Elsevier

Heart Rhythm

Volume 18, Issue 1, January 2021, Pages 27-33
Heart Rhythm

Clinical
Ablation
Premature ventricular complex site of origin and ablation outcomes in patients with prior myocardial infarction

https://doi.org/10.1016/j.hrthm.2020.07.037Get rights and content

Background

Frequent premature ventricular complexes (PVCs) are common after a myocardial infarction (MI), but data on PVC ablation in this population are limited.

Objective

The purpose of this study was to analyze data on PVC ablation in post-MI patients.

Methods

Three hundred thirty-two patients with frequent PVCs and left ventricular (LV) dysfunction were prospectively studied. Data from 67 patients (20%; age 63 ± 10 years; 65 men [93%]) with previous MI were compared with the remaining 265 patients.

Results

PVCs in post-MI patients originate predominantly from the LV (92% LV vs 6% right ventricle [RV]; P <.001). The most frequent sites of origin (SOO) were MI scar in 23 patients (34%) and left ventricular outflow tract (LVOT) in 22 patients (33%). A papillary muscle origin was more frequent in post-MI patients (16% vs 4%; P = .001), whereas an RV outflow tract origin was less frequent (1% vs 33%; P <.001) compared to patients without MI. In post-MI patients, PVC burden decreased from 29% ± 12% at baseline to 4.6% ± 7% (P <.001); left ventricular ejection fraction (LVEF) improved from 33.6% ± 8% to 42% ± 10% (P <.001); and New York Heart Association functional class improved from 2.1 ± 0.7 to 1.4 ± 0.5 points (P <.001) at 12 months. Compared with the remaining 265 patients, there were no differences in acute ablation success (85% vs 85%; P = .45), complication rate (6% vs 6%; P = .41), or absolute improvement in LVEF (8.8 ± 10 vs 9.9 ± 11 absolute points; P = .38).

Conclusion

PVC ablation significantly improves cardiac function and functional status in post-MI patients. PVCs predominantly originate from MI scar and LVOT. A papillary muscle SOO was found to be strongly associated with previous MI.

Introduction

Successful ablation of frequent premature ventricular complexes (PVCs) usually improves cardiac function in patients with depressed left ventricular ejection fraction (LVEF).1,2 This benefit initially was observed in patients with PVC-induced cardiomyopathy. Increasing evidence suggests that patients with previous structural heart disease (SHD) worsened by frequent PVCs also can obtain significant improvement in symptoms, functional capacity, and LVEF after catheter ablation.3,4 As a result, the current consensus document considers PVC ablation a class IIa recommendation in patients with SHD in whom frequent PVCs are suspected of contributing to left ventricular (LV) dysfunction.5 Data show that PVC burden is significantly higher in the post-myocardial infarction (MI) setting than in the general population.6 Although there is no evidence of a cause-and-effect relationship between frequent PVCs and sudden death, several studies have found an association between frequent PVCs and a worse prognosis in patients with a prior MI.7 However, little is known about PVC site of origin (SOO) or the response to PVC ablation in this specific population. A study by Sarrazin et al8 showed improvement of LVEF after PVC ablation in 15 patients with a prior MI and LV dysfunction compared to a control group without PVCs. However, these results have not been confirmed in larger patient populations.

The aim of the present study was to characterize PVC SOO, the efficacy of PVC ablation, and 12-month outcomes in a consecutive series of patients with frequent PVCs, LV dysfunction, and a history of MI. Data from this group were compared to that of the remaining patients with frequent PVCs and LV dysfunction without previous MI.

Section snippets

Patient sample

We report the results of a predefined secondary endpoint of an ongoing multicenter prospective study.9 Between November 2010 and December 2018, 332 consecutive patients with frequent PVCs and LV dysfunction were prospectively included in 8 international centers and followed for 12 months after ablation. Inclusion criteria were presence of LV systolic dysfunction (LVEF <50%); frequent PVCs (defined as burden >4% at baseline 24-hour Holter monitoring); and receiving optimal medical therapy for

Patient population

Three hundred thirty-two consecutive patients with LV dysfunction referred for frequent PVC ablation were included. Sixty-seven patients (age 63 ± 10 years; 65 men [93%]) had a previous MI (26 [39%] anterior MI). In this group, mean LVEF was 33.6% ± 8%, and mean baseline PVC burden was 29% ± 12%. Baseline characteristics of these patients are summarized in Table 1. Compared with the remaining 265 patients, post-MI patients were older (age 63 ± 10 years vs 56 ± 13 years; P <.001), more

Discussion

The present study reports the largest series of PVC ablation in post-MI patients with LV dysfunction. Ablation can be safely performed in this population with a good acute success rate, corroborating the previous description of Sarrazin et al.8 Most PVCs originate in the LV, with MI scar and the LVOT being the most frequent SOO. Patients showed significantly improved LVEF and functional status in the long term, without differences in the degree of improvement compared to patients without a

Conclusion

Ablation of frequent PVCs in post-MI patients results in improvement of cardiac function and NYHA functional class in a significant proportion of patients, especially if the PVC abolition is sustained during follow-up. The benefit obtained in this population is equivalent to that obtained in patients without previous MI. Most of the PVCs in this population arise from the LV, with MI scar and the LVOT the most frequent sites of origin. PVCs in post-MI patients originate more frequently from the

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Funding sources: The authors have no funding sources to disclose other than those listed in disclosures.

Disclosures: Dr Teres is supported by a research fellowship grant from the Swiss Heart Rhythm Foundation. Drs Berruezo and Mont are shareholders of Galgo Medical SL. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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