Ventricular disturbance of rhythm as a symptom of cardiovascular disease

The questions of the differential diagnosis of diseases accompanied by ventricular premature beats (ischemic heart disease, myocarditis, arrhythmogenic right ventricular dysplasia) are thrusted into the spotlight.

Re-entrant ventricular tachycardia as a complication of ablation of idiopathic ventricular premature beats from the right outflow tract: a case report

Background We report an unusual case of non-sustained ventricular tachycardia (NSVT) from the epicardial part of the right ventricular outflow tract (RVOT). Case summary A 37-year-old woman who underwent in 2006 an ablation for idiopathic ventricular premature beats (VPBs) from the RVOT presented with pre-syncopal NSVT in 2016. A cardiac workup showed no coronary disease, normal biventricular function, and no enhancement on cardiac magnetic resonance imaging. A metabolic positron emission tomography scan excluded inflammation. Biopsies revealed normal desmosomal proteins. An endocardial mapping revealed an area of low voltage potential (<0.5 mV) at the antero-septal aspect of the RVOT corresponding to the initial site of ablation from 2006. Activation mapping revealed poor prematurity and pace-mapping showed unsatisfactory morphologies in the RVOT, the left ventricle outflow tract and the right coronary cusp. An epicardial map revealed a low voltage area at the antero-septal aspect of the RVOT with fragmented potentials opposite to the endocardial scar. Pace-mapping demonstrated perfect match. An NSVT was induced and local electrocardiogram showed mid-diastolic potentials. Ablation was applied epicardially and endocardially without any complication. The patient was arrhythmia free at 4-year follow-up. Discussion Cardiac workup allowed to exclude specific conditions such as arrhythmogenic cardiomyopathy, tetralogy of Fallot, sarcoidosis, or myocarditis as a cause for NSVT from the RVOT. The epi and endocardial map showed residual scar subsequent to the first ablation which served as substrate for the re-entrant NSVT. This is the first case which describes NSVT from the epicardial RVOT as a complication from a previous endocardial ablation for idiopathic VPB.

Mechanism of ventricular premature beats elicited by left stellate ganglion stimulation during acute ischaemia of the anterior left ventricle

Aims Enhanced sympathetic activity during acute ischaemia is arrhythmogenic, but the underlying mechanism is unknown. During ischaemia, a diastolic current flows from the ischaemic to the non-ischaemic myocardium. This ‘injury’ current can cause ventricular premature beats (VPBs) originating in the non-ischaemic myocardium, especially during a deeply negative T wave in the ischaemic zone. We reasoned that shortening of repolarization in myocardium adjacent to ischaemic myocardium increases the ‘injury’ current and causes earlier deeply negative T waves in the ischaemic zone, and re-excitation of the normal myocardium. We tested this hypothesis by activation and repolarization mapping during stimulation of the left stellate ganglion (LSG) during left anterior descending coronary artery (LAD) occlusion. Methods and results In nine pigs, five subsequent episodes of acute ischaemia, separated by 20 min of reperfusion, were produced by occlusion of the LAD and 121 epicardial local unipolar electrograms were recorded. During the third occlusion, left stellate ganglion stimulation (LSGS) was initiated after 3 min for a 30-s period, causing a shortening of repolarization in the normal myocardium by about 100 ms. This resulted in more negative T waves in the ischaemic zone and more VPBs than during the second, control, occlusion. Following the decentralization of the LSG (including removal of the right stellate ganglion and bilateral cervical vagotomy), fewer VPBs occurred during ischaemia without LSGS. During LSGS, the number of VPBs was similar to that recorded before decentralization. Conclusion LSGS, by virtue of shortening of repolarization in the non-ischaemic myocardium by about 100 ms, causes deeply negative T waves in the ischaemic tissue and VPBs originating from the normal tissue adjacent to the ischaemic border.

The influence of radiofrequency ablation on quality of life in patients with ventricular premature beats

Objective – to determine the effect of radiofrequency ablation (RFA) on the quality of life (QOL) of patients with ventricular premature beats (VPB).Materials and methods. We included 53 cases of treatment of patients with monomorphic VPB. There were no obvious structural diseases of the heart in them. The age of patients ranged from 16 to 57 years, and the median age was 35.3 ± 12.4. Among patients 37 (69.8 %) were women. All patients underwent RFA aiming to remove the arrhythmogenic substrate of VPB. The indication for intervention was symptomatic VPB, refractory to drug treatment. All patients underwent QOL assessment using the SF-36 questionnaire prior to the procedure at 2, 6, and 12 months after it. QOL was also evaluated in 18 healthy subjects (group of comparison).Results. Assessment of QOL was performed according to 8 criteria (scales): physical activity (PA), vital activity (VA), pain (P), general health (GH), viability (V), social activity (SA), the role of emotional problems in life-limiting (EP), mental health (MH). We noted a significant increase in indicators on the scales that are responsible for the physical component of health for 2 months and continued to increase further to the data of the comparison group: FA (before RFA – 70,24 ± 26,10; in 2 months – 80,32 ± 22.02; in 6 months – 88.58 ± 24.84; in 12 months – 87.38 ± 17.07; GP – 88.32 ± 4.51), RF (before RFA – 47.43 ± 38.95; in 2 months – 70.11 ± 28.83; in 6 months – 71.28 ± 29.51; in 12 months – 69.17 ± 24.12; GP – 70.03 ± 16.34). B (before RFA – 68.84 ± 23.91; in 2 months – 67.12 ± 16.37; in 6 months – 69.83 ± 17.63; in 12 months – 69.03 ± 28.58; GP – 71.83 ± 7.35), PZ (before RFA – 61.88 ± 21.48; in 2 months – 66.05 ± 14.03; in 6 months – 68.59 ± 19.27; in 12 months – 70.23 ± 20.3; GP – 69.04 ± 7.48). Scales responsible for the mental component of health began to respond only after 6 months: HR (before RFA – 56.68 ± 34.46; in 2 months – 62.72 ± 17.54; in 6 months – 61.83 ± 20.15; in 12 months – 63.28 ± 18.08; GP – 61.34 ± 8.03), CA (before RFA – 67.31 ± 28.01; in 2 months – 71.37 ± 16.84; in 6 months – 72.54 ± 24.41; in 12 months – 75.54 ± 17.03; GP – 74.35 ± 8.59). PE (before RFA – 58.41 ± 34.08; 2 months – 66.73 ± 27.63; in 6 months – 67.70 ± 34.05; in 12 months – 68.36 ± 15.03; GP – 69.45 ± 18.07), PZ (before RFA – 59.03 ± 19.81, in 2 months – 64.18 ± 19.58; in 6 months – 61.45 ± 25.21; in 12 months – 61.73 ± 16.7; GP – 59.78 ± 5.01). In the period 2–12 months after surgical treatment, a statistically significant increase in FA and RF compared to the original condition was registered. For the remainder of the QOL components positive changes were recorded that had no statistically significant differences compared to the original condition.Conclusions. The QOL indicators that characterize physical health in patients with VPB prior to interventional treatment are significantly lower than those of virtually healthy individuals. In 2 months after successful RFA of the arrhythmogenic focus in patients with VPB, the QOL parameters significantly improved compared to the comparison group. Complete recovery of physical and mental health occurs between 6 and 12 months after the intervention of arrhythmia.

Elimination of Benign Ventricular Premature Beats or Ventricular Tachycardia with Catheter Ablation versus Two Different Optimal Antiarrhythmic Drug Treatment Regimens (Sotalol or Verapamil/Flecainide)

<b><i>Background:</i></b> Symptomatic idiopathic ventricular arrhythmias (VA), including premature beats (VPB) and nonsustained ventricular tachycardia (VT) are commonly encountered arrhythmias. Although these VA are usually benign, their treatment can be a challenge to primary and secondary health care providers. Mainstay treatment is comprised of antiarrhythmic drugs (AAD) and, in case of drug intolerance or failure, patients are referred for catheter ablation to tertiary health care centers. These patients require extensive medical attention and drug regimens usually have disappointing results. A direct comparison between the efficacy of the most potent AAD and primary catheter ablation in these patients is lacking. The ECTOPIA trial will evaluate the efficacy of 2 pharmacological strategies and 1 interventional approach to: suppress the VA burden, improve the quality of life (QoL), and safety. <b><i>Hypothesis:</i></b> We hypothesize that flecainide/verapamil combination and catheter ablation are both superior to sotalol in suppressing VA in patients with symptomatic idiopathic VA. <b><i>Study Design:</i></b> The Elimination of Ventricular Premature Beats with Catheter Ablation versus Optimal Antiarrhythmic Drug Treatment (ECTOPIA) trial is a randomized, multicenter, prospective clinical trial to compare the efficacy of catheter ablation versus optimal AAD treatment with sotalol or flecainide/verapamil. One hundred eighty patients with frequent symptomatic VA in the absence of structural heart disease or underlying cardiac ischemia who are eligible for catheter ablation with an identifiable monomorphic VA origin with a burden ≥5% on 24-h ambulatory rhythm monitoring will be included. Patients will be randomized in a 1:1:1 fashion. The primary endpoint is defined as &#x3e;80% reduction of the VA burden on 24-h ambulatory Holter monitoring. After reaching the primary endpoint, patients randomized to one of the 2 AAD arms will undergo a cross-over to the other AAD treatment arm to explore differences in drug efficacy and QoL in individual patients. Due to the use of different AAD (with and without β-blocking characteristics) we will be able to explore the influence of alterations in sympathetic tone on VA burden reduction in different subgroups. Finally, this study will assess the safety of treatment with 2 different AAD and ablation of VA.

Sonification of cardiac arrhythmias in the Beethoven’s music, or «The heartfelt music of Ludwig van Beethoven»-2

Researchers S. Vaisrub, B. Lüderitz, T.O. Cheng, Z.D. Goldberger et al. in different years (1980–2014) discovered the similarity of the rhythmic figure of the fragment of Ludwig van Beethoven’s piano sonata op. 81a «Les adieux» with an auscultative and electrocardiographic picture of ventricular premature beats. This allowed them to assume that the composer expressed in music his own irregular heartbeat. The hypothesis is very relevant, since sonification (the use of non-speech audio to convey information) of biological signals has a long history and is actively developing both in music and in medicine. This article is devoted to testing the hypothesis of sonification of cardiac arrhythmias in Beethoven’s music. An analysis of numerous musicological studies has shown that a variety of rhythmic figures, similar to the electrocardiographic signs of all known disorders of the cardiac rhythm, are found in many Beethoven’s works throughout 1799–1826. It is established that each of the revealed musical equivalents of cardiac arrhythmias is a certain means of musical expressiveness (musical language), the meaning and origin of which is known. Pathographic analysis showed the absence of a chronological link between «arrhythmic» music and the diseases of the composer. Any indication of the cardiac disease in Beethoven has not been found. Such results allow us to connect the music of Beethoven with his heart only in a some romantic sense.