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Background: Premature Ventricular Complexes (PVCs) are very common in clinical practice, with frequent PVCs (more than 30 beats per hour) or polymorphic PVCs significantly increasing the risk of mortality. Previous studies have shown that vagus nerve stimulation improves ventricular arrhythmias. Stimulation of the auricular distribution of the vagus nerve has proven to be a simple, safe, and effective method to activate the vagus nerve. Transcutaneous au ricular vagus nerve stimulation (taVNS) has shown promise in both clinical and experimental setting for PVCs; however, high-quality clinical studies are lacking, resulting in insufficient evidence of efficacy., Methods: The study is a prospective, randomized, parallel-controlled trial with a 1:1 ratio between the two groups. Patients will be randomized to either the treatment group (taVNS) or the control group (Sham-taVNS) with a 6-week treatment and a subsequent 12-week follow-up period. The primary outcome is the proportion of patients with a ≥ 50% reduction in the number of PVCs monitored by 24-hour Holter. Secondary outcomes include the proportion of patients with a ≥ 75% reduction in PVCs, as well as the changes in premature ventricular beats, total heartbeats, and supraventricular premature beats recorded by 24-hour Holter. Additional assessments compared score changes in PVCs-related symptoms, as well as the score change of self-rating anxiety scale (SAS), self-rating depression scale (SDS), and 36-item short form health survey (SF-36)., Discussion: The TASC-V trial will help to reveal the efficacy and safety of taVNS for frequent PVCs, offering new clinical evidence for the clinical practice., Trial Registration: Clinicaltrials.gov: NCT04415203 (Registration Date: May 30, 2020)., (© 2024. The Author(s).)

Ventricular tachycardia (VT) is a rare but potentially fatal complication in pregnancy. We present a case of a pregnant woman with cardiomyopathy due to frequent premature ventricular complexes (PVCs) and VT originating from the left ventricular outflow tract. After presenting late in the third trimester, the decision was made to deliver the fetus after 4 days of medication titration due to continued sustained episodes of VT. After delivery, the patient continued to have frequent PVCs and VT several months after discharge, and she ultimately underwent a PVC ablation with dramatic reduction in PVC burden and improvement in cardiomyopathy. Multidisciplinary planning with a pregnancy heart team led to appropriate contingency planning and a successful delivery. This case highlights how multidisciplinary management is best practice in pregnancy complicated by VT and the need for better diagnostic guidelines for PVC-induced cardiomyopathy in the setting of pregnancy., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Ventricular bigeminy due to myocardial ischemia has been reported in humans as well as in canine patients with obstructive gastrointestinal diseases. This is the first case report of ventricular bigeminy in a dog with a colonic torsion that resolved after fluid resuscitation and restoration of myocardial perfusion., Case Presentation: An 11-year-old, male neutered mixed breed dog presented with a one day history of vomiting, tenesmus, and lethargy. Physical examination identified an irregular heart rhythm and intermittent pulse deficits. A ventricular arrhythmia represented by ventricular premature complexes (VPCs) organized in bigeminy, was appreciated on a 3-lead electrocardiogram (ECG) with a single lead (II) view. Abdominal radiographs confirmed a colonic torsion. Prior to anesthetic induction, ventricular bigeminy was non responsive to fentanyl or lidocaine. The patient was anesthetized and intravascular volume deficit was identified by dampened plethysmographic wave amplitude (plethysomographic variability), audible softening of the Doppler sound, and more pronounced pulse deficits. Fluid resuscitation was achieved with a combination of intravenous crystalloid and colloid fluid therapy comprising 7.2% hypertonic saline and 6% hetastarch. The patient's cardiac rhythm converted to normal sinus after fluid resuscitation. The colonic torsion was surgically corrected. The patient recovered well from anesthesia and was ultimately discharged from the hospital 5 days later., Conclusions: The present case report highlights that myocardial ischemia can lead to ventricular arrythmias, such as ventricular bigeminy. This is the first documented case of ventricular bigeminy in the canine patient with a colonic torsion. Assessment of patient volume status and appropriate fluid resuscitation along with continuous electrocardiogram (ECG) monitoring are vital to patient stability under general anesthesia., (© 2024. The Author(s).)

Background: The 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 Design: The 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., Discussion: The 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 Registration: ClinicalTrial.gov NCT04909528. Registered on 17 June 2021. World health organization trial registration data set was shown in Supplementary Table 1., (© 2023. BioMed Central Ltd., part of Springer Nature.)

With an aging population and an explosion in ambulatory electrocardiographic monitoring, primary care clinicians will undoubtedly see an increase in patients presenting with premature ventricular complexes (PVCs), especially given how common they are in the general population. A sizable number of patients with PVCs are asymptomatic, and these PVCs have no significant clinical implications. In contrast, PVCs can predispose patients to or are a clinical marker of an underlying cardiomyopathy, heart failure, or sudden cardiac death. Such a dichotomy can create fear in dealing with PVCs in the outpatient setting, both in immediate situations and for surveillance and follow-up. In this review, we provide a comprehensive overview of the pathophysiologic basis of PVCs, appropriate diagnostic testing, management, and prognostic considerations necessary when faced with PVCs in the outpatient clinic. We also provide a simplistic approach to help guide the initial work-up of PVCs, basic treatment strategies, and indications of when to refer for cardiovascular specialty consultation to improve physician comfort and to enhance patient care., (Copyright © 2023 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

There is variability in treatment modalities for premature ventricular complexes (PVCs), including use of antiarrhythmic drug (AAD) therapy or catheter ablation (CA). This study reviewed evidence comparing CA vs AADs for the treatment of PVCs. A systematic review was performed from the Medline, Embase, and Cochrane Library databases, as well as the Australian and New Zealand Clinical Trials Registry, U.S. National Library of Medicine ClinicalTrials database, and the European Union Clinical Trials Register. Five studies (1 randomized controlled trial) enrolling 1,113 patients (57.9% female) were analyzed. Four of five studies recruited mainly patients with outflow tract PVCs. There was significant heterogeneity in AAD choice. Electroanatomic mapping was used in 3 of 5 studies. No studies documented intracardiac echocardiography or contact force-sensing catheter use. Acute procedural endpoints varied (2 of 5 targeted elimination of all PVCs). All studies had significant potential for bias. CA seemed superior to AADs for PVC recurrence, frequency, and burden. One study reported long-term symptoms (CA superior). Quality of life or cost-effectiveness was not reported. Complication and adverse event rates were 0% to 5.6% for CA and 9.5% to 21% for AADs. Future randomized controlled trials will assess CA vs AADs for patients with PVCs without structural heart disease (ECTOPIA [Elimination of Ventricular Premature Beats with Catheter Ablation versus Optimal Antiarrhythmic Drug Treatment]), with impaired LVEF (PAPS [Prospective Assessment of Premature Ventricular Contractions Suppression in Cardiomyopathy] Pilot), and with structural heart disease (CAT-PVC [Catheter Ablation Versus Amiodarone for Therapy of Premature Ventricular Contractions in Patients With Structural Heart Disease]). In conclusion, CA seems to reduce recurrence, burden, and frequency of PVCs compared with AADs. There is a lack of data on patient- and health care-specific outcomes such as symptoms, quality of life, and cost-effectiveness. Several upcoming trials will offer important insights for management of PVCs., Competing Interests: Funding Support and Author Disclosures Dr Kumar was supported in part from the NSW Early-Mid Career Fellowship; and has received research grants from Abbott Medical and Biotronik; and honoraria from Biosense Webster, Abbott Medical, Biotronik, and Sanofi Aventis. Dr De Silva is supported by a postgraduate research scholarship from the National Health and Medical Research Council of Australia. Dr Mahajan is supported by The Hospital Research Foundation Mid-Career Fellowship. Dr Qian was supported by an NSW Early-Mid Career Fellowship and Heart Foundation Postdoctoral Fellowship (105197).Mr Campbell has received speaker honoraria from Biosense Webster in the last 12 months. Dr Mahajan has served on the advisory board of Abbott and Medtronic. The University of Adelaide reports receiving on behalf of Dr Mahajan lecture and/or consulting fees from Abbott, Bayer, Biotronik, Medtronic, and Pfizer and research funding from Abbott, Bayer, and Medtronic. Dr Haqqani has received speaker honoraria from Boston Scientific and Abbott. Dr Lee has received consulting fees from Biosense Webster. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. All rights reserved.)

The recent 2022 European Society of Cardiology Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death are an update of the former 2015 European guidelines. With multiple tables, algorithms, and comprehensive integration of underlying study data, the new guideline is a user-oriented reference book for clinical practice that also covers special clinical situations such as cardiac arrhythmias in pregnancy or in the context of sports. Regarding the acute treatment of ventricular arrhythmias, cardioversion is now recommended in case of hemodynamically tolerated arrhythmias. Beyond that, the guideline places special emphasis on the management of the electrical storm. In long-term therapy, recommendations for drug therapy have been aligned with current heart failure guidelines. Catheter ablation of ventricular arrhythmias has gained importance not only for recurrent ventricular tachycardia under chronic amiodarone therapy and as an alternative to implantable cardioverter-defibrillators (ICDs) in selected patients with coronary artery disease, but especially for the treatment of idiopathic premature ventricular contractions and tachycardias. Risk stratification and criteria for primary preventive ICDs are still controversial topics, which are discussed in detail based on the specific disease entities., (© 2022. The Author(s).)

Premature ventricular complexes/contractions (PVCs) are relatively common, occurring in 3%-20% of the general population, and are often found during work-up of palpitations or incidentally on routine electrocardiographic testing. They are usually considered benign but can be a sign of underlying cardiac disease and cause significantly impairing symptoms. While often thought of as a problem for the cardiologist, it is not uncommon for PVCs to be identified initially in a primary care or inpatient general medicine setting. This paper will review etiologies, epidemiology, evaluation, and management of PVCs for the internist., (Copyright © 2022 Elsevier Inc. All rights reserved.)

There is a growing body of literature focusing on the morphology, management, and outcomes of PVCs in athletes. This review summarizes this literature and establishes recommendations on management, treatment, and indications for specialist referral in this patient population. The sports medicine physician's responses and recommendation should be made in conjunction with the athletes wishes. Medications or ablations are not always necessary in all athletes if they are followed with regular evaluations., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

On behalf of the European Heart Rhythm Association, we designed a survey, whose aim was to understand the trend(s) in the clinical management of idiopathic monomorphic premature ventricular contractions (PVCs) among European cardiologists and cardiac electrophysiologists. A total of 202 participants in the survey answered 27 multiple-choice questions on the clinical presentation, diagnosis and treatment of idiopathic monomorphic PVCs. The most common symptom in patients with idiopathic monomorphic PVCs is palpitations, according to the majority of responders (87%), followed by fatigue (29%) and dizziness (18%). Complete blood cell count, renal function with electrolytes levels, and thyroid function are the blood tests requested by the majority of respondents (65%, 92%, and 93%, respectively). Coronary artery disease and structural heart disease needs to be ruled out, according to the vast majority of participants (99%). A 24-h Holter ECG is the preferred ECG modality to assess the burden of PVCs (86% of respondents). Among the different option treatments, beta-blockers and class I antiarrhythmic drugs are by far (81% of respondents) the preferred pharmacological option in comparison with calcium antagonists and class III antiarrhythmic drugs. Catheter ablation has also a good reputation: 99% of responders are keen to use it, especially in patients with high burden of PVCs and when signs of cardiomyopathy occur., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: journals.permissions@oup.com.)

Background: We lack data on the effect of single premature ventricular contractions (PVCs) on the clinical and echocardiographic response after cardiac resynchronization therapy (CRT) device implantation. We aimed to assess the predictive value of PVCs at early, 1 month-follow up on echocardiographic response and all-cause mortality., Methods: In our prospective, single-center study, 125 heart failure patients underwent CRT implantation based on the current guidelines. Echocardiographic reverse remodeling was defined as a ≥ 15% improvement in left ventricular ejection fraction (LVEF), end-systolic volume (LVESV), or left atrial volume (LAV) measured 6 months after CRT implantation. All-cause mortality was investigated by Wilcoxon analysis., Results: The median number of PVCs was 11,401 in those 67 patients who attended the 1-month follow-up. Regarding echocardiographic endpoints, patients with less PVCs develop significantly larger LAV reverse remodeling compared to those with high number of PVCs. During the mean follow-up time of 2.1 years, 26 (21%) patients died. Patients with a higher number of PVCs than our median cut-off value showed a higher risk of early all-cause mortality (HR 0.97; 95% CI 0.38-2.48; P = 0.04). However, when patients were followed up to 9 years, its significance diminished (HR 0.78; 95% CI 0.42-1.46; P = 0.15)., Conclusions: In patients undergoing CRT implantation, lower number of PVCs predicted atrial remodeling and showed a trend for a better mortality outcome. Our results suggest the importance of the early assessment of PVCs in cardiac resynchronization therapy and warrant further investigations., (© 2022. The Author(s).)

Competing Interests: Competing interests: None declared.

We describe the unique phenomenon of occlusive venogram-induced suppression of premature ventricular complexes (PVC) arising from the epicardial left ventricular summit (LVS). Prior to ablation through the coronary sinus, routine occlusive venogram performed at the focus of PVC origin led to localized myocardial staining and simultaneous, sustained PVC suppression. Pace-mapping adjacent to the area of myocardial staining revealed near-identical PVC morphology match (98%). Routine occlusive venogram prior to ablation within the coronary venous system is safe and contributed to localization of the PVC focus., (© 2021 Wiley Periodicals LLC.)

Background: Premature ventricular contractions are the most common type of arrhythmia. The clinical symptoms are mainly palpitations. In severe cases, syncope, angina pectoris and heart failure may occur, which seriously affect people's lives and ability to work. Antiarrhythmic drugs have many side effects and should not be taken for long periods. Acupuncture has a significant effect on the treatment of premature ventricular contractions. Therefore, to evaluate the effectiveness and safety of acupuncture in the treatment of premature ventricular contractions, we conducted this study, with the goal of providing a scientific methodology for this alternative treatment., Methods: We searched PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wanfang Database, China Science Journal Database, and China Biomedical Literature Database. We selected all randomized clinical trials related to the use of acupuncture in the treatment of premature ventricular contractions published on or before October 10, 2021, and we will conduct literature screening and data extraction based on specific inclusion and exclusion criteria. We will use the bias risk assessment tool from the Cochrane Systematic Review Manual to evaluate the quality of the research selected for inclusion in our study. RevMan5.3 software will be used to perform statistical analysis on the data., Results: The results of this study will provide evidence for the effectiveness and safety of acupuncture in the treatment of premature ventricular contractions., Conclusion: The purpose of this study is to explore the efficacy of acupuncture in the treatment of patients with premature ventricular contractions and to provide an effective reference for clinicians and patients on its use., Inplasy Registration Number: INPLASY2021100040., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

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., (Published by Elsevier Inc.)

Background: Prediction of sudden cardiac death remains a significant challenge. There is some evidence that ventricular ectopic activity could be regarded as a predictive marker., Objectives: We carried out an analysis to explore whether premature ventricular complexes (PVCs) are a risk factor in implantable cardioverter-defibrillator (ICD) interventions., Material and Methods: The study method was a RR interval series analysis (n = 184) of arrhythmic events and controls from the ICD. Study group consisted of patients with a mean age of 55 ±27 years; 74% of them were male, 85% were secondary prevention patients, 62% had coronary artery disease (CAD), 15% hypertropic cardiomyopathy (HCM), 15% dilated cardiomyopathy (DCM), and 8% diseases of other etiology. The mean follow-up time was 64 months (range: 3-126 months). The study population was divide into patients with at least 1 appropriate intervention ventricular tachycardia/ventricular fibrillation (VT/VF) (group A, n = 101) and controls without interventions (group B, n = 83). The number of PVC/4000 RR cycles, the shortest coupling intervals between a PVC and preceding R as well as the number of PVCs of very short (180-220 ms), short (220-280 ms) and different cycle lengths (CL) as well as the incidence of short-long-short (SLS) sequences were compared., Results: The number of PVCs/4000 RR cycles was significantly higher in group A (263 ±32 compared to 43 ±17, p < 0.0001). The mean shortest PVC CL was significantly shorter in group A (320 ±13 compared to 400 ±38, p = 0.029). The number of PVCs with a very short CL was 1 ±0.4 compared to 0.1 ±0.1 (p = 0.028). The number of PVCs with a short CL was 5 ±1.2 compared to 0.6 ±0.4 (p = 0.0007) in groups A and B, respectively. The incidence of SLS sequences was significantly higher in group A than in group B (67 (94% of patients) and 4 (33% of patients) respectively (p < 0.0001))., Conclusions: Significant differences were found in the characteristics of PVCs and SLS sequences between patients with appropriate ICD interventions and controls. A newly developed basic computer program called PCRR was applied for RR interval analysis. This simple method could be a predictor of PVC burden and life-threatening arrhythmias in different populations.

Cardiac resynchronization therapy (CRT) is an integral part in the treatment of chronic heart failure. However, a high degree of biventricular pacing is essential for the effectiveness of this therapy. In addition to atrial fibrillation, premature ventricular contractions (PVC) are a common cause of reduced biventricular stimulation in CRT. In addition to the prognostically unfavorable reduction of biventricular pacing, PVC are generally associated with reduced outcome in the presence of structural heart disease. Options to increase biventricular stimulation percentage by reprogramming the CRT devices are limited in the majority of cases. Due to the mutual relationship between cardiomyopathy and ventricular arrhythmias, adequate heart failure therapy is essential for the reduction of ventricular ectopy. In addition to beta-blocker therapy, specific antiarrhythmic medication is mostly limited to class III antiarrhythmic drugs due to the structural heart disease usually present in CRT patients. Catheter ablation is superior to pharmacological therapy especially in the field of idiopathic PVC, but promising data are also available for catheter ablation of PVC in structural heart disease and CRT nonresponders.

Introduction: Hemodynamically-instable ventricular arrhythmias (VAs) are rare in patients with pulmonary hypertension (PH). To the best of our knowledge, only 1 case has been reported so far. Moreover, the pathogenesis of this kind of arrhythmia remains obscured and its treatment is challenging. Here we report another case and presented the substrate for VAs initiation and therapeutic effect of radiofrequency ablation., Patient Concerns: This is a 57-year-old man who presented paroxysmal palpitation associated with presyncope at rest. Surface electrocardiogram (ECG) revealed frequent ventricular premature contractions and non-sustained ventricular tachycardia when symptoms occurred. He also had a history of severe PH which was secondary to atrial septal defect and partial anomalous pulmonary venous drainage and suffered from obvious dyspnea when climbing stairs World Health Organization Class III (WHO Class III)., Diagnosis: Hemodynamically-instable VAs associated with severe PH., Intervention: Echocardiography revealed enlargement of right ventricle (right ventricle [RV]: 43 mm). Electrophysiological examination showed the origin of VAs is next to a small low-voltage zone of RV. Radiofrequency delivery at the origin successfully terminated VAs without occurrence of complication., Outcome: The patient was free from arrhythmias and got an improvement of exercise tolerance, just with mild dyspnea when climbing stairs World Health Organization Class II (WHO class II), during six-month follow up., Lessons: This case suggests the low-voltage zone of remodeled RV, which may be secondary to increased pulmonary artery pressure, serves as the substrate for VAs initiation in patient with PH. Radiofrequency ablation can successfully terminate VAs and the termination of VAs can significantly improve the patient's impaired exercise tolerance., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Premature ventricular complexes (PVCs) are often observed in patients presenting with heart failure with a reduced ejection fraction (HFrEF). PVCs may in some patients be considered to be the cause of heart failure, while in others it may be the consequence of heart failure. PVCs are important prognostic markers in HFrEF. The uncertainty whether PVCs are the cause or effect in HFrEF impacts clinical decision making. In this review, we discuss the complexity of the cause-effect relationship between PVCs and HFrEF. We demonstrate a workflow with the use of a trial period of amiodarone that may discover whether the reduced LVEF is reversible, the symptoms are due to PVCs and whether biventricular pacing can be increased by the reduction of PVCs. The use of non-invasive and invasive (high-density) mapping techniques may help to improve accuracy and efficacy in the treatment of PVC, which will be demonstrated. With these results in mind, we conclude this review highlighting the future directions for PVC research and treatment., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Mitral valve prolapse affects up to 3% of the population, with an annual risk of death of up to 2% a year. Presentation is often in the third to fourth decade of life. This report details an adolescent with mitral valve prolapse with non-specific symptoms but investigative findings of ventricular ectopy at higher heart rates. These patients warrant close surveillance to monitor for progressive arrhythmias and may progress to need an ICD., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Premature ventricular complexes (PVCs) are one of the most common arrhythmias seen in daily practice. Although PVCs are generally considered benign, they can lead to the development of cardiomyopathy and, rarely, can be associated with sudden cardiac death. Recently, the American College of Cardiology Electrophysiology Council published a state-of-the-art review on PVCs to provide diagnostic and therapeutic considerations for clinical practice. Presented are some important points about the diagnosis, approach, and treatment of PVCs.

Introduction: Ventricular ectopic beats (VEBs) are very common and often occur in hypertensive or obese individuals, as well as in patients presenting with either sleep apnea or structural cardiac disease. Sympathetic overactivity plays a crucial role in the development, continuation, and exacerbation of ventricular arrhythmias. Recent studies have reported the relevance of sympathetic activation in patients with ventricular arrhythmias and suggested a potential role for catheter-based renal denervation (RDN) in reducing the arrhythmic burden., Patient Concerns: We describe a 38-year-old female symptomatic patient that at the time of presentation was complaining of fatigue in response to minor and medium efforts and not tolerating any physical activity, and episodes of tachycardia associated with dyspnoea, pre-syncope, and syncope., Diagnosis: She had a high incidence of polymorphic VEBs on 24-hour-Holter monitoring who also presented with left ventricular (LV) hypertrophy for which she was treated with bisoprolol 10 mg/d. The 24-hour-Holter on bisoprolol at baseline showed sinus rhythm with an average heart rate of 92 bpm. There were 44,743 isolated VEBs. A total of 2538 nonsustained ventricular tachycardia events were registered. Her cardiac magnetic resonance imaging showed an increase in LV diastolic diameter and impairment of the right ventricle., Interventions: The patient underwent endocardial ablation of the right ventricular outflow tract and the LV free lateral wall, and concomitantly underwent bilateral RDN., Outcomes: Three months post-procedure, her 24-hour-Holter off medication demonstrated an average heart rate 72 bpm and a substantially reduced number of 2823 isolated monomorphic VEBs. Thus far, 18-months follow-up, she has been asymptomatic and doing physical exercises., Conclusion: In our current patient, we used RDN as a synergistic method to attenuate the sympathetic overactivity, which is narrowly linked to VEBs appearance. Our case report highlighted that RDN may become a potential adjuvant treatment for VEBs in the future.

Premature ventricular complex (PVC) is common in the general population. Symptoms vary from none to pronounced. The prognostic significance of PVC's depends on the presence of underlying structural heart disease. The clinical evaluation in patients with PVC aims at excluding structural heart disease and usually involves transthoracic echocardiogram and Holter. Patients without structural heart disease usually have a good prognosis. Frequent PVC's may cause impaired left ventricular function, which usually is reversible after treatment with drugs or ablation. A 12-lead ECG provides important information about PVC localization, however anatomical factors such as the heart's localization in the thorax as well as electrode placement and pharmacological treatment may affect the ECG appearance. In symptomatic patients with or without left ventricular impairment, pharmacological treatment or catheter ablation is indicated. However, in most cases the main goal is to reasure the patient of the good prognosis. To summarize, treatment of choice depends on symptoms, comorbidities, left ventricular function and patient's choice.

The case concerns a difficult but successful right ventricular outflow tract ectopy catheter ablation in a fit and well 33-year-old man with a 16-year history of symptomatic premature ventricular contractions (PVCs). Beta blockade medication had become ineffective in suppressing the PVCs, and a 24-hour Holter monitor revealed a high burden of ectopy (10%). An echocardiogram and cardiac MRI showed a structurally normal heart. During the procedure, it became impossible to uncurve the catheter, and it lodged in the patient's right femoral artery. Immediate collaboration with interventional cardiology and interventional radiology was required to resolve the issue. The case demonstrates that excellent teamwork and calling rapidly on input from subspecialties are integral to overcoming unexpected events and to achieve a safe and successful outcome. The patient involved was a medical student at the time and as one of the coauthors offers a unique insight., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Premature ventricular complexes (PVCs) are extremely common, found in the majority of individuals undergoing long-term ambulatory monitoring. Increasing age, a taller height, a higher blood pressure, a history of heart disease, performance of less physical activity, and smoking each predict a greater PVC frequency. Although the fundamental causes of PVCs remain largely unknown, potential mechanisms for any given PVC include triggered activity, automaticity, and reentry. PVCs are commonly asymptomatic but can also result in palpitations, dyspnea, presyncope, and fatigue. The history, physical examination, and 12-lead ECG are each critical to the diagnosis and evaluation of a PVC. An echocardiogram is indicated in the presence of symptoms or particularly frequent PVCs, and cardiac magnetic resonance imaging is helpful when the evaluation suggests the presence of associated structural heart disease. Ambulatory monitoring is required to assess PVC frequency. The prognosis of those with PVCs is variable, with ongoing uncertainty regarding the most informative predictors of adverse outcomes. An increased PVC frequency may be a risk factor for heart failure and death, and the resolution of systolic dysfunction after successful catheter ablation of PVCs demonstrates that a causal relationship can be present. Patients with no or mild symptoms, a low PVC burden, and normal ventricular function may be best served with simple reassurance. Either medical treatment or catheter ablation are considered first-line therapies in most patients with PVCs associated with symptoms or a reduced left ventricular ejection fraction, and patient preference plays a role in determining which to try first. If medical treatment is selected, either β-blockers or nondihydropyridine calcium channel blockers are reasonable drugs in patients with normal ventricular systolic function. Other antiarrhythmic drugs should be considered if those initial drugs fail and ablation has been declined, has been unsuccessful, or has been deemed inappropriate. Catheter ablation is the most efficacious approach to eradicate PVCs but may confer increased upfront risks. Original research remains necessary to identify individuals at risk for PVC-induced cardiomyopathy and to identify preventative and therapeutic approaches targeting the root causes of PVCs to maximize effectiveness while minimizing risk.

Premature ventricular contractions (PVCs) is one of the most common situations in the current cardiology practice. Although PVCs are generally benign in people without any structural heart disease, they may be associated with left ventricular dysfunction, cardiomyopathy, and, rarely, sudden death. Recently, there has been a considerable research in the pathophysiology of PVC, several clinical presentations in different situations, new proposals of successful diagnostic methods, and treatment modalities. Finally, the American College of Cardiology Electrophysiology Council has published a special report that deals with all the aspects of PVC. We reviewed the important points from this report that can be reflected in our daily practice.

Premature ventricular complexes (PVCs) are common arrhythmias in the clinical setting. PVCs in the structurally normal heart are usually benign, but in the presence of structural heart disease (SHD), they may indicate increased risk of sudden death. High PVC burden may induce cardiomyopathy and left ventricular (LV) dysfunction or worsen underlying cardiomyopathy. Sometimes PVCs may be a marker of underlying pathophysiologic process such as myocarditis. Identification of PVC burden is important, since cardiomyopathy and LV dysfunction can reverse after catheter ablation or pharmacological suppression. This state-of-the-art review discusses pathophysiology, clinical manifestations, how to differentiate benign and malignant PVCs, PVCs in the structurally normal heart, underlying SHD, diagnostic procedures (physical examination, electrocardiogram, ambulatory monitoring, exercise testing, echocardiography, cardiac magnetic resonance imaging, coronary angiography, electrophysiology study), and treatment (lifestyle modification, electrolyte imbalance, medical, and catheter ablation).

Cardiac resynchronization devices that sense left ventricular (LV) activity and can detect interruptions of resynchronization therapy are able to record all forms of desynchronization rhythms, which are triggered by misalignment of LV timing cycles. We report five cases of this desynchronization rhythm that were terminated by isolated left-sided ventricular premature complexes (LVPC) undetected by the right ventricular (RV) channel and unaccompanied by changes in the duration of the RV pacing cycles. In three cases, the devices did not even sense the LVPCs responsible for desynchronization termination. The restoration of resynchronization in our cases is in contrast to the traditional termination mode that is invariably associated with changes in the duration of the RV cycles., (© 2019 Wiley Periodicals, Inc.)

Ventricular arrhythmias can present as asymptomatic premature ventricular complexes (PVCs) or non-sustained ventricular tachycardia (VT), symptomatic presentation of the former arrhythmias, or sustained VT with minimal symptoms to full hemodynamic collapse. The most important and feared consequence of VT is sudden cardiac death (SCD). Independent of SCD risk, frequent ventricular arrhythmias can cause substantial symptoms. Implantable cardioverter defibrillators (ICDs) are the foundation of managing patients at high risk for SCD due to their ability to automatically identify and defibrillate malignant ventricular arrhythmias. Unfortunately, defibrillation is associated with significant physical and emotional adverse effects. Other treatment options include antiarrhythmic drugs, which have substantial toxicities and limited efficacy, and catheter ablation. The techniques and strategies for VT ablation have advanced considerably in recent years leading to a rapid expansion of indications and use. In this review, we discuss current state of the art therapies for ventricular arrhythmias and highlight some of the most promising areas of ongoing development., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Ventricular fibrillation (VF) storm after myocardial infarction (MI) is a life-threatening condition that necessitates multiple defibrillations. Catheter ablation is a potentially effective treatment strategy for VF storm refractory to optimal medical treatment. However, its impact on patient survival has not been verified in a large population., Methods: We conducted a multicenter, retrospective observational study involving consecutive patients who underwent catheter ablation of post-MI refractory VF storm without preceding monomorphic ventricular tachycardia. The target of ablation was the Purkinje-related ventricular extrasystoles triggering VF. The primary outcome was in-hospital and long-term mortalities. Univariate logistic regression and Cox proportional-hazards analysis were used to evaluate clinical characteristics associated with in-hospital and long-term mortalities, respectively., Results: One hundred ten patients were enrolled (age, 65±11years; 92 men; left ventricular ejection fraction, 31±10%). VF storm occurred at the acute phase of MI (4.5±2.5 days after the onset of MI during the index hospitalization for MI) in 43 patients (39%), the subacute phase (>1 week) in 48 (44%), and the remote phase (>6 months) in 19 (17%). The focal triggers were found to originate from the scar border zone in 88 patients (80%). During in-hospital stay after ablation, VF storm subsided in 92 patients (84%). Overall, 30 (27%) in-hospital deaths occurred. The duration from the VF occurrence to the ablation procedure was associated with in-hospital mortality (odds ratio for each 1-day increase, 1.11 [95% CI, 1.03-1.20]; P=0.008). During follow-up after discharge from hospital, only 1 patient developed recurrent VF storm. However, 29 patients (36%) died, with a median survival time of 2.2 years (interquartile range, 1.2-5.5 years). Long-term mortality was associated with left ventricular ejection fraction <30% (hazard ratio, 2.54 [95% CI, 1.21-5.32]; P=0.014), New York Heart Association class ≥III (hazard ratio, 2.68 [95% CI, 1.16-6.19]; P=0.021), a history of atrial fibrillation (hazard ratio, 3.89 [95% CI, 1.42-10.67]; P=0.008), and chronic kidney disease (hazard ratio, 2.74 [95% CI, 1.15-6.49]; P=0.023)., Conclusions: In patients with MI presenting with focally triggered VF storm, catheter ablation of culprit triggers is lifesaving and appears to be associated with short- and long-term freedom from recurrent VF storm. Mortality over the long-term follow-up is associated with the severity of underlying cardiovascular disease and comorbidities in this specific patient population.

Frequent premature ventricular complexes (PVCs) can cause an often reversible form of cardiomyopathy. The mechanism for the development of premature ventricular complex-induced cardiomyopathy (PIC) continues to be investigated, and animal models as well as human clinical trials suggest ventricular dyssynchrony to be an important component. In addition to a high PVC burden, this review will detail other risk factors associated with the development of PIC. PVCs can be a marker for the presence of other underlying disease and a thorough work-up, including cardiac magnetic resonance imaging with delayed contrast enhancement, needs to be considered to rule out the presence of structural heart disease. Management of PIC can involve catheter ablation or pharmacotherapy. Multicenter studies have shown a high success rate paired with a low complication rate with catheter ablation, and hence catheter ablation has emerged as the preferred therapeutic option for most patients with PIC. Advances in ablation strategy and technology have enhanced our ability to address certain challenging PVC locations. Important challenges that remain include understanding the coexistence of PIC with other forms of cardiomyopathy, whether there is an associated risk of sudden cardiac death, and the long-term effects on cardiac substrate of exposure to frequent PVCs., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: While there is an association between isolated mitral valve prolapse (MVP) and sudden cardiac arrest (SCA), the baseline characteristics and outcomes of patients with isolated MVP who experience ventricular arrhythmias (VAs) and then subsequently undergo catheter ablation and/or implantable cardioverter defibrillator (ICD) implantation are unknown., Methods: We performed a retrospective review of all patients at the Cleveland Clinic with isolated MVP between 1997 and 2016 who underwent VA catheter ablation or secondary prevention ICD implantation., Results: Of 617 screened patients, we identified 43 patients with isolated MVP and significant VA who underwent ICD placement (n = 13, 30%) or catheter ablation (n = 30, 70%). Both leaflets were most commonly involved (n = 22, 52%) with posterior MVP being next most common (n = 15, 36%). The most common foci of VA origin was the left ventricular papillary muscle (n = 9, 27%). Ablation was successful in the majority of cases (n = 20, 65%). At a mean follow-up of 2.5 years, 11 patients (26%) had recurrent VT., Conclusions: Patients with isolated MVP and VA were more likely to have bileaflet prolapse and at least moderate mitral regurgitation. VA originated more commonly from left-sided foci. While ablation was acutely successful in the majority of cases, there was still a moderate rate of VA recurrence. There is still more study needed on factors that will predict malignant VAs and management of these VAs in the MVP population., (© 2019 Wiley Periodicals, Inc.)

Premature ventricular complexes (PVCs) are usually benign, and commonly only severely symptomatic patients are treated. In the literature, frequent PVCs have been reported to cause ventricular dysfunction, which may improve after PVC treatment. PVCs can also worsen the prognosis in patients with structural heart disease. Catheter PVC ablation is often the treatment of choice considering the high success rates. Ventricular dysfunction due to frequent PVCs is not always easy to identify as patients can be asymptomatic and the interpretation of imaging tests may be challenging in the presence of frequent PVCs. Treatment of patients with mild ventricular dysfunction is still a matter of debate.

A 60-year-old female with premature ventricular contractions (PVCs) originating from the bottom of the posteromedial papillary muscle of the left ventricle underwent radiofrequency catheter ablation (RFCA) using an irrigated-tip catheter. During ablation of the PVCs, a loud steam pop was observed. Intracardiac echocardiography (ICE) revealed a growing, hyperechogenic intramyocardial microbubble formation around the catheter tip. The formation disappeared slowly and completely, leaving an endocardial laceration without pericardial effusion. ICE imaging is valuable during a difficult RFCA procedure, because ICE reveals the exact anatomical position of the catheter and thus allows rapid evaluation of the occurrence of steam popping and any possible subsequent complication.

Background: Sudden cardiac death (SCD) results from a complex interplay of abnormalities in autonomic function, myocardial substrate and vulnerability. We studied whether a combination of noninvasive risk stratification tests reflecting these key players could improve risk stratification., Methods: Patients implanted with an ICD in whom 24-hr holter recordings were available prior to implant were included. QRS fragmentation (fQRS) was selected as measure of myocardial substrate and a high ventricular premature beat count (VPB >10/hr) for arrhythmic vulnerability. From receiver operating characteristics analysis, detrended fluctuation analysis (DFA), turbulence slope, and deceleration capacity were selected for autonomic function. Adjusted Cox regression analysis with comparison of C-statistics was performed to predict first appropriate shock (AS) and total mortality., Results: A total of 220 patients were included in the analysis with an overall follow-up of 4.3 ± 3.1 years. A model including VPB >10/hr, inferior fQRS, and abnormal nonedited DFA was the best for prediction of AS after 1 year of follow-up with a trends toward improvement of the C-statistics compared to baseline (p = 0.055). The risk increased significantly with every abnormal test (HR 1.793, 95%CI 1.255-2.564). A model including fQRS in any region and abnormal edited DFA was the best for prediction of mortality after 3 years of follow-up with significant improvement of the C-statistics (p = 0.023). Each abnormal test was associated with a significant increase in mortality (HR 5.069, 95%CI 1.978-12.994)., Conclusion: Combining noninvasive risk stratification tests according to their physiological background can improve the risk prediction of SCD and mortality., (© 2018 Wiley Periodicals, Inc.)

Purpose of Review: Premature ventricular beats (PVCs) are frequently identified in healthy children with structurally normal hearts and generally have a benign clinical course often disappearing spontaneously. However, a small percentage of children may develop a cardiomyopathy. The purpose of this review is to understand which children may be at risk of development of left ventricular (LV) dysfunction with idiopathic PVCs., Recent Findings: There is increasing evidence that a ventricular ectopic burden more than 24% in adults may lead to LV dysfunction. Most of the pediatric studies to date are retrospective, small case series from single institutions and have conflicting results regarding a direct correlation of the PVC burden to LV dysfunction. Development of a cardiomyopathy from frequent PVCs in children is likely multifactorial relating to the burden itself, presence of higher levels of ectopy (couplets and runs of ventricular tachycardia) as well as the duration of ventricular ectopy. Understanding the duration of ectopy is often unknown as patients are asymptomatic and the irregular heart beat was identified at a well-child examination., Summary: Asymptomatic children with normal ventricular function and a low ectopy burden can be followed without any intervention and generally reassured. Children with an ectopy burden more than 30% are at some risk of developing LV dysfunction and should be more closely followed with noninvasive imaging. Development of symptoms attributed to the ectopy or signs of increasing LV dimensions or LV dysfunction should be treated with medication or catheter ablation.

Rationale: Co-occurrence of headache and arrhythmia is not rare. However, their causal relationship remains unclear. Here, we described a case of migraine-like headache relieving with pacemaker implantation. Our case study indicates that arrhythmia is causal for migraine-like headache, which, to our knowledge, has never been reported., Patient Concerns: A 63-year-old woman patient suffered from paroxysmal headache with a visual aura presenting like migraine for 2 years. No ophthalmic or neurological disorder was found, but cardiac examination detected bradycardia, which was confirmed by 24-hour dynamic electrocardiogram (DCG) revealing sinus bradycardia mixed with ventricular premature beats and supraventricular tachycardia. Transcranial doppler (TCD) detected an equal echo flat plaque on the anterolateral wall of the common carotid artery (CA) bifurcation., Diagnosis: Migraine-like headaches secondary to arrhythmia., Interventions: The patient underwent pacemaker implantation., Outcomes: Both visual aura and headache were resolved following pacemaker implantation., Lessons: To the best of the authors' knowledge, we are the first to report migraine-like headache as a secondary symptom of arrhythmia. Arrhythmia may aggravate insufficient blood supply to the brain due to CA lesion and induce a migraine-like headache. This case study indicated that pacemaker implantation could be a fundamental treatment for migraine-like headaches caused by cardiac arrhythmia.

Use of atrial pacing has been known, yet underutilized tool for effective temporary pacing whenever needed early after cardiac surgery. The reasons may be frequent failures of epicardial wires (fixed over atria intra-operative) leading to loss of capture. Endocardial atrial pacing sites for temporary pacing are unstable and hence continuous pacing with acceptable thresholds is impossible. We describe a case of ischemic cardiomyopathy and severe left ventricle systolic dysfunction who required atrial pacing post coronary artery bypass grafting (CABG) surgery for around 48-72 hours starting 4th day post operation when he had multiple episodes of ventricular fibrillation (VF) needing many defibrillation shocks. VF episodes were triggered by premature ventricular complexes (PVC) falling on as R on T. Episodes were refractory to anti-arrhythmic drugs and general anesthesia. These PVC were successfully overdriven by atrial pacing by fluoroscopically placing pacing lead in coronary sinus. This led to complete suppression of PVC induced VF for next 48-72 hours while the antiarrhythmic drugs were continued. Subsequently the patient was discharged in stable state. Atrial pacing, though quite valuable during the post-operative period after cardiac surgery, is underutilized, especially when pacing through surgically placed epicardial wire fails. This report is helpful in drawing attention towards coronary sinus (CS) as an alternate site for achieving stable, temporary atrial pacing during the post-operative period. This site can also be utilized for short term dual chamber pacing if required in post-operative state using transvenous CS site for atrial pacing and intraoperatively placed epicardial wire for ventricular pacing., (Copyright © 2018 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Background: Although large randomized clinical trials have found that primary prevention use of an implantable cardioverter-defibrillator (ICD) improves survival in patients with cardiomyopathy and heart failure symptoms, patients who receive ICDs in practice are often older and have more comorbidities than patients who were enrolled in the clinical trials. In addition, there is a debate among clinicians on the usefulness of electrophysiological study for risk stratification of asymptomatic patients with Brugada syndrome., Aim: Our analysis has 2 objectives. First, to evaluate whether ventricular arrhythmias (VAs) induced with programmed electrostimulation in asymptomatic patients with Brugada syndrome identify a higher risk group that may require additional testing or therapies. Second, to evaluate whether implantation of an ICD is associated with a clinical benefit in older patients and patients with comorbidities who would otherwise benefit on the basis of left ventricular ejection fraction and heart failure symptoms., Methods: Traditional statistical approaches were used to address 1) whether programmed ventricular stimulation identifies a higher-risk group in asymptomatic patients with Brugada syndrome and 2) whether ICD implantation for primary prevention is associated with improved outcomes in older patients (>75 years of age) and patients with significant comorbidities who would otherwise meet criteria for ICD implantation on the basis of symptoms or left ventricular function., Results: Evidence from 6 studies of 1138 asymptomatic patients were identified. Brugada syndrome with inducible VA on electrophysiological study was identified in 390 (34.3%) patients. To minimize patient overlap, the primary analysis used 5 of the 6 studies and found an odds ratio of 2.3 (95% CI: 0.63-8.66; P=0.2) for major arrhythmic events (sustained VAs, sudden cardiac death, or appropriate ICD therapy) in asymptomatic patients with Brugada syndrome and inducible VA on electrophysiological study versus those without inducible VA. Ten studies were reviewed that evaluated ICD use in older patients and 4 studies that evaluated unique patient populations were identified. In our analysis, ICD implantation was associated with improved survival (overall hazard ratio: 0.75; 95% confidence interval: 0.67-0.83; P<0.001). Ten studies were identified that evaluated ICD use in patients with various comorbidities including renal disease, chronic obstructive pulmonary disease, atrial fibrillation, heart disease, and others. A random effects model demonstrated that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.72; 95% confidence interval: 0.65-0.79; P<0.0001), and a second "minimal overlap" analysis also found that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.61-0.82; P<0.0001). In 5 studies that included data on renal dysfunction, ICD implantation was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.60-0.85; P<0.001).