Premature Ventricular Complexes Burden Research Articles

Long-term outcomes of catheter ablation for ventricular arrhythmias: comparing techniques with and without intracardiac echocardiography - what matters?

BackgroundThe increasing use of intracardiac echocardiography (ICE) in the ablation of premature ventricular complexes (PVCs) has raised questions about its true efficacy and safety.MethodsThis retrospective study collected the periprocedural complications and PVC burden post ablation. The risk factors of PVC recurrence was further explored.ResultsThe study included patients treated without ICE (control group, n = 451) and with ICE (ICE group, n = 155) from May 2019 to July 2022. The ICE group demonstrated significantly lower fluoroscopy times and X-ray doses. There were no major complications in the ICE group, and the difference in the occurrence of periprocedural complications between the groups was not statistically significant (p = 0.072). The long-term success rates were similar for the control and ICE groups (89.6% and 87.1%, respectively). The origin of PVCs was identified as the independent factor for ablation success.ConclusionsThe use of ICE did not confer an advantage with regard to long-term success in PVCs ablation. To thoroughly evaluate the safety and effectiveness of ICE in PVCs ablation, a prospective, multicenter, randomized study is warranted.

Initial Holter Electrocardiogram Index to Predict the Burden of Subsequent Persistent Premature Ventricular Complex in Childhood.

Asymptomatic premature ventricular complex (PVC) in childhood often disappears over time. However, predictive factors for persistent PVC are unknown. We examined predictive factors for persistent PVCs on initial Holter electrocardiogram (ECG) in pediatric patients with asymptomatic PVC.Methods and Results: The initial Holter ECG findings of untreated PVC patients (n=216) between 2010 and 2021 were examined. Multivariable analysis was performed to clarify predictive factors for subsequent persistent PVC burden for each index (age, sex, PVC burden, PVC origin, minimum and maximum mean RR intervals [RRmin and RRmax, respectively]) of the 3 heartbeats of baseline sinus rhythm immediately before the PVC. The median age at initial Holter ECG was 11.6 years (range 5.8-18.8 years), the PVC burden was 5.22% (range 0.01-44.21%), RRmin was 660 ms, RRmax was 936 ms, RRrange (=RRmax-RRmin) was 273 ms, and 15 (7%) PVC runs were identified. The median follow-up period was 5.1 years (range 0.8-9.4 years), and the final Holter PVC burden was 3.99% (range 0-36.38%). In multivariate analysis, RRrange was the only independent risk factor for predicting a final Holter PVC burden >10%, with an area under the curve of 0.920 using an RRrange of 600 ms as the cut-off value. A wide RRrange at the initial Holter ECG may be a predictive indicator for persistent PVC in childhood.

Value of 24h ambulatory ECG for prediction of sufficient number of premature ventricular complexes during catheter ablation

Abstract Introduction Successful catheter ablation (CA) of premature ventricular complexes (PVCs) depends on identification of the site of origin (SOO), but no parameter suggested for prediction of success from CA have been sufficiently validated in previous studies. Activation mapping and pace-mapping are invasive methods for the identification of SOO, and the burden of PVCs is critical for activation mapping to identify SOO. The number of PVCs in 24h ambulatory ECGs is claimed to predict occurrence of PVCs during the procedure, and hence procedural success, but the predictive value remains unknown. Purpose The primary objective of this study was to quantify the predictive value of pre-procedural of 24h ambulatory ECG with regard to sufficient number of PVCs during the CA procedure. Methods Patients admitted for CA of PVCs at our hospital from 2011-2020 were included. Data were retrospectivity collected from electronic health records. Clinical characteristics, results from clinical pre-procedural examinations, including 24h ambulatory ECG, exercise testing and echocardiogram, as well as acute outcomes were recorded. Results A total of 332 patients were included, CA was performed in 285 (86 %) patients, while 47 (14 %) patients had insufficient number of PVCs to allow adequate identification of SOO. Neither clinical characteristics nor results of cardiac imaging separated patients with sufficient and insufficient number of PVCs for CA, respectively. Patients with sufficient number of PVCs had nominally more PVCs in the preceding 24h ambulatory ECG, although the difference was not statistically significant (16007 (6509-26205) vs. 8332 (3066-20974), p = 0.055). A receiver operating characteristics (ROC) curve analysis of sufficient number of PVCs during CA and number of PVCs in the preceding 24h ambulatory ECG had an area under curve (AUC) of 0.610 (0.95% CI 0.498-0.722, p = 0.055). The commonly clinically used cut-off of >10 000 PVCs/24h had a positive predictive value of 67 % and a negative predictive value of 57 % for sufficient number of PVCs during CA. The median period from the 24h ambulatory ECGs to CA was 183 days (6 months). The positive and negative predicative values for >10 000 PVCs in 24h ambulatory ECG performed >6 months prior to the procedure were 67 % and 71 %, respectively, compared to 53 % and 61 % for 24h ECGs performed <6 months prior to the procedure. The ROC curve for sufficient number of PVCs during the procedure and number of PVCs in a 24h ambulatory ECG performed >6 months and <6 months prior to the procedure did not differ, with had AUC values of 0.665 and 0.584, respectively (p = 0.4). Conclusion In this retrospective analysis of a large cohort of patients admitted for CA of PVCs, number of PVCs in 24h ambulatory ECGs recorded prior to the procedure had a low predictive value for presence of PVCs during CA. Others parameters need to be evaluated to improve prediction.

Accuracy of pace-mapping using an automated template matching module for site of origin identification of idiopathic outflow tract premature ventricular contractions

Abstract Background Activation mapping (AM) is the preferred approach to identify the premature ventricular complexes (PVC) site of origin (SOO) but it is limited when PVCs are infrequent. Pace-mapping (PM) is often used in combination with AM. Yet, relying on PM as sole guide for ablation requires a high accuracy for detecting the PVC SOO. Limited data exists on the accuracy of automated PM using PASO™ for identifying the SOO of idiopathic PVCs, particularly in the left ventricular outflow tract (LVOT). In two cohorts with both idiopathic and non-idiopathic PVCs, a PASO™ >94% was associated with ablation success. Purpose This study evaluated the accuracy of PM using the automated digital pace-matching module integrated in the CARTO mapping system for identifying the SOO of idiopathic outflow-tract PVCs. It also compared its accuracy in the LVOT versus the right ventricular outflow tract (RVOT). Methods Consecutive patients undergoing successful ablation of idiopathic outflow-tract PVCs were prospectively included. AM and PM were performed with a 3.5mm tip catheter. PM was conducted at 2mA, 5mA, or 10mA output, selecting the lowest output that captured at each site. Ablation was performed at the site of earliest bipolar local activation time. The PVC SOO was defined as the site of acute ablation success. The distance between the best PM (BPM) and the SOO and the areas defined by PM ≥98%, ≥96%, and ≥94% were measured. Long-term success was defined by a ≥80% reduction in PVC burden at 3-month follow-up. Results In total, 27 patients were included; 18 had PVCs from the RVOT and 9 from the LVOT. All procedures were acutely successful after a median of 2 (IQR 1-3) radiofrequency applications (RFA) in the RVOT and one (IQR 1-2) RFA in the LVOT. In the RVOT, the median BPM was 98.1% (98.0-98.6), the median distance from the BPM to the SOO was 3.5 mm (IQR 0–8.5mm) and the areas of PM ≥98%, ≥96%, ≥94% were 1.2cm2 (0.5 – 1.8), 3.4cm2 (1.5-4.7) and 7.1cm2 (4.9-11.1). In the LVOT, the median BPM was 95.5% (IQR 94.9 – 97.8%) and the median distance from the BPM to the SOO was 8 mm (IQR 2–15mm). Only 3/9 patients with LVOT PVCs had a BPM ≥96% (1/9 ≥98%) and in all 3, the PVC SOO was coincident with the BPM site. From the remaining 6 patients, 5 had a BPM ≥94% but only in 2/5 the PVC SOO was within the area defined by the BPM site. In 26/27 (96%) patients, no PVC recurrence was documented after 3 months (median burden 0% [IQR 0-0]). Conclusions The accuracy of using the best pace-match provided by PASO™ for identifying the PVC SOO in the RVOT is high, making it a suitable target for limited ablation when activation mapping is not possible because of insufficient PVCs. In the LVOT, the best pace-match is frequently lower than in the RVOT and it misses the PVC SOO in almost half of the patients. The previously suggested PM >94% cut-off seems to be insufficient to identify the PVC SOO in both the RVOT and LVOT.TablePacemap

Radiofrequency catheter ablation using QDOT MICRO: single-center experience in treating outflow tract premature ventricular complexes

Abstract Aims This study sought to examine the efficacy of radiofrequency catheter ablation (RFCA) for premature ventricular complexes (PVCs) originating from the outflow tracts. The investigation utilized the QDOT MICRO™ (QDOT) catheter, known for enabling a temperature-controlled ablation strategy. Methods and results The study began in November 2022 at a single center. All patients (n=100, 57% male, mean age 49±18) were prospectively and consecutively enrolled and underwent PVCs ablation with QDOT-MICRO™ catheter. The procedural and efficacy data of the study population were compared with those of a control group composed of a cohort of 100 propensity score-matched patients who underwent the same procedure with the ThermoCool® SmartTouch® Catheter using the Ablation Index strategy. Acute procedural success was defined as the elimination of the targeted PVCs at the termination of the procedure. Clinical success was defined as at least an 80% decrease in PVCs burden. Follow-up visits with 24- to 48-h Holter monitoring were performed at baseline and 1, 3, and every 3 months thereafter. Both patients with follow-up <6 months and non-outflow tracts PVCs were excluded. In the study cohort, the average PVCs burden was 21,13% (IQR: 12,50, 24,44) and the RVOT PVCs were 58% (n=58). The mean procedure and fluoroscopy times were 113±103 and 18±15, respectively, and significantly differ between both groups (p=0.02 and p<0.001, respectively). Signals detected by the microelectrodes at the effective site of ablation differed significantly from those recorded by the standard bipolar electrodes (p<0.001). No major complication occurred during the procedures, and there was no procedure-related mortality. The freedom from PVCs recurrences was 86% in the QDOT group and 84% in the STSF group.Freedom from PVCs recurrences at a mean follow-up of 11.5±1.6 months did not significantly differ between both groups (86% vs 84%, respectively; p=0.65). Conclusion This study suggests that RFCA using the QDOT MICRO™ catheter is not only effective but also comparable to the standard approach for treating outflow tract PVCs. Moreover, the study highlights shorter fluoroscopy and procedure times, reinforcing the catheter's efficiency and safety. The use of microelectrodes proved beneficial in enhancing precision in RF delivery.

Premature Ventricular Contraction-Induced Cardiomyopathy: Contemporary Evidence from Risk Stratification, Pathophysiology, and Management.

Premature ventricular complexes (PVCs) are commonly encountered problems in clinical settings. The range of symptoms can be from asymptomatic to palpitations, fatigue, or heart failure symptoms. A higher burden of PVCs is a risk factor for development of PVC-induced cardiomyopathy (PIC). Rhythm evaluation by 12-lead ECG and an ambulatory monitoring device are essential. Currently, several imaging modalities, such as echocardiography and cardiac magnetic resonance imaging, are utilized to evaluate the underlying structure that may be related to PIC. Beta blockers and antiarrhythmic drugs are typically part of the initial management strategy. If these fail, catheter ablation of PVCs is typically the next step. The purpose of this article is to summarize the current evidence/knowledge about PIC.

Real World Data from Catheter Ablation of Ventricular Tachycardias and Premature Ventricular Complexes in a Tertiary Care Center.

Background: Catheter ablation in patients with ventricular arrhythmias (VA), such as ventricular tachycardias (VT) or frequent premature ventricular complexes (PVC), is increasingly considered an effective and safe therapy when performed in experienced centers. This study sought to determine acute success rates and complication rates of ablation procedures for patients with VA in a Swiss tertiary care center. Methods: All patients who underwent ablation therapy for VT and PVC at the University Heart Center in Zurich, Switzerland, between March 2012 and April 2017 were included in this analysis. Results: A total of 120 patients underwent catheter ablation for VT and PVC (69 and 51, respectively). Seventy percent of patients were male, and the mean age was 55.3 years. The most common indication for ablation was high PVC burden (47.5%), followed by paroxysmal VT (38.3%), ICD shocks (23.3%), incessant VT (12.5%), electrical storm (7.5%), and syncope (3.3%). Acute success rates for VT and PVC ablations were 94.2% and 92.2%, respectively. Rates for complications (including major and minor) for VT and PVC were 10.1% and 7.8%, respectively. Complications occurred only in patients with structural heart disease; no complications were noted in structurally normal hearts. Conclusions: Our results suggest that catheter ablation for VT and PVC has high acute success rates with a reasonable risk for complications in the setting of tertiary care centers, comparable to those reported in other studies.

Temporal association of ventricular arrhythmias and respiratory events in heart failure patients with central sleep apnoea

In contrast to obstructive sleep apnoea, the peak of sympathetic tone in central sleep apnoea occurs during the hyperventilation phase. To explore the temporal association of premature ventricular complex (PVC) burden in the context of the apnoea/hypopnoea-hyperpnoea cycle, the duration of apnoea/hypopnoea was defined as 100 %. We assessed the PVC burden throughout the apnoea/hypopnoea-hyperpnoea cycle during the periods of ±150 % in 50 % increments before and after the apnoea/hypopnoea phase. In this subanalysis of 54 SERVE-HF patients, PVC burden was 32 % higher in the late hyperventilation period (50–100 % after apnoea/hypopnoea) compared to the apnoea/hypopnoea phase.

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

BackgroundAblation of premature ventricular complexes (PVCs) originating from the parahisian area is challenging. Late gadolinium-enhanced cardiac magnetic resonance (LGE-CMR) scar may influence procedural outcomes; the impact of cardiac scar on parahisian PVCs has not been described. ObjectiveThe objective of this study was to examine the incidence and significance of LGE-CMR scarring in patients undergoing ablation for parahisian PVCs. MethodsConsecutive patients who underwent preprocedure LGE-CMR imaging and ablation of parahisian PVCs were included. Acute and long-term outcomes were examined. ResultsForty-eight patients were included (male, n = 37; age, 66 ± 10 years; ejection fraction, 50% ± 12%; preprocedure PVC burden, 21% ± 12%). Intramural LGE-CMR scar was present in 33 of 48 (69%) patients. Cryoablation was used in 9 patients; ablation in multiple chambers was required in 28 (58%) patients. The PVC site of origin (SOO) was intramural (n = 25 patients), left ventricular (n = 5), and right ventricular (n = 18). Patients with LGE-CMR scar were more likely to have intramural PVCs (64% vs 27%; P < .04) and to require ablation in multiple cardiac chambers (58% vs 13%; P < .02). Patients with intramural scar required longer duration of ablation delivery (31 ± 20 minutes vs 17 ± 8 minutes; P < .02). Acute procedural success was 69%; PVC burden on follow-up was 6% ± 9% and similar for those with and without scar. ConclusionAblation of parahisian PVCs often requires mapping and ablation of multiple cardiac chambers, with an intramural SOO identified in most patients. An intramural scar was associated with an intramural SOO of the PVCs requiring more extensive ablation procedures, with similar long-term outcomes compared with those without scar.

Three-Day Monitoring of Adhesive Single-Lead Electrocardiogram Patch for Premature Ventricular Complex: Prospective Study for Diagnosis Validation and Evaluation of Burden Fluctuation.

Wearable electrocardiogram (ECG) monitoring devices are used worldwide. However, data on the diagnostic yield of an adhesive single-lead ECG patch (SEP) to detect premature ventricular complex (PVC) and the optimal duration of wearing an SEP for PVC burden assessment are limited. We aimed to validate the diagnostic yield of an SEP (mobiCARE MC-100, Seers Technology) for PVC detection and evaluate the PVC burden variation recorded by the SEP over a 3-day monitoring period. This is a prospective study of patients with documented PVC on a 12-lead ECG. Patients underwent simultaneous ECG monitoring with the 24-hour Holter monitor and SEP on the first day. On the subsequent second and third days, ECG monitoring was continued using only SEP, and a 3-day extended monitoring was completed. The diagnostic yield of SEP for PVC detection was evaluated by comparison with the results obtained on the first day of Holter monitoring. The PVC burden monitored by SEP for 3 days was used to assess the daily and 6-hour PVC burden variations. The number of patients additionally identified to reach PVC thresholds of 10%, 15%, and 20% during the 3-day extended monitoring by SEP and the clinical factors associated with the higher PVC burden variations were explored. The recruited data of 134 monitored patients (mean age, 54.6 years; males, 45/134, 33.6%) were analyzed. The median daily PVC burden of these patients was 2.4% (IQR 0.2%-10.9%), as measured by the Holter monitor, and 3.3% (IQR 0.3%-11.7%), as measured in the 3-day monitoring by SEP. The daily PVC burden detected on the first day of SEP was in agreement with that of the Holter monitor: the mean difference was -0.07%, with 95% limits of agreement of -1.44% to 1.30%. A higher PVC burden on the first day was correlated with a higher daily (R2=0.34) and 6-hour burden variation (R2=0.48). Three-day monitoring by SEP identified 29% (12/42), 18% (10/56), and 7% (4/60) more patients reaching 10%, 15%, and 20% of daily PVC burden, respectively. Younger age was additionally associated with the identification of clinically significant PVC burden during the extended monitoring period (P=.02). We found that the mobiCARE MC-100 SEP accurately detects PVC with comparable diagnostic yield to the 24-hour Holter monitor. Performing 3-day PVC monitoring with SEP, especially among younger patients, may offer a pragmatic alternative for identifying more individuals exceeding the clinically significant PVC burden threshold.

Mitral annular disjunction in idiopathic ventricular fibrillation patients: just a bystander or a potential cause?

Previously, we demonstrated that inferolateral mitral annular disjunction (MAD) is more prevalent in patients with idiopathic ventricular fibrillation (IVF) than in healthy controls. In the present study, we advanced the insights into the prevalence and ventricular arrhythmogenicity by inferolateral MAD in an even larger IVF cohort. This retrospective multi-centre study included 185 IVF patients [median age 39 (27, 52) years, 40% female]. Cardiac magnetic resonance images were analyzed for mitral valve and annular abnormalities and late gadolinium enhancement. Clinical characteristics were compared between patients with and without MAD. MAD in any of the 4 locations was present in 112 (61%) IVF patients and inferolateral MAD was identified in 24 (13%) IVF patients. Mitral valve prolapse (MVP) was found in 13 (7%) IVF patients. MVP was more prevalent in patients with inferolateral MAD compared with patients without inferolateral MAD (42 vs. 2%, P < 0.001). Pro-arrhythmic characteristics in terms of a high burden of premature ventricular complexes (PVCs) and non-sustained ventricular tachycardia (VT) were more prevalent in patients with inferolateral MAD compared to patients without inferolateral MAD (67 vs. 23%, P < 0.001 and 63 vs. 41%, P = 0.046, respectively). Appropriate implantable cardioverter defibrillator therapy during follow-up was comparable for IVF patients with or without inferolateral MAD (13 vs. 18%, P = 0.579). A high prevalence of inferolateral MAD and MVP is a consistent finding in this large IVF cohort. The presence of inferolateral MAD is associated with a higher PVC burden and non-sustained VTs. Further research is needed to explain this potential interplay.

Complex Substrate Leading to PVC-Mediated Systolic Dysfunction in addition to Sustained Monomorphic VT in Repaired Tetralogy of Fallot.

Frequent premature ventricular complexes (PVCs) are associated with deleterious effects on left ventricular (LV) function in various clinical scenarios. Repaired tetralogy of Fallot (rTOF) is frequently affected by sustained ventricular arrhythmias dependent on complex post-surgical substrates. However, there is limited data regarding the potential of arrhythmogenic isthmuses to generate frequent PVCs and PVC-mediated LV systolic dysfunction development in rTOF. We present a case of rTOF experiencing relatively infrequent episodes of internal shocks for episodes of sustained monomorphic ventricular tachycardia and a high burden of PVCs associated with left ventricular systolic function deterioration, in which the successful substrate ablation of the anatomical VT isthmuses also led to PVC abolition and consequently to LV systolic function normalization. In such cases, understanding the pathogenic mechanisms that lead to LV dysfunction is only possible by rigorous clinical reasoning, which leads to a tailored specific treatment.

Ethanol Ablation of Refractory Premature Ventricular Complex Originating from a Left Ventricular Summit Communicating Vein after Radiofrequency Catheter Ablation Failed in a Dilated Cardiomyopathy Patient.

During follow-up of a 60-year-old patient with dilated cardiomyopathy, a Holter electrocardiogram revealed monomorphic premature ventricular complexes (PVCs) accounting for 21-30% of total beats. Oral beta-blockers led to no improvement in PVC burden. The first radiofrequency catheter ablation attempt identified the PVC arising from the left ventricle summit communicating vein (CV) but failed to eliminate the PVC's origin. The second ablation attempt with selective infusions of 100% ethanol into the summit CV resulted in immediate termination of PVCs. The post-ablation course was uneventful. Echocardiography showed an improved ejection fraction, and a repeated Holter electrocardiogram showed no recurrence of PVCs during follow-up. Ethics The RCVEA procedures were approved by the Takagi Hospital Ethical Committee and were performed under an institutional review board-approved protocol. (Kouhou-kai Ethical Committee, ID: KR168) Fundings This work was supported by the Takagi Hospital Cardiology Research Grant. The authors declare no competing interests. Acknowledgements: We thank the patient, the patient's family, and the medical staff of Takagi Hospital for their valuable cooperation and kind support. Consent Written informed consent was obtained from the patient for the publication of this case report and accompanying images.

Left ventricular hypertrophy and ventricular ectopy in mitral valve prolapse

Abstract Background Mitral valve prolapse (MVP) is associated with left ventricular hypertrophy (LVH). Individuals with sudden death ascribed to MVP have increased ventricular mass on autopsy. Whether LVH is a risk factor for ventricular arrhythmia in MVP is unknown. Purpose We aimed to describe factors associated with LVH in MVP and the association of LVH with ventricular ectopy in MVP. Methods We studied all 637 patients aged 18 - 90 years with MVP on echocardiography between 2016-19 at our institution (median age [interquartile range] 64.3 [52.3-73.6] years; 52.6% female; 16.2% African American). Echocardiograms were reviewed for LVH, ventricular size and function, and valvular pathology. Complex or frequent ventricular ectopy (cfVE) was defined as &amp;gt;1% burden of premature ventricular complexes or non-sustained ventricular tachycardia on ambulatory electrocardiogram or ≥2 premature ventricular complexes on a 10-second electrocardiogram. Multivariate logistic regression was used to assess relationships between MVP, LVH, and known associations of cfVE in MVP. Resul­ts: LVH was present in 144 (22.6%) patients. A history of hypertension (HTN) was present in 78/144 (54.2%) with LVH vs. 204/493 (41.5%) of those without LVH (p=0.008). On multivariate analysis, LVH was independently associated with moderate to severe mitral regurgitation (odds ratio [95% confidence interval] 3.6 [2.4-5.6]) and heart failure (3.2 [2.0-5.1]), but not HTN (1.3 [0.9-2.0], p=0.205). cfVE was present in 55/144 (38.2%) with LVH vs. 127/493 (25.8%) without LVH (p=0.005). Among those without HTN, cfVE was present in 26/66 (39.4%) of those with LVH vs. 68/288 (23.6%) without LVH (p=0.013). On multivariate analysis, independent predictors of cfVE were age (odds ratio [95% confidence interval] 2.9 [1.1-8.1], p=0.035), mitral annular disjunction (3.2 [1.9-5.3], p&amp;lt;0.0001), heart failure (2.4 [1.4-4.0], p=0.001), bileaflet MVP (2.2 [1.4-3.3], p&amp;lt;0.001), and electrocardiogram inferior lead T-wave inversion (2.2 [1.4-3.4], p&amp;lt;0.001), but not LVH (1.2 [0.7-1.9], p=0.486) whether in presence of HTN (1.0 [0.5-1.9], p=0.959) or absence of HTN (1.4 [0.7-2.8], p=0.344). Conclusion LVH is a common finding in MVP and is associated with mitral regurgitation and heart failure. LVH in MVP is not associated with increased ventricular ectopy. Ventricular ectopy in MVP is related to mitral morphological factors and heart failure.Multivariate predictors of cfVECharacteristics with and without LVH

Abstract 18674: Deep Phenotyping Arrhythmogenic MVP With Imaging and Genotyping Reveals Important Shared Genetic Etiology With Arrhythmia and Cardiomyopathy Genes

Introduction: Mitral valve prolapse (MVP) has a high population prevalence 2-4% with an arrhythmogenic subtype presenting with premature ventricular complexes (PVC) ventricular tachycardia (VT) and sudden death. There is a continued search for markers of MVP to help risk stratify patients. Hypothesis: Arrhythmogenic MVP shares genetic etiology with Mendelian causes of arrhythmia and cardiomyopathy Methods: Consecutive adult patients with arrhythmogenic MVP patients prospectively evaluated Results: A total of 33 cases (age 55±15 years, female 51.5%) presented with history of hypertension (33%), diabetes (3%), coronary disease (12%), atrial fibrillation (45%), bileaflet MVP (58%) and syncope (18%). ECG findings include inverted T-waves in inferior leads in 6%, pleomorphic PVC in 6%, Ventricular couplets in 51.5%, non-sustained VT in 73% and sustained VT in 33%; High PVC burden was seen in 55% of cases with burden 15±14%. Echocardiography noted LV ejection fraction of 55±8%, mitral regurgitations in 70% (severe 18%, moderate 27%, mild 24%), mitral annular disjunction in 39%, and Pickelhaube sign in 9% of cases. Cardiac magnetic resonance showed LVESV 113±119mm, LVEDV 117±70mm, and late Gadolinium enhancement in 48% with highest prevalence in basal inferolateral segment. PET-CT performed in 17 cases and showed fluorodeoxyglucose uptake in 24% cases, mostly in basal inferolateral segment as well. Genetic testing was performed in 23 cases and reported a putative pathogenic variant in 21.7%: FLNC (Exemplar case, Figure 1 ) cause of dilated cardiomyopathy, TBX5 cause of Holt-Oram syndrome, DSP cause of arrhythmogenic cardiomyopathy , TTN causes of dilated cardiomyopathy, MTO1 cause of mitochondrial hypertrophic cardiomyopathy. Conclusion: Full evaluation of arrhythmogenic MVP with multimodality imaging and genetic testing reveals high burden of fibrosis, inflammation, and candidate pathogenic variants.

Abstract 13269: Clinical and Electrophysiological Features of New Onset Ventricular Arrythmias Following Catheter Ablation of Atrial Fibrillation

Introduction: Data on new onset ventricular arrhythmias (VAs) following catheter ablation of atrial fibrillation (AF) is sparse. Hypothesis: We aimed to assess the incidence of new onset VA post AF RFA. Methods: We conducted a retrospective study of all patients at our institution that underwent AF ablation who also developed symptomatic high burden premature ventricular complexes (PVCs) requiring catheter ablation within 1 year of the index AF ablation procedure. All patients underwent post AF ablation monitoring with either 48 hr Holter monitors or implantable cardiac monitors. New onset VA was defined as symptomatic new onset PVC with &gt;5% burden. Data on PVC morphology and successful ablation sites was analyzed. Results: Out of 175 patients that underwent AF ablation during the study period, 2.8 % (n=5) patients developed new onset high burden PVCs requiring catheter ablation therapy within 1 year of AF ablation. Mean age was 68.6 + 11 years and all patients were male. Mean baseline LVEF was 56 + 9.6% and mean PVC burden was 10.3 + 8.8 %. A total of 9 PVCs were mapped in 5 patients. The number of VA morphology was 1 in 2 (40%) patients, 2 in 2 (40%) and 3 in 1 (20%) patient. Site of origin for the PVCs was in the left ventricle in all patients, with majority (55%) localizing to the LV outflow tract and summit region (table). Average time from AF RFA to PVC ablation was 4 + 2.9 months. PVC ablation was successful in all patients except one where ablation was deferred due to proximity to the conduction system. Conclusions: New onset VAs following catheter ablation of AF tend to localize to the LV outflow tract and areas of bipolar voltage abnormality. Potential mechanisms of new onset PVCs could include altered sympathetic tone due to ablation of cardiac ganglia, unmasking of PVCs due to regularization of ventricular rate and withdrawal of anti-arrhythmic medications. Further prospective studies are needed to understand true incidence of new onset VAs following AF ablation.

Abstract 14201: Double the Trouble: Extremely Rare Incidental Finding of a Double Interatrial Septum With Atrial Septal Aneurysm and Coexisting Patent Foramen Ovale

Case: A 59-year-old&amp;nbsp;female with a past medical history of hypothyroidism and IgG deficiency presents to cardiology clinic due to palpitations and premature ventricular complexes (PVCs) noted at a recent urgent care visit. In-office vitals, physical exam, labs, and EKG were unremarkable. Ambulatory cardiac monitoring showed predominantly sinus rhythm with a PVC burden of 1.4%. Echocardiogram revealed an extremely rare structural anomaly – a double interatrial septum (DIAS) with atrial septal aneurysm. Cardiac MRI (cMRI) further confirmed the presence of a DIAS enclosing an interatrial space, along with blood flow within the interatrial space and a discontinuity in the anterior right lateral atrial septum suggestive of a patent foramen ovale (PFO). There was no evidence of thrombus within the interatrial or intracardiac spaces. Mild right atrial enlargement was seen. The patient was initiated on aspirin for cardioembolic stroke prophylaxis. Discussion: DIAS is a highly rare congenital cardiac anomaly with limited number of cases in literature. It has been described as a midline third atrium resulting in a “tri-atrial heart”. As of 2018, less than 20 cases have been cited. DIAS is characterized by two parallel interatrial septa along with a clear echo lucent midline space that expands in systole and collapses in diastole. This case is unique as it is one of the few to include additional characterization with cMRI. Patients with DIAS are usually asymptomatic but can experience cardioembolic events as the interatrial space is at risk for thrombus formation. Communication across the DIAS makes these events more likely. Unlike with atrial fibrillation/flutter, no current criteria for anticoagulation (AC) initiation exists for DIAS given the scarcity of cases. While some sources advocate for use of anti-platelet agents, others have indicated a preference for oral AC. Our patient had an interatrial space and a PFO but lacked communication across the DIAS, had low bleeding risk, and no other classic risk factors of Virchow’s triad. We determined her risk for thrombus formation to be relatively low, and thus initiated her on aspirin over oral AC. Percutaneous closure of the interatrial space was deferred as it has been dismissed as a viable treatment option in the literature.

Transcutaneous electrical vagus nerve stimulation to suppress premature ventricular complexes (TREAT PVC): study protocol for a multi-center, double-blind, randomized controlled trial

BackgroundThe autonomic nervous system can be responsible for the initiation and maintenance of arrhythmias. Low-level tragus stimulation (LLTS), a noninvasive form of autonomic neuromodulation, has been shown to be effective in treating atrial fibrillation. We intended to treat frequent premature ventricular complexes (PVCs) with LLTS.Methods and designThe present study will be a prospective multicenter, double-blind, randomized, controlled trial to assess the antiarrhythmic effects of LLTS on frequent PVCs in patients without structured heart disease (SHD). A total of 100 patients with PVC burden > 10% will be randomly assigned to the active or sham LLTS in 1:1 fashion and receive the proposed intervention for 6 months. The primary outcome is PVC burden at 6 months as assessed by 10 days of continuous ambulatory electrocardiographic monitoring. Secondary outcomes include heart rate variability (HRV), quality of life, skin sympathetic nerve activity, and inflammatory markers. Adverse events will also be recorded.DiscussionThe present trial will be the first to evaluate the effect of LLTS on frequent PVCs on patients without SHD. LLTS may serve as a low-cost, minimal-risk, and non-invasive alternative to conventional antiarrhythmic therapy.Trial registrationClinicalTrial.gov NCT04909528. Registered on 17 June 2021. World health organization trial registration data set was shown in Supplementary Table 1.

Electrocardiographic Characteristics, Identification, and Management of Frequent Premature Ventricular Contractions.

Premature ventricular complexes (PVCs) are frequently encountered in clinical practice. The association of PVCs with adverse cardiovascular outcomes is well established in the context of structural heart disease, yet not so much in the absence of structural heart disease. However, cardiac magnetic resonance (CMR) seems to contribute prognostically in the latter subgroup. PVC-induced myocardial dysfunction refers to the impairment of ventricular function due to PVCs and is mostly associated with a PVC burden > 10%. Surface 12-lead ECG has long been used to localize the anatomic site of origin and multiple algorithms have been developed to differentiate between right ventricular and left ventricular outflow tract (RVOT and LVOT, respectively) origin. Novel algorithms include alternative ECG lead configurations and, lately, sophisticated artificial intelligence methods have been utilized to determine the origins of outflow tract arrhythmias. The decision to therapeutically address PVCs should be made upon the presence of symptoms or the development of PVC-induced myocardial dysfunction. Therapeutic modalities include pharmacological therapy (I-C antiarrhythmic drugs and beta blockers), as well as catheter ablation, which has demonstrated superior efficacy and safety.

Are antiarrhythmic agents indicated in premature ventricular complex-induced cardiomyopathy and when?

Premature ventricular complexes (PVCs) are the most common ventricular arrhythmia that are encountered in the clinical practice. Recent data suggests that high PVC burden may lead to the development of PVC-induced cardiomyopathy (PVC-CM) even in patients without structural heart disease. Treatment for effective suppression of PVCs, can reverse PVC-CM. Both antiarrhythmic drugs (AADs) and catheter ablation (CA) are recognized treatment modalities for any cardiac arrhythmias. However, with increasing preference of CA, the role of AADs needs further defining regarding their efficacy, safety, indications and patient selection to treat PVC-CM. To ascertain the role of AADs to treat PVC-CM; whether they are indicated to treat PVC-CM, and if so, when, we interrogated PubMed and other search engines for English language publications with key words premature ventricular complexes (PVCs), cardiomyopathy, anti-arrhythmic drugs, catheter ablation, and pharmacological agents. All publications were carefully reviewed and scrutinized by the authors for their inclusion in the review paper. For illustration of cases, ethical standard was observed as per the 1975 Declaration of Helsinki, and the patient was treated as per the prevailing standard of care. Informed consent was obtained from the patient for conducting the ablation procedure. Our literature search specifically the pharmacological treatment of PVC-CM with AADs revealed significant paradigm shift in treatment approach for PVCs and PVC-induced cardiomyopathy. No major large, randomized control trials of AADs versus CA for PVC-CM were found. We found that beta-blockers and calcium channel blockers are particularly effective in the treatment of PVCs originating from right ventricular outflow tract. For Class Ic AADs - flecainide and propafenone, small clinical studies showed Class Ic AADs to be effective in PVC suppression, but their usage was not recommended in patients with significant coronary artery disease. Mexiletine was found to have modest effect on PVC suppression. Studies showed sotalol to significantly reduce PVCs frequency in patients receiving both low and high doses. Studies also showed amiodarone to have higher successful PVC suppression, but not recommended as a first-line treatment for patients with idiopathic PVCs in the absence of symptoms and left ventricular dysfunction. For dronedarone, no major clinical data were available. Based on the available data in the literature, we conclude that AADs play important role in the treatment of PVC-induced cardiomyopathy. However, appropriate patient selection criteria are vitally important, and in general terms AADs are indicated or polymorphic PVCs, epicardial PVCs; and when CA procedure is contraindicated, or not feasible or failed.