Propensity-score matched comparison of renal and neurohormonal effects of catheter ablation for frequent premature ventricular contractions in patients with and without systolic dysfunction

Background

Catheter ablation (CA) for premature ventricular contractions (PVCs) restores cardiac and renal functions in patients with reduced left ventricular ejection fraction (LVEF); however, its effects on preserved EF remain unelucidated.

Methods

The study cohort comprised 246 patients with a PVC burden of >10% on Holter electrocardiography. Using propensity matching, we compared the changes in B-type natriuretic peptide (BNP) levels and estimated glomerular filtration rate (eGFR) in patients who underwent CA or did not.

Results

Postoperative BNP levels were decreased significantly in the CA group, regardless of the degree of LVEF, whereas there was no change in those of the non-CA group. Among patients who underwent CA, BNP levels decreased from 44.1 to 33.0 pg/mL in those with LVEF ≥50% (p = .002) and from 141.0 to 87.9 pg/mL in those with LVEF <50% (p < .001). Regarding eGFR, postoperative eGFR was significantly improved in the CA group of patients with LVEF ≥50% (from 71.4 to 74.7 mL/min/1.73 m2, p = .006), whereas it decreased in the non-CA group. A similar trend was observed in the group with a reduced LVEF. Adjusted for propensity score matching, there was a significant decrease in the BNP level and recovery of eGFR after CA in patients with LVEF >50%.

Conclusions

This study showed that CA for frequent PVCs decreases BNP levels and increases eGFR even in patients with preserved LVEF.

Left ventricular remodeling in premature ventricular contraction-induced cardiomyopathy: Effect of coupling intervals and atrioventricular dissociation

Background

Left ventricular dyssynchrony (LVD) and postextrasystolic potentiation (PESP) associated with premature ventricular contractions (PVCs) may play a role in the development of premature ventricular contraction-induced cardiomyopathy (PVC-CM). Long-coupled (LC) PVCs have a greater LVD than short-coupled (SC) PVCs, whereas SC-PVCs have a stronger PESP than LC-PVCs.

Objective

The purpose of this study was to compare SC-PVCs and LC-PVCs to evaluate the roles of LVD, PESP, and atrioventricular dissociation (AVD) in the development of PVC-CM.

Methods

Thirty-six canines underwent pacemaker implantation to induce bigeminal right ventricular apical epicardial PVCs (50% burden) for 12 weeks. Telemetry assessed PVC burden and AVD. Animals were grouped as SC-PVC (coupling interval [CI] 200-220ms), LC-PVC (CI 330 ms), or sham (control). Echocardiographic changes, AVD, and hemodynamics were monitored for 12 weeks.

Results

PVC burden was similar between SC-PVC and LC-PVC groups but was statistically higher in the SC-PVC group (50% vs 47.5%; P = .028). After 12 weeks, left ventricular ejection fraction (LVEF) significantly decreased in both SC-PVC and LC-PVC groups (47.1% ± 1.4% and 45.5% ± 2%, respectively) compared to sham group (61% ± 1.6%; P <.001). Overall AVD was similar between SC-PVC and LC-PVC groups, and there was no significant correlation between AVD and reduction in LVEF at 12 weeks (r = 0.09, P = .5; and r = 0.06, P = .8, respectively). Additionally, both SC-PVC and LC-PVC groups experienced substantial declines in max and min dP/dt after 12 weeks compared to baseline.

Conclusion

Neither PVC CI nor AVD played an independent role in the development or severity of PVC-CM. LVD and PESP make equal relative contributions to the development of PVC-CM.

Cardiomyopathy induced by premature ventricular contractions with ventricular escape beats in the compensatory pause: A case report and brief review of the literature

RATIONALE

We reported a case with cardiomyopathy induced by frequent premature ventricular contractions (PVCs) and followed ventricular escape beats (VEBs). PVCs with VEBs in the compensatory pause which induced cardiomyopathy is rarely reported. Also, the case exhibited many characteristics of PVCs which were more likely to induce cardiomyopathy, like the location of origin, the longer coupling interval, and the QRS wave companied with the P wave.

PATIENT CONCERNS

A 53-year-old man with left ventricular (LV) dysfunction presented with palpation, chest distress, and dyspnea for 3 years. Holter revealed a high burden of ventricular rhythm of PVCs and another wide QRS patterns (96,562 total beats with 87,330 wide QRS beats in 24 hours). The LV ejection fraction decreased to 34% and the left ventricle, right and left atria all dilated.

DIAGNOSIS

He was diagnosed with PVC-induced cardiomyopathy.

INTERVENTIONS

The patient experienced intracardiac electrophysiological examination which revealed frequent PVCs followed by VEBs in the compensatory pause. Activation mapping of the PVCS and ablation were performed.

OUTCOMES

PVCs and VEBs disappeared after ablation. The LV ejection fraction increased to 46% at 2 days after the procedure. The diameters of the right and left atria were also significantly reduced.

LESSONS

VEBs may occur during the compensatory pause of PVCs. PVCs with VEBs can lead to a high burden of ventricular rhythm and LV dysfunction. Ablation of the PVCs can also eliminate VEBs and improve the LV function.

Increase in Heart Rate-dependent Left Atrial Pressure is Associated with Symptoms in Patients with Paroxysmal Atrial Fibrillation: Conclusion

BACKGROUND

It remains unclear why some patients with the same heart rate (HR) during an atrial fibrillation (AF) have subjective symptoms, whereas others do not. We assessed the hypothesis that different responses of arterial and left atrial blood pressures to rapid stimulation may be associated with the symptoms of AF.

METHODS

A total of 110 patients who underwent catheter ablation for paroxysmal AF were retrospectively studied. Asymptomatic AF was defined as a European Heart Rhythm Association (EHRA) score of Ⅰ for AF-related symptoms. The left atrial pressure (LAP) was measured during sinus rhythm (SR), in 10 pacing per minute (ppm) increments from 100 ppm to the Wenckebach block rate in high right atrial pacing.

RESULTS

Asymptomatic AF was observed in 19/110 patients (17%). Patients with symptomatic AF showed higher E/e' ratio and gradual LAP increase that was dependent on the pacing rate. Patients with asymptomatic AF had decreased LAP at 100 ppm compared that at SR, and thereafter, LAP gradually increased depending on the pacing rate. The rate of LAP change compared to that at SR was significantly lower in patients with asymptomatic AF than that in patients with symptomatic AF. The rate of LAP change was independently associated with AF symptoms. This article is protected by copyright. All rights reserved.

OUP accepted manuscript

Electrical disturbances, such as atrial fibrillation (AF), dyssynchrony, tachycardia, and premature ventricular contractions (PVCs), are present in most patients with heart failure (HF). While these disturbances may be the consequence of HF, increasing evidence suggests that they may also cause or aggravate HF. Animal studies show that longer-lasting left bundle branch block, tachycardia, AF, and PVCs lead to functional derangements at the organ, cellular, and molecular level. Conversely, electrical treatment may reverse or mitigate HF. Clinical studies have shown the superiority of atrial and pulmonary vein ablation for rhythm control and AV nodal ablation for rate control in AF patients when compared with medical treatment. Ablation of PVCs can also improve left ventricular function. Cardiac resynchronization therapy (CRT) is an established adjunct therapy currently undergoing several interesting innovations. The current guideline recommendations reflect the safety and efficacy of these ablation therapies and CRT, but currently, these therapies are heavily underutilized. This review focuses on the electrical treatment of HF with reduced ejection fraction (HFrEF). We believe that the team of specialists treating an HF patient should incorporate an electrophysiologist in order to achieve a more widespread use of electrical therapies in the management of HFrEF and should also include individual conditions of the patient, such as body size and gender in therapy fine-tuning.

Clinical and translational insights on premature ventricular contractions and PVC-induced cardiomyopathy

The medical community's understanding of the consequences of premature ventricular contractions (PVCs) and PVC-induced cardiomyopathy has been derived mostly from observational and large population-based studies. Due to the difficulty of predicting the development of PVC-cardiomyopathy, the acute and chronic cardiac effects of PVCs and the mechanism of PVC-cardiomyopathy have been derived from pre-clinical studies with large animal models. Recently, these studies have described myocardial substrates that could potentially increase morbidity and mortality in patients with frequent PVCs and PVC-cardiomyopathy. In this paper, we provide an up-to-date comprehensive review of these pre-clinical and clinical studies.

Eccentric hypertrophy in an animal model of mid- and long-term premature ventricular contraction-induced cardiomyopathy

BACKGROUND

Tachycardia and heart rate irregularity are proposed triggers of premature ventricular contraction-induced cardiomyopathy (PVC-cardiomyopathy). Bigeminal premature atrial and ventricular contractions (PACs and PVCs) increase heart rate and result in rhythm irregularities but differ in their effects on ventricular synchrony. Comparing chronic bigeminal PACs with PVCs would provide insights into mechanisms of PVC-cardiomyopathy.

OBJECTIVE

To compare the impact of chronic PACs and PVCs on ventricular hemodynamics, structure, and function.

METHODS

Pacemakers were implanted in 27 canines to reproduce atrial (PACs, n = 7) or ventricular bigeminy (PVCs, n = 11) for 12 weeks, and compared to sham-operated animals (n = 9). Four additional animals were exposed to long-term bigeminal PVCs (48 weeks). Hemodynamic changes were assessed using a pressure-transducing catheter at baseline and 12 weeks. Cardiac remodeling was monitored by transthoracic echocardiography throughout the 12- and 48-week protocols in the respective groups.

RESULTS

PVC group demonstrated a significant decrease in left ventricular (LV) ejection fraction and contractility (max dP/dt), impaired LV lusitropy (min dP/dt), and increase in LV dimensions and LV mass at 12 weeks without further deterioration beyond 16 weeks. Despite increased LV mass, relative wall thickness decreased, consistent with eccentric hypertrophy. No significant cardiac remodeling was noted in either sham or PAC groups at 12 weeks.

CONCLUSION

In contrast to bigeminal PACs, PVCs result in a cardiomyopathy characterized by reduced LV ejection fraction, LV dilation, and eccentric hypertrophy that plateaus between 12 and 16 weeks. The lack of remodeling in chronic PACs suggests that tachycardia and heart rate irregularity do not play a significant role on the development of PVC-cardiomyopathy.

Arrhythmia-Induced Cardiomyopathy: JACC State-of-the-Art Review

Arrhythmias coexist in patients with heart failure (HF) and left ventricular (LV) dysfunction. Tachycardias, atrial fibrillation, and premature ventricular contractions are known to trigger a reversible dilated cardiomyopathy referred as arrhythmia-induced cardiomyopathy (AiCM). It remains unclear why some patients are more prone to develop AiCM despite similar arrhythmia burdens. The challenge is to determine whether arrhythmias are fully, partially, or at all responsible for an observed LV dysfunction. AiCM should be suspected in patients with mean heart rate >100 beats/min, atrial fibrillation, and/or premature ventricular contractions burden ≥10%. Reversal of cardiomyopathy by elimination of the arrhythmia confirms AiCM. Therapeutic choice depends on the culprit arrhythmia, patient comorbidities, and preferences. Following recovery of LV function, patients require continued follow-up if an abnormal myocardial substrate is present. Appropriate diagnosis and treatment of AiCM is likely to improve quality of life and clinical outcomes and to reduce hospital admission and health care spending.

[Premature ventricular contractions and tachycardia in a structurally normal heart : Idiopathic PVC and VT]

Premature ventricular contractions (PVC) are a common, often incidental and mostly benign finding. Treatment is indicated in frequent and symptomatic PVC or in cases of worsening of left ventricular function. Idiopathic ventricular tachycardia (VT) is mostly found in patients with a structurally healthy heart. These PVC/VT usually have a focal origin. The most likely mechanism is delayed post-depolarization. Localization of the origin is based on the creation of an activation map with or without combination of pace mapping. Idiopathic PVC/VT are most frequently located on the outflow tracts of the right and left ventricles, including the aortic root. Other typical locations include the annulus of the tricuspid or mitral valve, papillary muscles and Purkinje fibers. Catheter ablation is an alternative to antiarrhythmic medication in symptomatic monomorphic PVC/VT. The success rate is good whereby mapping and ablation can often represent a challenge. This article is the fifth part of a series dedicated to specific advanced training in the field of special rhythmology and invasive electrophysiology. It describes the pathophysiological principles, types and typical findings that can be obtained during an electrophysiological investigation.

Hemodynamic consequences of premature ventricular contractions: Association of mechanical bradycardia and postextrasystolic potentiation with premature ventricular contraction-induced cardiomyopathy

BACKGROUND

The relationships between hemodynamic consequences of premature ventricular contractions (PVCs) and development of premature ventricular contraction-induced cardiomyopathy (PVC-CM) have not been investigated.

OBJECTIVE

The purpose of this study was to correlate concealed mechanical bradycardia and/or postextrasystolic potentiation (PEP) to PVC-CM.

METHODS

Invasive arterial pressure measurements from 17 patients with PVC-CM and 16 controls with frequent PVCs were retrospectively analyzed. PVCs were considered efficient (ejecting PVCs) when generating a measurable systolic arterial pressure. PEP was defined by a systolic arterial pressure of the post-PVC beat ≥5 mm Hg higher than the preceding sinus beat. Every PVC was analyzed for 10 minutes before ablation, and the electromechanical index (EMi = number of ejecting PVCs/total PVC) and postextrasystolic potentiation index (PEPi = number of PVCs with PEP/total PVC) were calculated.

RESULTS

EMi was 29% ± 31% in PVC-CM and 78% ± 20% in controls (P <.0001). PEPi was 41% ± 28% in PVC-CM and 14% ± 10% in controls (P = .001). There was no control in groups of low EMi or high PEPi. EMi and PEPi were not significantly correlated to left ventricular dimensions or function in PVC-CM patients. PVC coupling interval was related to both ejecting PVCs and PEP.

CONCLUSION

Patients with PVC-CM more often display nonejecting PVCs and PEP compared to controls.

A new mapping method to estimate exit sites of ventricular arrhythmias using intracardiac echocardiography and M-mode for catheter ablation

Background

Catheter ablation of premature ventricular complexes (PVCs) has been used as a curative therapy in many cases. Intracardiac ultrasound with a magnetic sensor probe has recently become available for catheter ablation. In this study, we assessed a new mapping method, contraction mapping, for determining the optimal ablation sites using intracardiac ultrasound and M-mode. This study sought to assess the accuracy of the new mapping method using intracardiac echocardiography.

Methods

Eighteen patients (10 males and eight females; mean age, 63±12 years) with 104 mapping points diagnosed as idiopathic PVCs were included in this study. At the mapping points, the time interval from the onset of the QRS to the onset of the contraction (QRS-c-time) and the local activation time were measured using M-mode with an intracardiac echo probe and using the conventional method. The correlation between the QRS-c-time and local activation time were studied.

Results

The QRS-c-time was significantly correlated with the local activation time (activation time=−66.8+0.882 * QRS-c-time, R2=0.728, p<0.0001).

Conclusions

Contraction mapping could help determine the local activation time without the delivery of a catheter to the mapping points.

Premature ventricular contraction-induced cardiomyopathy: an emerging entity

INTRODUCTION

Over the past 10-15 years, there has been an increasing amount of evidence that frequent premature ventricular contractions (PVCs) are associated with the development of a reversible cardiomyopathy. Areas covered: This review considers current evidence of the association between PVCs and the development of cardiomyopathy, risk factors, and available treatment modalities based on available published literature. Expert commentary: The field is rapidly evolving, although evidence is based primarily on observational studies. Pharmacological therapy may suppress PVCs and lead to resolution of cardiomyopathy in many patients. In addition, catheter ablation has emerged as an effective treatment modality that has compared favorably to pharmacological antiarrhythmic therapy. The excellent outcome in successfully treated patients should prompt physicians to consider whether frequent PVCs may be a contributing factor in patients with heart failure.

Ventricular premature depolarization QRS duration as a new marker of risk for the development of ventricular premature depolarization-induced cardiomyopathy

BACKGROUND

Frequent ventricular premature depolarizations (VPDs) can cause cardiomyopathy (CMP). The mechanisms underlying its development remain unclear, with VPD burden being only a weak predictor of risk.

OBJECTIVE

To determine whether VPD QRS duration at the time of initial presentation could predict risk for the subsequent development of CMP in patients with normal left ventricular ejection fraction (LVEF).

METHODS

From consecutive patients referred for ablation between January 1, 2006, and April 2, 2013, with ≥10% VPDs on 24-hour Holter monitoring, we identified 45 patients with normal LVEF and an electrocardiogram of the targeted VPD, who were then followed for at least 6 months (median 14 months; interquartile range [IQR] 8-32 months) before intervention. We excluded patients with structural or genetic heart disease.

RESULTS

Of the 45 patients, 28 (62%) maintained normal LVEF and 17(38%) developed VPD-induced CMP. VPD burden was similar (26.5% [IQR 19.3%-39.5%] vs 26.0% [IQR 16.4%-41.0%]; P = 0.4) between the 2 groups. Patients who developed VPD-induced CMP had significantly longer VPD QRS duration (159 ms vs 142 ms; P < .001) and a longer sinus QRS duration (97 ms vs 89 ms; P = .04). A VPD QRS duration of ≥153 ms best predicted development of VPD CMP (82% sensitivity and 75% specificity). Longer VPD QRS duration and a non-outflow tract site of VPD origin were independent risk factors for left ventricular dysfunction after multivariate analysis.

CONCLUSION

VPD QRS duration longer than 153 ms and a non-outflow tract site of origin might be useful predictors of the subsequent development of VPD-induced CMP.

Radiofrequency ablation can reverse the structural remodeling caused by frequent premature ventricular contractions originating from the right ventricular outflow tract even in a "normal heart"

OBJECTIVE

The aim of this study was to evaluate whether frequent premature ventricular contractions originating from the right ventricular outflow tract remodel the cardiac structure and function in patients with a "seemingly normal heart" and whether radiofrequency ablation can reverse this remodeling.

METHODS

Sixty-eight patients with idiopathic frequent premature ventricular contractions originating from the right ventricular outflow tract and normal heart structure and function were enrolled in this study. The patients were divided into three groups according to the therapeutic method: radiofrequency ablation group (24 cases), anti-arrhythmia drug group (26 cases), and control group (18 cases without any treatment). Clinical Registration number: ChiCTR-ONRC-12002834 RESULTS: The basic patient characteristics were comparable between the three groups, except for the premature ventricular contraction rate, which was significantly lower in the control group. After six months of follow up, the premature ventricular contraction rate was significantly reduced in the radiofrequency ablation group, which was accompanied by a significant decrease in the following cardiac cavity inner diameters, as determined by echocardiography: right atrium (33.33±3.78 vs. 30.05±2.60 mm, p = 0.001), right ventricle (23.24±2.40 vs. 21.05±2.16 mm, p = 0.020), and left ventricle (44.76±4.33 vs. 41.71±3.44 mm, p = 0.025). These results were similar in the anti-arrhythmia drug group, although this group exhibited a smaller extent of change (right atrium: 33.94±3.25 vs. 31.27±3.11 mm, p = 0.024; right ventricle: 22.97±3.09 vs. 21.64±2.33 mm, p = 0.049; left ventricle: 45.92±6.38 vs. 43.84±5.67 mm, p = 0.039), but not in the control group (p>0.05). There was a tendency toward improvement in the cardiac functions in both the radiofrequency ablation and anti-arrhythmia drug groups. However, these differences were not statistically significant (p>0.05).

CONCLUSIONS

These results indicate that radiofrequency ablation can potentially reverse the cardiac remodeling caused by frequent premature ventricular contractions even in structurally normal hearts and that frequent premature ventricular contractions should be abated even in structurally normal hearts.