Premature Ventricular Complex Catheter Ablation

Premature ventricular complex (PVC) catheter ablation is recommended for patients with symptomatic frequent PVCs (palpitations, fatigue, exertional intolerance) refractory to or intolerant of beta-blocker therapy, PVC burden ≥10-15% with PVC-induced cardiomyopathy, or impending tachycardia-induced cardiomyopathy. Common origins include right ventricular outflow tract (RVOT, ~70%), left ventricular outflow tract (LVOT), aortic and pulmonary cusps, fascicles (idiopathic fascicular VT), papillary muscles, and crux of the heart.

Pre-procedural workup includes 12-lead ECG and ambulatory monitoring to characterize PVC morphology, polymorphism, and burden, plus echocardiography or cardiac MRI to assess LV function and exclude structural disease. CMR is particularly valuable in non-RVOT origins to detect myocardial scar suggesting ischemic or non-ischemic cardiomyopathy, where ablation strategy and risk profile differ.

Mapping techniques include activation mapping during PVCs (earliest endocardial activation typically 25-45 ms before QRS onset), pace mapping (12/12 match), and substrate mapping for scar-related VT. Radiofrequency ablation at the earliest activation site achieves acute success in 80-95% for idiopathic outflow tract PVCs. Complications include cardiac tamponade, AV block (fascicular), coronary artery injury (LVOT), and stroke. Long-term success rate is 70-90% with significant improvement in LV function in PVC-induced cardiomyopathy.