23-Year-Old Male Lacrosse Player with Palpitations During a Scrimmage
A 23-year-old male lacrosse player with no significant medical history reported having new onset palpitations while standing on the sideline at practice. He denied shortness of breath, chest pain, or pre-syncope. He denied any stimulant use. He had no family history of arrhythmia, arrhythmogenic right ventricular cardiomyopathy(ARVC), premature cardiovascular disease, or sudden unexplained death. Physical examination was grossly normal except for premature beats on auscultation. Electrocardiogram, shown in Figure 1, was consistent with sinus rhythm and ventricular bigeminy. The premature ventricular contractions (PVCs) were monomorphic with a left bundle branch (LBBB) pattern and inferior axis suggestive of focal right ventricular outflow tract (RVOT) origin. No epsilon waves were noted. The patient was given a Holter monitor which showed a 35% PVC burden as well as sustained episodes of both bigeminy and trigeminy (Figure 2). He reported feeling palpitations that corresponded with runs of ectopic beats. A high-quality echocardiogram was performed which showed preserved biventricular size and function as well as normal valvular function. In particular, the right ventricle was well visualized and did not demonstrate any abnormalities.
Figure 1: Initial ECG
Figure 2: Holter Monitor Results
What is the most appropriate step in the management of this patient?