Ectopic Beats

How does the normal heart rhythm function?

The normal heart rhythm originates from a natural pacemaker which is located in the right upper chamber of the heart. The natural pacemaker, known as the sinus node, fires off electrical impulses at regular intervals, akin to a ‘switch’ at the top of the heart going on and off at regular intervals. The electrical activity then spreads to the rest of the heart though specialized channels in the heart, which could be thought of as electrical activity being conducted through a system of ‘wires’. These ‘wires’ conduct electricity from the top chambers to the bottom chambers of the heart. In response to the spread of these electrical impulses, the heart beats at regular intervals.

How do ectopic beats arise?

Ectopic beats are extra beats that arise from an abnormal site that is different from the normal pacemaker of the heart (the sinus node). Ectopic beats can be thought of as extra electrical impulse that originate from an abnormal ‘switch’. Therefore, in a patient with ectopic beats, after every few beats from natural pacemaker (the sinus node ‘switch’), an extra beat will fire off from the abnormal site (ectopic ‘switch’). The extra beat typically occurs a short time after a normal beat and is therefore commonly referred to as a premature ectopic beat. In the majority of cases, the abnormal ‘switch’ fires off in a random fashion and therefore the heart does not beat in a synchronized fashion.

Ectopic beats may arise from multiple locations in the heart. Extra beats that arise from the top chambers of the heart (atria) are called supraventricular ectopic beats (or premature supraventricular ectopic beats). Extra beats arising from the lower chambers (ventricles) are known as ventricular ectopic beats (or premature ventricular ectopic beats).

What are the symptoms associated with ectopic beats?

A significant proportion of the general population will have a small number of ectopic beats which typically do not cause symptoms or have any adverse effects on heart function. Specifically, up to three-quarters of healthy people in the general population have a small number of ectopic beats from the lower heart chambers.1 However some patients can have a high number of ectopic beats that can be very symptomatic and have a significant impact on quality of life. Ectopic beats are generally not associated with life threatening consequences although they may be of more concern if they are associated with heart muscle weakness (discussed below).

Ectopic beats from the upper and lower chambers of the heart can cause symptoms. Palpitations are common symptom associated with ectopic beats. Patients may experience a thumping heartbeat which may be followed by a sensation of a pause in the heartbeat (which may feel as though the heart stopping transiently). The ectopic beats may also cause a fluttering sensation or a sensation of a racing heartbeat. In addition to palpitations, patients with ectopic may experience a reduction in exercise capacity, difficulty in breathing when exercising, and fatigue.

Are ectopic beats related to heart muscle weakness?

The majority of patients with ectopic beats have normal heart function. However, in a proportion of patients with ectopic beats from the lower chamber of the heart, the ectopic beats can cause a reduction in heart muscle function, referred to as a cardiomyopathy. These patients may experience significant breathing difficulties and a marked reduction in their exercise capacity. If the ectopic beats are the cause of heart muscle weakness, this is generally a reversible situation, with the expectation of recovery of heart muscle function after elimination of the ectopic beats. Of note, in certain circumstances, a patient may have an underlying heart muscle abnormality that causes the ectopic beats. Therefore, ectopic beats can be the cause or a consequence of heart muscle weakness (cardiomyopathy).

How are ectopic beats diagnosed?

Your physician will take a detailed history with particular emphasis on the pattern, the frequency and the severity of the symptoms. Any potential triggers that bring on or worsen the symptoms will also be identified. The extent to which the symptoms are affecting a patient’s quality of life is an important determinant on the treatment strategy.

ECG

In patients with frequent ectopic beats, an electrocardiographic (ECG) heart tracing may be sufficient to confirm the diagnosis. In addition to confirming the diagnosis of ectopic beats, the ECG features of the ectopic beats will provide important clues as to the region of the heart where the abnormal beats are originating.

Wearable heart monitors

In a significant proportion of patients with ectopic beats, more advanced tests to monitor the heart rhythm over a prolonged period of time (typically 24 hours) will be required. In some patients, these monitors are performed to confirm a diagnosis of ectopic beats (in cases where the ECG did not capture to ectopic beats). The monitors are important to determine how many ectopic beats a patient experiences over a prolonged period of time.

Imaging of the heart

As discussed above, in a proportion of patients, frequent ectopic beats can result in a reduction in heart muscle function. Furthermore, ectopic beats may be the result of an underlying heart muscle problem. Therefore, imaging of the structure of the heart, using an echocardiogram (ultrasound test to look at the heart’s structure and function) or more advanced imaging tests (such as cardiac MRI) is likely to be performed.

What are the treatment options?

Amongst patients who have frequent ectopic beats and significant associated symptoms, treatment to eliminate or suppress ectopic beats should be considered. Treatment of the ectopic beats is a particularly important consideration amongst patients who have developed weakness of the heart muscle function due to the ectopic beats.

Options for treatment include either a catheter ablation procedure with the aim of eliminating the ectopic beats or medications to suppress the ectopic beats. In a large proportion of cases, patient choice is the major determinant of the best treatment strategy. A patient’s decision to pursue a catheter ablation procedure may be influenced by adverse side effects associated with medications, the inconvenience of having to take regular medications and/or failure of medications to suppress the arrhythmia. Of  note, previous research studies have demonstrated that catheter ablation is more effective than treatment with medications.

Dr Mahida’s publications on heart rhythm abnormalities from the ventricles

  • Berte B, Cochet H, Dang L, Mahida S, Moccetti F, Hilfiker G, Bondietti J, Ruschitzka F, Jaïs P, Scharf C, Kobza R. Image-guided ablation of scar-related ventricular tachycardia: towards a shorter and more predictable procedure. J Interv Card Electrophysiol. 2019 Dec 19. doi: 10.1007/s10840-019-00686-w.
  • Adlan AM, Campbell T, Fairbairn T, Aggarwal S, Nawaytou O, Penha D, Todd D, Mahida S. Retrograde aortic access during ventricular tachycardia ablation: indications, techniques and challenges. J Cardiovasc Electrophysiol. 2019 Nov;30(11):2629-2639. doi: 10.1111/jce.14163. Epub 2019 Sep 18.
  • Mahida S, Stevenson WG. Thoughts on inducibility. Heart Rhythm. 2019 Apr;16(4):e37-e38. doi: 10.1016/j.hrthm.2019.01.003.
  • Mahida S, Venlet J, Saguner AM, Kumar S, Baldinger SH, AbdelWahab A, Tedrow UB, Castelletti S, Pantazis A, John RM, McKenna WJ, Lambiase PD, Duru F, Sapp JL, Zeppenfeld K, Stevenson WG. Ablation compared with drug therapy for recurrent ventricular tachycardia in arrhythmogenic right ventricular cardiomyopathy: Results from a multicenter study. Heart Rhythm. 2018 Oct 23. pii: S1547-5271(18)31043-9
  • Mahida S, Sacher F, Dubois R, Sermesant M, Bogun F, Haïssaguerre M, Jaïs P, Cochet H. Cardiac Imaging in Patients With Ventricular Tachycardia. Circulation. 2017 Dec 19;136(25):2491-2507.
  • Kumar S, Baldinger SH, Kapur S, Romero J, Mehta NK, Mahida S, Fujii A, Tedrow UB, Stevenson WG. Right ventricular scar-related ventricular tachycardia in nonischemic cardiomyopathy:Electrophysiological characteristics, mapping, and ablation of underlying heart disease. J Cardiovasc Electrophysiol. 2018 Jan;29(1):79-89.
  • Derval N, Duchateau J, Mahida S, Eschalier R, Sacher F, Lumens J, Cochet H, Denis A, Pillois X, Yamashita S, Komatsu Y, Ploux S, Amraoui S, Zemmoura A, Ritter P, Hocini M, Haissaguerre M, Jaïs P, Bordachar P. Distinctive Left Ventricular Activations Associated With ECG Pattern in Heart Failure Patients. Circ Arrhythm Electrophysiol. 2017 Jun;10(6).
  • Berte B, Sacher F, Wielandts Y, Mahida S, Pillois X, Weerasooriya R, Bernus O, Jaïs  P. A new cryoenergy for ventricular tachycardia ablation: a proof-of-concept study. Europace. 2017 Aug 1;19(8):1401-1407. doi: 10.1093/europace/euw217.
  • Kumar S, Baldinger SH, Romero J, Fujii A, Mahida S, Tedrow UB, Stevenson WG. Substrate-Based Ablation Versus Ablation Guided by Activation and Entrainment Mapping for Ventricular Tachycardia: A Systematic Review and Meta-Analysis. J Cardiovasc Electrophysiol. 2016 Dec;27(12):1437-1447. doi: 10.1111/jce.13088.
  • Yamashita S, Cochet H, Sacher F, Mahida S, Berte B, Hooks D, Sellal JM, Al Jefairi N, Frontera A, Komatsu Y, Lim HS, Amraoui S, Denis A, Derval N, Sermesant M, Laurent F, Hocini M, Haïssaguerre M, Montaudon M, Jaïs P. Impact of New Technologies and Approaches for Post-Myocardial Infarction Ventricular Tachycardia Ablation During Long-Term Follow-Up. Circ Arrhythm Electrophysiol 2016 Jul;9(7):e003901. doi: 10.1161/CIRCEP.116.003901.
  • Yamashita S, Sacher F, Mahida S, Berte B, Lim HS, Komatsu Y, Amraoui S, Denis A, Derval N, Laurent F, Sermesant M, Montaudon M, Hocini M, Haïssaguerre M, Jaïs P, Cochet H. Image Integration to Guide Catheter Ablation in Scar-related Ventricular Tachycardia. J Cardiovasc Electrophysiol. Jun;27(6):699-708
  • Baldinger S, Kumar S, Barbhaiya CR, Mahida S, Epstein L, Michaud G, John R, Tedrow U, Stevenson W. Epicardial Radiofrequency Ablation Failure during Ablation Procedures for Ventricular Arrhythmias – Reasons and Implications for Outcomes. Circulation Arrhythmia and Electrophysiology. 2015 Dec;8(6):1422-32.
  • Berte B, Sacher F, Venlet J, Andreu D, Mahida S, Aldhoon B, De Potter T, Sarkozy A, Tavernier R, Marius A, Deneke T, Kautzner J, Berruezo A, Cochet H, Zeppenfeld K, Jaïs P. VT Recurrence after VT ablation in Non-Ischaemic Cardiomyopathy: Incomplete Ablation or Disease Progression? A Multicentric European Study. J Cardiovasc Electrophysiol. 2016 Jan;27(1):80-7.
  • Berte B, Cochet H, Magat J, Naulin J, Sacher F, Ghidoli D, Pillois X, Casassus F, Yamashita S, Mahida S, Derval N, Hocini M, Quesson B, Bernus O, Haïssageurre M, Jaïs P. Irrigated needle ablation creates larger and more transmural ventricular lesions compared to standard unipolar ablation in an ovine model. Circulation Arrhythmia and Electrophysiology. 2015 Dec;8(6):1498-506.
  • Berte B, Komatsu Y, Denis A, Pillois X, Kim S, Yamashita S, Sacher F, Mahida S, Hooks D, Sellal JM, Amraoui S, Derval N, Hocini M, Haïssaguerre M, Jaïs P, Cochet H. Characterization of the Left-Sided Substrate in Arrhythmogenic Right Ventricular Cardiomyopathy. Circulation Arrhythmia and Electrophysiology. 2015 Dec;8(6):1403-12.
  • Berte B, Relan J, Sacher F, Pillois X, Appetiti A, Yamashita S, Casassus F, Hooks D, Sellal JM, Amraoui S, Mahida S, Denis A, Derval N, Hocini M, Haïssaguerre M, Jaïs P. Impact of electrode type on mapping of scar-related VT. J Cardiovasc Electrophysiol. 2015 Jul 22. doi: 10.1111/jce.12761.
  • Kumar S, Barbhaiya C, Nagashima K, Balindger S, Choi, EK, Mahida S, Sobieszczyk P, Eisenhauer A, Couper GS, Epstein LM, John, RM, Michaud GM, Tedrow U, Stevenson WG. What to do when Percutaneous Endo and Epicardial Radiofrequency Catheter Ablation Attempts fail to treat Ventricular Arrhythmias? Approaches and Outcomes. Circulation Arrhythmia and Electrophysiology. 2015 Jun;8(3):606-15.
  • Sacher F, Reichlin T, Zado E, Field ME, Viles-Gonzalez JF, Peichl P, Ellenbogen KA, Maury P, Dukkipati S, Picard F, Kautzner J­, Barandon L, Koneru JN, Ritter P, Mahida S, Calderon J, Derval N, Denis A, Cochet H, Shepard RK, Corre J, Coffey JO, Garcia F, Hocini M, Tedrow U, Haissaguerre M, MD, d’Avila A, Stevenson WG, Marchlinski ME and Jais P. Characteristics of VT Ablation in Patients with Continuous Flow Left Ventricular Assist Devices. Circulation Arrhythmia and Electrophysiology 2015 Jun;8(3):592-7.
  • Kumar S, Bazaz R, Barbhaiya CR, Enriquez AD, Helmbold AF, Chinitz J, Baldinger SH, Mahida S, McConville JW, Tedrow U, John RM, Michaud GF, Stevenson WG. “Needle-in-needle” Epicardial access: Preliminary Observations with a Modified Technique for Facilitating Epicardial Interventional Procedures. Heart Rhythm. 2015 Jul;12(7):1691-7.
  • Shah AJ, Lim HS, Yamashita S, Zellerhoff S, Berte B, Mahida S, Hooks D, Aljefairi N, Derval N, Denis A, Sacher F, Jais P, Dubois R, Hocini M, Haissaguerre M. Noninvasive mapping of ventricular tachycardia’s. Card Electrophysiol Clin. 2015 Mar;7(1):99-107.
  • Yamashita S, Sacher F, Mahida, S, Berte B, Lim H, Komatsu Y, Amraoui S, Denis A, Derval, N, Laurent, F, Montaudon M, Hocini M, Haïssaguerre M, Jaïs P, and Cochet H. The role of high-resolution image integration to visualize left phrenic nerve and coronary arteries during epicardal ventricular tachycardia ablation. Circulation Arrhythmia and Electrophysiology. 2015 Feb 21. pii: CIRCEP.114.002420.
  • Hooks DA, Berte B, Yamashita S, Mahida S, Sellal JM, Aljefairi N, Frontera A, Derval N, Denis A, Hocini M, Haïssaguerre M, Jaïs P, Sacher F. New Strategies for Ventricular Tachycardia and Ventricular Fibrillation Ablation. Expert Rev Cardiovasc Ther. 2015 Feb 10:1-14.
  • Mahida, S; Derval, N; Sacher, F; Leenhardt, A; Deisenhofer, I; Babuty D; Schläpfer J; de Roy, L; Frank, R; Yli-Mayry, S; Mabo, P; Rostock, T; Nogami, A; Pasquié, J; de Chillou, C; Kautzner, J; Jesel, L; Maury, P; Berte, B; Yamashita S; Roten L; Lim H; Denis, A; Bordachar P; Ritter P; Probst, V; Hocini, M; Jaïs, P, and Haïssaguerre, M. Role of Electrophysiologic Studies in Predicting Risk of Ventricular Arrhythmia in Early Repolarization Syndrome. J Am Coll Cardiol. 2015 Jan 20;65(2):151-9
  • Berte B, Sacher F, Cochet H, Mahida S, Yamashita S, Lim HS, Denis A, Derval N, Hocini M, Haïssaguerre M, Jaïs P. J Cardiovasc Electrophysiol. 2015 Jan;26(1):42-50.
  • Berte B, Sacher F, Mahida S, Yamashita S, Lim HS, Denis A, Derval N, Hocini M, Haïssaguerre M, Cochet H, Jaïs P. Impact of septal radiofrequency ventricular tachycardia ablation: insights from magnetic resonance imaging. Circulation. 2014 Aug 19;130(8):716-8.
  • Mahida S, Berte B, Yamashita S, Derval N, Denis A, Shah A, Amraoui S, Hocini M, Haissaguerre M, Jais P, Sacher F. New Ablation Technologies and Techniques. Arrhythm Electrophysiol Rev. 2014 Aug;3(2):107-12.
  • Lim HS, Sacher F, Cochet H, Berte B, Yamashita S, Mahida S, Zellerhoff S, Komatsu Y, Denis A, Derval N, Hocini M, Haïssaguerre M, Jaïs P. Safety and prevention of complications during percutaneous epicardial access for the ablation of cardiac arrhythmias. Heart Rhythm. 2014 Sep;11(9):1658-65. doi: 10.1016/j.hrthm.2014.05.041

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