Volume 9, Issue 1, Pages (January 2012)

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Volume 9, Issue 1, Pages 86-90 (January 2012) Myocardial performance is reduced immediately prior to ventricular ectopy Poul Erik Bloch Thomsen, MD, PhD, Thomas Fritz Hansen, MD, Christian Jons, MD, Thue Olsen, MD, Arne Johannessen, MD, PhD, Knud Særmark, MSc, PhD, Scott McNitt, MS, Mark Haigney, MD, Peter Sogaard, MD, PhD Heart Rhythm Volume 9, Issue 1, Pages 86-90 (January 2012) DOI: 10.1016/j.hrthm.2011.08.023 Copyright © 2012 Heart Rhythm Society Terms and Conditions

Figure 1 Standard ECG leads I–III and V1. S-1, S-2, S-3, and S-4 are the last four sinus beats before the ventricular premature beat (VPB), respectively. Heart Rhythm 2012 9, 86-90DOI: (10.1016/j.hrthm.2011.08.023) Copyright © 2012 Heart Rhythm Society Terms and Conditions

Figure 2 Patient 9. A: Tissue tracking image with the region of interest positioned in the basal part on the intraventricular septum. Systolic longitudinal shortening on the region of interest is displaced in sinus beats S-4 to S-1 prior to the ventricular premature beat (VPB). In S-1 and S-2, a decrease in longitudinal systolic shortening occurs compared to S-3 and S-4 (13.7, 13.5, 11.7 to 6.8 mm). B: Region of interest position in the basal part of the lateral wall. Systolic longitudinal shortening decreases only in S-1 compared to S-2, S-3, and S-4, and the shortening is comparable to the systolic longitudinal shortening of the VPB in the intraventricular septum. Heart Rhythm 2012 9, 86-90DOI: (10.1016/j.hrthm.2011.08.023) Copyright © 2012 Heart Rhythm Society Terms and Conditions

Figure 3 Results of tissue Doppler echocardiography in the four sinus beats preceding a ventricular premature beat. Peak systolic myocardial velocity and longitudinal shortening are decreased by approximately 40%, and left ventricular (LV) ejection time is decreased by 15%. There were no differences in the lateral or septal measurements regardless of the location of the ectopic focus. IVS = intraventricular septum; LAT = lateral wall; TT = tissue tracking. Heart Rhythm 2012 9, 86-90DOI: (10.1016/j.hrthm.2011.08.023) Copyright © 2012 Heart Rhythm Society Terms and Conditions

Figure 4 Comparison of longitudinal shortening of S-1 between a spontaneous ventricular premature beat (VPB) and a paced VPB with identical coupling intervals in patient 23. The patient had a CRT-D device implanted with the right ventricular coil electrode screwed into the right ventricular septum (RV-lead), and simultaneous biventricular pacing was performed. A: Spontaneous VPB with coupling interval of 400 ms showing a decrease in longitudinal systolic shortening of S-1 compared to S-2, and S-3 (7.8, 11.0, to 10.0 mm). B: Single paced VPB is introduced with a coupling interval of 440 ms. There is no decrease in systolic shortening of S-1 compared to S-2, and S-3, (10.3, 8.8, and 10.0). See text for further discussion. Heart Rhythm 2012 9, 86-90DOI: (10.1016/j.hrthm.2011.08.023) Copyright © 2012 Heart Rhythm Society Terms and Conditions

Figure 5 Schematic illustration of the suggested mechanism of the prearrhythmic reduction in myocardial performance in patient 5. Standard ECG recordings and intracardiac electrograms recorded during radiofrequency ablation with the ablation catheter positioned close to the ectopic pacemaker (EPM). Shown are standard ECG leads I, aVF, V2, V1, and V6. The ablation catheter records an amplified unipolar (ABL uni) and bipolar electrogram (ABL d). Two local voltage potentials (LP and LPvpb) are present, indicating impaired electrical conduction. The LP potential is recorded 60 ms after the onset and within the QRS complex of the last sinus beat (S-1) and the local ventricular potential (V-1), whereas LPvpb is recorded 45 ms prior to the QRS complex of the VPB (vertical red lines). The red box illustrates the EPM surrounded by an area of depressed conductivity (gray shaded area). S-1 is conducted into the zone of impaired conduction (blue line) and probably is blocked. As a consequence, the contraction also is impaired, resulting in a decrease in ejection time, peak systolic velocity, and longitudinal shortening of S-1. The EPM is protected by entrance block from the sinus impulse and therefore can fire and depolarize the zone of slow conduction in the opposite direction (blue line) leading to LPvpb giving rise to the QRS complex of the VPB. See text for further discussion. Heart Rhythm 2012 9, 86-90DOI: (10.1016/j.hrthm.2011.08.023) Copyright © 2012 Heart Rhythm Society Terms and Conditions