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AimsThis study aimed to examine the clinical benefits of targeted ablation of all Premature ventricular complex (PVC) morphologies vs. predominant PVC only.Methods and resultsA total of 171 consecutive patients with reduced left ventricular ejection fraction (LVEF) and ≥2 PVC morphology with high burden (>10%/day) undergoing their first ablation procedure were included in the analysis. At the initial procedure, prevalent PVC alone was ablated in the majority. However, at the redo, all PVC morphologies were targeted for ablation. : At the first procedure, 152 (89%) patients received ablation of the dominant PVC only. In the remaining 19 (11%) patients, all PVC morphologies were ablated. At two years, high PVC burden was detected in 89 (52%) patients. Repeat procedure was performed in 78 of 89, where all PVC morphologies were ablated. At 5 years after the repeat procedure, 71 (91%) had PVC burden of ConclusionIn this observational series, ablation of all PVC morphologies was associated with significantly lower PVC burden and improvement of LVEF at long-term follow-up, compared with ablation of the dominant morphology only.

Synopsis We review the current data on epidemiology, the clinical significance, the pathophysiologic mechanisms, and the treatment of VAs in the setting of COVID-19. VAs prevail in 0.15-8% of in hospitalized patients, but only sustained and rapid tachyarrhythmias are purportedly associated with a significant increase in mortality. Multiple factors can elicit VAs, which are ultimately deemed to be a marker of severe systemic disease rather than a distinct cardiac condition. Even though the electrophysiologist plays a determinant role in the secondary prevention of VAs, a multidisciplinary approach is indispensable for primary prophylaxis and acute management.

Tests to detect active viral infection and related immune response in the staff and patients attending health care facilities effectively identified positive cases presenting with or without symptoms of coronavirus disease (COVID)-19. Subsequent home isolation of these contagious cases helped curb the chance of the spread of infection at the workplace. Furthermore, serologic tests conducted postvaccination facilitated the detection of individuals with poor immune response following active immunization that would likely require further safety measures to protect themselves from contracting the infection in health care facilities.

Aim: In view of the long-standing recognition that gross domestic product (GDP) does not capture the unremunerated work largely conducted by women upon which societal well-being depends, to discuss the implications for GDP of maternal, newborn, child and adolescent health (MNCAH), and its influences on health, well-being and prosperity across the life course and across generations. Methods: A wide-ranging discussion of the informal think-tank The Venice Forum was held over two days, with inputs from invited experts in person and online. Results: There was consensus that a strong case could be made for inclusion of unremunerated work largely conducted by women as a positive contribution to GDP in view of its impact on future health and prosperity, and conversely exclusion from GDP of outputs from industries which harm health. Conclusion: Taken with the current challenges from COVID, climate change and conflict, there is a compelling need to redefine economic progress through equitable models and metrics that incorporate short-/medium-/long-term societal value of activities that improve MNCAH.

BACKGROUND: Residual peri-device leakage (PDL) is frequent after left atrial appendage occlusion (LAAO). Little is known about management strategies, procedural aspects and outcomes of interventional PDL closure.AIMS: The aim of this study was to assess the safety and feasibility of PDL closure after LAAO.METHODS: Fifteen centres contributed data on baseline characteristics, in-hospital and follow-up outcomes of patients who underwent PDL closure after LAAO. Outcomes of interest included acute success and complication rates and long-term efficacy of the procedure.RESULTS: A total of 95 patients were included and a cumulative number of 104 leaks were closed. The majority of PDLs were detected within 90 days (range 41-231). Detachable coils were the most frequent approach (42.3%), followed by the use of the AMPLATZER Vascular Plug II (29.8%) and the AMPLATZER Duct Occluder II (17.3%). Technical success was 100% with 94.2% of devices placed successfully within the first attempt. There were no major complications requiring surgical or transcatheter interventions. During follow-up (96 days [range 49-526]), persistent leaks were found in 18 patients (18.9%), yielding a functional success rate of 82.7%, although PDLs were significantly reduced in size (pre-leak sizemax: 6.1±3.6 mm vs post-leak sizemax: 2.5±1.3 mm, p5 mm. Major adverse events during follow-up occurred in 5 patients (2 ischaemic strokes, 2 intracranial haemorrhages, and 1 major gastrointestinal bleeding).CONCLUSIONS: Several interventional techniques have become available to achieve PDL closure. They are associated with high technical and functional success and low complication rates.

Objectives The aim of this study was to evaluate the efficacy of radiofrequency (RF) energy applications targeting the atrial side of a significant residual leak in patients with acute and chronic evidence of incomplete percutaneous left atrial appendage (LAA) occlusion. Background RF applications have been proved to prevent recanalization of intracranial aneurysms after coil embolization, thereby favoring complete sealing. From a mechanistic standpoint, in vitro and in vivo experiments have demonstrated that RF promotes collagen deposition and tissue retraction. Methods Forty-three patients (mean age 75 ± 7 years mean CHA2DS2-VASc score 4.6 ± 1.4, mean HAS-BLED score 4.0 ± 1.1) with residual leaks ≥4 mm after Watchman implantation were enrolled. Procedural success was defined as complete LAA occlusion or presence of a mild or minimal (1- to 2-mm) peridevice leak on follow-up transesophageal echocardiography (TEE), which was performed approximately 45 days after the procedure. Results RF-based leak closure was performed acutely after Watchman implantation in 19 patients (44.2%) or scheduled after evidence of significant leaks on follow-up TEE in 24 others (55.8%). The median leak size was 5 mm (range: 4-7 mm). On average, 18 ± 7 RF applications per patient (mean maximum contact force 16 ± 3 g, mean power 44 ± 2 W, mean RF time 5.1 ± 2.5 minutes) were performed targeting the atrial edge of the leak. Post-RF median leak size was 0 mm (range: 0-1 mm). A very low rate (2.3% [n = 1]) of major periprocedural complications was observed. Follow-up TEE revealed complete LAA sealing in 23 patients (53.5%) and negligible residual leaks in 15 (34.9%). Conclusions RF applications targeting the atrial edge of a significant peri-Watchman leak may promote LAA sealing via tissue remodeling, without increasing complications. (RF Applications for Residual LAA Leaks [REACT]; NCT04726943 )

In the early visual system, corticothalamic feedback projections greatly outnumber thalamocortical feedforward projections. Extensive experimental and modeling work has been devoted to the functional impact of the feedforward pathway, but the role of its denser feedback counterpart remains elusive. Here, we propose a novel unifying framework where thalamic recurrent interactions and corticothalamic feedback act in a closed-loop fashion to attune multiple stimulus representations. At each position of the visual field, the loop puts into competition local representations of the stimulus in thalamus and cortex through direct excitation of narrow topologically-aligned portions of the thalamus, accompanied with peri-geniculate nucleus mediated broad inhibition suppressing the topological surround. We built a detailed conductance-based spiking model incorporating retinal input, lateral geniculate nucleus, peri-geniculate nucleus, primary visual cortex, and all the relevant intra-areal and feedback pathways. For the first time we perform comparative analyses between model configurations with completely or locally inactivated cortico-thalamic feedback, as in the experimental preparations. The model mechanistically explains (i) the existence of intra-thalamic surround suppression, (ii) the sensitivity of thalamic neurons to orientation tuning, (iii) the cortex-dependent center-surround opponency in thalamic cells, (iv) the cortical increase of size and orientation selectivity, (v) the cortically enhanced competition between cross-oriented domains within the hypercolumn, and (vi) the selective suppression of cortical functional connectivity. Our results integrate decades of experimental and theoretical research, supporting the hypothesis that cortico-thalamic loop exerts competitive influence between neighboring regions in the thalamus and cortex, complementing the lateral intra-V1 interactions in center-surround contextual modulation.

AimsWe performed a retrospective nonrandomized study to analyze the results of a microsurgery of intracranial meningiomas using 2-μm thulium flexible handheld laser fiber (Revolix jr).MethodsFrom February 2014 to December 2021, 75 nonconsecutive patients suffering from intracranial meningiomas, admitted in our department, have been operated on with microsurgical technique assisted by 2-μm thulium flexible handheld laser. We have reviewed demographic and clinical data to evaluate safety and efficacy of the technique.ResultsThere were no complications related to the use of the 2-μm thulium laser. We operated on a high percentage of cranial base and tentorial and posterior fossa meningioma in our series. The neurological outcome and degree of resection did not differ from previous series. The neurosurgical team found the laser easy to use and practical for avoiding bleeding and traction.ConclusionThe use of 2-μm thulium fiber handheld flexible laser in microsurgery of intracranial meningiomas seems to be safe and to facilitate tumor resection, especially in “difficult” conditions (e.g., deep seated, highly vascularized, and hard tumors). Even if in this limited retrospective trial the good functional outcome following conventional microsurgery had not further improved, nor the surgical time was reduced by laser, focusing its use on “difficult” (large and vascularized) cases may lead to different results in the future.

Objectives This study evaluated the long-term efficacy of a standard antithrombotic strategy versus half-dose direct oral anticoagulation (DOAC) after Watchman implantation. Background No consensus currently exists on the selection of the most effective antithrombotic strategy to prevent device-related thrombosis (DRT) in patients undergoing endocardial left atrial appendage closure. Methods After successful left atrial appendage closure, consecutive patients were prescribed a standard antithrombotic strategy (SAT) or long-term half-dose DOAC (hdDOAC). The primary composite endpoint was DRT and thromboembolic (TE) and bleeding events. Results Overall, 555 patients (mean age 75 ± 8 years, 63% male; median CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category] score 4 [interquartile range (IQR): 3-6]; median HAS-BLED [hypertension, abnormal renal or liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol] score 3 [IQR: 2-4]) were included. Patients were categorized into 2 groups (SAT: n = 357 vs hdDOAC: n = 198). Baseline clinical characteristics were similar between groups. The median follow-up duration was 13 months (IQR: 12-15 months). DRT occurred in 12 (2.1%) patients, all in the SAT group (3.4% vs 0.0%; log-rank P = 0.009). The risk of nonprocedural major bleeding was significantly more favorable in the hdDOAC group (0.5% vs. 3.9%; log-rank P = 0.018). The rate of the primary composite endpoint of DRT and TE and major bleeding events was 9.5% in SAT patients and 1.0% in hdDOAC patients (HR: 9.8; 95% CI: 2.3-40.7; P = 0.002). Conclusions After successful Watchman implantation, long-term half-dose DOAC significantly reduced the risk of the composite endpoint of DRT and TE and major bleeding events compared with a standard, antiplatelet-based, antithrombotic therapy.

Introduction Watchman FLX has been recently approved for left atrial appendage occlusion (LAAO) in the US. Intracardiac echocardiography (ICE) - which is already commonly used to guide trans-septal access - can serve as an alternative to TEE, simplifying the procedure and reducing associated costs. Herein, we report our experience with ICE-guided LAAO with Watchman FLX. Methods and results This cohort study included the first 190 consecutive patients who underwent LAAO with Watchman FLX in our center. LAAO was successful in all patients without significant peri-procedural, device-related complications in either group. Compared to TEE, we observed a significant reduction in procedural times when using ICE. In addition, there was a potentially clinically relevant reduction in fluoroscopy dose, mainly secondary to fewer cine acquisition runs. At follow-up, no cases of device embolism were noted, whereas the rate of device-related thrombosis and peri-device leaks were comparable between groups. Conclusion ICE-guided LAAO with Watchman FLX is safe and feasible, with a significant reduction in procedural time and potential reduction in fluoroscopy dose when compared to TEE.

Essential tremor (ET) may severely impact patient's Quality of Life. Several techniques such as radiofrequency, deep brain stimulation (DBS), gamma knife (GK) radiosurgery and high-intensity focused ultrasound may be used for the surgical treatment of ET. The aim of this paper is to summarize the most recent available literature on DBS, transcranial magnetic resonance-guided focused ultrasound (tcMRgFUS) and GK, and to compare indications, targets, and effectiveness of these surgical techniques for the treatment of ET.A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The literature search was performed on the three largest medical databases (PubMed, Scopus, and Web of Science). This systematic review is focused on the effectiveness and safety of GK, DBS, and tcMRgFUS as functional neurosurgical techniques for the treatment of ET. The aim of this study was to compare these techniques by evaluating mode, target, effectiveness in improving motor outcomes, and rates of adverse effects.Articles meeting the predetermined criteria were included. Data for DBS, tcMRgFUS, and GK were analyzed and compared for indications, patient selection, advantages vs. disadvantages, and treatment targets for essential tremor.DBS, tcMRgFUS and GK are effective techniques for the treatment of ET. Despite different functioning principles, all three surgical techniques require a proper functional diagnosis to define accurate indications for patient selection. Their indication depends upon the patient's neurological condition and their effectiveness relies on proper targeting.

Atrial fibrillation (AF) and premature ventricular complexes (PVC) are common arrhythmias. We aimed to investigate AF prevalence in patients with PVC and its impact on PVC ablation outcomes.Consecutive patients undergoing PVC ablation at a single institution between 2016 and 2019 were included and prospectively followed for 2 years. Patients with severe valvular heart disease, hyperthyroidism, malignancy, alcohol use disorder and advanced renal/hepatic diseases were excluded. Twelve-lead electrocardiograms were used to diagnose AF and assess PVC morphology. All PVCs were targeted for ablation using 4-mm irrigated-tip catheters at standardized radiofrequency power guided by 3-D mapping and intracardiac echocardiography. Patients were followed with remote monitoring, device interrogations and office visits every 6 months for 2 years. Detection of any PVCs in follow-up was considered as recurrence.A total of 394 patients underwent PVC ablation and 96 (24%) had concurrent AF. Patients with PVC and AF were significantly older (68.2 ± 10.8 vs. 58.3 ± 15.8 years, p .001), had lower LV ejection fraction (43.3 ± 13.3% vs. 49.6 ± 12.4%, p .001), higher CHAAF was documented in 1/4 of patients undergoing PVC ablation and was associated with lower procedural success at long-term follow-up. This was likely attributed to older age, worse LV function and higher prevalence of multiple PVC morphologies in patients with concurrent AF.

Background Patients undergoing left atrial appendage occlusion (LAAO) often are at increased risk for bleeding or thromboembolic events. In most implanting centers, baseline blood is drawn as a pre-procedural check-up. However, it is unknown what laboratory parameters have added value in this specific population. Platelet count (PLC) and mean platelet volume (MPV) may identify which patients are at risk for thromboembolic events or bleeding. Materials and methods Five implanting centers retrospectively gathered data on pre-procedural platelet markers. Composite endpoints on thromboembolic events (stroke, transient ischemic attack, device-related thrombus and systemic embolism) and bleeding (minor, major, and intracranial hemorrhage) were collected. Results and conclusions A total of 1138 patients were included (73 ± 8 years, 63% male, CHA2DS2-VASc: 4.4 ± 1.5; HAS-BLED: 3.2 ± 1.1). Implanted devices consisted of Watchman 2.5/FLX (n = 778), Amplatzer Cardiac Plug/AMULET (n = 315), or another device (n = 45). Baseline PLC was present in 91% and MPV in 41%. PLC was significantly lower in the 97 patients developing a thromboembolic event (206 ± 73 vs. 225 ± 72*10*9/L, P = 0.028), but no difference in MPV was observed (9.7 ± 1.4 vs. 9.5 ± 1.5 fL, P = 0.40). In another 97 patients, significant bleeding was observed during follow-up. No difference in baseline PLC was found (216 ± 79 vs. 207 ± 72*10^9/L, P = 0.30) and a trend towards lower MPV could be observed (9.5 ± 1.3 vs. 9.8 ± 1.5 fL, P = 0.07). Patients developing bleeding more often were discharged with antiplatelet therapy, while patients developing a thromboembolic event more often received anticoagulation therapy. In conclusion, occurrence of a thromboembolic event was associated with lower baseline PLC, which may be explained by PLC being lower in more frail patients.

This article reviews the latest available data in regard to the diagnosis, management, and intervention of both central and peri-device leaks that arise after left atrial appendage closure (LAAC). The aim of this article is to have a better understanding of both addressing leaks arising after LAAC, and which interventions and closure methods are best served for each type of residual leak based on etiology, size, and operator experience.

Complex atrial tachyarrhythmias (CATs) are commonly observed in patients with prior catheter ablation or cardiac surgery. These arrhythmias are challenging to map and ablate. Historically, entrainment mapping was utilized to characterize CAT. With the advent of high-definition mapping (HDM), full visualization of the CAT circuit is possible which may obviate the need for entrainment mapping.We sought to investigate the outcomes of catheter ablation of CAT guided only by HDM. Consecutive patients who underwent CAT ablation from 2017 to 2021 were included in our study (excluding right atrial tachyarrhythmias). Patients were sorted by the type of mapping performed. Group I consisted of patients where HDM alone was utilized with no attempt of entrainment. Group II consisted of patients where both entrainment and HDM were utilized.A total of 67 patients were included in our study, with 40 patients in HDM group (I) and 27 patients in entrainment group (II). No statistically significant difference regarding 1-year freedom from atrial arrhythmias was found between the two groups (80% vs 77.8%, p = 0.819). Four CATs were terminated by entrainment during procedure versus none in the HDM-only group (p = 0.011).CAT ablation with HDM alone yielded similar 1-year freedom from atrial arrhythmias compared to ablation with HDM and entrainment. Entrainment combined with HDM was associated with higher undesired CAT interruption rate. Further validation is needed with randomized control trials.

Electrical isolation of pulmonary veins (PVI) is the cornerstone of invasive treatment of atrial fibrillation (AF). However, arrhythmia-free survival of a PVI only approach is suboptimal in patients with persistent and long-term persistent AF. Hybrid AF ablation has been developed with the aim of combining the advantages of a thoracoscopic surgical ablation (direct visualization of anatomical structures to be spared and the possibility to perform epicardial lesions) and endocardial ablation (possibility to check line block, confirm PVI, and possibility to perform cavotricuspid isthmus ablation). Patient selection is of utmost importance. In persistent and long-term persistent AF, hybrid AF ablation demonstrated promising results in terms of AF free survival. It has been associated with a relatively low complication rate if performed in centers with expertise in hybrid procedures and experience with both surgical and endocardial ablation. Different techniques have been described, with different approaches and lesion sets. The aim of this review is to provide a state-of-the-art overview of hybrid AF ablation.

Subcutaneous implantable cardioverter-defibrillator (S-ICD) is an effective alternative to transvenous implantable cardioverter-defibrillator. General anesthesia (GA) is considered the standard sedation approach because of the pain caused by the manipulation of subcutaneous tissue with S-ICD implantation. However, GA carries several limitations, including additional risk of adverse events, prolonged in-room times, and increased costs.The purpose of this study was to define the effectiveness and safety of tumescent local anesthesia (TLA) in comparison to GA in patients undergoing S-ICD implantation.We performed a prospective, nonrandomized, controlled, multicenter study of patients referred for S-ICD implantation between 2019 and 2020. Patients were allocated to either TLA or GA on the basis of patient's preferences and/or anesthesia service availability. TLA was prepared using lidocaine, epinephrine, sodium bicarbonate, and sodium chloride. All patients provided written informed consent, and the institutional review board at each site provided approval for the study.Sixty patients underwent successful S-ICD implantation from July 2019 to November 2020. Thirty patients (50%) received TLA, and the rest GA. There were no differences between groups with regard to baseline characteristics. In-room and procedural times were significantly shorter with TLA (107.6 minutes vs 186 minutes; P.0001 and 53.2 minutes vs 153.7 minutes; P.0001, respectively). Pain was reported less frequently by patients who received TLA. The use of opioids was significantly reduced in patients who received TLA (23% vs 62%; P = .002).TLA is an effective and safe alternative to GA in S-ICD implantation. The use of TLA is associated with shorter in-room and procedural times, less postprocedural pain, and reduced usage of opioids and acetaminophen for analgesia.

We describe a case of pacemaker implant guided by intracardiac echocardiography and three-dimensional anatomical mapping in a pregnant patient, with no peri-procedural use of radiation.

Intracardiac echocardiography (ICE) is a valuable tool and should be standard of care in any modern electrophysiology laboratory. Through real-time imaging of cardiac anatomy, ICE is used to guide electrophysiology procedures and monitor for complications. This article is a short overview of the application of real-time ICE imaging during atrial fibrillation ablation procedures.

Numerical geodynamo simulations capture several features of the spatial and temporal geomagnetic field variability on historical and Holocene timescales. However, a recent analysis questioned the a...

Middle cranial fossa surgery commonly is approached either performing a subtemporal or a pterional craniotomy. To maximize a basitemporal region exposure, an adjunctive bone drilling could be required. In these cases, a watertight dura and temporalis muscle closure are mandatory.To describe a modified temporalis muscle dissection in middle cranial fossa surgery to increase basitemporal region exposure while assuring a safe and effective closure thus avoiding cerebrospinal fluid (CSF) leakage.A total of 8 patients have been enrolled. Five pterional and 3 subtemporal approaches were performed. In all cases, the novel subfascial muscle dissection and temporalis muscle splitting technique named "the double S technique," was performed to cut up the temporal muscle.In all cases, a subgaleal drainage was used and removed within 48 hours. No cases of postoperative CSF leak or hematoma collection were reported.The double S technique is a safe and effective alternative to enhance the basitemporal region exposure while avoiding the potential, common risk of CSF leak.

Objective To assess the safety and efficacy of a novel immunosuppressive regimen-combination Methotrexate/Prednisone (cMtx/P)-in the management of severe refractory rPPP. Methods In this multicenter, nonrandomized, retrospective, observational study, 408 consecutive patients diagnosed with persistent rPPP between 2017 and 19 were included. Patients with refractory symptoms despite 3 months of conventional therapy were initiated on a 4-week regimen of oral steroids. Persistence of symptoms at this point, that is, rPPP (n = 25; catheter based = 18, open surgical = 7) prompted therapy with Methotrexate (7.5-15 mg weekly) with folate supplementation along with low dose prednisone (5 mg PO) for a further 3 months. Patients were followed for a total of 11.3 ± 1.8 months. Results Treatment refractory rPPP occurred in 6.1% of the study population prompting immunosuppressive therapy with cMtx/P. All patients demonstrated complete symptom resolution following 3 months of treatment with an 85% decline in clinically significant pericardial effusions. One patient developed recurrent pericarditis during the 11-month follow-up. Therapy was well tolerated with no significant drug related adverse effects. Conclusion cMtx/P therapy is a safe and effective adjunct in the management of rPPP refractory to standard therapy.

Probabilistic Point Clouds Registration (PPCR) is an algorithm that, in its multi-iteration version, outperformed state-of-the-art algorithms for local point clouds registration. However, its performances have been tested using a fixed high number of iterations. To be of practical usefulness, we think that the algorithm should decide by itself when to stop, on one hand to avoid an excessive number of iterations and waste computational time, on the other to avoid getting a sub-optimal registration. With this work, we compare different termination criteria on several datasets, and prove that the chosen one produces very good results that are comparable to those obtained using a very large number of iterations, while saving computational time.

Atrial fibrillation (AF) is a complex and multi-factorial rhythm disorder. Catheter ablation is widely used for the management of AF. However, it is limited by relapse of the arrhythmia necessitating repeat procedures.This review aims to discuss the predictors of post-ablation recurrent AF including age, gender, genetic predisposition, AF type and duration, comorbidities, lifestyle factors, echocardiographic parameters of heart chambers, left atrial fibrosis and ablation strategies and targets. An extensive literature search was undertaken on PubMed and Google Scholar to obtain full texts of relevant AF-related articles.Maintenance of stable sinus rhythm is the main intended outcome of AF ablation. Therefore, it is very crucial to identify the risk factors that may influence the ablation success. Most of these predictors such as comorbidities, ablation strategy and targets and lifestyle factors are either reversible or modifiable. Thus, not only the awareness of these known risk factors by both patients and their physicians but also future research to identify the unknown predictors are critical to optimize care in this multi-faceted morbidity.

Objectives This study evaluated the association of the post-ablation scar with stroke risk in patients undergoing atrial fibrillation (AF) ablation. Background Late gadolinium enhancement–...

Chagas disease is caused by infection from the protozoan parasite Trypanosoma cruzi. Although it is endemic to Latin America, global migration has led to an increased incidence of Chagas in Europe, Asia, Australia, and North America. Following acute infection, up to 30% of patients will develop chronic Chagas disease, with most patients developing Chagasic cardiomyopathy. Chronic Chagas cardiomyopathy is highly arrhythmogenic, with estimated annual rates of appropriate implantable cardioverter-defibrillator therapies and electrical storm of 25% and 9.1%, respectively. Managing arrhythmias in patients with Chagasic cardiomyopathy is a major challenge for the clinical electrophysiologist, requiring intimate knowledge of cardiac anatomy, advanced training, and expertise. Endocardial-epicardial mapping and ablation strategy is needed to treat arrhythmias in this patient population, owing to the suboptimal long-term success rate of endocardial mapping and ablation alone. We also describe innovative approaches to improve acute and long-term clinical outcomes in patients with refractory ventricular arrhythmias following catheter ablation, such as bilateral cervicothoracic sympathectomy and bilateral renal denervation, among others.