Salute

One speaks of a volley when at least three or more ES occur consecutively in the ECG without a normal beat in between: NEEE - N - N - (Herold 2022).

Salvos are differentiated between:

• Atrial volleys

These (Stierle 2020) belong together with the SVES-couplets to the group of complex SVES (Hall 2008). They can be precursors of atrial fibrillation (Stierle 2020).

• Ventricular volleys

In the classification according to Lown (see VES), ventricular volleys belong to the complex VES grade IV b (Herold 2022). Nowadays, however, the Lown classification is hardly used anymore (Braun 2022)

Centers of increased automaticity as a trigger for volleys are found particularly in adolescents and young adults (Bob 2001).

- Presence of one or more centers of increased automaticity (most common cause).

- Z. n. myocardial infarction (Bob 2001)

The cause of VES may be:

- Myocardial ischemia

- hypoxia

- abnormalities of electrolytes (especially hypokalemia)

- increased sympathetic tone (Kasper 2015)

- Digitalis intoxication (in this case, bigeminal and trigeminal symptoms occur in particular [Herold 2022])

- hyperthyroidism (Haas 2011)

- congenital heart defects

- inflammatory heart diseases

- cardiac tumors (Paul 2018)

- Certain medications such as catecholamines, quinidine, atropine, antiarrhythmics, theophylline

- Intoxication with alcohol, barbiturates (Wolff 2012).

- idiopathic (Ip 2017)

Triggers for SVES can be:

- Idiopathic

In otherwise healthy individuals, triggers for SVES can be: overtiredness, emotional arousal, consumption of coffee, nicotine, alcohol (Herold 2022), cocaine (Haas 2011).

- paroxysmal atrial fibrillation

Increased ectopic atrial activity predominantly from the pulmonary vein area is found

- fever

- infections (van Aken 2007)

- acidosis

- hypoxia

- in the context of heart disease (Heaton 2022)

- congenital heart defects leading to atrial strain

- during atrial surgery

- drug-induced, e.g. digitalis, antiarrhythmics, sympathomimetics

- electrolyte disturbances, especially hypokalemia, hypercalcemia, hypomagnesemia (Haas 2011)

- Biochemical due to malformations of sodium channels, in BMP2- mutations:

Malformation of sodium channels may be the cause of pulmonary hypertension (Heaton 2022).

• Atrial ES:

SVES are extrasystoles originating from an automatic center located above the His bundle (Haas 2011).

In this case, the premature contraction covers the entire heart and usually shows atrial and ventricular complexes in mutual relation on the ECG. The ventricular complexes are normal because the extra stimulus originates above the His bundle and can therefore propagate from there along normal conduction pathways into the chambers of the myocardium (Roskamm 2013).

In patients with paroxysmal atrial fibrillation, volleys of SVES may occur due to increased atrial activity from the pulmonary vein area (Greten 2010).

• Ventricular ES:

In VES, premature contraction of the ventricles occurs. Depolarization occurs first in the ventricle in which the VES originated and only then in the other ventricle (Kasper 2015). Premature excitation can be triggered by:

- an increased automaticity

- a triggered automaticity

- a reentry mechanism (Haas 2011)

Salvos do not cause any symptoms in some patients (Bob 2001). However, it may also result in:

- Vigilance disorders

- Circulatory failure (Help 2020)

- palpitations (Bob 2001)

- syncope

Volleys of VES can cause syncope or presyncope (Haas 2011).

If salvos are detected in the ECG, a detailed examination of the patient is required in any case (König 2013) with, for example, 12-lead ECG, long-term ECG, stress ECG, echocardiography, magnetic resonance imaging, and possibly also coronary angiography, LV and RV angiography (Bob 2001).

Programmed pacing is of secondary importance because it has little diagnostic or prognostic value (Bob 2001).

12- channel ECG

With this, salvos can be determined quantitatively.

Long-term ECG

The long-term ECG can be used to detect or exclude the occurrence and frequency of volleys, as well as to monitor the success of antiarrhythmic therapy (Haas 2011).

Stress ECG

This can be used to verify volleys that occur only under physical stress (Bob 2021).

Echocardiography

Echocardiography is used to assess in particular:

- ventricular function

- evidence of cardiomyopathy

- evidence of ventricular hypertrophy

- Indications of diseases of the heart valves (Kasper 2015).

Electrophysiological examination (Ozturk 2013).

This is a three-dimensional mapping procedure that can be used to examine different types of cardiac arrhythmias (Schmitt 2002). It can also be used to locate the origin of the volleys (Lewalter 2019).

• Salvos may cause reduced ejection fraction of the heart (Help 2020).
• Atrial volleys:

They may be predictors of atrial fibrillation (Diener 2021).

• Life-threatening arrhythmias:

In organic heart disease such as acute myocardial infarction, volleys may be harbingers of life-threatening arrhythmias, including ventricular fibrillation. Also considered harbingers are:

- clustered polytopic and polymorphic VES

- couplets

- bigeminy

- R on T phenomenon (Herold 2022)

In the case of short salvos from the right ventricular outflow tract, therapy is not necessary (Bob 2001).

If the left ventricular ejection fraction is still > 40%, treatment with antiarrhythmic drugs is usually not necessary either (König 2013).

Symptomatic volleys respond to class Ic antiarrhythmics(sodium channel blockers [Muser 2021]), especially flecainide (Bob 2001).

Dosage recommendation: flecainide 200 - 400 mg / d i. v. or 200 mg / d p. o. (Litmathe 2018).

• Radiofrequency catheter ablation (RFCA or CA).

(RF)CA is indicated in patients with syncope or recurrence of volleys (Bob 2001).

(RF)CA, after locating the origin of the volleys, can usually terminate them in ≥ 90% of patients (Bob 2001) (Ozturk 2013).

The best results can be achieved with (RF)CA if the arrhythmia focus is singular and can be easily reached with the ablation catheter, e.g., if it is located in the right or left ventricular outflow tract (Braun 2022).

Prognosis depends on the underlying disease (König 2013).

When volleys occur in patients with post-myocardial infarction together with a reduced left ventricular ejection fraction of <40%, this increases mortality (Bob 2001).

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