Premature beats are a common clinical arrhythmia. Patients with premature beats tend to have palpitations, cardiac arrest, throat pulling discomfort, etc. Patients usually describe their symptoms as “heart beating in the throat”, “missed pulse”, “pulse The patient usually describes the symptoms as “heart beating in the throat”, “missed pulse”, “pulse is faster all of a sudden”, etc. The clinical classification of premature beats is often based on the location of the origin of the beats: atrial, junctional, or ventricular. Because premature beats are common, we often see questions about premature beats on the internet consultation, and many patients are more concerned about the treatment of premature beats. In general, the treatment of premature beats requires consideration of various factors. However, the treatment of premature beats can be based on a number of factors, but it is possible to adjust the living habits first (pay attention to rest, avoid straining and staying up late at night, avoid stimulating foods and drugs, such as strong tea and coffee, etc.), and then use medication if necessary (the decision will be made after reading the relevant information). If there are still more premature contractions after medication or if medication is not effective, radiofrequency ablation is recommended if necessary. (Click here for my article “Screening and Treatment of Premature Ventricular Pulsations and Ventricular Tachycardia”). However, many patients still have more questions about the need for catheter ablation to treat premature beats and some related issues. In this article, we will summarize the answers to some of the following common questions in the context of our own consultations on premature beats and our center’s specific experience data, in order to provide reference for more patients and to minimize detours. It is important to note that catheter ablation is considered after drug therapy. At present, ventricular premature contractions (premature ventricular contractions and ventricular anterior contractions) are the most commonly known types of premature contractions. The following section will focus on ventricular premature as an example. When do premature beats require catheter ablation? Studies have found that frequent symptomatic ventricular premature beats (premature load >5%) have a significant impact on cardiac function in patients without organic heart disease, causing a decrease in left heart function and an increase in left ventricular end-diastolic internal diameter. The risk of premature ventricular load-mediated cardiomyopathy is greatest at 24% (sensitivity 79%, specificity 78%). In addition, ventricular prematureness can induce malignant ventricular arrhythmias, such as ventricular fibrillation and polymorphic ventricular tachycardia. Therefore, based on the fact that the normal number of beats (“heartbeats”) in a normal person is around 100,000 in a day (60-80 beats/min multiplied by 60 minutes multiplied by 24 hours), then 5% is about 5,000, which is often used as a cut-off point (cut-off value) for the treatment of premature beats in clinical practice. Of course, the presence of premature atrial beats can also lead to heart enlargement and cardiac decompensation. Therefore, although the current research evidence is not sufficient for atrial premature, it can still be treated with reference to the criteria for ventricular premature. Therefore, at present, the main reference for whether premature beats need to be treated with radiofrequency ablation in clinical practice is the number of premature beats. If the number of premature beats is still high after pharmacological treatment or if pharmacological treatment is not effective, catheter ablation may be an option. Patients without organic heart disease with 24-hour ambulatory monitoring that reveals more than 10,000 premature ventricular contractions are also an indication for catheter ablation. In some patients with significant symptoms, catheter ablation may also be considered when the premature beats are above 4000-5000, if necessary. Ventricular premature contractions with organic heart disease can also be treated with catheter ablation. However, the success rate of catheter ablation in patients with ventricular tachycardia with organic heart disease is not high, and some of them deteriorate into ventricular flutter and ventricular fibrillation. If ventricular fibrillation is induced by premature beats, then in principle, ICD (buried cardioverter-defibrillator) implantation is required. Of course, if it is clear that premature beats frequently induce ventricular fibrillation, ventricular tachycardia, and other malignant arrhythmias, then radiofrequency ablation treatment can be considered without regard to its frequency if drug therapy is ineffective. When can catheter ablation be done for premature beats and are there any requirements? As mentioned before, in general, radiofrequency ablation can be considered when there are around 10,000 premature beats. Then why is it necessary to have a certain number of premature beats before radiofrequency ablation can be performed? If there is no premature beats or very few premature beats before the surgery, it is difficult to mark the origin of premature beats clearly during the surgery, although it can be roughly marked, but the effect of ablation treatment under rough marking is poor, and it may be “blind cat meets dead rat”. “There is a possibility that the ablation treatment will be successful, but more likely it will be a general failure of “blind men feeling the elephant”, as if there is still a certain tenacious life under the indiscriminate bombardment – premature beats. 2. Judgment of the immediate effect of surgery: for example, if the premature beats are rare at the time of surgery, then during the observation period after surgery, it is difficult to judge whether the premature beats are successfully removed by the doctor through surgical ablation, or whether they have already stopped occurring. Therefore, it is usually necessary to have a certain amount of premature beats before surgery, so that the immediate efficacy of the surgery can be judged, and the resurgence of premature beats after surgery can be avoided. 3. Observation of the efficacy after surgery: If the premature beats are very few and there are not many special events, such as ventricular fibrillation and ventricular tachycardia, then the efficacy of premature beats after surgery can be judged. Then it is difficult to judge the efficacy of premature beats after surgery. In normal people, several hundred premature beats are common, especially in elderly people, where 1-2,000 atrial or ventricular premature beats are common in a day, in which case it is difficult to say whether the premature beat surgery is successful or not. What is the success rate of ablation of premature beats? Is there any recurrence? The success rate of catheter ablation of premature beats is influenced by many factors, such as the location of the origin of the beat, the choice of the device, and the experience of the surgeon (see my article “Analysis of failed ablation of supraventricular tachycardia (including pre-excitation) and postoperative recurrence and recommendations for management” here). Of course, the two most important factors affecting the success of the procedure are the location of the origin of the premature beats and the experience of the surgeon. The overall success rate of atrial premature beats can generally reach about 95% because of the current comprehensive and clear understanding of the atria and their adjacent anatomy. However, for premature atrial beats that originate at special sites, such as the inner ear and epicardium, the success rate may be lower, and the operation may even have to be abandoned because of the high risk. In the case of ventricular premature beats, the success rate of radiofrequency ablation is discounted because of the thickness of the ventricular muscle, the location of origin, and whether there is a combination of cardiomyopathy and other factors. Of course, in selected patients with ventricular premature beats, the success rate is probably between 80-90%. The most common location of origin with a high success rate is the right ventricular outflow tract, where the success rate can reach 95% in experienced centers. Other relatively common and specific sites of origin include the parasternal Hirschsprung bundle, aortic root, suprapulmonary valve, distal branches of the coronary sinus, pericuspid tricuspid valve, left ventricular outflow tract, and left ventricular papillary muscle, which have relatively low success rates. However, in experienced centers, the success rate can still reach about 90%. Theoretically, there is a chance of recurrence of premature beats after radiofrequency ablation treatment. The recurrence rate may vary greatly from center to center, but in our center, because of the specific measures such as fine measurement before ablation, close observation of ablation response during ablation, and strict observation of ablation effect after ablation, the recurrence rate after ablation of premature beats can be significantly reduced. Do we have to use 3D system for ablation of premature beats? Will the success rate be higher? In recent years, the emergence of 3D calibration system has provided a powerful weapon for clinical electrophysiologists. It can improve the accuracy of the markings, reduce the exposure time, etc. However, is it necessary to use a 3-D system for ablation of premature beats? Does the use of 3D necessarily increase the success rate? Personally, I don’t think so. For example, we have successfully ablated premature ventricular contractions in the right ventricle with a single catheter (click here for my article “A case of successful radiofrequency ablation of right ventricular parasternal Hirschsprung’s bundle ventricular contraction with a single catheter”). Because the location of the premature contraction is over there; it is over there if you find it or not; it is still over there if you reach it or not; it is still over there if you hit it or not; it is not going to be detected preferentially or earlier because of the weapon you use. In other words, in surgery, the most critical thing is no longer the location of the origin of the premature beat, but the experience of the surgeon and the operating technique. If a surgeon can master the anatomical characteristics of the particular site, accurately determine the location of the target point according to the body surface and intracavitary electrocardiogram before the operation, has a more skillful catheter operation technique, and uses the energy titration method for ablation in combination with the necessary contrast examination, then basically most premature beats can be cured by a general ablation catheter. Therefore, the key to ablation of premature beats lies in the experience, skill, patience and confidence of a center and its physicians, and the device is only an aid and a help. Therefore, it is recommended that patients considering radiofrequency ablation for premature beats should choose a large center for the treatment. How is radiofrequency ablation for premature beats performed? How long does it take? What do I need to pay attention to? Radiofrequency ablation of premature beats is performed in two steps, which is usually called electrophysiological examination + radiofrequency ablation treatment. First, the cause of premature beats and the corresponding lesions are identified through electrophysiological examination, and then the need for and the possibility of the next step of RF ablation are decided. The electrophysiological examination also involves careful labeling of the premature lesion (sometimes with specific drugs to increase the incidence of premature contractions and thus the success rate of the labeling). During the electrophysiological examination, the patient needs to cooperate and understand that there is no need to be afraid of uncomfortable manifestations such as increased panic attacks and increased premature beats, as these can be controlled and are necessary to further improve the success rate of the procedure. We often encounter patients who need to perform special actions or behaviors to induce premature beats, such as moving a certain part of the body, breathing in and out, lifting the head, coughing, or even talking or other actions to induce premature beats. In such cases, the patient’s cooperation and understanding are required. After the location of the premature beat is detected, the focal myocardium is “scalded” by radiofrequency energy, which makes this part of the myocardium inactive, and the premature beats no longer occur. After it is determined that the premature lesion has been eliminated by ablation, the procedure is not completely finished. At this point, it is particularly important to observe the induced premature contractions, i.e., to repeat the electrophysiological procedures described above, in order to assess the effectiveness of the ablation procedure. In some patients, the resurgence of the lesion occurs during the observation period, which, if not detected intraoperatively, inevitably affects the final outcome of the procedure. Therefore, the active cooperation and understanding of the patient is still needed during this observation and review phase, because the doctor and patient have the same goal, to completely solve the problem of premature beats. Generally speaking, the whole operation takes about 1-2 hours, but for some special cases, it sometimes takes a long time, which requires the patient’s understanding and cooperation, because the doctor will always want to solve the lesion completely, and some lesions are really challenging. It is usually necessary to prepare and schedule the surgery 1-2 days in advance, and after the surgery the patient is usually hospitalized for 1-2 days for observation to understand the post-operative recovery, especially the changes in the surgical wound. The vast majority of patients can be successfully discharged from the hospital the day after surgery. Of course, if the arrangements go well, the total length of stay is usually about 3 days. If everything goes well, the number of days can even be reduced to 2 days, i.e., the patient is admitted in the morning, checked for the necessary items, and then discharged the next day. It is especially important to remind female patients that if they are still menstruating, it is usually recommended that they be admitted 1-2 days after they have cleared. Because the procedure is usually performed electively, these are adjustable and have great benefits for their own safety and for reducing hospitalization costs. What is the cost of radiofrequency ablation of premature beats? The specific cost of radiofrequency ablation of premature beats may vary. When ablation is performed at some special sites, special site imaging is also required, such as ablation of ventricular premature in the distal branches of the coronary sinus and the aortic sinus, so that the cost of the procedure must be slightly increased. We can only speak about our unit’s experience, because all materials used are single-use, usually around 25,000, depending on how much and what kind of materials are used during the procedure. If the ablation treatment is performed with a single catheter in our center, its cost is even less than 20,000! This is less than the cost of ablation of supraventricular tachycardia and preexcitation! If there is medical insurance, the patient only has to bear part of the cost, depending on the local medical insurance regulations. Of course, the cost may be higher if a 3D scaler system and a special scaler catheter are used, because of the difference in price due to the different equipment. Can multiple premature contractions be treated by ablation? Premature multifocal contractions may be caused by the same origin combined with different exits, or by different origins with different patterns. In addition, multiple premature contractions are more common in patients with organic heart disease. Therefore, the success rate of surgery may be relatively lower. Currently, radiofrequency ablation of multiple premature beats is treated with relative caution because it is difficult to determine the exact cause before the procedure. However, if the patient has many premature beats and one of them is the main manifestation, radiofrequency ablation can be considered even if the patient has multiple premature beats, if the symptoms are obvious and require active treatment. Of course, the goal of radiofrequency ablation is to reduce the number of premature contractions, but it is difficult to achieve a complete cure. In our clinic, we have several patients with preoperative multiple ventricular prematureities, and after catheter ablation, the number of premature beats can be significantly reduced, and the symptoms can be significantly relieved. Therefore, the problem of multiventricular prematureness needs to be considered on an individual basis, with specific analysis of the problem rather than a one-size-fits-all approach.