A New Combined Parameter to Predict Premature Ventricular Complexes Induced Cardiomyopathy: Impact and Recognition of Epicardial Origin.

INTRODUCTION: Reversible premature ventricular complexes-induced cardiomyopathy (PVC-CMP) is a well-described, multi-factorial entity. Single predictors, such as PVC burden or QRS duration, may not apply equally to all patients in contemporary unselected populations including patients with structural heart disease (SHD) or with particular origin such as epicardial (EPI) PVC. We sought to evaluate clinical criteria associated with PVC-CMP notably focusing on the EPI origin impact and ECG recognition and the value of a new composite predictor of PVC-CMP, the PVC-CMP-Index. METHODS AND RESULTS: We studied 107 consecutive patients (69 men; mean age = 56 ± 16 years) with frequent PVC (23.1 ± 11.5%) referred for PVC ablation. Thirty-six patients (33.6%) had an underlying SHD and 25 patients (23.4%) an EPI PVC origin. After a mean follow-up of 22.7 ± 15.3 months, 72.9% achieved a long-term successful ablation and 54.2% had PVC-CMP. PVC-CMP prevalence was significantly higher in patients with an EPI compared to endocardial PVC focus (84.0% vs. 45.1%, respectively, P < 0.001). EPI PVC origin (OR = 68.7 IC95% [3.5-1363], P = 0.005), as well as SHD (OR = 12.3 IC95% [1.6-92.6], P = 0.015), was independent predictor of PVC-CMP. While PVC burden (AUC = 0.78) or PVC-QRS width (AUC = 0.68) independently predicted PVC-CMP, the PVC-CMP-Index (values ≥39) defined as: PVC burden (0-1) × PVC-QRS width (milliseconds) × a constant C (1.28 for SHD or 2 for ECG suggesting EPI origin based on our ECG 3-step algorithm), highly correlated with PVC-CMP (AUC = 0.91, sensitivity = 93%, specificity = 80%). CONCLUSION: We developed a new index, which incorporates PVC burden, QRS width, and presence of SHD or suspected EPI origin that best predicted PVC-CMP.

Pulmonary artery sarcoma: a rare cause of dyspnoea.

A 72-year-old woman with no significant medical history presented to the emergency room for severe dyspnoea. The initial clinical diagnosis was acute pulmonary embolism. Heparin infusion was initiated while awaiting a computed tomographic scan but the patient's condition deteriorated dramatically and stat echocardiogram showed tamponade. Post-evacuation echo showed a dilated right ventricle with pulmonary hypertension and obstruction of the right pulmonary artery by a homogeneous mass attached to the pulmonary artery, suggesting a tumour rather than a thrombus. Computed tomographic scan confirmed the presence of an obstructive mass with almost no perfusion of the right lung. The patient was referred to cardiac surgery and the mass was removed, with anatomo-pathological diagnosis of a typical pulmonary artery sarcoma. Unfortunately, the patient died a few days after surgery. Primary pulmonary artery sarcoma is a rare tumour that arises in the central pulmonary arteries. Clinical presentation is often attributed to other causes of pulmonary hypertension, like pulmonary embolism. Magnetic resonance imaging could help to distinguish a soft tissue mass from a thrombus but definitive diagnosis is almost always made at surgery or autopsy since patients usually present in acute and unstable situations. Prognosis is poor, from several months to a few years, and depends on how early the diagnosis is made, the presence of recurrence or metastasis after surgical resection, and the use of adjuvant therapy like radiation and chemotherapy.

Prevalence and clinical impact of QRS duration in patients with low-flow/low-gradient aortic stenosis due to left ventricular systolic dysfunction.

AIMS: To evaluate the prognostic impact of QRS width in patients with low-flow/low-gradient aortic stenosis (LF/LGAS). METHODS AND RESULTS: Among 88 consecutive patients referred to our institution for LF/LGAS from September 1994 to March 2007, baseline demographic, clinical, echocardiographic, and electrocardiographic data were collected. This population was divided into two groups according to baseline QRS duration (cut-off QRS ≥130 ms). Follow-up data, including electrocardiographic evolution and overall mortality, were analysed. The mean follow-up duration was 3.1 (2.2-6.2) years. In the whole group, 67 patients underwent surgical aortic valve replacement. Forty-nine patients (56%) had a QRS duration ≥130 ms. Among operated patients, there was no significant change in QRS duration between baseline and latest follow-up (126 ± 26 ms vs. 131 ± 25 ms; P = 0.82). In addition, wider QRS was a strong independent predictor of overall mortality (hazard ratio 2.20, 95% confidence interval 1.15-4.24; P = 0.027). CONCLUSION: Significant intraventricular conduction disturbances are common in patients with LF/LGAS and do not recover after aortic valve replacement. QRS duration is strongly associated with mortality in this selected population.

Persistent atrial fibrillation presenting in sinus rhythm: pulmonary vein isolation versus pulmonary vein isolation plus electrogram-guided ablation.

BACKGROUND: The classification of atrial fibrillation as paroxysmal or persistent (PsAF) is clinically useful, but does not accurately reflect the underlying pathophysiology and is therefore a suboptimal guide to selection of ablation strategy. AIM: To determine if additional substrate ablation is beneficial for a subset of patients with PsAF, in whom long periods of sinus rhythm (SR) can be maintained. METHODS: We included patients presenting with PsAF in whom continuous periods of SR>3months were documented. All patients were in SR on the day of the procedure. Electrical pulmonary vein isolation (PVI) was performed in all patients. Additional electrogram (EGM)-guided ablation was left to the discretion of the operator. Patient characteristics and follow-up were analysed with respect to presence or absence of additional EGM-guided ablation. RESULTS: Sixty-five patients (mean age 60.1±8.9years; 81.5% men) met the inclusion criteria. EGM-guided ablation was performed in 32 (49%) patients. Patients with and without EGM-guided ablation had similar baseline characteristics. Absence of EGM-guided ablation was one of the independent predictors for arrhythmia recurrences after the index procedure (hazard ratio 0.24; confidence interval 0.12-0.47). After a median follow-up of 18±10months, the number of procedures required was significantly higher in the 'PVI-only' group (2.24±0.75 vs. 1.84±0.81; P=0.04) to achieve a similar success rate (84% vs. 81%; P=0.833). CONCLUSION: The addition of EGM-guided ablation requires fewer procedures to achieve similar clinical efficacy in mid-term follow-up compared with a PVI-only strategy in patients with PsAF presenting for ablation in SR.

Acute pericardial effusion following atrial fibrillation ablation: characteristics and relationship with arrhythmia recurrences.

BACKGROUND: Pericardial effusion (PE) can occur during or after atrial fibrillation (AF) ablation, and may induce atrial arrhythmia. AIM: To characterize the impact of PE on arrhythmia recurrences following AF ablation. METHODS: Patients referred for a first radiofrequency AF ablation were studied prospectively. Transthoracic echocardiography was performed before and 24h after the procedure. If PE was present, transthoracic echocardiography was repeated at 1 month to evaluate PE evolution. Early arrhythmia recurrences (EARs) were defined as any arrhythmia documented within 1 month of the procedure. RESULTS: PE was diagnosed in 18/81 patients (22%); and was present in significantly more patients with persistent versus paroxysmal AF (14/40 [35%] vs 4/41 [10%]; P=0.008). PEs were mild (mean 6 ± 3mm), mainly asymptomatic (89%), and none required pericardiocentesis. Early and late arrhythmia recurrences were present in 25/81 (31%) and 29/81 (36%), respectively. The incidence of PE was significantly higher among patients with EARs versus those without (12/25 [48%] vs 6/56 [11%]; P=0.0004). By multivariable analysis, PE and duration in AF were the two independent predictors of EARs. PE incidence was similar in patients with and without late arrhythmia recurrences. At 1 month, no patients had PE on transthoracic echocardiography. CONCLUSION: PE following radiofrequency AF ablation is frequent, particularly following persistent AF ablation. This effusion is generally mild, mainly asymptomatic, and independently associated with EARs.