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Hemodynamic Consequences of Premature Ventricular Contractions

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Hemodynamic Consequences of Premature Ventricular Contractions Hemodynamic consequences of premature ventricular contractions: Association of mechanical bradycardia and postextrasystolic potentiation with premature ventricular contraction-induced cardiomyopathy Sophie Billet, MD,* Anne Rollin, MD,* Pierre Mondoly, MD,* Benjamin Monteil, MD,* Pauline Fournier, MD,* Eve Cariou, MD,* Marie Sadron Blaye-Felice, MD,* Michel Galinier, MD,* Didier Carrié, MD,* Olivier Lairez, MD,* Clément Delmas, MD,* Philippe Maury, MD*† From the *Department of Cardiology, University Hospital Rangueil, Toulouse, France, and †Unité Inserm U 1048, Toulouse, France. BACKGROUND The relationships between hemodynamic conse- potentiation index (PEPi 5 number of PVCs with PEP/total PVC) quences of premature ventricular contractions (PVCs) and develop- were calculated. ment of premature ventricular contraction-induced cardiomyopathy 6 6 (PVC-CM) have not been investigated. RESULTS EMi was 29% 31% in PVC-CM and 78% 20% in con- trols (P ,.0001). PEPi was 41% 6 28% in PVC-CM and 14% 6 10% OBJECTIVE The purpose of this study was to correlate concealed in controls (P 5 .001). There was no control in groups of low EMi or mechanical bradycardia and/or postextrasystolic potentiation high PEPi. EMi and PEPi were not significantly correlated to left ven- (PEP) to PVC-CM. tricular dimensions or function in PVC-CM patients. PVC coupling in- terval was related to both ejecting PVCs and PEP. METHODS Invasive arterial pressure measurements from 17 pa- tients with PVC-CM and 16 controls with frequent PVCs were retro- CONCLUSION Patients with PVC-CM more often display noneject- spectively analyzed. PVCs were considered efficient (ejecting ing PVCs and PEP compared to controls. PVCs) when generating a measurable systolic arterial pressure. PEP was defined by a systolic arterial pressure of the post-PVC beat 5 KEYWORDS Ablation; Cardiomyopathy; Mechanical bradycardia; mm Hg higher than the preceding sinus beat. Every PVC was analyzed Postextrasystolic potentiation; Premature ventricular contraction for 10 minutes before ablation, and the electromechanical index (Heart Rhythm 2019;16:853–860) 2018 Heart Rhythm Society. 5 © (EMi number of ejecting PVCs/total PVC) and postextrasystolic All rights reserved. Introduction PVCs carry some hemodynamic consequences that have Although premature ventricular contractions (PVCs) are not been investigated so far. For example, the lack of commonly considered as benign findings in the absence of mechanical efficiency of PVCs may lead to concealed mechan- 13,14 structural heart disease, some patients with frequent PVCs ical bradycardia. Postextrasystolic potentiation (PEP) is a will develop premature ventricular contraction-induced cardio- well-known physiological cardiac property defined by a tran- 15 myopathy (PVC-CM), which is reversible after elimination of sient increase in inotropism after a premature beat. Although the PVCs.1–5 However, only 5% of patients with frequent potential relationships between these features and severe left PVCs will present with PVC-CM,6 and reliable prediction of ventricular (LV) dysfunction or development of PVC-CM the late occurrence of PVC-CM remains elusive. Even if have been evoked,16 they have not been investigated to date. some parameters have been found independently associated The aim of this study was to assess potential relationships with PVC-CM in patients with frequent PVCs, mechanisms between hemodynamic consequences of PVCs and the pres- leading to PVC-CM are still hypothetical.2,4,5,7–12 ence of PVC-CM. Methods fl All authors have reported that they have no con icts relevant to the con- Thirty-three successive patients referred for radiofrequency tents of this paper to disclose. Address reprint requests and correspon- dence: Dr Philippe Maury, Cardiology, University Hospital Rangueil, (RF) ablation of frequent PVCs in whom invasive monitoring 31059 Toulouse Cedex 09, France. E-mail address: mauryjphil@hotmail. of the arterial pressure was available were retrospectively com. included. These patients presented with frequent PVCs 1547-5271/$-see front matter © 2018 Heart Rhythm Society. All rights reserved. https://doi.org/10.1016/j.hrthm.2018.12.008 854 Heart Rhythm, Vol 16, No 6, June 2019 associated with unexplained CM (PVC-CM group) or with normal heart (control group). Patients with frequent nonsus- tained ventricular tachycardia (.1% QRS complexes) were excluded. In the PVC-CM group (n 5 17), alteration of LV systolic function (left ventricular ejection fraction [LVEF] ,50%) and LV dilation could not be linked to an underlying structural heart disease after usual complete investigations (radionuclide or coronary angiography), persisted after 3 months of optimal drug therapy, and regressed after ablation in every case (.10% increase in LVEF).17 In the control group (n 5 16), patients with preserved LVEF and normal LV dimensions were ablated for symptomatic PVCs after failure of antiarrhythmic therapy. Twenty-four–hour ambulatory recordings were per- Figure 1 Example of premature ventricular contraction bigeminy without formed before the procedure in every patient. PVC burden any significant aortic ejection, as can be seen on the arterial pressure curve. and polymorphism were noted, as well as the presence of interpolated beats or episodes of bigeminy/trigeminy defined PEP by uninterrupted episode(s) of .5 minutes’ duration. PEP was considered present when the systolic arterial pres- LVEF and end-diastolic LV diameter and volumes were sure of the sinus beat following a PVC was 5 mm Hg higher evaluated at baseline in each patient by echocardiography than that of the sinus beat preceding the PVC (Figure 2). This after at least 3 successive sinus cardiac beats. threshold was based on the value of the SD of systolic pres- sure of sinus beats. Ablation procedure Because of the variability in PEP, PEP was also evaluated Antiarrhythmic drugs were discontinued at least 5 half-lives for every PVC over the same 10-minute period. The ratio before the procedure except for amiodarone. Isoproterenol between the number of PVCs with PEP and the total number was perfused when PVCs were absent at the beginning of of PVCs was calculated and termed the postextrasystolic the procedure. Activation mapping was used combined with potentiation index (PEPi). PEP was not evaluated during pace-mapping. Epicardial foci were defined by PVCs ablated periods of bigeminy (1 patient with PVC-CM and permanent inside the coronary sinus. RF energy was delivered with bigeminy could not be included in these measurements). irrigated-tip catheters using power of 30–50 W. Acute success was defined by elimination of the targeted PVC after 30 mi- Correlations of PVC hemodynamics to ECG nutes of observation with and without isoproterenol infusion. parameters In a second set of measurements, different time intervals were Hemodynamic measurements retrieved from 6 ejecting and 6 nonejecting PVCs and from 6 Invasive arterial pressure was constantly monitored during PVCs with and 6 PVCs without PEP in each patient, avoiding the whole procedure by a pressure transducer connected to periods of bigeminy. Previous cycle length, PVC coupling the 5F to 8F short or long sheath introduced into the femoral interval, and duration of post-PVC pause were determined, artery. Air bubbles were flushed from the system, and the zero as well as electromechanical delay (EMD) (between QRS level for arterial blood pressure was taken at the level of the onset and onset of ejection) and peak electromechanical right atrium. Arterial pressure curve was stored together delay (pEMD) (between QRS onset and peak of ejection) with 12-lead ECG on the electrophysiological recording sys- of both sinus beats and PVCs. tem. Measurements were performed retrospectively on screen All measurements were performed with calipers on screen before insertion of any catheter inside the sheath. at 50 mm/s speed. Intraobserver variability in such measure- ments has been already shown to be acceptable7 and was not Mechanical efficiency tested again in this study. PVCs were considered hemodynamically efficient when generating a visible systolic arterial pressure (ie, 5mm Follow-up Hg) on the descending slope of the diastolic pressure of the Antiarrhythmic drugs were stopped, whereas beta-blockers and previous beat (ejecting PVC) (Figure 1). heart failure medications were discontinued only after normal- Because of the variability in PVC-generated arterial pres- ization of LV function and dimensions. In the PVC-CM group, sure, mechanical efficiency was evaluated for every PVC all patients underwent repeat echocardiography at 3 months for over a 10-minute period. The ratio between the number of confirmation of the diagnosis. Twenty-four–hour ambulatory ejecting PVCs and the total number of PVCs was calculated recordings at 3 months were performed in every patient from and termed the electromechanical index (EMi). In case of both groups. A .80% decrease of PVC burden compared to sustained bigeminy, EMi was calculated over 5 minutes of baseline was defined as long-term success of the ablation bigeminy and 5 minutes of nonbigeminy rhythms. procedure.17 Billet et al Hemodynamic Consequences of Premature Ventricular Contractions 855 Figure 2 Example of postextrasystolic potentiation after premature ventricular contraction (PVC). Systolic arterial pressure is significantly increased compared to the beat before PVC. Informed consent was obtained from all patients. The study Logistic regression was performed to determine parameters was performed in accordance with ethical
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