Outflow tract ventricular premature beats ablation in the presence or absence of structural heart disease: Technical considerations and clinical outcomes

Background

Premature ventricular beats (PVBs) are early depolarization of the myocardium originating in the ventricle. In case of very frequent PVBs, patients are severely symptomatic with impaired quality of life and are at risk of pre-syncope, syncope, heart failure, and sudden cardiac death particularly in the presence of structural heart disease. Ventricular outflow tracts are the most common sites of origin of idiopathic PVBs especially in patients without structural heart disease. We examined the role of radiofrequency catheter ablation in suppression of monomorphic PVBs of outflow tract origin in the presence or absence of structural heart disease, and its impact on improvement of left ventricular (LV) systolic function.

Methods

Thirty-seven highly symptomatic patients with PVBs burden exceeding 10% were enrolled, provided that PVBs are monomorphic, originating in ventricular outflow tracts and regardless the presence or absence of structural heart disease. Patients were divided into 2 groups according to PVB site origin (RVOT vs. LVOT). 3D electro-anatomical mapping modalities were used in all patients employing activation mapping technique in the majority of cases. Acute success was considered when PVBs completely disappeared or when residual sporadic PVBs ≤ 1 beats/min or ≤10 beats/30 min after RF ablation. Patients were followed up for a mean period of 5.4 ± 1.2 months with long-term success defined as complete disappearance or marked reduction by more than 75% in the PVBs absolute number on 24 h holter monitoring.

Results

Mean age of the study group was 39.9 ± 12.97 years, including 22 (59.4%) males. PVBs originated in RVOT in 17 cases and in LVOT in the remaining 20 cases. Prevalence of structural heart disease and consequently shortness of breath was higher in LVOT group. Initial ECG localization matched EP localization in the majority (94%) of cases. R wave duration index was the only significant independent predictor for RVOT origin with cut off value of <0.3 (P = 0.0057) upon multivariate analysis. Acute success was encountered in 32 (86%) patients with all cases of failure in the LVOT group. Recurrence occurred in 5 (15%) cases without significant difference between both groups. All cases of recurrence had residual PVBs at the end of the procedure. 18 cases out of the study group showed significant improvement of their EF (>5%) at the end of the follow-up period with no significant differences between both groups (p = 0.09). A linear correlation was observed between PVBs burden at follow up and magnitude of improvement of LV EF, particularly in patients with resting LV dysfunction and increased LV internal dimensions.

Conclusions

RF ablation is an effective and safe method for elimination of outflow tract PVBs irrespective of their origin and the presence or absence of structural heart disease. PVBs burden after ablation appears to be the main determinant for reversal of PVB induced myopathy particularly in those with increased LV internal dimensions.