Evaluation and treatment of premature ventricular contractions in heart failure with reduced ejection fraction

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

Innovations and paradigm shifts in atrial fibrillation ablation

Treatment of symptomatic atrial fibrillation has seen important changes in the past decades. Advancements have especially been made in the field of non-pharmacological treatment of this disease. Patients in whom a rhythm control strategy is chosen the place of catheter ablation has become more frontline therapy in the past years. The procedure itself has also seen changes in technologies that can be used, either using point-by-point radiofrequency or one of the single-shot techniques. One of the major limitations that remain is that re-do procedures are often necessary due to incomplete pulmonary vein isolation and/or atrial fibrillation being initiated by other mechanisms than pulmonary vein triggers. Therefore, there is further need for developing ablation tools that reproducibly isolate the pulmonary vein transmurally. Furthermore, addressing the underlying conditions before and after catheter ablation has been shown to be of great importance. In this review, we will give an overview of the evolution of catheter ablation, highlight the latest technologies and their future endeavours, and lifestyle modifications are being discussed as part of the catheter ablation strategy

Appropriate Implantable Cardioverter-Defibrillator Therapy in Patients with Ventricular Arrhythmia of Unclear Cause in Secondary Prevention of Sudden Cardiac Death

In this study, we sought to investigate the occurrence of appropriate implantable cardioverter-defibrillator (ICD) therapies and inappropriate shocks in secondary prevention ICD recipients with ventricular arrhythmia of unclear cause and ventricular arrhythmia in the context of underlying heart disease. In this retrospective study, consecutive patients with an ICD implanted for secondary prevention in the University Medical Center Groningen (UMCG), the Netherlands between 1 January 2012 and 31 December 2018 were included. Patients were classified as having ventricular arrhythmia of unclear cause if no clear cause was found which could explain the index ventricular arrhythmia. The primary outcome was appropriate ICD therapy. The study population consisted of 257 patients. In 220 patients, an underlying heart disease could be identified as the cause of ventricular arrhythmia, while 37 patients had an unclear cause of ventricular arrhythmia. The median age was 64 years (interquartile range (IQR) 53-72 years). Forty-five (18%) patients were women. During a median duration of follow-up of 6.2 years (IQR 4.8-7.8 years), appropriate ICD therapy occurred in 95 (37%) patients. This number was 90 (41%) in the group with a clear etiology and 5 (14%) in the group with an unclear etiology. In multivariable analysis, index ventricular arrhythmia of unclear cause was associated with fewer appropriate ICD therapies (HR 0.37 [95% CI 0.14-0.99]; p = 0.048), as well as an increased risk of inappropriate ICD shocks (HR 3.71 [95% CI 1.17-11.80]; p = 0.026). Index ventricular arrhythmia of unclear cause was significantly associated with fewer appropriate ICD therapies. </p

Myocardial Scar Characterization and Future Ventricular Arrhythmia in Patients With Ischemic Cardiomyopathy and an Implantable Cardioverter-Defibrillator

Background: Implantable cardioverter-defibrillator (ICD) therapy is associated with several deleterious effects, which can be reduced by antiarrhythmic drugs or catheter ablation. However, it is largely unknown which patients might benefit from these therapies. Therefore, this study aimed to investigate whether myocardial scar characterization improves risk stratification for ventricular arrhythmia (VA) occurrence in patients with ischemic cardiomyopathy and an ICD.Methods: In this study, 82 patients with ischemic cardiomyopathy who received an ICD were enrolled retrospectively. Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) images were analyzed using an investigational software tool to obtain quantitative data regarding the total scar, core, and border zone (BZ). Data regarding the QRS complex was obtained from electrocardiography (ECG). The primary endpoint was appropriate ICD therapy.Results: During a median follow-up duration of 3.98 years [interquartile range (IQR) 2.89–5.14 years], appropriate therapy occurred in 24 (29.3%) patients. Patients with appropriate ICD therapy had a significantly larger total scar mass [60.0 (IQR 41.2–73.4) vs. 43.3 (IQR 31.2–61.2) g; P = 0.009] and BZ mass [32.9 (IQR 26.9–42.4) vs. 24.5 (IQR 18.8–32.5) g; P = 0.001] than those without appropriate therapy. In multivariable Cox regression analyses, total scar mass [hazard ratio (HR) 1.02 [95% confidence interval (CI) 1.00–1.04]; P = 0.014] and BZ mass (HR 1.04 [95% CI 1.01–1.07]; P = 0.009) independently predicted appropriate ICD therapy. Core mass and the QRS complex, however, were not significantly associated with the primary endpoint.Conclusion: LGE-CMR-based, but not ECG-based myocardial scar characterization improves risk stratification for VA occurrence in patients with ischemic cardiomyopathy who received an ICD