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Bertels RA, Kammeraad JAE, van Geloven N, Filippini LH, van der Palen RLF, Tak RO, Frerich S, Vanagt W, Rehbock JJB, Knobbe I, Kuipers IM, de Riva M, Zeppenfeld K, Blom NA. ECTOPIC trial: The efficacy of flEcainide Compared To metOprolol in reducing Premature ventrIcular contractions. A randomized open label cross-over study in pediatric patients. Heart Rhythm 2024:S1547-5271(24)03090-X. [PMID: 39089565 DOI: 10.1016/j.hrthm.2024.07.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 07/15/2024] [Accepted: 07/26/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Frequent premature ventricular contractions (PVCs) in children are usually considered benign. Symptoms and/or left ventricular dysfunction are indications for treatment with anti-arrhythmic drugs (AAD). OBJECTIVE To evaluate the efficacy of flecainide versus metoprolol in reducing PVCs in children. METHODS A randomized open label cross-over trial children with a PVC-burden of >15% on Holter; successively treated with metoprolol and flecainide or vice versa, with a drug free interval of at least two weeks. Holter measurements were repeated before and after the start of the AAD. RESULTS Sixty patients were screened, 19 patients could be included. Median age was 13.9 years (IQR 5.5 years). Mean baseline PVC-burden was 21.7% (N=18, SD±14.0) before the start of flecainide and 21.2% (N=17, SD±11.5) before the start of metoprolol. In a mixed model analysis the estimated mean reduction in PVC-burden was 10.6 percentage-points (95%-CI 5.8-15.3) for flecainide and 2.4 percentage-points (95%-CI -2.7-7.5) for metoprolol, with a significant difference of 8.2 percentage-points (95%-CI of 0.86-15.46, P=0.031). Exploratory analysis revealed that 9/18 patients treated with flecainide and 1/17 patients treated with metoprolol, had a reduction to a PVC-burden below 5%. No discriminating factors between flecainide-responders and non-responders were found; the mean plasma level was not significantly different (0.34 mg/L versus 0.52 mg/L, P=0.277). CONCLUSIONS In children with frequent PVCs flecainide led to a significant greater reduction of PVC-burden, compared to metoprolol. Flecainide was effective in only a subgroup of patients, which appears to be unrelated to the plasma level. (Dutch Trial Register number 26689).
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Affiliation(s)
- Robin A Bertels
- Willem-Alexander Children's Hospital - Leiden University Medical Center; Albinusdreef 2, Leiden, the Netherlands.
| | - Janneke A E Kammeraad
- Erasmus MC - Sophia Children's Hospital; Dr. Molewaterplein 40, Rotterdam, the Netherlands
| | - Nan van Geloven
- Department of Biomedical Data Sciences - Leiden University Medical Center, Albinusdreef 2, Leiden, the Netherlands
| | - Luc H Filippini
- Juliana Children's Hospital - HAGA Hospital; Els Borst-Eilersplein 275, The Hague, the Netherlands
| | - Roel L F van der Palen
- Willem-Alexander Children's Hospital - Leiden University Medical Center; Albinusdreef 2, Leiden, the Netherlands
| | - Ramon O Tak
- Department of pediatrics - St Antonius Hospital; Koekoekslaan 1, Nieuwegein, the Netherlands
| | - Stefan Frerich
- MosaKids Children's Hospital - Maastricht University Medical Center; P. Debyelaan 25, Maastricht, the Netherlands
| | - Ward Vanagt
- Beatrix Children's Hospital - University Medical Center Groningen; Hanzeplein 14, Groningen, the Netherlands
| | - Jan J B Rehbock
- Department of pediatrics - HAGA Hospital Zoetermeer; Toneellaan 1, Zoetermeer, the Netherlands
| | - Ingmar Knobbe
- Emma Children's Hospital - Amsterdam University Medical Centers; Meibergdreef 9, Amsterdam, the Netherlands
| | - Irene M Kuipers
- Emma Children's Hospital - Amsterdam University Medical Centers; Meibergdreef 9, Amsterdam, the Netherlands
| | - Marta de Riva
- Department of Cardiology - Leiden University Medical Center, Albinusdreef 2, Leiden, the Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology - Leiden University Medical Center, Albinusdreef 2, Leiden, the Netherlands
| | - Nico A Blom
- Willem-Alexander Children's Hospital - Leiden University Medical Center; Albinusdreef 2, Leiden, the Netherlands; Emma Children's Hospital - Amsterdam University Medical Centers; Meibergdreef 9, Amsterdam, the Netherlands
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2
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Zhang B, Yu J, Wu Y, Li X, Xie X, Tao A, Yang B. The significance of heart rate variability in patients with frequent premature ventricular complex originating from the ventricular outflow tract. Clin Cardiol 2024; 47:e24174. [PMID: 37859500 PMCID: PMC10766131 DOI: 10.1002/clc.24174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/27/2023] [Accepted: 10/09/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND As an indicator of cardiac autonomic nervous activity, heart rate variability (HRV) is closely linked to premature ventricular complexes (PVCs). However, its role in patients with frequent PVCs originating from the ventricular outflow tract remains unclear. HYPOTHESIS Here, we hypothesize that there may be alterations in HRV among patients with frequent PVCs originating from the ventricular outflow tract, which could play significant roles in the management of such patients. METHODS A retrospective study was conducted, including 106 patients with frequent outflow tract PVCs and 106 healthy participants as controls. HRV was assessed based on the 24-hour Holter recording. The originating foci of PVCs were identified during radiofrequency catheter ablation. RESULTS Patients with frequent outflow tract PVCs exhibited decreased levels of high frequency (HF), standard deviation of all NN intervals, and standard deviation of the average NN intervals, but increased ratios of low frequency to HF (LF/HF ratio), even after propensity score-matched analysis. Further investigation revealed that patients with PVCs originating from right ventricular outflow tract (RVOT) had much higher LF/HF ratios. Multivariate logistic regression analysis demonstrated that the LF/HF ratio was independently associated with PVCs originating from RVOT. Receiver operating characteristics curve indicated that the LF/HF ratio effectively determined the origin of PVCs (the area under the curve = 0.75, p < .001). CONCLUSIONS Patients with frequent outflow tract PVCs exhibited impaired HRV. Additionally, the LF/HF ratio played a significant role in determining the origin of outflow tract PVCs.
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Affiliation(s)
- Baowei Zhang
- Center of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiChina
| | - Jinbo Yu
- Center of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiChina
| | - Yizhang Wu
- Center of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiChina
| | - Xiaorong Li
- Center of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiChina
| | - Xin Xie
- Center of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiChina
| | - Aibin Tao
- Department of Cardiologythe affiliated People's Hospital of Jiangsu UniversityZhenjiangJiangsuChina
| | - Bing Yang
- Center of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiChina
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3
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Prisco AR, Castro JR, Roukoz H, Tholakanahalli VN. Premature Ventricular Complexes: Benign versus Malignant - How to approach? Indian Pacing Electrophysiol J 2023; 23:189-195. [PMID: 37714513 PMCID: PMC10685167 DOI: 10.1016/j.ipej.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/22/2023] [Accepted: 09/12/2023] [Indexed: 09/17/2023] Open
Abstract
Premature Ventricular Complexes (PVCs) refer to electrical activity arising from ventricles resulting in ventricular contraction independent of the native rhythm. PVCs by themselves are common in the general population but based on the origin of the PVCs, either related to anatomical or electrical substrate, the disease process has a widely varied presentation and prognosis. The clinical presentation of symptoms may vary from being extremely benign, or very severe (malignant). Benign PVCs include those that are asymptomatic or induce very mild symptoms including palpitations, lightheadedness, chest discomfort, or the sensation of skipped beats. The middle range of PVCs present as heart failure or heart failure complicated by PVCs. The malignant variety may present as syncope, or sudden cardiac death. In this review we describe the multiple facets of PVC presentation and strategies of clinical management.
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Affiliation(s)
- Anthony R Prisco
- University of Minnesota, Department of Medicine, Division of Cardiology, USA
| | - Jorge Reyes Castro
- University of Minnesota, Department of Medicine, Division of Cardiology, USA
| | - Henri Roukoz
- University of Minnesota, Department of Medicine, Division of Cardiology, USA
| | - Venkatakrishna N Tholakanahalli
- University of Minnesota, Department of Medicine, Division of Cardiology, USA; Minneapolis VA Health Care System, Department of Medicine, Division of Cardiology, USA.
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4
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Tsiachris D, Botis M, Doundoulakis I, Bartsioka LI, Tsioufis P, Kordalis A, Antoniou CK, Tsioufis K, Gatzoulis KA. Electrocardiographic Characteristics, Identification, and Management of Frequent Premature Ventricular Contractions. Diagnostics (Basel) 2023; 13:3094. [PMID: 37835837 PMCID: PMC10572222 DOI: 10.3390/diagnostics13193094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/09/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023] Open
Abstract
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.
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Affiliation(s)
- Dimitris Tsiachris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, “Hippokration” Hospital, 11527 Athens, Greece; (M.B.); (I.D.); (L.I.B.); (P.T.); (A.K.); (C.-K.A.); (K.T.); (K.A.G.)
- Athens Heart Center, Athens Medical Center, 15125 Athens, Greece
| | - Michail Botis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, “Hippokration” Hospital, 11527 Athens, Greece; (M.B.); (I.D.); (L.I.B.); (P.T.); (A.K.); (C.-K.A.); (K.T.); (K.A.G.)
| | - Ioannis Doundoulakis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, “Hippokration” Hospital, 11527 Athens, Greece; (M.B.); (I.D.); (L.I.B.); (P.T.); (A.K.); (C.-K.A.); (K.T.); (K.A.G.)
| | - Lamprini Iro Bartsioka
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, “Hippokration” Hospital, 11527 Athens, Greece; (M.B.); (I.D.); (L.I.B.); (P.T.); (A.K.); (C.-K.A.); (K.T.); (K.A.G.)
| | - Panagiotis Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, “Hippokration” Hospital, 11527 Athens, Greece; (M.B.); (I.D.); (L.I.B.); (P.T.); (A.K.); (C.-K.A.); (K.T.); (K.A.G.)
| | - Athanasios Kordalis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, “Hippokration” Hospital, 11527 Athens, Greece; (M.B.); (I.D.); (L.I.B.); (P.T.); (A.K.); (C.-K.A.); (K.T.); (K.A.G.)
| | - Christos-Konstantinos Antoniou
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, “Hippokration” Hospital, 11527 Athens, Greece; (M.B.); (I.D.); (L.I.B.); (P.T.); (A.K.); (C.-K.A.); (K.T.); (K.A.G.)
- Athens Heart Center, Athens Medical Center, 15125 Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, “Hippokration” Hospital, 11527 Athens, Greece; (M.B.); (I.D.); (L.I.B.); (P.T.); (A.K.); (C.-K.A.); (K.T.); (K.A.G.)
| | - Konstantinos A. Gatzoulis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, “Hippokration” Hospital, 11527 Athens, Greece; (M.B.); (I.D.); (L.I.B.); (P.T.); (A.K.); (C.-K.A.); (K.T.); (K.A.G.)
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Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2022; 43:3997-4126. [PMID: 36017572 DOI: 10.1093/eurheartj/ehac262] [Citation(s) in RCA: 810] [Impact Index Per Article: 405.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Cojocaru C, Penela D, Berruezo A, Vatasescu R. Mechanisms, time course and predictability of premature ventricular contractions cardiomyopathy-an update on its development and resolution. Heart Fail Rev 2022; 27:1639-1651. [PMID: 34510326 DOI: 10.1007/s10741-021-10167-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2021] [Indexed: 01/05/2023]
Abstract
Frequent premature ventricular contractions (PVCs) associated left ventricular systolic dysfunction (LVSD) is a well-known clinical scenario and numerous predictors for cardiomyopathy (CMP) development have been already thoroughly described. It may present as a "pure" form of dissynchrony-induced cardiomyopathy or it may be an aggravating component of a multifactorial structural heart disease. However, the precise risk to develop PVC-induced CMP (which would allow for tailored-patient monitoring and/or early treatment) and the degree of CMP reversibility after PVC suppression/elimination (which may permit appropriate candidate selection for therapy) are unclear. Moreover, there is limited data regarding the time course of CMP development and resolution after arrhythmia suppression. Even less known are the other components of PVC-induced CMP, such as right ventricular (RV) and atrial myopathies. This review targets to synthetize the most recent information in this regard and bring a deeper understanding of this heart failure scenario. The mechanisms, time course (both in experimental models and clinical experiences) and predictors of reverse-remodelling after arrhythmia suppression are described. The novel experience hereby presented may aid everyday clinical practice, promoting a new paradigm involving more complex, multi-level and multi-modality evaluation and possible earlier intervention at least in some patient subsets.
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Affiliation(s)
- C Cojocaru
- Clinical Emergency Hospital, Bucharest, Romania
| | - D Penela
- Heart Institute, Teknon Medical Centre, Barcelona, Spain
| | - Antonio Berruezo
- Medical Centre Teknon, Grupo Quironsalud, Barcelona, Spain. .,Heart Institute, Teknon Medical Centre, Barcelona, Spain.
| | - R Vatasescu
- Clinical Emergency Hospital, Bucharest, Romania
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7
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Dong Y, Li X, Zheng W, Man Y, Liu J, Yu P, Zhang F, Yang B, Cao K. Prevalence and heart rate variability characteristics of premature ventricular contractions detected by 24-hour Holter among outpatients with palpitations in China: a cross-sectional study. BMJ Open 2022; 12:e059337. [PMID: 35918118 PMCID: PMC9351320 DOI: 10.1136/bmjopen-2021-059337] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To analyse the prevalence and heart rate variability (HRV) characteristics of premature ventricular contraction (PVC) detected by 24-hour Holter among Chinese outpatients with palpitations. DESIGN A cross-sectional study. SETTING This study was conducted in a tertiary hospital. PARTICIPANTS A total of 4754 outpatients who received 24-hour Holter for palpitations. MAIN OUTCOME MEASURES Prevalence, HRV time-domain and frequency-domain analyses of 24-hour Holter, and echocardiographic parameters were assessed. Propensity score matching (PSM) was applied to balance baseline variables (age, gender) to decrease the bias between comparison groups. RESULTS The prevalence of PVC was 67.7% (3220/4754), and was higher in men than women (69.9% vs 66.0%, p=0.004); the prevalence of frequent PVCs (PVC burden≥5%) was 7.7% (368/4754). Older patients had the highest frequency of PVC among all patients. However, among 3220 patients with PVC, younger patients' PVC burden was much higher. Matched 1:1 by age and gender, the HRV time-domain parameters in patients with PVC were all lower than those in patients without PVC (all p<0.05); for the HRV frequency-domain parameters, the patients with frequent PVCs had a higher low frequency/high frequency (LF/HF) ratio (5.4 vs 2.8, p<0.001) than those with PVC burden less than 5%. CONCLUSIONS The prevalence of PVC and frequent PVCs were 67.7% and 7.7%, respectively, detected by 24-hour Holter among Chinese outpatients with palpitations. Decreased HRV time-domain parameters suggested the occurrence of PVC, and increased LF/HF ratio represented the imbalance of autonomic nervous system in patients with frequent PVCs. Further studies are needed to understand the HRV indexes in PVC patients.
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Affiliation(s)
- Yan Dong
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiaorong Li
- Department of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wei Zheng
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yilong Man
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jin Liu
- Science and Technology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ping Yu
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Fengxiang Zhang
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Bing Yang
- Department of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Kejiang Cao
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Demir S, Gulsen K, Kepez A, Uslu A, Kup A, Celik M, Kanar BG, Yildirim C, Tulumen E, Akgun T. Predictors of positive response to beta-blockers for treatment of premature ventricular complexes. J Electrocardiol 2021; 70:50-55. [PMID: 34922221 DOI: 10.1016/j.jelectrocard.2021.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/28/2021] [Accepted: 11/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of the present study is to investigate the possible factors that might be predictive of effective antiarrhythmic effect of beta-blockers on premature ventricular complexes (PVC). METHODS Data of 190 eligible consecutive patients to whom beta-blocker therapy had been initiated for treatment of PVC's were retrospectively evaluated. The Holter recording acquired before beta-blocker initiation and the first Holter acquired after beta blocker initiation during follow up was comprehensively evaluated for each patient. Parameters obtained from pre- and post-beta-blocker 24 h Holter recordings were compared with each other and possible predictors were evaluated for positive response to beta-blocker therapy. RESULTS Sixty-one patients (32.1%) were observed to respond beta-blocker therapy with at least 50% reduction of daily PVC burden. Patients who responded to beta-blockers had significantly higher ratio of patients who had positive correlation between hourly heart rate and corresponding hourly PVC number (fast HR-PVC status) compared with non-responders (73.8% vs 48.1%, p < 0.001). Binary logistic regression analysis revealed PVC QRS width (Odds ratio: 0.971; p: 0.037) and fast HR-PVC status (Odds ratio: 2.935; p: 0.007) as the independent predictors of positive response to beta-blockers for treatment of PVC. CONCLUSION Positive correlation between hourly heart rate and PVC incidence was found to be independent positive predictor and PVC QRS width was found to be independent negative predictor of beta-blocker success in our study. This observation might have important clinical implications to guide medical treatment of PVCs in clinical practice.
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Affiliation(s)
- Serdar Demir
- Kartal Koşuyolu Heart Training and Research Hospital, Cardiology Clinic, Istanbul, Turkey
| | - Kamil Gulsen
- Kartal Koşuyolu Heart Training and Research Hospital, Cardiology Clinic, Istanbul, Turkey
| | - Alper Kepez
- Marmara University School of Medicine, Department of Cardiology, Istanbul, Turkey.
| | - Abdulkadir Uslu
- Kartal Koşuyolu Heart Training and Research Hospital, Cardiology Clinic, Istanbul, Turkey
| | - Ayhan Kup
- Kartal Koşuyolu Heart Training and Research Hospital, Cardiology Clinic, Istanbul, Turkey
| | - Mehmet Celik
- Kartal Koşuyolu Heart Training and Research Hospital, Cardiology Clinic, Istanbul, Turkey
| | - Batur Gonenc Kanar
- Marmara University School of Medicine, Department of Cardiology, Istanbul, Turkey
| | - Cagan Yildirim
- Marmara University School of Medicine, Department of Cardiology, Istanbul, Turkey
| | - Erol Tulumen
- Koc University Faculty of Medicine, Department of Cardiology, Istanbul, Turkey
| | - Taylan Akgun
- Kartal Koşuyolu Heart Training and Research Hospital, Cardiology Clinic, Istanbul, Turkey
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Affiliation(s)
- Koji Higuchi
- Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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10
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Tang JKK, Andrade JG, Hawkins NM, Laksman ZW, Krahn AD, Bennett MT, Heilbron B, Chakrabarti S, Yeung-Lai-Wah JA, Deyell MW. Effectiveness of medical therapy for treatment of idiopathic frequent premature ventricular complexes. J Cardiovasc Electrophysiol 2021; 32:2246-2253. [PMID: 34216056 DOI: 10.1111/jce.15150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/20/2021] [Accepted: 06/21/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The relative effectiveness of medical therapy compared with a conservative approach of monitoring in patients with idiopathic frequent premature ventricular complexes (PVCs) is uncertain. We evaluated the effectiveness of medical versus conservative therapy for frequent PVCs. METHODS Patients with frequent PVCs (≥5%) were prospectively enrolled in this cohort study between 2016 and 2020. In patients with normal cardiac function and no structural heart disease, those receiving medical therapy were compared with controls without therapy. Patients were followed longitudinally for change in PVC burden and with serial echocardiography. RESULTS Overall, 120 patients met inclusion criteria (mean: 56.5 ± 14.6 years, 54.2% female) with 53 on beta-blockers or calcium channel blockers (BBs/CCBs), 27 on Class I or III antiarrhythmic drugs (AADs), and 40 patients treated conservatively. Median initial PVC burden ranged from 15.5% to 20.6%. The median relative reduction of PVCs was 32.7%, 30.5%, and 81.3%, in the conservative therapy, BBs/CCBs, and AADs cohorts, respectively. AADs had greater PVC reduction compared with BBs/CCBs (p = 0.017) and conservative therapy (p = 0.045). PVC reduction to <1% was comparable across groups at 35.0%, 17.0%, 33.3%, respectively. Four patients (4/120, 3.3%) developed left ventricular dysfunction. Rates of adverse drug reactions and medication discontinuation were similar between groups, with no serious adverse events noted. CONCLUSION In patients with idiopathic frequent PVCs, BB, and CCB have limited effectiveness in PVC reduction. Class I and III AADs have superior effectiveness for medical therapy in symptomatic patients, but only achieved complete PVC resolution suppression in one-third of patients.
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Affiliation(s)
- Jacky K K Tang
- Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason G Andrade
- Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nathaniel M Hawkins
- Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Zachary W Laksman
- Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew D Krahn
- Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew T Bennett
- Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brett Heilbron
- Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Santabhanu Chakrabarti
- Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - John A Yeung-Lai-Wah
- Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marc W Deyell
- Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
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Hori Y, Temma T, Wooten C, Sobowale C, Chan C, Swid M, Ajijola OA. Cardiac afferent signaling partially underlies premature ventricular contraction-induced cardiomyopathy. Heart Rhythm 2021; 18:1586-1595. [PMID: 33845214 DOI: 10.1016/j.hrthm.2021.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/18/2021] [Accepted: 04/04/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The mechanisms underlying premature ventricular contraction (PVC)-induced cardiomyopathy (PIC) remain unknown. Transient receptor potential vanilloid-1 (TRPV1) afferent fibers are implicated in the reflex processing of cardiac stress. OBJECTIVE The purpose of this study was to determine whether cardiac TRPV1 afferent signaling promote PIC. METHODS A PIC swine model (50% PVC burden) was created via an implanted pacemaker. We selectively depleted cardiac TRPV1 afferent fibers using percutaneous epicardial application of resiniferatoxin (RTX). Animals were randomized to PVC only (n = 11), PVC+RTX (n = 11), or control (n = 6). We examined early-stage (4 weeks after implantation; n = 5) and late-stage PIC (8 weeks after implantation; n = 6). At terminal experimentation, animals underwent echocardiography, serum sampling, and physiological and autonomic reflex testing. RESULTS Depletion of cardiac TRPV1 afferents by RTX treatment was confirmed by absent sensory fibers and absent functional responses to TRPV1 activators. Left ventricular ejection fraction was worse in late-stage than early-stage PIC (P <.01). At 4 weeks (early stage), left ventricular ejection fraction was higher in PVC+RTX vs PVC animals (51.7% ± 1.6% vs 45.0% ± 2.1%; P = .030), whereas no significant difference between PVC and PVC+RTX was observed at 8 weeks (late stage). Histologic studies demonstrated reduced fibrosis in PVC+RTX vs PVC alone at 4 weeks (2.27% ± 0.14% vs 3.01% ± 0.21%; P = .020), suggesting that RTX mitigated profibrotic pathways induced by persistent PVCs. CONCLUSION TRPV1 afferent depletion alleviates left ventricular dysfunction in early- but not late-stage PIC. This temporal effect suggests that multiple pathways promote PIC, of which TRPV1 afferents are a part.
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Affiliation(s)
- Yuichi Hori
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, University of California, Los Angeles, California
| | - Taro Temma
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, University of California, Los Angeles, California
| | - Christian Wooten
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, University of California, Los Angeles, California
| | - Christopher Sobowale
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, University of California, Los Angeles, California
| | - Christopher Chan
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, University of California, Los Angeles, California
| | - Mohammed Swid
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, University of California, Los Angeles, California
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, University of California, Los Angeles, California.
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Demir S, Gulsen K, Kepez A, Uslu A, Kup A, Kanar BG, Kayan F, Yildirim C, Akgun T. Predictors of adequate intraprocedural premature ventricular complex (PVC) frequency during idiopathic PVC ablation. Herz 2021; 46:476-481. [PMID: 33464357 DOI: 10.1007/s00059-020-05017-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 11/10/2020] [Accepted: 12/20/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of the present study was to determine the predictors of adequate intraprocedural premature ventricular complex (PVC) frequency for successful mapping and ablation of idiopathic PVCs. METHODS A total of 101 consecutive patients (45 men; age: 47.9 ± 14.2 years) who had undergone idiopathic PVC ablation between 01 November 2018 and 24 June 2020 constituted our study population. Clinical and demographic data, procedural details and 24 h rhythm recordings that had been recorded before the procedure were retrospectively evaluated. Total PVC burden and diurnal variability assessed by the ratio of night time (22:00-06:00) over day time (06:00-22:00) PVC burden was calculated. The relationship between hourly PVC number and heart rate was also evaluated for each patient. Clinical characteristics and Holter parameters were compared between groups with and without adequate intraprocedural frequency of PVCs that permitted activation mapping. RESULTS In all, 27 patients (26.7%) had infrequent intraprocedural PVCs which necessitated isoproterenol infusion or cancellation of ablation procedure due to inability of activation mapping. PVC burden was significantly higher in the group with frequent intraprocedural PVCs (26.1 ± 9.4% vs 21.2 ± 10.3%; p: 0.026). There were no significant differences between groups regarding the relationship between hourly PVC number and heart rate or the ratio of night/day PVC burden. Binary logistic regression analysis revealed the 24 h Holter PVC burden as the sole parameter that is significant predictor of frequent intraprocedural PVCs permitting activation mapping. CONCLUSION The 24 h PVC burden was the only predictor of adequate intraprocedural PVC frequency permitting activation mapping during idiopathic PVC ablation.
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Affiliation(s)
- Serdar Demir
- Cardiology Clinic, Kartal Kosuyolu High Speciality Educational and Research Hospital, Istanbul, Turkey
| | - Kamil Gulsen
- Cardiology Clinic, Kartal Kosuyolu High Speciality Educational and Research Hospital, Istanbul, Turkey
| | - Alper Kepez
- Department of Cardiology, Marmara University School of Medicine, Istanbul, Turkey.
| | - Abdulkadir Uslu
- Cardiology Clinic, Kartal Kosuyolu High Speciality Educational and Research Hospital, Istanbul, Turkey
| | - Ayhan Kup
- Cardiology Clinic, Kartal Kosuyolu High Speciality Educational and Research Hospital, Istanbul, Turkey
| | - Batur Gonenc Kanar
- Department of Cardiology, Marmara University School of Medicine, Istanbul, Turkey
| | - Fethullah Kayan
- Cardiology Clinic, Mardin Kiziltepe State Hospital, Mardin, Turkey
| | - Cagan Yildirim
- Department of Cardiology, Marmara University School of Medicine, Istanbul, Turkey
| | - Taylan Akgun
- Cardiology Clinic, Kartal Kosuyolu High Speciality Educational and Research Hospital, Istanbul, Turkey
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13
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Bertels RA, Kammeraad JAE, Zeelenberg AM, Filippini LH, Knobbe I, Kuipers IM, Blom NA. The Efficacy of Anti-Arrhythmic Drugs in Children With Idiopathic Frequent Symptomatic or Asymptomatic Premature Ventricular Complexes With or Without Asymptomatic Ventricular Tachycardia: a Retrospective Multi-Center Study. Pediatr Cardiol 2021; 42:883-890. [PMID: 33515328 PMCID: PMC8110481 DOI: 10.1007/s00246-021-02556-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 01/15/2021] [Indexed: 11/26/2022]
Abstract
The aim of the study is to compare the efficacy of flecainide, beta-blockers, sotalol, and verapamil in children with frequent PVCs, with or without asymptomatic VT. Frequent premature ventricular complexes (PVCs) and asymptomatic ventricular tachycardia (VT) in children with structurally normal hearts require anti-arrhythmic drug (AAD) therapy depending on the severity of symptoms or ventricular dysfunction; however, data on efficacy in children are scarce. Both symptomatic and asymptomatic children (≥ 1 year and < 18 years of age) with a PVC burden of 5% or more, with or without asymptomatic runs of VT, who had consecutive Holter recordings, were included in this retrospective multi-center study. The groups of patients receiving AAD therapy were compared to an untreated control group. A medication episode was defined as a timeframe in which the highest dosage at a fixed level of a single drug was used in a patient. A total of 35 children and 46 medication episodes were included, with an overall change in PVC burden on Holter of -4.4 percentage points, compared to -4.2 in the control group of 14 patients. The mean reduction in PVC burden was only significant in patients receiving flecainide (- 13.8 percentage points; N = 10; p = 0.032), compared to the control group and other groups receiving beta-blockers (- 1.7 percentage points; N = 18), sotalol (+ 1.0 percentage points; N = 7), or verapamil (- 3.9 percentage points; N = 11). The efficacy of anti-arrhythmic drug therapy on frequent PVCs or asymptomatic VTs in children is very limited. Only flecainide appears to be effective in lowering the PVC burden.
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Affiliation(s)
- Robin A Bertels
- Willem-Alexander Children's Hospital-Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, Leiden, the Netherlands.
| | - Janneke A E Kammeraad
- Sophia Children's Hospital-Erasmus Medical Center, Dr. Molewaterplein 40, Rotterdam, the Netherlands
| | - Anna M Zeelenberg
- Willem-Alexander Children's Hospital-Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, Leiden, the Netherlands
| | - Luc H Filippini
- Juliana Children's Hospital-HAGA Hospital, Els Borst-Eilersplein 275, The Hague, the Netherlands
| | - Ingmar Knobbe
- VU Medical Center-Amsterdam UMC, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Irene M Kuipers
- Emma Children's Hospital-Amsterdam UMC, Meibergdreef 9, Amsterdam, the Netherlands
| | - Nico A Blom
- Willem-Alexander Children's Hospital-Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, Leiden, the Netherlands
- Emma Children's Hospital-Amsterdam UMC, Meibergdreef 9, Amsterdam, the Netherlands
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Bury TM, Lerma C, Bub G, Laksman Z, Deyell MW, Glass L. Long ECGs reveal rich and robust dynamical regimes in patients with frequent ectopy. CHAOS (WOODBURY, N.Y.) 2020; 30:113127. [PMID: 33261339 DOI: 10.1063/5.0023987] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/26/2020] [Indexed: 06/12/2023]
Abstract
We have analyzed the electrocardiographic data collected during continuous 7-day ambulatory recordings in patients with frequent premature ventricular complexes (PVCs). We analyze the dependence of the frequency and patterns of PVCs on the heart rate and the time of the day. Patients display rhythms of a complex yet consistent structure. In a given patient, the pattern remains robust over different days and particular repetitive patterns appear at specific heart rates, suggesting the appearance of bifurcations in the dynamics. Over the course of 24 h, we find that in some patients, patterns appear to depend only on the heart rate, whereas in others, both the time of the day and the heart rate play a role in controlling the dynamics. Identifying parameter values at which bifurcations occur facilitates the development of dynamical models for arrhythmia. The use of powerful recording and analysis techniques will enable improved analysis of data and better understanding of mechanisms of arrhythmia in individual patients.
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Affiliation(s)
- T M Bury
- Department of Physiology, McGill University, 3655 Promenade Sir William Osler, Montreal, Quebec H3G 1Y6, Canada
| | - C Lerma
- Departamento de Instrumentación Electromecánica, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico
| | - G Bub
- Department of Physiology, McGill University, 3655 Promenade Sir William Osler, Montreal, Quebec H3G 1Y6, Canada
| | - Z Laksman
- Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia V6E 1M7, Canada
| | - M W Deyell
- Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia V6E 1M7, Canada
| | - L Glass
- Department of Physiology, McGill University, 3655 Promenade Sir William Osler, Montreal, Quebec H3G 1Y6, Canada
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15
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He YE, Xue YZ, Gharbal A, Qiu HX, Zhang XT, Wu RZ, Wang ZQ, Rong X, Chu MP. Efficacy of radiofrequency catheter ablation for premature ventricular contractions in children. J Interv Card Electrophysiol 2020; 60:535-542. [PMID: 32430761 DOI: 10.1007/s10840-020-00753-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/14/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE This study evaluated the efficacy and safety of transcatheter radiofrequency ablation (RFCA) in treating ventricular premature contractions (PVCs) in children, summarized the countermeasures during intraoperative ventricular fibrillation (VF), and improved the safety of ventricular premature treatment. METHODS A retrospective analysis was conducted on 75 children with PVCs who received RFCA in the Second Affiliated Hospital of Wenzhou Medical University from January 2010 to April 2019. Data including age, sex, body weight, ejection fraction, left ventricular end diastolic diameter, burden and number of PVCs/24 h, origin of PVCs, and its complications were collected. Paired t test was used to compare changes in cardiac function before and after surgery. RESULTS Among the 75 cases treated with RFCA, 68 were successfully ablated, giving a success rate of 90.67%. After ablation, the left ventricular ejection fraction (LVEF) of the children was 69.13 ± 3.81%, which was significantly higher than that before surgery (69.13 ± 3.81% vs. 66.21 ± 3.22%, P = 0.012). One of the patients experienced VF during the operation, with no other complications. The initial locus of origin was the anterior septum of the right ventricular outflow tract, but VF occurred during the ablation process. Mean follow-up time was 39 ± 33 months, with two recurrent cases (2.94%). CONCLUSIONS Performing RFCA in children is safe and effective, with a low recurrence rate and few complications. VF is not an indication to cease surgery; the key to eliminating complications is repositioning the catheter and finding a more accurate origin point.
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Affiliation(s)
- Yue-E He
- Children's Heart Centre, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Yue-Zhen Xue
- Children's Heart Centre, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Abdulla Gharbal
- Children's Heart Centre, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Hui-Xian Qiu
- Children's Heart Centre, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Xu-Ting Zhang
- Children's Heart Centre, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Rong-Zhou Wu
- Children's Heart Centre, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Zeng-Quan Wang
- Children's Heart Centre, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Xing Rong
- Children's Heart Centre, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China
| | - Mao-Ping Chu
- Children's Heart Centre, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang, China.
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16
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Koca H, Kucukosmanoglu M, Icen YK, Koca F, Ardıc ML, Koc M. A new approach to radiofrequency catheter ablation of premature ventricular contractions: The diurnal variation index. J Electrocardiol 2020; 59:106-111. [DOI: 10.1016/j.jelectrocard.2020.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/22/2019] [Accepted: 01/08/2020] [Indexed: 10/25/2022]
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17
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Editorial commentary: Cardiac arrest and the young: Will we ever be able to predict the unpredictable? Trends Cardiovasc Med 2020; 31:125-126. [PMID: 32115339 DOI: 10.1016/j.tcm.2020.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 02/08/2020] [Indexed: 11/20/2022]
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18
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O’Quinn MP, Mazzella AJ, Kumar P. Approach to Management of Premature Ventricular Contractions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:53. [DOI: 10.1007/s11936-019-0755-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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