Origin Of Premature Ventricular Contractions Research Articles

Distal-to-proximal delay for ablation of premature ventricular contractions.

Ablation of premature ventricular contractions (PVCs) has emerged as a safe and effective treatment in patients experiencing a high PVCs burden. Mapping of PVCs origin may sometimes be challenging. We sought to evaluate the accuracy of a new electrophysiological criterion, the distal-to-proximal (DP) delay, at localizing the optimal site for ablation of ventricular ectopic foci. Consecutive patients with ablation attempts of symptomatic PVCs were included. Prematurity and DP delay-that is, the time duration between the onset of ablation catheter distal bipolar electrogram and the onset of proximal bipolar electrogram-were measured at successful and unsuccessful ablation sites by three blinded experienced electrophysiologists. Mean DP delay at effective ablation sites (N = 30) was significantly higher than at ineffective sites ( N = 55) (23 ± 9 vs 11 ± 8 milliseconds; P < 0.0001). DP delay had good-to-excellent interrater reliability. A DP delay greater than or equal to 15 milliseconds had the highest accuracy at predicting a successful ablation site (sensitivity 0.97, the area under receiver operating characteristic curve 0.87; P < 0.0001). DP delay is an additional, simple, and effective electrophysiological parameter to accurately localize PVCs foci.

The safety of catheter ablation for premature ventricular contractions in patients without structural heart disease

BackgroundPatients with frequent premature ventricular contractions (PVCs) are often symptomatic. Catheter ablation was usually indicated to eliminate symptoms in patients with PVCs-induced cardiomyopathy. Currently, PVCs-ablation is also applied for patients with PVCs and no structural heart diseases (SHD); however, the safety and efficacy of ablation in these patients remains unclear.MethodsIn this retrospective study, data from patients who underwent ablation for PVCs from January 2010 to December 2016 at our hospital was retrieved. Predictors of complications and acute procedural success were evaluated.ResultsA total of 1231 patients (mean age 47.8 ± 16.8 years, 59% female) were included. The overall complication rate was 2.7%, and the most common complication was hydropericardium. Two ablation-related mortalities occurred. One patient died of coronary artery injury during the procedure and the other died from infectious endocarditis. Location (left ventricle and epicardium) was the main predictor of complications, with right ventricular outflow tract (RVOT) predicting fewer complications. The acute procedural success rate was 94.1% in all patients. The main predictor of acute procedural success was RVOT origin, while an epicardial origin was a predictor of procedural failure.ConclusionLocations of left ventricle and epicardium were predictors of procedural complications for patients with PVCs. Therefore, ablation is not recommended in these patients. For other origins of PVCs, particularly RVOT origin, ablation is a safety and effective treatment.

Geometrical constraint of sources in noninvasive localization of premature ventricular contractions

The inverse problem of electrocardiography for localization of a premature ventricular contraction (PVC) origin was solved and compared for three types of the equivalent cardiac electrical generator: transmembrane voltages, epicardial potentials, and dipoles. Instead of regularization methods usually used for the ill-posed inverse problems an assumption of a single point source representative of the heart generator was applied to the solution as a geometrical constraint.Body surface potential maps were simulated from eight modeled origins of the PVC in the heart model. Then the maps were corrupted by additional Gaussian noise with the signal-to-noise ratio (SNR) from 20 to 10dB and used as the input of the inverse solution. The inverse solution was computed from the first 30ms of the ventricular depolarization. It was assumed that during this period only a small part of the heart volume is activated thus it can be represented by a single point electrical source.Generally, the localization error was more dependent on the PVC origin position than on the type of the used heart generator. The most stable localization error between the inversely found results and the true PVC origin was not larger than 20mm for PVC origins located in the left ventricular wall and on the right ventricular anterior side. For such cases, the localization was robust to the noise up to SNR of 10dB for all studied types of the cardiac generator. For SNR 10dB the results became unstable mainly for the PVC origins in the septum and posterior right ventricle for the dipolar heart generator and for epicardial potentials defined on the pericardium when the range of the localization error increased up to 50mm. When the results for different electrical heart generators were considered altogether, the mean radius of the cloud of results did not exceed 20mm and the localization error of the cloud center was smaller than that obtained for a particular type of the cardiac generator.Combination of results from different models of a single point cardiac electrical generator can provide better information for the preliminary noninvasive localization of PVC than the use of one type of the generator.

Radiofrequency catheter ablation of premature ventricular contractions in children under CARTO3 system: a retrospective study from one single center

Objective: To evaluate the clinical effect and summarize the experience of radiofrequency catheter ablation (RFCA) for children suffered from premature ventricular contractions (PVCs). Methods: This retrospective study was conducted by descriptive analysis. A total of 108 cases with frequent PVCs from Shanghai Children's Medical Center were treated with RFCA under the guidance of CARTO3 system from January 2011 to December 2016. The immediate success rate of the procedure, the recurrence rate and the perioperative complications were summarized. The constituent ratio of different PVCs origins, the trend of overall procedure time and success rate in recent years were analyzed. Statistical analyses were performed using F test. Results: Immediate success of RFCA was achieved in 104 cases (96.3%, 104/108) and 4 cases (3.7%, 4/108) failed. The PVCs recurred during follow-up of over 6 months in 5 cases (4.8%, 5/104) . There were no severe complications related to the procedure. The sites of PVCs origin, in 52 cases originated from right ventricular outflow track (48.2%, 52/108) , 17 cases originated from left ventricular outflow track (15.7%, 17/108) and 26 cases originated from tricuspid annulus (24.1%, 26/108) . Among the three predilection sites of PVCs, the operation time was (141±46) min for right ventricular outflow track, (155±50) min for left ventricular outflow track, and (166±57) min for tricuspid annulus. However, the difference was not statistically significant (F=1.79, P=0.17) . X-ray exposure time was (14±8) minutes for right ventricular outflow track ablation, (32±14) minutes for left ventricular outflow track ablation and (16±8) minutes for tricuspid annulus ablation respectively. The exposure time for the ablation on left ventricle was significantly longer than the other two sites (F=5.12, P=0.018) . Conclusion: RFCA is safe and effective for PVCs in children with high success rate and low recurrence and complication rates.

Premature outflow tract ventricular contraction combined with complete bundle branch block: the characteristic electrocardiographic and ablation target potential features

Objective: To explore the characteristics of electrocardiogram(ECG) and target potential features of premature ventricular contraction (PVC) in patients with complete left/right bundle branch block (CL/RBBB) and compare with those without CL/RBBB. Methods: A retrospective analysis was done in 8 outflow tract PVC patients with CL/RBBB, who successfully underwent radiofrequency ablation from August 2009 to June 2017. According to the bundle branch block chamber, patients were divided into the complete right bundle branch block (CRBBB) group (n=4) and the complete left bundle branch block (CLBBB) group (n=4). The control group were those who successfully underwent ablation at the same position as the above two groups but without CL/RBBB. The characteristics of ECG and target potential features were compared among groups. Results: One case in the CRBBB group was successfully ablated in the great cardiac vein with precordial R/S>1 transition at V(1) and one case in the CLBBB group was successfully ablated in the right coronary cusp with precordial R/S>1 transition at V(2), while other 6 cases were all with precordial R/S>1 transition at lead V(4). Precordial R/S>1 transition was not later than sinus rhythm (SR) in the CLBBB group. No statistical difference was found in the QRS complex duration between SR and PVC in the CL/RBBB patients [(134.38±23.80)ms vs (156.75±25.93)ms, P>0.05], while statistical difference was shown in the control group [(92.63±5.76)ms vs (140.25±15.97)ms, P<0.05]. Conclusion: Bundle branch block can lead to misjudgment of PVC origin with CL/RBBB during sinus rhythm, thus the origin chamber of the PVC should be determined according to the mapping and ablation result.

Localization of Origins of Premature Ventricular Contraction by Means of Convolutional Neural Network From 12-Lead ECG.

This paper proposes a novel method to localize origins of premature ventricular contractions (PVCs) from 12-lead electrocardiography (ECG) using convolutional neural network (CNN) and a realistic computer heart model. The proposed method consists of two CNNs (Segment CNN and Epi-Endo CNN) to classify among ventricular sources from 25 segments and from epicardium (Epi) or endocardium (Endo). The inputs are the full time courses and the first half of QRS complexes of 12-lead ECG, respectively. After registering the ventricle computer model with an individual patient's heart, the training datasets were generated by multiplying ventricular current dipoles derived from single pacing at various locations with patient-specific lead field. The origins of PVC are localized by calculating the weighted center of gravity of classification returned by the CNNs. A number of computer simulations were conducted to evaluate the proposed method under a variety of noise levels and heart registration errors. Furthermore, the proposed method was evaluated on 90 PVC beats from nine human patients with PVCs and compared against ablation outcome in the same patients. The computer simulation evaluation returned relatively high accuracies for Segment CNN (∼78%) and Epi-Endo CNN (∼90%). Clinical testing in nine PVC patients resulted an averaged localization error of 11mm. Our simulation and clinical evaluation results demonstrate the capability and merits of the proposed CNN-based method for localization of PVC. This paper suggests a new approach for cardiac source localization of origin of arrhythmias using only the 12-lead ECG by means of CNN, and may have important applications for future real-time monitoring and localizing origins of cardiac arrhythmias guiding ablation treatment.

ECG morphology of premature ventricular contractions predicts the presence of myocardial fibrotic substrate on cardiac magnetic resonance imaging in patients undergoing ablation.

The most likely origin of premature ventricular contractions (PVCs) may be deduced from surface electrocardiogram (ECG) analysis while planning an electrophysiological study (EPS). Apart from purely benign forms of increased ventricular ectopy, myocardial substrate (e.g., regional fibrosis) may be present in certain cases, which will significantly impact the ablation approach. Cardiac magnetic resonance (CMR) imaging can reliably identify fibrotic target lesions and, hence, may assist in adequate patient selection and procedural planning. We analyzed 101 patients (59% males, mean age 57.15 ± 15.5 years, mean PVC count 19,801 ± 14,021 per 24 hours) referred for ablation of PVCs. The CMR (1.5T, Philips Ingenia, Best, The Netherlands) protocol included cine and three-dimensional-delayed enhancement imaging using standard cardiac geometries. On surface, ECG right bundle branch block (RBBB) morphology was present in 43% of patients. Twenty-one patients showed the fibrotic substrate on CMR. On univariate analysis, both RBBB morphology (P<0.001) and presence of multiple PVC morphologies (≥2) significantly predicted the presence of fibrotic substrate (P=0.01), which various baseline characteristics including left ventricular ejection fraction (45.7 ± 12.6% vs. 50.6 ± 11.0%, P=0.08) failed to do. CMR-identified fibrosis was associated with the site of origin of the clinical PVCs during EPS and was successfully treated by radiofrequency ablation in 93% (PVC reduction>95%). In patients with RBBB morphology and/or multiple PVC patterns, CMR imaging before ablation may be helpful due to the increased prevalence of fibrotic lesions with regard to patient stratification and periprocedural management.

In vivo validation of a novel algorithm for automatic premature ventricular contractions recognition.

Template-matching algorithms are routinely used in the catheter ablation of patients with premature ventricular contractions (PVCs). However, systematic analysis of the accuracy and spatial resolution of such systems is lacking. Therefore, the aim of this evaluation was to perform a systematic in vivo validation of performance of a novel automated template-matching algorithm. In a porcine model, paced beats simulating PVCs from different origins were investigated. The ability to discriminate between sinus rhythm and PVCs was tested by simulating PVCs using sequential pacing from different cardiac chambers. The accuracy of the algorithm in correctly classifying PVCs was reviewed by an independent investigator. In addition, the spatial resolution of pace matching was evaluated by assessing the QRS morphology discrimination at a distance of 0, 2, 4, and 6 mm of a simulated PVCs focus. The specificity of the algorithm for recognizing simulated PVCs was 99.6% and the sensitivity was 85.3%. There was a significant difference in the discrimination metric discrimination metric (with 0% being a perfect match and 100% being no correlation) between PVC origin (median 0%, interquartile range (IQR) 0-2%) versus at 2 mm (5%, IQR 2-7%), 4 mm (16%, IQR 11-21%), and 6 mm (24%, IQR 19-28%, P < 0.001 for all). The c-statistic for discrimination between PVC origin and a distance ≥ 2 mm was 0.93. Automated template matching had high specificity and sensitivity, with good spatial discrimination and a pace-mapping resolution in range of 2 mm. Clinical application of this algorithm may assist in the interventional treatment of patients with PVCs.

Mismatch between the origin of premature ventricular complexes and the noncompacted myocardium in patients with noncompaction cardiomyopathy patients: involvement of the conduction system?

Noncompaction cardiomyopathy (NCCM) is considered to be the result of an arrest in the normal myocardial embryogenesis. The histological, developmental, and electrophysiological explanation of ventricular arrhythmias in NCCM is still unknown. The aim of this study was to determine the origin of premature ventricular contractions (PVCs) in NCCM and to identify any predominant arrhythmic foci. Retrospective data from our NCCM registry including 101 patients were analyzed. A total number of 2069 electrocardiograms (ECGs) were studied to determine the origin of PVCs. Echocardiographic data were analyzed in patients with PVCs in all 12 leads. Segments affected by noncompaction (NC) were compared with the origin of PVCs. PVCs were documented in 250 ECGs from 55 (54%) patients. Thirty-five ECGs recorded PVCs on all 12 leads and the origin of 20 types of PVCs could be determined. Ninety-five percent of PVCs did not originate from left ventricular NC myocardial areas and two PVCs (10%) had a true myocardial origin. All other PVCs originated from structures such as the outflow tracts (8/20), the fascicles (7/20), especially the posteromedial fascicle (6/20), and the mitral and tricuspid annulus (3/20). Our data suggest that PVCs in NCCM mainly originate from the conduction system and related myocardium.

69-02: Anatomical Based Prediction of Left VS Right Outflow Tract Origin of Premature Ventricular Contractions

69-02: Anatomical Based Prediction of Left VS Right Outflow Tract Origin of Premature Ventricular Contractions

Localization of premature ventricular contractions from the papillary muscles using the standard 12-lead electrocardiogram: a feasibility study using a novel cardiac isochrone positioning system.

The precise localization of the site of origin of a premature ventricular contraction (PVC) prior to ablation can facilitate the planning and execution of the electrophysiological procedure. In clinical practice, the targeted ablation site is estimated from the standard 12-lead ECG. The accuracy of this qualitative estimation has limitations, particularly in the localization of PVCs originating from the papillary muscles. Clinical available electrocardiographic imaging (ECGi) techniques that incorporate patient-specific anatomy may improve the localization of these PVCs, but require body surface maps with greater specificity for the epicardium. The purpose of this report is to demonstrate that a novel cardiac isochrone positioning system (CIPS) program can accurately detect the specific location of the PVC on the papillary muscle using only a 12-lead ECG. Cardiac isochrone positioning system uses three components: (i) endocardial and epicardial cardiac anatomy and torso geometry derived from MRI, (ii) the patient-specific electrode positions derived from an MRI model registered 3D image, and (iii) the 12-lead ECG. CIPS localizes the PVC origin by matching the anatomical isochrone vector with the ECG vector. The predicted PVC origin was compared with the site of successful ablation or stimulation. Three patients who underwent electrophysiological mapping and ablation of PVCs originating from the papillary muscles were studied. CIPS localized the PVC origin for all three patients to the correct papillary muscle and specifically to the base, mid, or apical region. A simplified form of ECGi utilizing only 12 standard electrocardiographic leads may facilitate accurate localization of the origin of papillary muscle PVCs.

Eighth TRM Forum on Computer Simulation and Experimental Assessment of Cardiac Function: Towards Integration of Cardiac Functions.

Since 1998, the Theo Rossi di Montelera (TRM) forum has brought together researchers working on computer modelling, experimental research, and clinical research, with the objective to facilitate the translation of research findings in computer modelling of the heart into the clinical field. The 8th TRM forum was held at Lugano, Switzerland, on 6–8 December 2015, organized by the TRM foundation and hosted by the Center for Computational Medicine in Cardiology in Lugano. The theme was ‘Towards Integration of Cardiac Functions’. In this forum, cardiac function was addressed from the perspectives of electrical cardiac function, mechanical cardiac function, and circulatory function. Electrical cardiac function is generally assessed clinically with a body-surface electrocardiogram (ECG). However, the ECG represents an integrative measure of whole heart electrical activity, from which it is sometimes challenging to derive information about local cardiac activity. Computer models can help us to derive better patient-specific knowledge from routine ECG and determine the underlying electrical activation sequence. An example was presented by Cardone-Noott et al. 1 with a multi-scale computational study on the role of ventricular endocardial activation sequences on QRS complex variations in both healthy hearts and in the presence of intraventricular block. This study provides physiological insights on ECG biomarkers in terms of QRS morphology and location of early endocardial activation sites. Van Dam et al. 2 presented a novel method to localize premature ventricular contractions on the papillary muscles using a 12-lead ECG together with cardiac anatomy and torso geometry derived from magnetic resonance imaging (MRI). The precise localization of the site of origin of premature ventricular contractions could facilitate the planning and execution of an ablation procedure. Saha et al. 3 developed a computer model of the atria and torso to study the changes in P wave morphology resulting from pulmonary vein (PV) ablation. Results were …

Papillary Muscle起源の心室期外収縮に対しCARTO SOUNDを使用したカテーテルアブレーションが奏効したCPAの1例

Papillary Muscle起源の心室期外収縮に対しCARTO SOUNDを使用したカテーテルアブレーションが奏効したCPAの1例

Premature ventricular contraction-induced cardiomyopathy: Related clinical and electrophysiologic parameters

Factors associated with premature ventricular contraction-induced cardiomyopathy (PVCi-CMP) remain debated. The purpose of this study was to test the correlation of various factors to the presence PVCi-CMP in a large multicenter population. One hundred sixty-eight consecutive patients referred for ablation of frequent premature ventricular contractions (PVCs) were included. Patients were divided into 2 groups: group 1 with suspected PVCi-CMP (96 patients, ejection fraction 38% ± 10%, left ventricular end-diastolic diameter 62 ± 8 mm, with or without additional structural heart disease); and group 2 (control group, 72 patients with normal ejection fraction and left ventricular dimensions). Various clinical and electrophysiologic parameters were compared between groups. In univariate analysis, left ventricular origin of PVC, lack of palpitations, long PVC coupling interval, epicardial origin of the focus, long sinus beat QRS duration, male gender, high PVC burden, presence of polymorphic PVCs, high PVC QRS duration, and older age were significantly related to the presence of PVCi-CMP. In multivariate analysis, only lack of palpitations, PVC burden, and epicardial origin remained significantly and independently correlated with the presence of cardiomyopathy. Even if sinus QRS duration or PVC left ventricular origin were also found independently linked to PVCi-CMP in the whole population, they were no longer correlated when patients with additional heart disease were excluded. Lack of palpitations, PVC burden, and epicardial origin are independent factors that identify patients prone to developing PVCi-CMP.

Effect of burden and origin sites of premature ventricular contractions on left ventricular function by 7-day Holter monitor.

Recent studies have shown that premature ventricular contractions (PVCs) could enlarge the heart, but its risk factors are incompletely understood as a single 24-hour recording cannot reflect the true PVC burden due to day-to-day variability. Our purpose was to investigate the effect of burden and origin sites on left ventricular (LV) function in patients with PVCs by 7-day Holter electrocardiography (ECG). From May 2012 to August 2013, 112 consecutive patients with PVCs were recruited from the authors' affiliated hospital. All patients received 2-dimensional transthoracic echocardiography, 12-lead routing ECG and 7-days Holter ECG. Serum N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were measured. A total of 102 participants with PVCs were included in the final analysis. Origin of PVCs from the tricuspid annulus had the highest burden and NT-proBNP level. LV papillary muscle had a higher LV ejection fraction (EF) level and a lower LV end-systolic dimension (ESD) than other PVC foci (P<0.05). The high burden group had a higher LV end-diastolic dimension (EDD) and LVESD but lower LVEF than the other two groups (P<0.05). Female, older age, physical work, and history of PVCs had a significantly positive correlation with symptoms. Male, older age, physical work, and high burden were positive predictors of enlarged LVEDD, LVESD and higher serum NT-proBNP level, but lower LVEF. Seven-day dynamic ECG Holter monitor showed the true PVC burden on patients with PVCs. PVCs with a lower burden or origin from the LV papillary muscle and the fascicle were relatively benign, while PVCs with a higher burden or origin from the tricuspid annulus may lead to cardiac dysfunction.

Quantitative spatial cardiac localization of premature ventricular contractions using the cardiac isochrone positioning system

Introduction The precise localization of the site of origin of a premature ventricular contraction (PVC ) or ventricular tachycardia (VT) prior to ablation would facilitate the planning and execution of the electrophysiological procedure [1]. Current electrocardiographic imaging (ECGI) techniques uses body surface mapping that is costly, complex, and requires as many as 256 leads to localize the PVC origin. We have developed and tested the novel cardiac isochrone positioning system (CIPS) utilizing the readily available 12 lead ECG to localize the PVC origin.

Coupling Interval Variability Differentiates Ventricular Ectopic Complexes Arising in the Aortic Sinus of Valsalva and Great Cardiac Vein From Other Sources: Mechanistic And Arrhythmic Risk Implications

The objective of this study was to determine whether premature ventricular contractions (PVCs) arising from the aortic sinuses of Valsalva (SOV) and great cardiac vein (GCV) have coupling interval (CI) characteristics that differentiate them from other ectopic foci. PVCs occur at relatively fixed CI from the preceding normal QRS complex in most patients. However, we observed patients with PVCs originating in unusual areas (SOV and GCV) in whom the PVC CI was highly variable. We hypothesized that PVCs from these areas occur seemingly randomly because of the lack of electrotonic effects of the surrounding myocardium. Seventy-three consecutive patients referred for PVC ablation were assessed. Twelve consecutive PVC CIs were recorded. The ΔCI (maximum - minimum CI) was measured. We studied 73 patients (age 50 ± 16 years, 47% male). The PVC origin was right ventricular (RV) in 29 (40%), left ventricular (LV) in 17 (23%), SOV in 21 (29%), and GCV in 6 (8%). There was a significant difference between the mean ΔCI of RV/LV PVCs compared with SOV/GCV PVCs (33 ± 15 ms vs. 116 ± 52 ms, p < 0.0001). A ΔCI of >60 ms demonstrated a sensitivity of 89%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 94%. Cardiac events were more common in the SOV/GCV group versus the RV/LV group (7 of 27 [26%] vs. 2 of 46 [4%], p < 0.02). ΔCI is more pronounced in PVCs originating from the SOV or GCV. A ΔCI of 60 ms helps discriminate the origin of PVCs before diagnostic electrophysiological study and may be associated with increased frequency of cardiac events.

Quantitative localization of premature ventricular contractions using myocardial activation ECGI from the standard 12-lead electrocardiogram

BackgroundThe precise localization of the site of origin of a premature ventricular contractions (PVC) prior to ablation would facilitate the planning and execution of the electrophysiological procedure. Current electrocardiographic imaging (ECGI) techniques require body surface maps, a costly and complex procedure, that requires as many as 256 leads to localize the PVC origin. We developed and tested a novel myocardial activation based ECGI technique utilizing the readily available 12-lead ECG to localize the PVC origin. MethodsThe major components of the 12-lead ECGI method are: the source model, proximity effect and spatial orientation, volume conductor, and patient specific model of the heart, lungs, and thorax as derived from magnetic resonance imaging (MRI). For the PVC origin localization, the fastest route algorithm is used on patient specific models created by newly developed morphing software. PVC localization by the 12-lead ECGI was correlated to the site of successful ablation. ResultsSeven patients that underwent electrophysiological mapping and ablation of PVCs were studied. All patients (7/7) had accurate prediction of the PVC origin. However in two patients, no specific MRI was used for localization that resulted in an incorrect switch between the RV free wall and septum of the RVOT. With patient-specific models, these latter two cases would likely be localized correctly. ConclusionsThis feasibility study of a novel myocardial activation-based ECGI using only the standard 12-lead ECG shows promise to localize the origin of PVC. This ECGI method yields activation estimates of isochrones on both ventricles from which the PVC origin location is derived. This method has the capability to localize the PVC from any part of the ventricular endocardium, intra-myocardium or epicardium.

The evaluation of irrigating ablation catheter in the treatment for severely symptomatic premature ventricular contractions

IntroductionRadiofrequency catheter ablation (RFCA) of symptomatic ventricular premature contractions has been reported to be a safe and effective treatment option, and may be considered in patients with extremely symptomatic or...

CSPE Young Investigator Award Session

CSPE Young Investigator Award Session