Detection of concealed structural heart disease by imaging in patients with apparently idiopathic premature ventricular complexes: A review of current literature

Abstract

Background Premature ventricular complexes (PVCs) are the most common form of ventricular arrhythmia in the general population. While in most cases PVCs represent a primitive phenomenon with benign behavior, in a non‐negligible proportion of subjects frequent PVCs may be epiphenomenon of underlying occult heart diseases, requiring special medical attention since they have been resulted linked to increased total and cardiac mortality. Nevertheless, PVCs themselves, when incessantly frequent, may be responsible for left ventricular dysfunction in otherwise normal heart. Aim of this narrative review is to update current knowledge on the general approach to patients with frequent PVCs on the basis of available data, with a special focus on the value of imaging. Hypothesis Routine diagnostic work‐up not infrequently miss subtle concealed arrhythmic substrate, leading to erroneously refer to such arrhythmias as to “idiopathic”. Methods Literature search of PVCs articles was conducted in PubMed and Scopus electronic database. Results Conflicting data arise from literature about the true clinical significance of idiopathic PVCs. There is growing body of data providing evidence that more advanced non‐invasive imaging modalities, such as cardiac magnetic resonance, have an incremental diagnostic and prognostic value. On the other hand, in some cases the prognostic significance of isolated subtle myocardial structural abnormalities in patients with PVCs, still remains area of uncertainty. Conclusion In selected subjects with PVCs and high‐risk features for concealed arrhythmic substrate, traditional assessment to rule out the presence of heart disease, including surface ECG and transthoracic echocardiography, should be implemented with more advanced cardiovascular imaging modalities.

Cardiac Magnetic Resonance to Detect the Underlying Substrate in Patients with Frequent Idiopathic Ventricular Arrhythmias

“…Moreover, parametric mapping (T1, T2 and ECV mapping) for the assessment of a myocardial oedema and tissue characterisation was not performed as the sequences were not available at our centre. Finally, it should be taken into consideration that, in a few of the cases, the myocardial pathology and/or scarring identified on CMR may be just an incidental finding not directly related to the PVC aetiology [ 47 ].…”

Magnetic Resonance Detects Structural Heart Disease in Patients with Frequent Ventricular Ectopy and Normal Echocardiographic Findings

“…There is an increasing body of evidence recently summarized in comprehensive reviews [27][28][29] about the role of CMR in evaluation and risk-assessment of patients with ventricular arrhythmia. However, the studies behind this evidence were performed in different settings and populations, and a majority were carried out with restrictive inclusion criteria and in selected groups.…”

Diagnosis and Treatment of Idiopathic Premature Ventricular Contractions: A Stepwise Approach Based on the Site of Origin

“…Although PVCs commonly occur in subjects with morphologically normal hearts, it is crucial to exclude an underlying SHD due to its impact on the therapeutic approach and risk stratification. In this regard, cardiac imaging plays a central role (Table 2) [37,38]. Transthoracic echocardiogram (TTE) represents the first line diagnostic test, and its main role is to detect a reduced left ventricular ejection fraction (LVEF), which may either point to an underlying SHD or be secondary to the high PVCs burden (as in PVCs-CMP) [38,39].…”

“…In this regard, cardiac imaging plays a central role (Table 2) [37,38]. Transthoracic echocardiogram (TTE) represents the first line diagnostic test, and its main role is to detect a reduced left ventricular ejection fraction (LVEF), which may either point to an underlying SHD or be secondary to the high PVCs burden (as in PVCs-CMP) [38,39]. LVEF is best measured in the sinus beat after the first post-extrasystolic beat or, in case of bigeminy, by averaging measures taken during PVCs and sinus beats [40,41].…”

“…However, several lines of evidence have subsequently supported the notion that PVC suppression with either AAD or CA may result in improved EF and heart failure symptoms, and these treatments should be considered among patients at higher risk of developing PVC-CMP, especially in cases of high PVC burden. The PVC burden threshold at which AAD and/or CA should be considered is variably defined as >10% (the threshold after which most cases of PVC-CMP occur), >16-24% (the statistically optimal discriminatory cut-off value for PVC-CMP), or >6% (the threshold indicating a potential benefit of CA) [38,41,66,72]. Apart from the PVC burden, other predictors of PVC-CMP include wider PVC QRS duration and epicardial origin of PVCs as a result of a higher degree of LV dyssynchrony during the PVC beat.…”