Frequent Ventricular Premature Beats in Children and Adolescents: Natural History and Relationship with Sport Activity in a Long-Term Follow-Up

Advancements in the diagnosis and management of premature ventricular contractions in pediatric patients

Background

Premature ventricular contractions (PVCs) are relatively common arrhythmias in the pediatric population, with implications that range from benign to potentially life-threatening. The management of PVCs in children poses unique challenges, and recent advancements in diagnostic and therapeutic options call for a comprehensive review of current practices.

Methods

This review synthesizes the latest literature on pediatric PVCs, focusing on publications from the past decade. We evaluate studies addressing the epidemiology, pathophysiology, diagnosis, and treatment of PVCs in children, including pharmacological, non-pharmacological, and invasive strategies.

Results

The review identifies key advancements in the non-invasive detection of PVCs, the growing understanding of their genetic underpinnings, and the evolving landscape of management options. We discuss the clinical decision-making process, considering the variable significance of PVCs in different pediatric patient subgroups, and highlight the importance of individualized care. Current guidelines and consensus statements are examined, and areas of controversy or limited evidence are identified.

Conclusions

Our review underscores the need for a nuanced approach to PVCs in children, integrating the latest diagnostic techniques with a tailored therapeutic strategy. We call for further research into long-term outcomes and the development of risk stratification tools to guide treatment. The potential of emerging technologies and the importance of multidisciplinary care are also emphasized to improve prognoses for pediatric patients with PVCs.

The Relationship between Depression Symptoms and Physical Activity in Children with Idiopathic Ventricular Extrasystoles

Background and Objectives: Depression in childhood often co-occurs with anxiety disorders and a range of somatic symptoms. Recent studies have identified physical activity as a target for preventing the onset of depression. However, idiopathic ventricular extrasystoles (VEs) in children are sometimes associated with somatic symptoms and limitations in physical activity. The occurrence of arrhythmia can also be distressing for children and their parents. This study was conducted to determine the relationship between symptoms of depression, physical activity, and somatic symptoms in children with idiopathic VE. Materials and Methods: This study of children with structurally normal hearts and VE was approved by the local ethics committee (no. 2021/10-1383-859(1). The authors designed a questionnaire to assess symptoms, physical activity, and general well-being. As part of that, symptoms of depression were evaluated with a modified pediatric PHQ-9 (MP-PHQ-9) questionnaire, with scores ≤4 for no, 5-9 for mild, 10-14 for moderate, and ≥15 for severe depression. Children aged ≥12 years and parents who assessed their children's condition completed the questionnaires. All children also underwent 24-h electrocardiography and echocardiography to evaluate arrhythmia frequency and cardiac condition. Results: Questionnaires were completed by 60 children's parents and 39 children (≥12 years old). The median children's age was 13 years. Palpitations were experienced by 26 (43.3%), chest pain by 13 (21.7%), and exercise intolerance by 15 (25%) children. All patients had normal ventricular function and hemodynamically normal hearts. The median score of the MP-PHQ-9 completed by parents was 2, and by children was 4. The median VE frequency was 4.77 (0.1-32.77) % per 24 h. We found that 31 (51.7%) children engaged in extra-sports participation with a median time of 3.75 h per week. Eleven of the children were suspended from sports. There was no significant difference between VE frequency and MP-PHQ-9 scores. Higher MP-PHQ-9 scores were noted for symptomatic children who engaged in <5 h per week of physical activity. Conclusions: Higher depression scores were found for children with somatic symptoms than those without symptoms. Children who were physically active for less than 5 h per week also had higher depression risk scores than those who were more active. Our research has shown that parents underestimate the signs of depression in their children.

Athletes and suspected catecholaminergic polymorphic ventricular tachycardia: Awareness and current knowledge

INTRODUCTION

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a cardiac inherited arrhythmogenic disease potentially leading to sudden cardiac death that is determined by electrical instability exacerbated by acute adrenergic tone.

METHODS AND RESULTS

Despite its life-threatening nature, CPVT remains potentially unnoticed since diagnosis may be difficult especially in apparently healthy athletes. This review summarizes current knowledge and shortcomings of CPVT, focusing on genetics, arrhythmic mechanisms, sport preparticipation screening, and current recommendations.

CONCLUSIONS

The paper captures the importance of CPVT athletes regarding the necessity of risk stratification, as well as the importance of maintaining a healthy lifestyle.

Ventricular arrhythmias recorded on 12-lead ambulatory electrocardiogram monitoring in healthy volunteer athletes and controls: what is common and what is not

AIMS

Premature ventricular beats (PVBs) in athletes are often benign, but sometimes they may be a sign of an underlying disease. We evaluated the prevalence, burden, and morphology of PVBs in healthy voluntary athletes and controls with the main purpose of defining if certain PVB patterns are 'common' and 'training related' and, as such, are more likely benign.

METHODS AND RESULTS

We studied 433 healthy competitive athletes [median age 27 (18-43) years, 74% males] and 261 age- and sex-matched sedentary subjects who volunteered to undergo 12-lead 24 h ambulatory electrocardiogram (ECG) monitoring (24H ECG), with a training session in athletes. Ventricular arrhythmias (VAs) were evaluated in terms of their number, complexity [i.e. couplet, triplet, or non-sustained ventricular tachycardia (NSVT)], exercise inducibility, and morphology. Eighty-six percent of athletes and controls exhibited a total of ≤10 PVBs/24 h, and >90% did not show any couplets, triplets, or runs of NSVT > 3 beats. An higher number of PVBs correlated with increasing age (P < 0.01) but not with sex and level of training. The most frequent morphologies among the 36 athletes with >50 PVBs were the infundibular (44%) and fascicular (22%) ones. In a comparison between athletes and sedentary individuals, and male and female athletes, no statistically significant differences were found in PVBs morphologies.

CONCLUSION

The prevalence and complexity of VAs at 24H ECG did not differ between athletes and sedentary controls and were not related to the type and amount of sport or sex. Age was the only variable associated with an increased PVB burden. Thus, no PVB pattern in the athlete can be considered 'common' or 'training related'.

Moderator Band and Ventricular Tachycardia: Structural or Functional Substrate?

The moderator band (MB) is an intracavitary structure of the right ventricle composed of muscular fibers encompassing specialized Purkinje fibers, separated each other by collagen and adipose tissue. In the last decades, premature ventricular complexes originating within the Purkinje network have been implicated in the genesis of life-threatening arrhythmias. However, right Purkinje network arrhythmias have been much less reported in the literature compared to the left counterpart. The MB has unique anatomical and electrophysiological properties, which may account for its arrhythmogenicity and may be responsible for a significant portion of idiopathic ventricular fibrillation. MB embodies autonomic nervous system cells, with important implications in arrhythmogenesis. Some idiopathic ventricular arrhythmias, defined as the absence of any identifiable structural heart disorder, can begin from this site. Due to these complex structural and functional peculiarities strictly interplayed each other, it is arduous to determine the precise mechanism underlying MB arrhythmias. MB-related arrhythmias should be differentiated from other right Purkinje fibers arrhythmias because of the opportunity for intervention and the unusual site for the ablation poorly described in the literature. In the current paper, we report the characteristics and electrical properties of the MB, their involvement in arrhythmogenesis, clinical and electrophysiological peculiarities of MB-related arrhythmias, and current treatment options.

Psychological Wellbeing and Perceived Fatigue in Competitive Athletes after SARS-CoV-2 Infection 2 Years after Pandemic Start: Practical Indications

The COVID-19 pandemic deeply affected sports and athletes, influencing performance and psychological wellbeing. In order to provide useful guidelines for coaches, a web-based survey was conducted. Three web-based questionnaires were administered during the last phase of the Omicron wave to a total of 204 Italian athletes (age 24.96 ± 9.82): an informative questionnaire to collect sociodemographic data and infection symptoms information, the Fatigue Severity Scale (FSS) and the General Health Questionnaire-12 (GHQ-12). No differences between infection sequels of different variant typologies were found over the long term after the infection. The most frequently declared symptoms included cough (50%), muscular skeletal impairments (48%) fatigue (43%) and fever (43%). Results showed that female athletes have a higher risk of developing post-COVID-19 symptoms, GHQ-12 worse results (p = 0.005) and greater fatigue (p = 0.0002) than males. No significant difference in infection incidence between high- and low-level athletes was found. Endurance athletes showed greater perceived fatigue than anaerobic sports athletes (p = 0.045). Conclusions: These results suggested the need for specific approaches and continuous updating to differentiate training programs for different athletes during the return to play. Medical controls and daily monitoring of athletes of all levels after the infection could be advisable.

The Value of Continuous Electrocardiographic Monitoring in Pediatric Cardiology: A Local Center Experience

Objectives

This study aims to evaluate the value of Holter monitoring in pediatric cases and look for the best predictor for abnormal Holter monitoring.

Methodology

All patients referred with cardiac symptoms associated or possibly related to abnormal cardiac rhythm from January 2019 to December 2020 were retrospectively reviewed. The demographic, clinical, 12-lead electrocardiography (ECG), echocardiography, and Holter monitoring results were reviewed. Multinomial logistic regression analysis was used to assess the correlation between gender, age, type of symptoms, ECG, and echo abnormalities, and Holter monitoring results were analyzed.

Results

During the study period, a total of 189 Holter monitoring was performed for 187 patients. The mean age at the performance of Holter monitoring was 88.6 ± 57 months. The female/male ratio was 1.5:1. The commonest indications for Holter monitoring were abnormal 12-lead ECG (30.7%), palpitations (30.7%), syncopal attacks (12.7%), and chest pain (6.9%). Patients with congenital heart disease (CHD) pre- or post-cardiac intervention constitute 9% of the total Holter monitoring cases. Apart from sinus arrhythmia, 12-lead ECG was abnormal in 57 (30%) patients, with premature atrial complexes (PACs) being the most common abnormality. Echocardiography was abnormal in 67 (35.4%) cases, with secundum atrial septal defect (ASD) (6.3%) and mitral valve prolapse (5.8%) being the commonest abnormalities. The Holter monitoring was completely normal in 89 (47.1%) cases. The commonest Holter abnormalities were PACs (12.7%), supraventricular tachycardia (SVT) (5.8%), and premature ventricular complexes (PVCs) (4.8%). There were 24 patients with SVT, and eight of them had normal Holter monitoring. One patient with SVT had ablation by the electrophysiologist. Using the multinomial logistic regression analysis, significantly abnormal 12-lead ECG, the presence of CHD, and abnormal echocardiography predict the presence of abnormal Holter results with a statistically significant p-value.

Conclusion

Most pediatric arrhythmias are benign. Holter monitoring provides reassurance for the patient and family. Abnormal Holter monitoring is more often observed in patients with paroxysmal or persistently abnormal 12-lead ECG with or without associated cardiac abnormalities or cardiac interventions. The yield of Holter monitoring is low in children referred because of chest pain, palpitations, or syncope with no other cardiac symptoms and with a structurally and functionally normal heart.

Incidental electrocardiogram abnormalities in children undergoing polysomnography

STUDY OBJECTIVES

Monitoring electrocardiogram (ECG) is an integral component of pediatric polysomnography (PSG). There is limited data regarding arrhythmia and conduction disturbances in the pediatric population undergoing a PSG. In this work we present abnormal ECG findings during PSG in our sleep center.

METHODS

A retrospective chart review from children who underwent PSG read by a single Sleep Medicine physician in the last year was carried out. Findings in children without cardiac disease and with first or second degree atrioventricular block (AVB) were compared to those from children with premature ventricular contractions (PVC).

RESULTS

A total of 1,235 PSGs were included. Twenty-four children (9 girls and 15 boys) aged 2-17 years (median 9 years) were identified with arrhythmias or conduction disturbances (1.9%). Nineteen out of 24 of these children (79.2%) had obstructive apnea-hypopnea index (oAHI) > 1 event/h; this frequency was not significantly different from that found in the whole group of 1,235 children. No statistically significant difference was found between children with AVB or PVC. Seven out of nine children with AVB and seven out of 10 with PVC had oAHI > 1 event/h, while eight children with AVB out of nine and four out of 10 with PVC were males (Fisher exact test p=0.04). None of the children were found to have a structural or conduction abnormality when referred to cardiology.

CONCLUSIONS

Our study supports that ECG abnormalities are rare in PSGs of children and not associated with cardiac disease or sleep disorders but appear more commonly in males.

Clinical management of young competitive athletes with premature ventricular beats: A prospective cohort study

BACKGROUND

Premature ventricular beats (PVBs) are not an unusual finding and their interpretation is sometimes challenging. Unfortunately, few data on the characteristics of PVBs that correlate with the risk of an underlying heart disease are available in athletes.

OBJECTIVES

The aim of this prospective study was to investigate the diagnostic and prognostic value of PVBs characteristics in competitive athletes.

METHODS

From a cohort of 1751 athletes evaluated at our sports cardiology centre, we enrolled 112 competitive athletes <40 years of age (mean age 21 ± 10 years) and with no known heart disease referred for PVBs. All athletes underwent physical examination, ECG, 12‑lead ambulatory ECG monitoring, exercise testing, and echocardiography. Further investigations including cardiac magnetic resonance were performed for abnormal findings at first-line evaluation or for specific PVBs characteristics.

RESULTS

The majority (79%) of athletes exhibited monomorphic PVBs with a fascicular or infundibular pattern (common morphologies). A definitive diagnosis of cardiac disease was reached in 26 athletes (23% of the entire population) and correlated with uncommon PVBs morphology (p < 0.001) and arrhythmia complexity (p < 0.001). The number of PVBs/24-h was lower in athletes with cardiac disease than in those with normal heart (p < 0.05). During the follow-up a spontaneous reduction of PVBs and no adverse events were observed.

CONCLUSIONS

Infundibular and fascicular PVBs were the most common morphologies observed in athletes with ventricular arrhythmias referred for cardiological evaluation. Morphology and complexity of PVBs, but not their number, predicted the probability of an underlying disease. Athletes with PVBs and negative investigation showed a good prognosis.

Syncope and Palpitations: A Review

Syncope and palpitations are common complaints for patients presenting to their primary care provider. They represent symptoms that most often have a benign etiology but rarely can be the first warning sign of a serious condition, such as arrhythmias, structural heart disease, or noncardiac disease. The history, physical examination, and noninvasive testing can, in most cases, distinguish benign from pathologic causes. This article introduces syncope and palpitations, with emphasis on the differential diagnoses, initial presentation, diagnostic strategy, and various management strategies.