Short-term efficacy and safety of radiofrequency ablation for idiopathic premature ventricular contractions

Abstract

Premature ventricular contractions (PVCs) are common arrhythmias that may impair quality of life and lead to PVC-induced cardiomyopathy. Radiofrequency ablation (RFA) has emerged as an effective treatment option for symptomatic and drug-refractory idiopathic PVCs, yet real-world data remain limited. This retrospective single-center study included 53 patients who underwent RFA for idiopathic PVCs between December 2022 and June 2024. Demographic, clinical, and procedural data were analyzed. Acute procedural success, 6-month recurrence, and complications were evaluated according to PVC localization. The mean age of the cohort was 52.1 ± 12.9 years, and 62.3% were female. Acute procedural success was achieved in 84.9% of patients. The most frequent origin was the right ventricular outflow tract (60.4%), followed by the left ventricle (26.4%), coronary cusp (11.3%), and para-Hisian region (1.9%). At 6-month follow-up, recurrence occurred in 6.6% of patients. Complications included 2 cases of steam pop with mild pericardial effusion and 2 cerebrovascular events, both with complete recovery. Age was identified as an independent predictor of acute procedural success (P < .05). RFA is a safe and effective treatment for idiopathic PVCs, providing high acute success and low recurrence rates. Early intervention in symptomatic or drug-refractory patients may improve outcomes and help prevent PVC-induced cardiomyopathy.

1. Introduction

Premature ventricular contractions (PVCs) are among the most common ventricular arrhythmias and are detected in the majority of individuals undergoing electrocardiographic monitoring for extended periods. The reported frequency of PVCs varies across studies, depending on the duration and method of monitoring. In the ARIC study, PVCs were identified in 5.5% of participants using a 2-minute electrocardiogram (ECG), whereas 24-hour Holter monitoring detected at least 1 PVC in 69% of healthy individuals aged 25 to 41 years.^[1,2]

PVCs can occur through triggered activity, enhanced automaticity, or reentry mechanisms. Various factors – including age, hypertension, coronary artery disease, male sex, stimulant use, stress, and sleep deprivation – contribute to their occurrence.^[3,4] Although often considered benign, PVCs can significantly impair quality of life and lead to left ventricular dysfunction or PVC-induced cardiomyopathy if frequent or sustained.^[5]

Pharmacologic therapy, typically with beta-blockers or calcium channel blockers, is often the first-line approach; however, efficacy remains limited, and many patients experience persistent symptoms. The use of other antiarrhythmic drugs is restricted due to adverse effects and proarrhythmic potential.^[6] Catheter-based radiofrequency ablation (RFA) has emerged as an effective alternative, particularly for symptomatic or drug-refractory idiopathic PVCs. According to the current European Society of Cardiology guidelines, catheter ablation is recommended as a class I indication for PVCs originating from the right ventricular outflow tract (RVOT) or fascicular regions and as a class IIa indication for other idiopathic PVC origins.^[7–9]

While the efficacy and safety of RFA for idiopathic PVCs have been extensively reported, most available evidence is derived from multicenter studies or heterogeneous populations, often limiting the interpretation of short-term procedural outcomes and real-world complication profiles at the single-center level.

Real-world, single-center data focusing specifically on short-term efficacy, recurrence patterns, and safety outcomes of RFA for idiopathic PVCs remain limited.

Therefore, this study aims to provide a detailed evaluation of the short-term efficacy and safety of RFA for idiopathic PVCs in a real-world, single-center setting, with subgroup analyses according to anatomic localization. By focusing on a homogeneous patient cohort and standardized procedural techniques, we seek to offer practical insights into predictors of acute procedural success, recurrence, and complication patterns in daily electrophysiology practice.

2. Materials and methods

2.1. Study design

This was a single-center, retrospective observational study conducted at the Celal Bayar University Cardiology Department. We reviewed the medical records of patients who underwent RFA for idiopathic PVCs between December 2022 and June 2024. The study adhered to the Declaration of Helsinki and was approved by the Ethics Committee of Celal Bayar University Faculty of Medicine (approval code: 20.478.486; approval date: January 8, 2025).

2.2. Patient selection

Patients were included if they met one or more of the following criteria: symptomatic idiopathic PVCs, PVC-related or PVC-aggravated cardiomyopathy, or a PVC burden >20% on 24-hour Holter monitoring. Exclusion criteria included significant structural heart disease or incomplete records.

Significant structural heart disease was defined as the presence of left ventricular ejection fraction (LVEF) <50%, cardiomyopathy, prior myocardial infarction with structural myocardial abnormalities, significant valvular heart disease, or congenital heart disease detected by echocardiography or cardiac imaging.

Secondary causes of PVCs, such as anemia, hormonal disorders, and electrolyte imbalances, were excluded based on laboratory evaluations. Patients’ habits, lifestyle, and medications were reviewed and addressed prior to ablation. All patients had documented PVCs on standard ECGs. PVC localization was preliminarily assessed based on surface ECG characteristics, including the transition zone and inferior axis.

Transthoracic echocardiography was performed in all patients. In 2 patients with LVEF < 50%, cardiac magnetic resonance imaging (MRI) was used to further evaluate etiology.

2.3. Electrophysiological study and ablation procedure

All ablation procedures were performed using the CARTO™ 3 System (Biosense Webster Inc., Diamond Bar). A ThermoCool SmartTouch™ catheter (Biosense Webster Inc., Diamond Bar) was used to deliver radiofrequency energy for a minimum of 60 seconds at 35 to 40 W at the site of earliest activation. The PASO™ automated pace mapping module (Biosense Webster Inc., Diamond Bar) was utilized when necessary.

Acute procedural success was defined as complete elimination of PVCs or a reduction in PVC burden to <5% at the end of the procedure. Six-month success was defined as a PVC burden of <5% on 24-hour follow-up Holter monitoring.

2.4. Follow-up and outcome definitions

Patients were followed for 6 months postprocedure with clinical assessments and Holter monitoring. Recurrence was defined as a PVC burden ≥5% on follow-up Holter or return of symptoms attributable to PVCs. Complications related to the procedure were also documented.

The 6-month follow-up period was selected because previous studies have demonstrated that the majority of PVC recurrences occur within the first 3 to 6 months after ablation, making this duration sufficient to assess short-term procedural efficacy and safety.

2.5. Statistical analysis

Data analysis was performed using SPSS version 21.0 (SPSS Inc., Chicago). Descriptive statistics were reported as means ± standard deviation, medians with interquartile ranges (IQR), or percentages, as appropriate. Continuous variables were compared using the Student t test or Kruskal–Wallis test depending on distribution. Categorical variables were analyzed using the chi-square test. A P-value of <.05 was considered statistically significant.

3. Results

Between December 2022 and June 2024, 53 patients underwent RFA for idiopathic PVCs, and 33 patients (62.3%) were female. The mean age of the study population was 52.1 ± 12.9 years, with a range of 23 to 79 years. In the cohort, 17 patients did not use any medications, while beta-blockers were the most commonly used drug group, with 25 patients on this therapy. Three patients were receiving both beta-blockers and class 1 antiarrhythmic drugs. Other clinical features are presented in Table 1.

Table 1.

Baseline characteristics and symptoms of patients (N = 53).

Age (yr), median (IQR)	52.1 ± 12.9
Female, n (%)	33 (62.3)
Hypertension, n (%)	18 (34)
Diabetes mellitus, n (%)	9 (17)
Coronary artery disease, n (%)	4 (7.5)
LVEF (%), mean ± SD	57.4 ± 7.2
Palpitation, n (%)	50 (94)
Fatigue, n (%)	35 (66)
Dizziness/presyncope, n (%)	17 (32)
Syncope, n (%)	2 (3.7)
Drugs
None	17 (32)
β blocker	25 (47.1)
Calcium channel blocker	8 (15)
Group 1 antiarrhythmics	3 (5.6)
Group 3 antiarrhythmics	3 (5.6)

IQR = interquartile range, LVEF = left ventricular ejection fraction, SD = standard deviation.

The observed mean LVEF was 57.4 ± 7.2%. Seven patients had an LVEF < 50%, of which 4 patients showed improvement to LVEF > 50% during the 6-month follow-up, while the procedure was unsuccessful in 3 patients.

When analyzed by localization, PVCs most commonly originated from the RVOT in 32 (60.4%) patients, followed by the left ventricle in 14 (26.4%) patients, the coronary cusp (CC) in 6 (11.3%) patients, and the para-Hisian region in 1 (1.9%) patient.

Upon subgroup analysis of localizations, PVCs originating from the RVOT were most commonly identified in the posteroseptal region (15 patients, 46.9%). Left ventricular PVCs (LV PVCs) were equally distributed between the aortomitral continuity (AMC) and the summit region, with each accounting for 6 cases (42.9%). Among CC PVCs, the left CC was the most frequent site (4 cases, 66.7%). One patient was identified with PVCs originating from the para-Hisian region. Overall, acute procedural success was achieved in 45 patients (84.9%). No significant differences were observed in acute procedural success rates across different localizations (P = .12). The success rates by localization and subgroup are presented in Table 2.

Table 2.

PVC localizations with acute and 6-month follow-up procedural success rates.

	Patients (N = 53)	Acute success	Follow-up success
RVOT	32 (60.4%)	29 (90.6%)	27 (84.3%)
Posteroseptal	15 (46.9%)	12	11
Septum	10 (31.25%)	10	10
Free wall	7 (21.8%)	7	6
LV	14 (26.4%)	11 (78.5%)	10 (71.4%)
LV summit	6 (42.9%)	4	3
AMC	6 (42.9%)	6	6
Anterior papillary muscle	1 (7.1%)	1	1
Posterior papillary muscle	1 (7.1%)	0	–
CC	6 (11.3%)	5 (83.3%)	5 (83.3%)
Left coronary cusp	4 (66.7%)	3	3
Right coronary cusp	2 (33.3%)	2	2
Para-Hisian origin	1	0	–

AMC = aortomitral continuity, CC = coronary cusp, LV = left ventricular, PVC = premature ventricular contraction, RVOT = right ventricular outflow tract.

Acute procedural failure was observed in 3 patients (9.4%) with RVOT-origin PVCs, 3 patients (21.5%) with LV PVCs, 1 patient (16.7%) with CC-origin PVCs, and 1 patient with para-Hisian origin PVCs. Age was identified as an independent risk factor for acute procedural success (P = .04).

In the para-Hisian case, the earliest activation sites were located very close to the His bundle recordings, posing a high risk of atrioventricular block; therefore, the procedure was terminated, and cryoablation was planned as a follow-up intervention (Fig. 1).

Figure 1.

(A) The earliest focal activation site, indicated in red on the 3D electroanatomical map, was identified in close proximity to regions (yellow dots) with prominent His bundle potentials. The close anatomical relationship between the earliest activation point and the His bundle poses a high risk for atrioventricular (AV) block. The red arrow indicates the QS pattern observed in the unipolar electrogram recordings at the earliest activation site. (B) Surface ECG showing a narrow QRS morphology originating from the para-Hisian region, closely resembling intrinsic QRS. During normal sinus conduction prior to the PVC, the His potential is marked by a yellow arrow. The green line demonstrates the significant early activation in this region. AP = anteroposterior, ECG = electrocardiogram, INF = inferior, LAO = left anterior oblique, LAT = lateral, LL = left lateral, PA = posteroanterior, PVC = premature ventricular contraction, QRS = QRS complex, RAO = right anterior oblique, RL = right lateral, SUP = superior.

For LV summit PVCs, due to their proximity to coronary arteries, the procedure could not proceed endocardially. Despite attempts at ablation from the distal coronary sinus in 2 such patients, the procedures were unsuccessful (Fig. 2). In a PVC originating from the posterior papillary muscle of the mitral valve, procedural failure occurred due to stabilization issues. Additionally, in 1 patient with a left CC-origin PVC, ablation attempts from within the CC and left ventricular outflow tract (LVOT) side of the aortic valve were unsuccessful.

Figure 2.

PVC originating from the LV summit was evaluated using multiple approaches: aortic cusps, subcusp region, and distal great cardiac vein (GCV). RFA was unsuccessful despite early activation (30 ms pre-QRS) recorded in the subcusp region. The ECG on the left displays a typical inferior axis and early precordial transition in V1, characteristic of LV summit PVCs. AP = anteroposterior, ECG = electrocardiogram, GCV = great cardiac vein, INF = inferior, LAO = left anterior oblique, LAT = lateral, LCC= left coronary cusp, LL = left lateral, LMCA = left main coronary artery, LV = left ventricular, PA = posteroanterior, PVC = premature ventricular contraction, QRS = QRS complex, RAO = right anterior oblique, RCC = right coronary cusp, RL = right lateral, SUBCUSP = subcusp region, SUP = superior.

During the 6-month follow-up period, recurrence was observed in 3 patients (6.6%): 2 (6.8%) in the RVOT PVC group and 1 (9.09%) in the LV PVC group. Of these, 2 patients underwent repeat ablation, excluding 1 patient from the RVOT group, and successful ablation was achieved.

Steam pop was observed in 2 patients during the study. In one patient, pericardiocentesis was required, while in the other, a small amount of self-limiting pericardial effusion was detected and managed conservatively. Both instances of steam pop occurred during ablation of the posteroseptal region of the RVOT.

Cerebrovascular events were observed in 2 patients following LV PVC ablations, one originating from the LV summit and the other from the AMC. MRI diffusion-weighted image evaluations revealed acute ischemic changes in both cases. At the 6-month follow-up, no residual neurological deficits were detected in either patient.

Ablation for paroxysmal supraventricular tachycardia was performed in 4 patients during the index procedure. Among these patients, atrioventricular nodal reentrant tachycardia was identified in 3 cases, while atrioventricular reentrant tachycardia was diagnosed in 1 case.

Vascular complications at the intervention site were observed in 2 patients. Both were managed with conservative treatment.

4. Discussion

This study evaluated the efficacy and safety of RFA in the treatment of PVCs, along with short-term outcomes. PVCs are the most common ventricular arrhythmias and are frequently encountered in daily practice.^[3] Although PVCs are more commonly observed in males, it is noteworthy that the majority of the patient population in our study were females.^[10]

Idiopathic PVCs originate from focal sites, making them suitable candidates for long-standing RFA use. They most commonly originate from the outflow tract, with 70% to 80% arising from the RVOT. However, recent studies have shown an increasing number of ablations targeting PVCs originating from the LVOT, with some series reporting LVOT-origin PVCs surpassing those from RVOT in prevalence.^[11,12]

Acute procedural success rates for PVC ablation are generally reported to range between 80% and 90%, with some studies highlighting success rates as high as 96%.^[7,13–15] Our findings are in line with these studies, with an overall acute success rate in our cohort of 84.9%. Notably, PVCs originating from the RVOT are associated with higher success rates compared with other localizations.^[16] On the other hand, there is evidence suggesting that PVC localization does not significantly influence procedural success rates.^[16,17] In our study, although PVC localization did not demonstrate a statistically significant impact on acute success rates (P = .12), numerically lower acute success rates were observed in PVCs originating from the LV. Age has been identified as an independent predictor of acute procedural success in several ablation studies. Younger patients may have less myocardial fibrosis, fewer complex arrhythmogenic substrates, and more focal PVC origins, which may facilitate accurate mapping and effective lesion formation. By contrast, advanced age is often associated with structural myocardial changes, increased myocardial scarring, and heterogeneous conduction properties, potentially reducing procedural efficacy. These mechanisms may partly explain the observed association between younger age and higher acute procedural success rates in our cohort.

Certain PVC localizations, such as mural origin, inaccessible summit regions, papillary muscle origin, epicardial origin, or cusp regions, are associated with reduced procedural success rates and an increased likelihood of recurrence. To enhance success rates, nonconventional ablation techniques, such as bipolar ablation, unipolar ablation, needle ablation, and ethanol ablation, can be utilized. The use of intracardiac echocardiography has been shown to improve success rates, particularly in papillary muscle and intramural PVCs.^[18,19] In our study, we did not employ nonconventional ablation techniques or utilize intracardiac echocardiography.

Complications of catheter ablation procedures for PVCs are observed in 0% to 5%.^[7] Vascular injury is the most commonly encountered complication, typically managed with conservative treatment. However, idiopathic PVC ablation, although rare, can lead to severe complications such as cardiac tamponade, aortic injury, perforation, coronary artery damage, and cerebrovascular events. The reported mortality rate for these procedures is 0.16%.^[20] In our study, no mortality was observed during the acute procedure or the 6-month follow-up period.

Ablation of LV PVCs can be performed via a retroaortic or transseptal approach. For AMC PVCs, we opted for the transseptal route. Although rare, transseptal puncture can lead to potentially lethal complications due to its anatomical proximity to critical structures, such as cardiac tamponade, aortic root injury, and thromboembolic events.^[21] In our study, transseptal puncture was performed in 6 patients, and no complications were encountered.

Cerebrovascular complications are rarely reported (1.2%) and can occur due to left ventricular thrombus or aortic plaques. Although there are no definitive recommendations, maintaining an activated clotting time >250 ms during the procedure and ensuring that the patient is on antiplatelet therapy, such as aspirin, prior to the procedure appear to reduce the risk of these complications.^[22] Cerebrovascular events were noted in 2 patients (3.7%) undergoing LV PVC ablation, despite maintaining an activated clotting time >250 ms during the procedure. These events, likely related to aortic plaques, occurred on postprocedure days 1 and 4 and were confirmed by MRI. Both patients demonstrated complete recovery during their 6-month follow-up. Although cerebrovascular events occurred despite adequate intraprocedural anticoagulation, these findings highlight the clinical relevance of meticulous periprocedural management during left-sided PVC ablation. Potential mechanisms include catheter-related thromboembolism, aortic plaque disruption during retrograde aortic manipulation, or microembolization not fully prevented by systemic anticoagulation. Our findings underscore the importance of careful patient selection, strict anticoagulation protocols, and heightened vigilance during left ventricular ablation procedures, particularly in patients with suspected aortic atherosclerosis.

A higher PVC burden has been associated with increased mortality and the development of heart failure. Mohanty et al demonstrated that complete elimination of PVCs or a reduction in PVC burden to <5% was associated with significant improvements in LVEF.^[23,24] In our cohort, 7 patients presented with LVEF < 50% at baseline. At the 6-month follow-up, LVEF improved to >50% in 4 of these patients, while the remaining 3 patients with persistently reduced LVEF had unsuccessful acute procedural outcomes.

It is important to acknowledge several limitations of this study. First, it was designed as a single-center, retrospective study, which inherently introduces risks such as selection bias, incomplete data collection, and limited control over confounding variables. Furthermore, the relatively small sample size restricts the generalizability of our findings to broader clinical settings. In addition, the lack of a control group, such as patients receiving pharmacologic therapy or conservative management, and the lack of implementation of nonconventional ablation techniques limit the ability to draw causal inferences regarding the observed outcomes.

5. Conclusion

The key takeaway from this retrospective study is that RFA is an effective and safe treatment modality for PVC management. While PVCs are generally considered a benign phenomenon, early RFA should be considered in symptomatic patients or those who prefer to avoid long-term medication. In particular, early RFA combined with medical therapy has been shown to be effective in PVC-induced cardiomyopathies.

The study highlights the need for further research to explore the impact of age, identified as an independent factor influencing acute ablation success. Additionally, our findings suggest that the success of RFA is not significantly influenced by PVC localization, demonstrating that RFA can be effectively applied to regions beyond the RVOT.

As digital mapping technologies continue to advance, they are likely to optimize outcomes, making RFA even more impactful in PVC management.

Acknowledgments

The authors thank the staff of the electrophysiology laboratory at Celal Bayar University for their technical assistance and patient care support.

Author contributions

Conceptualization: Mustafa Uçar.

Methodology: Mustafa Uçar, Mustafa Özcan Soylu.

Data curation: Nurullah Çetin.

Formal analysis: Nurullah Çetin.

Supervision: Ferhat Özyurtlu.

Visualization: Mustafa Özcan Soylu.

Resources: Muhammed İkbal Şaşmaz.

Validation: Muhammed İkbal Şaşmaz.

Writing – original draft: Mustafa Uçar.

Writing – review & editing: Ferhat Özyurtlu.