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.

Keywords: cardiac magnetic resonance; premature ventricular complexes; risk stratification.

Figure 1

Predictors of cardiac magnetic resonance abnormalities in patients with apparently idiopathic premature ventricular complexes (PVCs). The odds‐ratio of each factor is indicated on the horizontal axis and color coded within the circles; the area of each circle is proportional to the numerosity of the sample investigated. CMP: cardiomyopathy; RBBB: right bundle branch block; SCD: sudden cardiac death [Correction added on 14th October 2019, after first online publication: Figure 1 replaced with updated figure, which includes updated references.]

Figure 2

Forest plot showing the results of principal studies investigating the risk of major adverse cardiovascular events associated with the presence of myocardial structural abnormalities detected by cardiac magnetic resonance in patients with apparently idiopathic ventricular arrhythmias [Correction added on 14th October 2019, after first online publication: Figure 2 replaced with updated figure, which includes updated references.]

Figure 3

Proposed flow‐chart for the diagnostic work‐up and management of patients presenting with apparently idiopathic premature ventricular complexes (PVCs). Careful evaluation of personal history, baseline electrocardiogram (ECG) and PVC features should be always the first step in the diagnostic work‐up of patients with frequent PVCs (left panel); complementary diagnostics may be needed to rule out suspected causes of PVCs (eg, valvular or ischemic heart disease). When features suggestive of truly idiopathic PVCs are present (central panel, green triangle), no further investigations are mandatory. Conversely, when one or more high‐risk features (central panel, red triangle) are present, further investigations with advanced imaging techniques should be considered in order to detect possible underlying structural abnormalities deserving proper medical attention and specific treatment (right panel) CMP: cardiomyopathy; CT: computed tomography; FDG‐PET: fluorodeoxyglucose positron emission tomography; LBBB: left bundle branch block; LV: left ventricle; NSVT: non‐sustained ventricular tachycardia; RBBB: right bundle branch block; SCD: sudden cardiac death; SHD: structural heart disease; TT: transthoracic