. Results Among all patients (30.8% (peri-)myocarditis, 20.0% ischemic, 15.4% dilated cardiomyopathy, 15.4% idiopathic, 7.7% nonischemic, 7.7% congenital heart disease) undergoing ablation of 20 PVC morphologies (median 1 (IQR 1-2) per patient; 75.0% non-outflow tract; 70.0% left-sided), myocardial scarring was present in 11/13 (84.6%). Wall thinning &amp;lt;5 mm covering an area of 36.1±17.8 cm² contained the PVC origin in 4/13 (30.8%) patients and was safely targeted with radiofrequency lesions with up to 45 W (maximum power: median 32 W (IQR 30-35)) (Figure 1). Imaging-guided bipolar ablation was performed in 5/8 (62.5%) patients with previously therapy-refractory PVCs including foci at the left ventricular summit and the right ventricular outflow tract each in 2 and the left coronary cusp in one patient (Figure 2). PVCs were efficiently suppressed with less radiofrequency lesions (5.4±3.8 vs. 55.8±36.9; p=0.0160) with shorter duration (4.1±3.2 min vs. 23.3±13.5 min; p=0.0152) compared to prior unipolar ablation. Bipolar lesions resulted in a higher impedance (158 Ω (IQR 101-174) vs. 106 Ω (IQR 99-124); p=0.0025), while requiring a lower temperature (36 °C (IQR 35-38) vs. 39 °C (IQR 36-43); p=0.0001) and less power (26 W (IQR 20-30) vs. 30 W (IQR 25-31); p=0.0376). Complete suppression of the clinical PVC was reached in all 13 patients. During a follow-up of 396.8±299.7 days, PVC burden decreased from 20.1±14.3% to 1.7±1.6% (p=0.0172). Conclusions Imaging-derived tissue visualization enables determination of myocardial wall thinning &amp;lt;5 mm as a substrate for recurrent PVCs, which can be safely targeted. Three-dimensional imaging efficiently guides high power lesion application and bipolar ablation of PVCs at anatomically challenging foci.Anatomically challenging fociImaging-guided bipolar ablation

Omnipolar mapping and vector mapping in premature ventricular contractions ablation: a comparison with bipolar mapping

Abstract Background Omnipolar Mapping, with HD Grid high-density mapping catheter, overcomes the dependency of EGM characteristics to wavefront orientation, reconstructing the highest peak-to-peak voltage attainable within the electric field and the real wavefront direction, displayed in the form of a local activation vector [1][2]. Methods Consecutive patients who underwent radiofrequency ablation of PVCs from October 2021 to August 2023 at the Hospital Clinic of Barcelona were included in the study. EAM was performed with EnsiteX mapping system, Advisor HDgrid was used as mapping catheter. An activation map was performed if enough PVC burden. The area of interest was determined by earliest activation time combined with the morphology of unipolar electrogram during activation mapping. RF was delivered at the area of interest with target temperature of 45°C and maximum power of 50W. Both bipolar and omnipolar maps were analysed retrospectively. The reviewer was blinded to the ablation set for this analysis. A window of interest was created uniformally for all maps by defining a caliper within 15 ms before the onset of PVC. Activation vectors were displayed on the map and visually analysed. Three specific patterns were identified: Starburst, Homogeneous and Chaotic. Area of the earliest activation was measured. Earliest site of bipolar and omnipolar maps and specific location of star burst pattern were tagged. The site of the effective RF ablation was identified and the distance between points was determined. Results 18 patients were included. Overall, 11(61%) were males; age: 57,9±15,2 ys, 6(33%) patients haven't structural heart disease, 4(22%) presented PVC-induced cardiomyopathy. Mean left ventricular ejection fraction was 46±10. Mean PVC burden was 27±10%. In 9(50%) patients, PVCs were ablated from RVOT, 4(22%) in LVOT, 1(5%) in the left superior fascicle, 1(5%) in the antero-lateral papillary muscle, 2(10%) in the perihissian area and 1(5%) in the aortomitral continuity. Compared with bipolar, omnipolar mapping showed a smaller area of earliest activation(2,13±1,9mm2 vs 3,34±2,1 mm2,p&amp;lt;0,001), a shorter distance of the earliest point to starburst region(4,2±4,1mm vs 7,8±4,2mm,p&amp;lt;0,001) and shorter distance to the effective ablation site(6,1±3,9 mm vs 8,33±4,2mm, p&amp;lt;0,07). No significative difference was found between the effective RF ablation site and the starburst area compared to the distance between the effective RF ablation site and the omnipolar earliest deflection (6,11±3,9mm vs 6,5±4,3mm, p=0,6). No statistical significative difference was found between the timing of the earliest deflection in both settings (33,2±12,5 ms vs 31,5±12 ms, p=0,2) Conclusions Omnipolar mapping allows a better identification of the area of interest in PVC’s ablation compared to bipolar mapping. Vector mapping is a valuable asset to identify the earliest activation point to guide PVCs catheter ablation.Retrospective EAM analysisArea/distance measurements

Bipolar catheter ablation of left ventricular summit PVC

Abstract Background Premature ventricular contractions (PVC) arising from the left ventricular summit are a challenging arrhythmia to manage, often refractory to conventional radiofrequency ablation. This study aimed to investigate the effectiveness of bipolar ablation as a therapeutic option for PVCs originating from this anatomically complex region. Methods We conducted a retrospective analysis of a prospective ablation registry to identify patients with recurrent, symptomatic PVCs originating from the left ventricular (LV) summit who underwent bipolar ablation. Bipolar ablation involved the use of two ablation catheters, delivering radiofrequency energy from opposite sides of the summit. The catheters were connected by a dedicated adapter, allowing to connect one ablation catheter in position of a return electrode. Procedural success was defined as the elimination of PVCs during the procedure and freedom from PVCs on follow-up monitoring. Results were compared to a similar patient group who had received unipolar ablation of summit-PVCs. Results A total of 12 pts received bipolar ablation between July 2022 and October 2023. Three pts underwent ablation for VT and were excluded. A total of 9 pts (mean age 57±18 years, n=7 [78%] male, BMI 28±5kg/m2) were included in the analysis. All but one had a history of a previous unsuccessful ablation attempt (median 1 [1-2]). In a group of 33 patients undergoing unipolar ablation 8 (32%) had received ≥ 1 previous ablation and were included in the analysis. Baseline parameters did not differ between groups. The acute procedural success rate for bipolar ablation was 89% in bipolar pts and 75% in unipolar pts, with a mean procedural time of 173±33 min, a mean fluoroscopy time of 14±9 min (158±55 min [p=0.478] and 14±12 min [p=0.995] for unipolar pts). Bipolar ablation was performed between the LVOT and RVOT in 6, and between LVOT and the distal CS in 6 pts with 25-35 W. No major complications were detected in bipolar pts while one non-fatal tamponade occurred in the unipolar pts group. Follow-up data at 97 [93-269] days revealed a sustained reduction in PVC burden in bipolar pts (from 18±13% to 7±9%; p=0.026) while unipolar ablation did not show a significant burden reduction (15±6% to 11±10%; p=0.382). The success rate of a relative burden reduction &amp;gt;50% did not differ significantly between the groups (bipolar: 6 pts [67%] 3 pts [38%]; p=0.347). Conclusion Bipolar ablation offers an effective and safe therapeutic approach for PVCs originating from the LV summit. It significantly reduced PVC burden in this analysis. The data suggest that a repeat procedure after a failed summit PVC ablation should only be performed if bipolar ablation is available during the second procedure. Larger studies are warranted to confirm efficacy and safety of this ablation method.

Electrocardiographic characteristics and catheter ablation of premature ventricular complex- mediated ventricular fibrillation

Abstract Background Premature ventricular contractions (PVCs) can trigger ventricular fibrillation (VF) in patients with/or without structural heart disease. There are limited data on coexisting electrocardiographic (ECG) features and catheter ablation outcomes in these patients which could suggest the concomitant presence of an abnormal electrical and structural substrate. Purpose We investigated ECG and electroanatomic characteristics and clinical outcomes in patents who underwent catheter ablation of PVCs triggering VF. Methods We analyzed data from a consecutive series of patients who underwent catheter ablation between 08/2019 and 04/2023 for PVCs triggering VF. On the 12-lead ECG, we assessed the following abnormalities: (a) Early repolarization (ER) pattern in either inferior or lateral leads (Figure 1), or (b) QRS Notching of either the native sinus beat or PVC (Figure 2). Post-ablation follow up outcomes were collected using a combination of ICD interrogation, remote transmission and clinical follow up. Results The cohort included 15 patients: age 52.1±16.8 years, 46.7% females, and 26.7% presenting with VF storm. On average, there were 3.8 HV shocks/per patient from an ICD prior to the index ablation procedure (range: 0-19 shocks). On the 12-lead ECG, the mean coupling interval of the PVC leading to VF was 204±82 ms, and an overall narrow PVC morphology with a mean QRS duration of 107±17 ms. We observed early repolarization (ER) in 6 (40%) of the cohort. In most patients (n=11; 73.3%), at least one of the 2 ECG abnormalities were present. An endocardial-only approach was adequate in all patients, and during catheter ablation, Purkinje potentials were targeted in 10 (66%) of the patients. Based on activation and pace-mapping, the PVCs were localized to the following sites: (a) left ventricular (LV) septum in 11 (73.3%), (b) papillary muscles in 2 (13.3%), and (c) other sites such as the Moderator band and right ventricular outflow tract in the remaining 2 (13.3%) patients. The ablation locations on the LV septum extended from basal to mid-septum. After an average of 1.7 ablation procedures targeting PVC-triggering VF, 12 (80%) patients remained free of sustained ventricular arrhythmias and ICD shocks, over a mean follow up of 479±395 days. Conclusion In most patients with PVCs-triggering VF, there was an evidence of an ECG abnormality either in the form of an ER pattern or notching of either the Sinus QRS or the PVC complex on pre-ablation ECG. During ablation, Purkinje potentials and PVCs were mapped to and ablated in the region of the LV interventricular septum and papillary muscles. Over long-term follow up, catheter ablation seemed durable and effective in reducing VF episodes and ICD shocks.Presence of Early Repolarization patternPresence of a notching pattern in the Si

Clinical accuracy of a 3-dimensional multielectrode non-invasive ECG mapping vest in premature ventricular contraction ablation procedures

Abstract Background Invasive 3D mapping is the current gold standard in determining premature ventricular contraction (PVC) localization. However, given its invasive nature, unawareness of PVC origin beforehand may lead to prolonged procedure times and increased complications risk. Purpose In this study, we compared the diagnostic accuracy of a non-invasive 3-dimensional mapping ECG vest (MECGV) with invasive 3D mapping and ablation successful points as a reference. We also evaluated 12-lead ECG based pre-procedural PVC localization accuracy of 2 expert operators blinded to clinical findings. Methods In 15 consecutive adult patients between the ages of 35 to 69 (male n: 9, median age: 48), MECGV and subsequently a 3D mapping with uneventful successful PVC RF catheter ablation were performed and included in the study. PVC localization estimations of MECGV method and the EP experts' locatization predictions were compared separately with invasive 3D ablation results using the Cohen's kappa method and with the help of a 16-segmentation model we created for the ease of the analyses . Results Results were presented on Table-1. MECGV was found to be highly compatible (Cohen's kappa 0.968, p&amp;lt;0.001) with the RF ablation results. However operators assessments were found to be less coherent with invasive 3D mapping (Operator 1 Cohen's kappa 0.571, p 0.033, Operator 2 Cohen's kappa 0.618, p: 0.019, respectively). MECGV accuracy was %87 in pinpointing the PVC focus. The only 2 localizations that MECGV failed were on the septal aspects of the heart (Picture-2 Failure of defining the focus on LVOT septal instead of RVOT septal) Conclusion MECGV method seems to be highly compatible with invasive 3D mapping techniques in detection of PVC localization and bests EP expert estimates in this regard. However, it also seem to have some pitfalls especially on septal aspects of the heart.Table-1 and segmentation schemePicture-1

Predictors of improvement in LV ejection fraction post PVC ablation

Abstract Introduction Premature ventricular contraction (PVC) is a frequently encountered finding in routine ECGs, that in certain individuals may be followed by reduction in ejection fraction (EF). This may be improved or even reversed with a medical or interventional reduction of ectopic burden. Objective The primary objective of this study is to assess the potential effectiveness of cardiac ablation in suppressing PVC and subsequently enhancing the EF. Further we aim to establish predictive factors of the success of the intervention. Methods In a retrospective data analysis at a single medical centre, we examined records of 116 patients who underwent ectopic ablation, with 10 patients having more than 1 ablation. Demographic information, heart-related conditions along with the presence of a scar on MRI, was collected. The study also recorded pre- and post-procedure PVC burden and EF measurements. Results Demographics and procedural details are in table 1. It was found that patients participating in this study were predominantly male (66.4%), on average 60.1 (± 13.6) years old, overweight (BMI 29.8 ± 5.4) with no additional heart disease (56%) and no scarring on MRI (55%).The PVC burden before ablation (27.9 ± 12.7) significantly reduced to 8.0 ± 11.2 post-ablation (p &amp;lt; 0.005), marking an average relative reduction of 68.1% (± 44.1%). Successful interventions, defined by a reduction exceeding 50%, were observed in 79% of patients. The EF increased from 39.6 ± 8.9 to 47.5 ± 10.7 post-ablation (p &amp;lt; 0.005), corresponding to an average increase by 8.4 ± 8.5. Notably amongst the patients who had a successful ablation, 36% of patients achieved normalized EF (&amp;gt;55%) and 42% showed an improvement of at least 5%. A strong correlation emerged between the relative change in PVC and the ejection fraction measured after ablation, with an increase by 0.10 for every percent reduction (p &amp;lt; 0.00). The relative increase in the EF% was significantly higher in patients where the PVC burden was reduced by at least 50% (figure 1). Linear fixed effect modelling explored the influence of patient characteristics on the model. Patients with higher BMI had a lower EF after ablation with same relative reduction in PVC (p &amp;lt; 0.03). Similarly, a scar on MRI and associated heart condition was associated with reduced improvement in ejection fraction (p &amp;lt; 0.02). Also, for every increase in age patients had a reduction of 0.2 EF after ablation (p &amp;lt; 0.01). Right heart PVC’s were ablated more successfully, and had higher EF post ablation (p &amp;lt; 0.01). Conclusion In conclusion, reduction in PVC burden increases the EF after treatment. Increasing BMI, age and presence of associated heart disease can negatively impacted LVEF post ablation. Further research could improve the model that predicts improvement in LV function post successful PVC ablation.Figure 1Table 1