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22.02.2015
Natural history of ventricular premature contractions in children with a structurally normal heart: does origin matter? Aims Premature ventricular contractions (PVCs) are thought to be innocent in children with normal hearts, especially if they disappear during exercise. Conclusion We conclude that there is a difference in the natural history between PVC-LBBB and PVC-RBBB in children with an anatomically normal heart.
Frequent premature ventricular contractions (PVCs) are rare in healthy children and young adults.
Although probably benign, there are two reasons to hesitate to discharge children with frequent PVCs from follow-up.
The natural history studies in children considered PVCs, irrespective of the origin from RV or LV. We evaluated the children three-yearly during follow-up by history, physical examination, ECG, 24-h Holter recording, echocardiography, and an exercise test.
During ergometry (?7 years; bicycle test), heart rate at rest and during exercise was measured. All children had a normal anatomy of the heart with LV dimensions that were within normal limits. Our study showed that indeed the percentage of PVCs in children with a structurally normal heart decreases spontaneously with age. Moreover, in adults with frequent premature beats from the RV, although asymptomatic, abnormalities of the RV outflow tract were found on echocardiogram and magnetic resonance.12,13 Despite these anatomical abnormalities, the prognosis of these patients was good and none showed progression to clinical manifestations of ARVC.
Knowing that PVCs from the LV nearly disappear during childhood, we are in favour of discharging these children from follow-up, if the (family) history is normal as well as the echocardiogram and if the PVCs disappear with exercise. To study the natural history it was necessary to analyse the data in different age groups, which unfortunately resulted in small numbers of children in some age group. We conclude that the natural history of PVCs in children with an anatomically normal heart differs depending on the origin of the PVCs. Premature Ventricular Contraction (PVCs of the heart) is a pause in physical heart response, whereas PVCs of emotion are theoretical pauses suggested to be observed during a Physician’s emotional response to their patient.
ECG showing three normal beats and a pre-ventricular (PVC)  followed by a compensatory pause.
A relatively common event where the heartbeat is initiated by Purkinje fibres in the ventricles rather than by the sinoatrial node, the normal heartbeat initiator.
The crews in the cockpits also monitor for spikes in their emotions and counter them with appropriate antidotes. Challenge your friends and family to see who can shoot the marshmallows the longest distance! The aim of our study was to study the natural history of PVCs in childhood and whether there is a difference between PVCs originating from the right [premature ventricular contraction with left bundle branch block (PVC-LBBB)] or the left ventricle [premature ventricular contraction with right bundle branch block (PVC-RBBB)].
Premature ventricular contraction with right bundle branch block disappears during childhood.
First, a prolonged period of very frequent PVCs may lead to left ventricular (LV) dilatation7 and, secondly, PVCs originating from the right ventricle (RV) might be the first symptom of arrhythmogenic right ventricular cardiomyopathy (ARVC). The data of the children were analysed in different age groups (1–3, 3–5, 5–8, 8–12, 12–16, and ?16 years).


If PVCs were present, it was determined whether they originated from the RV [premature ventricular contraction with left bundle branch block (PVC-LBBB)] or from the LV [premature ventricular contraction with right bundle branch block (PVC-RBBB)]. Premature ventricular contractions were expressed as a percentage of the total number of QRS complexes per 24 h.
Measurements of LV dimensions and walls were made by two-dimensional and M-mode echocardiography on a parasternal short-axis view using standard techniques. Representative ECGs demonstrating the PVC morphology (BBB and frontal axis) to illustrate the specific type of ventricular ectopy are shown in Figure 1. However, if the origin of the premature beats is taken into account, this is only true for premature beats originating from the LV (PVC-RBBB). There are indications from studies in adults with structurally normal hearts that frequent premature ventricular beats may influence LV function.
Because the percentage of PVCs from the RV did not diminish during childhood, we advise to follow these children with 2–3 year intervals, especially for LV function and the small risk of developing ARVC. The natural history is not different if a child has couplets or only single PVCs, as was found earlier by Paul et al.14 Thus, couplets are not a risk factor for the development of VT. In contrast with our findings in children with frequent PVCs, resolution of idiopathic VT was seen more often in patients with a VT originating from the RV.15,16 The only explanation can be that there is a different electrophysiological substrate for frequent PVCs and idiopathic VT in children with a structurally normal heart. To determine the natural history of PVCs, a much longer follow-up, in which the data are collected prospectively, would have been desirable.
The normal rhythm of the heart is called normal sinus rhythm, like the first and the last two beats on the ECG tracing above. The electrical events of the heart detected by the electrocardiogram allow a PVC to be easily distinguished from a normal heart beat.
Feel free to join the discussion by leaving comments, and stay updated by subscribing to the RSS feed. Although probably true, this benign influence of suppression by exercise is never proved by prospective studies. Therefore, we retrospectively studied the natural history of PVCs in relation to their origin in children with a structurally normal heart.
It was determined whether the PVCs were uniform or multiform, and whether there were couplets or ventricular tachycardias (VTs). The exercise test was finished when complaints of fatigue or ventricular arrhythmias (couplets or VT) occurred. Premature ventricular contraction with left bundle branch block was seen in 41% of the children, PVC-RBBB in 36%, and in 23%, the origin of the PVC could not be determined. The percentage of premature beats originating from the RV (PVC-LBBB) did not change over time.
Facchini et al.7 found a subclinical but significant increase of LV dimensions in patients with frequent PVCs compared with the control group.
Occasionally, the ventricles of the heart contact early causing a Spike in amplitude and duration. Although a PVC can be a sign of decreased oxygenation to the myocardium (cardiac muscle) often PVCs are benign and may even be found in otherwise healthy hearts. Premature ventricular contraction with left bundle branch block does not disappear and, therefore, it may be necessary to follow these children even during adulthood.


The opposite, induction of ventricular arrhythmias by exercise is of course a sign of structural or electrical heart disease, although it was occasionally found in otherwise healthy children.5 The natural history of PVCs in children with a structurally normal heart seems favourable as many studies, although with small patient numbers, show a decrease in numbers of PVCs during follow-up and no morbidity or mortality.
The aim of our study was to judge if the natural history was different for PVCs originating from the RV or LV and if this might have consequences for the follow-up policy. Left ventricular end-diastolic diameter (LVEDD) was measured between the endocardium of the intraventricular septum and the posterior LV wall at the chordal level, expressed in millimeters and plotted on percentile curves adjusted for weight.9 Left ventricular end-systolic diameter (LVESD) was measured likewise. In eight children, the PVCs did not disappear but decreased in percentage at the highest heart rates. A recent study of Bogun et al.11 found a decreased LV ejection fraction in 37% of the patients with frequent premature beats, which normalized after radiofrequency ablation of the premature beats. This egregious beat, called Pre-ventricular Contraction (PVC), is followed by a delay, called the compensatory pause before the next normal sinus beat.
Most children had no complaints at all and were referred because of an accidentally found irregular heart rate. In all children, PVCs disappeared at about the same heart rate as during the Holter recording. Like others we found that PVCs in children with a structurally normal heart were well tolerated, without morbidity or mortality.
Left ventricular dysfunction found in adults with frequent PVCs may be an argument to continue to follow these children, as well as the potential, but small risk of developing ARVC. Repetitive echocardiograms were performed when the children still had >10% PVCs in the Holter recording.
We do not know the response of the PVCs to exercise in these patients, and it is not known whether the PVCs were already present in the childhood or developed later in the adulthood. We advise that follow-up of children consists of Holter recording, echocardiogram, and exercise testing. Couplets were found in 47% of the total group of children and consisted mostly of PVC with a fusion beat. Arrhythmias documented by 24 hour continuous electrocardiographic monitoring in 50 male medical students without apparent heart disease. There were two first or second degree family members with complaints of irregular heart beat. Arrhythmias documented by 24-hour continuous ambulatory electrocardiographic monitoring in young women without apparent heart disease.
There was no difference in the occurrence of couplets or VT between the PVC-LBBB and PVC-RBBB groups. Mean heart rate at which the PVCs disappeared was not different between the PVC-LBBB and PVC-RBBB groups. None of the children developed repetitive monomorphic VT or sustained VT of either the right ventricular or the LV origin during follow-up. Increased left ventricular dimensions in patients with frequent nonsustained ventricular arrhythmia and no evidence of underlying heart disease.



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