Premature ventricular complex (PVC) ablation has been shown to improve left ventricular ejection fraction (LVEF) and New York Heart Association functional class in patients with left ventricular ...dysfunction. Both are considered key variables in predicting risk of sudden cardiac death.
The objective of this study was to assess whether ablation might remove the primary prevention (PP) implantable cardioverter-defibrillator (ICD) indication in patients with frequent PVC.
Sixty-six consecutive patients with PP-ICD indication and frequent PVC 33 (50%) men; mean age 53 ± 13 years; 11 (17%) with ischemic heart disease underwent PVC ablation. The ICD was withheld and the indication was reevaluated at 6 and 12 months.
LVEF progressively improved from 28% ± 4% at baseline to 42% ± 12% at 12 months (P < .001). New York Heart Association functional class improved from 2 patients with NYHA functional class I (3%) at baseline to 35 (53%) at 12 months (P < .001). The brain natriuretic peptide level decreased from 246 ± 187 to 176 ± 380 pg/mL (P = .004). The PP-ICD indication was removed in 42 patients (64%) during follow-up, from 38 (92%) of them at 6 months, showing an independent association with baseline PVC burden and successful sustained ablation. In patients with successful sustained ablation, a cutoff value of 13% PVC burden had a sensitivity of 100% and a specificity of 93% (area under the curve 99%) for removing ICD indication postablation. No sudden cardiac deaths or malignant ventricular arrhythmias were observed.
In patients with frequent PVC and PP-ICD indication, ablation improves LVEF and, in most cases, allows removal of the indication. Withholding the ICD and reevaluating within 6 months of ablation seems to be a safe and appropriate strategy.
The World Heart Federation (WHF) commenced a Roadmap initiative in 2015 to reduce the global burden of cardiovascular disease and resultant burgeoning of healthcare costs. Roadmaps provide a ...blueprint for implementation of priority solutions for the principal cardiovascular diseases leading to death and disability. Atrial fibrillation (AF) is one of these conditions and is an increasing problem due to ageing of the world’s population and an increase in cardiovascular risk factors that predispose to AF. The goal of the AF roadmap was to provide guidance on priority interventions that are feasible in multiple countries, and to identify roadblocks and potential strategies to overcome them.
Since publication of the AF Roadmap in 2017, there have been many technological advances including devices and artificial intelligence for identification and prediction of unknown AF, better methods to achieve rhythm control, and widespread uptake of smartphones and apps that could facilitate new approaches to healthcare delivery and increasing community AF awareness. In addition, the World Health Organisation added the non-vitamin K antagonist oral anticoagulants (NOACs) to the Essential Medicines List, making it possible to increase advocacy for their widespread adoption as therapy to prevent stroke. These advances motivated the WHF to commission a 2020 AF Roadmap update. Three years after the original Roadmap publication, the identified barriers and solutions were judged still relevant, and progress has been slow.
This 2020 Roadmap update reviews the significant changes since 2017 and identifies priority areas for achieving the goals of reducing death and disability related to AF, particularly targeted at low-middle income countries. These include advocacy to increase appreciation of the scope of the problem; plugging gaps in guideline management and prevention through physician education, increasing patient health literacy, and novel ways to increase access to integrated healthcare including mHealth and digital transformations; and greater emphasis on achieving practical solutions to national and regional entrenched barriers. Despite the advances reviewed in this update, the task will not be easy, but the health rewards of implementing solutions that are both innovative and practical will be great.
Abbreviations CIED cardiovascular implantable electronic device COVID‐19 coronavirus disease 2019 ECG electrocardiogram EMR electronic medical record MCT mobile cardiac outpatient telemetry ...SARS‐CoV‐2 severe acute respiratory syndrome coronavirus 2 VF ventricular fibrillation VT ventricular tachycardia TABLE OF CONTENTS 1 NEED FOR DIGITAL HEALTH DURING THE COVID‐19 PANDEMIC 2 2 MONITORING STRATEGIES DURING A PANDEMIC: Life‐threatening arrhythmias (ventricular tachycardia VT/ventricular fibrillation VF) can occur in up to 6% of hospitalized patients with COVID‐19 infection. 3 There have also been several case reports of atrioventricular block in hospitalized patients, which is otherwise rarely described during viral illness. 4,5 Although the residual left ventricular dysfunction and arrhythmic risk are currently unknown, preliminary pathophysiological, 6 histological, 7 and imaging 8 data suggest that SARS‐CoV‐2 infection holds the potential to induce durable myocardial changes predisposing to arrhythmias or heart failure. Information is limited, however, on how parameters such as QTc measured on a single‐ (or limited number) lead ECG can reliably substitute for 12‐lead ECG information. 18,19 In one study, QT was underestimated by smartphone single‐lead ECG. 20 Outpatient The principles of remote patient management, crossing geographic, social, and cultural barriers, can be extended to outpatient care and are important to maintain continuity of care for non‐COVID‐19 patients. 21‐23 Virtual clinics move far beyond simple telephone contacts by integrating information from photos, video, mobile heart rhythm, and mobile health devices recording ECG, and remote cardiovascular implantable electronic device (CIED) interrogations. 24 A variety of platforms have been developed and used specifically to provide telehealth to patients via video teleconferencing 25,26 (Table 1). CIED, wearable/mobile health, and clinical data can be integrated into clinician workflow. 2 TABLEExamples of remote ECG and heart rate monitoring devices Device Type CE mark FDA clearance Additional features/Notes Website Handheld devices AliveCor KardiaMobile Wireless Yes Yes FDA cleared for AF (1‐lead) and for QTc (6L) for COVID‐19 patients on HCQ ± AZM https://www.alivecor.com/kardiamobile Beurer ME 90 Wireless 1‐lead ECG Yes No https://www.beurer.com/web/gb/products/medical/ecg‐and‐pulse‐oximeter/mobile‐ecg‐device/me‐90‐bluetooth.php Cardiac Designs ECG Check Wireless 1‐lead ECG Yes Yes https://www.cardiacdesigns.com CardioComm Solutions HeartCheck CardiBeat and ECG Pen Wireless 1‐lead ECG Yes Yes https://www.theheartcheck.com COALA Wireless 1‐lead ECG Yes Yes Remote lung auscultation https://www.coalalife.com Eko DUO Wireless 1‐lead ECG Yes Yes Remote cardiac auscultation/ phonocardiogram https://www.ekohealth.com Omron Blood Pressure + EKG Monitor Wireless 1‐lead ECG + BP cuff No Yes United States and Canada only https://omronhealthcare.com EKGraph Wireless 1‐lead ECG No Yes United States https://sonohealth.org Mobile cardiac telemetry devices Qardio QardioCore Chest strap 1‐lead ECG Yes No ECG, HR, HRV, RR, activity https://www.getqardio.com/qardiocore‐wearable‐ecg‐ekg‐monitor‐iphone BardyDx CAM Patch 1‐lead ECG Yes Yes Under clinical investigation for QTc monitoring in COVID‐19 patients https://www.bardydx.com BioTel Heart Patch 1‐lead ECG Yes—only for extended Holter Yes FDA cleared for QTc monitoring https://www.myheartmonitor.com/device/mcot‐patch BodyGuardian MINI Family/BodyGuardian MINI PLUS Wireless Patch: 1‐lead ECG/ Wired 3‐lead ECG Yes Yes ECG, HR, HRV, RR https://www.preventicesolutions.com/hcp/body‐guardian‐mini‐family iRhythm Zio patch/Zio AT Patch 1‐lead ECG Yes Yes https://www.irhythmtech.com InfoBionic MoMe Kardia Wired 3‐lead ECG Yes Yes Remote lung auscultation https://infobionic.com MediBioSense MBS HealthStream, VitalPatch, MCT Patch 1‐lead ECG Yes Yes Monitors up to 8 vital signs https://www.medibiosense.com MEMO Patch Patch/watch 1‐lead ECG No No Asia; Korea FDA approved https://www.huinno.com MediLynx PocketECG Wired 3‐lead ECG Yes Yes HRV https://www.pocketecg.com RhythMedix RhythmStar Wired 3‐lead ECG No Yes https://www.rhythmedix.com Samsung S‐patch Cardio Patch 1‐lead ECG Yes No Asia; Korea FDA approved https://www.samsungsds.com/global/en/solutions/off/cardio/cardio.html Smartwatches Apple Watch 1‐lead ECG Yes Yes FDA cleared for AF notification https://www.apple.com/watch Withings Move ECG 1‐lead ECG Yes No Requires Health Mate app for ECG analysis/AF detection https://www.withings.com/us/en/move‐ecg Abbreviations: AF, atrial fibrillation; AZM, azithromycin; BP, blood pressure; ECG, electrocardiogram; FDA, Food & Drug Administration; HCQ, hydroxychloroquine; HR, heart rate; HRV, heart rate variability; RR, respiratory rate.
Besides their impact on ventricular filling, they serve as a volume reservoir, host pacemaker cells and important parts of the cardiac conduction system (e.g. sinus node, AV node), and secrete ...natriuretic peptides like atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) that regulate fluid homoeostasis. ...atrial cells (both cardiomyocytes and non-cardiomyocyte elements like fibroblasts, endothelial cells, and neurons) react briskly and extensively to pathological stimuli 3 and are susceptible to a range of genetic influences 7. ...atrial pathologies have a substantial impact on cardiac performance, arrhythmia occurrence, and stroke risk 1,8. ...while some pathological processes may affect the atria very selectively (e.g. atrial fibrillation-induced remodelling), most cardiomyopathies that affect the atria also involve the ventricles to a greater or lesser extent. ...we have proposed here a working histological/ pathopysiological classification scheme for atrial cardiomyopathies ( Table 1; Fig. 1). ...this classification is purely descriptive and in contrast to other classifications (NYHA class, CCS class etc.), there is no progression in severity from EHRAS class I to EHRAS IV ( Table 2). Unlike ventricular cardiomyocytes, atrial cardiomyocytes do not possess an extensive T-tubule network but they do have prominent sarcoplasmic reticulum (SR) elements known as Z-tubules 33. ...the atrial sarcolemma does not protrude into the cell, and voltage-operated Ca2+ channels mainly function at the cell periphery 34.
Objectives This study aimed to assess the benefit after ablation of premature ventricular complexes (PVC) in patients with frequent PVC and left ventricular (LV) dysfunction, regardless of previous ...structural heart disease (SHD) diagnosis, PVC morphology, or estimated site of origin. Background Ablation of PVC in patients with LV dysfunction is usually restricted to patients with suspected PVC-induced cardiomyopathy. Methods Consecutive patients with frequent PVC and LV dysfunction accepted for ablation at 4 centers were prospectively included. Of the 80 patients included, 27 (34%) had a diagnosis of SHD. Results Successful sustained ablation (SSA) was achieved in 53 (66%) patients, and LVEF improved in these patients from 33.7 ± 8% to 43.8 ± 9.4% and 45.8 ± 10.9% at 6 and 12 months, respectively (p < 0.05), without differences related to previous diagnosis of SHD (p = 0.69). BNP decreased from 109 64 to 242 pg/ml to 60 25 to 170 pg/ml, 50 14 to 130 pg/ml, and 60 19 to 81 pg/ml at 1, 6, and 12 months (p < 0.05). Patients in NYHA class I increased from 12 (23%) to 42 (79%) at 12 months (p < 0.05). A 13% baseline PVC burden had 100% sensitivity and 85% specificity to predict an absolute increase ≥5% in LVEF after SSA. Although 20 patients with >13% PVC and SSA had class I indication for cardioverter defibrillator implantation, these indications were absent at 6 months post-ablation. Conclusions Independently of the presence of SHD, the SSA of frequent PVC in patients with depressed LVEF induced a progressive clinical and functional improvement. Improvement in heart failure parameters was related to baseline PVC burden and persistence of ablation success.
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