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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.

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.

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.

AimsLeft atrial appendage electrical isolation (LAAEI) has been shown to improve freedom from all-atrial arrhythmia recurrence in patients with non-paroxysmal atrial fibrillation (AF). The aim of this study is to investigate the long-term efficacy and safety outcomes of LAAEI in patients with non-paroxysmal AF undergoing catheter ablation.Methods and resultsA systematic review of Medline, Cochrane, and Embase was performed for clinical studies evaluating the benefit of LAAEI in non-paroxysmal AF. Nine studies with a total of 2336 patients were included (mean age: 65 ± 9 years, 63% male). All studies included patients with persistent AF, long-standing persistent AF, or both. At a mean follow-up of 40.5 months, patients who underwent LAAEI had significantly higher freedom from all-atrial arrhythmia recurrence than patients who underwent standard ablation alone [69.3% vs. 46.4%; risk ratio (RR) 0.54; 95% confidence interval (CI) 0.42–0.69; P ConclusionAt long-term follow-up, LAAEI led to a significantly higher improvement in freedom from all-atrial arrhythmia recurrence in patients with non-paroxysmal AF, when compared to standard ablation alone. Importantly, this benefit was achieved without an increased risk of acute procedural complications or cerebral thromboembolic events.

Background Thromboembolic stroke is a rare but devastating consequence of atrial fibrillation (AF) ablation. Transesopheageal echocardiography (TEE) is recommended to rule out left atrial appendage thrombus (LAA); however, its utilization is variable. Objective To assess whether TEE is mandatory in patients undergoing AF ablation on uninterrupted DOACs. Methods Data from our prospective, multicenter registry of AF patients undergoing radiofrequency catheter ablation on uninterrupted DOACs was analyzed. All included patients were on anticoagulation for at least four-weeks before ablation. All AF ablation procedures were performed under ICE guidance. Prior to transseptal puncture, heparin bolus was administered, followed by continuous infusion, with target activated clotting time over 300 seconds. Results A total of 6186 patients [3180 (51.4%): apixaban, 2528 (40.9%): rivaroxaban, 404 (6.5%): dabigatran, and 74 (1.2%): edoxaban] were analyzed. The mean age of the study population was 69.4 ± 10.3 years, of which 4194 (67.8%) patients were male and 5120 (82.8%) patients had persistent and long-standing persistent AF. The mean CHA2DS2-VASc score was 2.86 ± 1.58; the mean CHADS2 score was 1.65 ± 1.14. ICE ruled out LAA and LA thrombus in all patients and revealed ‘smoke’ in 1672 (27.03%) patients. Transient ischemic attack was noted in one patient with long-standing persistent AF, in the setting of a missed dose of rivaroxaban prior to ablation. Conclusion Our study showed that performance of AF ablation in patients on uninterrupted DOACs without TEE is safe and feasible in high stroke-risk patients. Elimination of routine pre-ablation TEE would have significant economic and clinical implications.

Background Coronavirus disease‐2019 (COVID‐19) causes severe illness and multi‐organ dysfunction. An abnormal electrocardiogram is associated with poor outcome, and QT prolongation during the illness has been linked to pharmacological effects. This study sought to investigate the effects of the COVID‐19 illness on the corrected QT interval (QTc). Method For 293 consecutive patients admitted to our hospital via the emergency department for COVID‐19 between 01/03/20 ‐18/05/20, demographic data, laboratory findings, admission electrocardiograph and clinical observations were compared in those who survived and those who died within 6 weeks. Hospital records were reviewed for prior electrocardiograms for comparison with those recorded on presentation with COVID‐19. Results Patients who died were older than survivors (82 vs 69.8 years, p 455 ms (males) and >465 ms (females) (p = 0.028, HR 1.49 [1.04‐2.13]), as predictors of mortality. QTc prolongation beyond these dichotomy limits was associated with increased mortality risk (p = 0.0027, HR 1.78 [1.2‐2.6]). Conclusion QTc prolongation occurs in COVID‐19 illness and is associated with poor outcome.

Background Twelve-lead electrocardiogram (ECG) criteria have been developed to identify idiopathic ventricular arrhythmias (VAs) from the left ventricular (LV) papillary muscles (PAPs), but accurate localization remains a challenge. Objective The purpose of this study was to develop ECG criteria for accurate localization of LV PAP VAs using lead V1 exclusively. Methods Consecutive patients undergoing mapping and ablation of VAs from the LV PAPs guided by intracardiac echocardiography from 2007 to 2018 were reviewed (study group). The QRS morphology in lead V1 was compared to patients with VAs with a "right bundle branch block" morphology from other LV locations (reference group). Patients with structural heart disease were excluded. Results One hundred eleven patients with LV PAP VAs (mean age 54 ± 16 years; 65% men) were identified, including 64 (55%) from the posteromedial PAP and 47 (42%) from the anterolateral PAP. The reference group included patients with VAs from the following LV locations: fascicles (n = 21), outflow tract (n = 36), ostium (n = 37), inferobasal segment (n = 12), and apex (5). PAP VAs showed 3 distinct QRS morphologies in lead V1 93% of the time: Rr (53%), R with a slurred downslope (29%), and RR (11%). Sensitivity, specificity, positive predictive value, and negative predictive value for the 3 morphologies combined are 93%, 98%, 98%, and 93%, respectively. The intrinsicoid deflection of PAP VAs in lead V1 was shorter than that of the reference group (63 ± 13 ms vs 79 ± 24 ms; P Conclusion VAs originating from the LV PAPs manifest unique QRS morphologies in lead V1, which can aid in rapid and accurate localization.

Managing arrhythmias from the left ventricular summit and interventricular septum is a major challenge for the clinical electrophysiologist requiring intimate knowledge of cardiac anatomy, advanced training and expertise. Novel mapping and ablation strategies are needed to treat arrhythmias originating from these regions given the current suboptimal long-term success rates with standard techniques. Herein, we describe innovative approaches to improve acute and long-term clinical outcomes such as mapping and ablation using the septal coronary venous system and the septal coronary arteries, alcohol ablation, coil embolization, and ablation of all early sites among others.

BACKGROUND The pathologic process of ARVC (arrhythmogenic right ventricular cardiomyopathy) typically originates in the epicardium or subepicardial layers with progression toward endocardium. However, in the most recent ARVC international task force consensus statement, epicardial ventricular tachycardia (VT) ablation is recommended as a Class I indication only in patients with at least one failed endocardial VT ablation attempt. OBJECTIVE The aim of this meta-analysis is to assess the outcomes of ARVC patients undergoing combined endo-epicardial VT ablation, as compared to endocardial ablation alone. METHODS A systematic review of PubMed, Embase, and Cochrane was performed for studies reporting clinical outcomes of endo-epicardial VT ablation vs endocardial-only VT ablation in patients with ARVC. Fixed-Effect model was used if I2 < 25 and the Random-Effects Model was used if I2 ≥ 25%. RESULTS Nine studies consisting of 452 patients were included (mean age 42.3 ± 5.7 years; 70% male). After a mean follow-up of 48.1 ± 21.5 months, endo-epicardial ablation was associated with 42% relative risk reduction in VA recurrence as opposed to endocardial ablation alone (risk ratio [RR], 0.58; 95% confidence interval [CI], 0.45-0.75; P

Fluoroscopy continues to be considered an indispensable part of atrial fibrillation (AF) ablation worldwide. Deleterious effects of radiation exposure to patients, physicians, and catheter laboratory personnel are gaining increased consideration. Safety and efficacy of a fluoroless approach for AF ablation is comparable with outcomes achieved with fluoroscopy use. This article focuses on AF ablation with zero fluoroscopy use as well as current evidence on efficacy and safety of this technique. In contrast, minimal fluoroscopy is an alternative. Relying on intracardiac echocardiography for transseptal access and electroanatomic mapping for catheter manipulation can help implement this approach on a wider scale.

The optimal ablation strategy for non-paroxysmal atrial fibrillation remains controversial. Non-PV triggers have been shown to have a major arrhythmogenic role in these patients. Common sources of non-PV triggers are: posterior wall, left atrial appendage, superior vena cava, coronary sinus, vein of Marshall, interatrial septum, crista terminalis/Eustachian ridge, and mitral and tricuspid valve annuli. These sites are targeted empirically in selected cases or if significant ectopy is noted (with or without a drug challenge), to improve outcomes in patients with non-paroxysmal atrial fibrillation. This article focuses on summarizing the current evidence and the approach to mapping and ablation of these frequent non-PV trigger sites.

The posterior wall of the left atrium may promote atrial fibrillation (AF) due to its propensity for fibrosis, in addition to a high prevalence of non-pulmonary vein triggers. Multiple smaller studies have assessed the incremental value of posterior wall isolation (PWI) in addition to standard atrial fibrillation. Similarly, this method has shown promise as an ablation strategy for patients with persistent AF, when PVI alone has shown only modest efficacy. We performed an extensive literature search and systematic review of studies that compared AF ablation plus PWI versus control. We separately assessed the recurrence rates of all atrial arrhythmias (AF/AFL/AT), as well as separate recurrence rates of AF and atrial tachycardia/atrial flutter (AT/AFL) after ablation. Risk ratio (RR) 95% confidence intervals were measured using the Mantel-Haenszel method. The random effects model was used due to heterogeneity (I2) > 25%. Seven studies with a total of 1151 patients were included. Patients who underwent concomitant PWI experienced less recurrence of all atrial arrhythmias post ablation (RR 0.77; 95% CI 0.62–0.96, p = 0.02) and less recurrence of AF (RR 0.55; 95% CI 0.39–0.77, p < 0.01). There was no difference in onset of AT/AFL (RR 0.96; 95% CI 0.62–1.48, p = 0.85) after ablation. These results were replicated in subgroup analysis of patients with persistent AF. Based on the results of this meta-analysis, concomitant PWI is associated with less recurrence of AF and all atrial arrhythmias after ablation, without an increase in the risk for post-ablation AFL/AT.

Loss of contractility leading to stasis of blood flow following left atrial appendage electrical isolation (LAAEI) could lead to thrombus formation.This study evaluated the incidence of thromboembolic events (TE) in post-LAAEI cases "on" and "off" oral anticoagulation (OAC).A total of 1,854 consecutive post-LAAEI patients with follow-up transesophageal echocardiography (TEE) performed in sinus rhythm at 6 months to assess left atrial appendage (LAA) function were included in this analysis.The TEE at 6 months revealed preserved LAA velocity, contractility, and consistent A waves in 336 (18%) and abnormal parameters in the remaining 1,518 patients. In the post-ablation period, all 336 patients with preserved LAA function were off OAC. At long-term follow-up, patients with normal LAA function did not experience any stroke events. Of the 1,518 patients with abnormal LAA contractility, 1,086 remained on OAC, and the incidence of stroke/transient ischemic attack (TIA) in this population was 18 of 1,086 (1.7%), whereas the number of TE events in the off-OAC patients (n = 432) was 72 (16.7%); p 0.001. Of the 90 patients with stroke, 84 received left atrial appendage occlusion (LAAO) devices. At median 12.4 months (interquartile range: 9.8 to 15.3 months) of device implantation, 2 (2.4%) patients were on OAC because of high stroke risk or personal preference, whereas 81 patients discontinued OAC after LAAO device implantation without any TE events.LAAEI is associated with a significant risk of stroke that can be effectively reduced by optimal uninterrupted OAC or LAAO devices.

Background Atrial fibrillation (AF) triggers within the coronary sinus (CS)/great cardiac vein (GCV) and the left atrial appendage (LAA) have been recognized as nonpulmonary vein triggers of AF. Objective The aim of this study was to describe an electrical connection between the LAA and CS/GCV and its importance in achieving LAA electrical isolation (LAAEI). Methods A total of 488 consecutive patients undergoing catheter ablation for persistent or long-standing persistent AF who showed firing from the LAA and/or from the CS/GCV were enrolled in this multicenter prospective study. In all patients, potential defragmentation of the CS/GCV to achieve isolation and LAAEI was attempted with both endocardial and epicardial ablation. Results In 7% (n = 34) of these patients, after attempting endocardial LAAEI, the LAA was isolated during epicardial ablation in the GCV. In 8% (n = 39) of patients after attempting endocardial LAA isolation, the LAA was isolated during ablation along the endocardial aspect of the GCV. The presence of a venous branch connecting the GCV with the LAA was found in all these patients. In 23% (n = 112) of patients, the isolation of the LAA also isolated the GCV. In all these patients, LAA dissociated firing was present together with the CS/GCV recordings. Conclusion These findings suggest the presence of a distinct electrical connection between the GCV and the LAA. The clinical relevance of our results requires further investigation. Ablation in the CS/GCV can result in inadvertent isolation of the LAA. Ablation of the GCV is relevant to achieve LAAEI. Considering the potential long-term implications, ablation in the distal CS/GCV should prompt assessment of LAA conduction.

Background Mitral valve prolapse (MVP) is a common valve condition and has been associated with sudden cardiac death. Premature ventricular contractions (PVCs) from the papillary muscles (PMs) may play a role as triggers for ventricular fibrillation (VF) in these patients. Objectives To characterize the electrophysiological substrate and outcomes of catheter ablation in patients with MVP and PM PVCs. Methods Of 597 patients undergoing ablation of ventricular arrhythmias during the period 2012-2015, we identified 25 patients with MVP and PVCs mapped to the PMs (64% female). PVC-triggered VF was the presentation in 4 patients and a fifth patient died suddenly during follow-up. The left ventricle ejection fraction (LVEF) was 50.5% ± 11.8% and PVC burden was 24.4% ± 13.1%. A cardiac magnetic resonance imaging was performed in nine cases and areas of late gadolinium enhancement were found in four of them. A detailed LV voltage map was performed in 11 patients, three of which exhibited bipolar voltage abnormalities. Complete PVC elimination was achieved in 19 (76%) patients and a significant reduction in PVC burden was observed in two (8%). In patients in which the ablation was successful, the PVC burden decreased from 20.4% ± 10.8% to 6.3% ± 9.5% (P = 0.001). In 5/6 patients with depressed LVEF and successful ablation, the LV function improved postablation. No significant differences were identified between patients with and without VF. Conclusions PM PVCs are a source of VF in patients with MVP and can induce PVC-mediated cardiomyopathy that reverses after PVC suppression. Catheter ablation is highly successful with more than 80% PVC elimination or burden reduction.

Objectives This study sought to investigate the substrate, procedural strategies, safety, and outcomes of catheter ablation (CA) for ventricular tachycardia (VT) in patients with aortic valve replacement (AVR). Background VT ablation in patients with AVR is challenging, particularly when mapping and ablation in the periaortic region are necessary. Methods We identified consecutive patients with mechanical, bioprosthetic, and transcatheter AVR who underwent CA for VT refractory to antiarrhythmic drugs and analyzed VT substrate, approach to LV access, complications, and long-term outcomes. Results Overall, 29 patients (87% men, mean age 67.9 ± 9.8 years, left ventricular ejection fraction 39 ± 10%) with prior AVR (13 mechanical, 15 bioprosthetic, 1 transcatheter AVR) underwent 40 ablations from 2004 to 2016. Left-sided mapping/CA was performed in 27 patients (36 procedures). Access was retrograde aortic in 11 procedures (all bioprosthetic), transseptal in 24 (13 mechanical; 10 bioprosthetic; 1 transcatheter AVR), or transventricular septal in 1. Periaortic bipolar or unipolar scar was detected in all 24 patients in whom detailed periaortic mapping was performed. Clinical VT circuit(s) involved the periaortic region in 10 patients (34%), 2 (7%) had bundle branch re-entry VT, and 17 (59%) had substrate unrelated to AVR. There were 2 major complications (both related to vascular access). Only 2 patients (9.1%) had VT recurrence. Over median follow-up of 12.8 months, 11 patients died (none as a result of recurrent VT). Conclusions Whereas most patients undergoing CA for VT after AVR had VT from substrate unrelated to AVR, periaortic scar is universally present and bundle branch re-entry can be the VT mechanism. CA can be safely performed with excellent long-term VT elimination.

Introduction Empirical pulmonary vein isolation (PVI) remains the cornerstone for catheter ablation of atrial fibrillation (AF). Various ablation strategies and modalities are continually tested with the aim of improving ablation outcomes. Although focal impulse and rotor modulation (FIRM)-guided ablation is currently used as an adjunct to pulmonary vein isolation (PVI), evidence supporting this strategy is conflicting. We sought to examine whether the utilization of FIRM-guided ablation with or without PVI is associated with a decrease in all-atrial arrhythmia recurrence as compared to PVI alone. Methods A systematic review of PubMed, Cochrane, and Embase was performed for head-to-head study designs comparing outcomes of patients who underwent FIRM-guided ablation with or without PVI to those who underwent PVI. The primary efficacy endpoint was all-atrial arrhythmia recurrence. The secondary endpoint was complication rates. Results Overall, six studies comprising 716 patients undergoing either FIRM-guided ablation +/- PVI vs PVI were included (mean age 63.4 ± 9.2, male 74%, 11.5% paroxysmal AF, 88.5% non-paroxysmal AF). After a mean follow-up of 18.8 months, FIRM-guided ablation with or without PVI was not associated with improvement in all-atrial arrhythmia recurrence rate compared to PVI alone (43.4% vs 45.9%, Risk Ratio [RR] 1.06, 95% Confidence Interval [CI] 0.77-1.47, P=0.70). No statistically significant difference was noted in complication rates between the two groups (RR 1.66, 95% CI 0.08-34.54, P=0.74). Conclusion In this meta-analysis of head-to-head comparisons, FIRM-guided ablation with or without PVI did not provide any benefit in improving all-atrial arrhythmia recurrence at follow-up when compared to PVI alone. This article is protected by copyright. All rights reserved.

Introduction: General anesthesia is routinely used during the implantation of S-ICD which dramatically prolongs total procedure time, patient recovery time and adds unnecessary potential complications. The tumescent local anesthesia (TLA) technique provides anesthesia of large areas of skin and subcutaneous tissue by means of the direct infiltration of large volumes of a dilute local anesthetic solution into subcutaneous fat. Hypothesis: TLA during S-ICD implantation is feasible and associated with a reduction in total procedure time. Methods: A retrospective analysis was conducted in two medical centers during 2019. Five patients underwent S-ICD with TLA due to baseline conditions that represented relative contraindications to general anesthesia (e.g, muscular dystrophy). A large volume of a local anesthesia solution (i.e., 1 liter of normal saline, 30 cc of 1% lidocaine, 30 cc of bupivacaine, 1 mg of epinephrine, 12.5 mEq of sodium bicarbonate) was used in each patient and injected 10 minutes prior to incisions. Five other patients who underwent S-ICD under general anesthesia served as controls. The skin-to-skin time, total length of procedure and post-procedural pain levels were compared between groups. Results: A total of 10 patients were included (male: 60%; mean age: 62 ± 16). All devices were implanted for primary prevention of sudden cardiac death. TLA was considered the best anesthetic approach in five patients who had medical conditions that represented a high risk of complications if general anesthesia was employed. In the group of TLA, an average of 260 ± 45 cc was administered. The skin-to-skin times were 44.8 ± 13.9 minutes in patients who underwent general anesthesia vs. 46.2 ± 14.3 minutes in TLA (p = 0.3). The total procedural time was 148 ± 28 min vs 64.2 ± 13.4 min (p Conclusions: S-ICD implantation using TLA appears to be a feasible and safe option in patients with contraindications to general anesthesia. This technique significantly decreases total procedure time with better post-procedural pain control.

Introduction: Radiofrequency catheter ablation (CA) is the preferred treatment for premature ventricular contractions (PVCs). Ionizing radiation has major side effects for both patients and personnel in the electrophysiology laboratory. Fluoroless procedures are routinely performed for atrial fibrillation and simple PVC cases. Nonetheless, left ventricular (LV) summit/intramural PVCs cases are more challenging and clinical outcomes and complications have been poorly studied in this category with the use of fluoroless ablation. Hypothesis: We aimed to compare acute, long-term success rate and complications between fluoroless procedures versus standard approach for left ventricular (LV) summit/intramural PVCs. Methods: We conducted a retrospective analysis of patients who underwent PVC ablation under fluoroscopy and non-fluoroscopy at two institutions. Results: A total of 41 cases were enrolled (male: 61%; mean age: 55 ). Twenty-five cases underwent ablation under fluoroscopy whereas 16 underwent non-fluoroscopy ablation. Acute success was seen in 88% of non-fluoroscopy cases compared to 87.5% in the fluoroscopy group ( p = 0.9). The PVC recurrence at 12 months was similar between both groups (non-fluoroscopy: 15% vs Fluoroscopy: 18%) ( p = 0.9). No complications occurred in any group. Conclusions: Fluoroless CA is an emerging technique in the treatment of LV summit/intramural PVCs that appears to have similar clinical outcomes and complications compared to conventional fluoroscopic procedures.

Introduction: Randomized controlled trials (RCTs) have shown improved outcomes in patients undergoing first-line catheter ablation of ventricular tachycardia/ventricular fibrillation (VT/VF) in patients with ischemic cardiomyopathy (ICM). Nonetheless, the impact of Left ventricular ejection fraction (LVEF) on the outcomes after catheter ablation (CA) have not been studied. Hypothesis: LVEF has a strong impact on the outcome after CA for VT in patients with ICM. Methods: RCTs evaluating first-line ablation versus medical therapy in patients with VT and ICM were included. Risk estimates and 95% confidence intervals (CI) were measured. Results: Four RCTs with a total of 505 patients (mean age 66 ± 9 years, 89% male, 80% with previous revascularization) were included. Mean LVEF was 35 ± 8%. At a mean follow-up of 24 ± 9 months, a significant benefit in survival-free from appropriate ICD therapies was observed in all patients undergoing first-line catheter ablation compared to medical management (RR 0.70, 95% CI 0.56-0.86). In patients with moderately depressed LVEF (>30-50%), first line VT ablation was associated with a statistically significant reduction in the composite endpoint of survival-free VT/VF and appropriate ICD therapies (HR: 0.52, 95% CI: 0.36-0.76), whereas there was no difference in patients with severely depressed LVEF ( Conclusions: Patients with ICM and VT undergoing first-line ablation have a significant lower rate of appropriate ICD therapies without a mortality difference compared to patients receiving an initial approach based on medical therapy. The beneficial effect was only observed in patients with moderately depressed LVEF (>30-50%).

Introduction: Randomized controlled trials (RCTs) have shown improved outcomes in patients undergoing first-line catheter ablation of ventricular tachycardia/ventricular fibrillation (VT/VF) in patients with ischemic cardiomyopathy (ICM). Herein, outcomes were stratified based on left ventricular ejection fraction (LVEF). Methods: RCTs evaluating first-line ablation versus medical therapy in patients with VT and ICM were included. Risk estimates and 95% confidence intervals (CI) were measured. Results: Four RCTs with a total of 505 patients (mean age 66 ± 9 years, 89% male, 80% with previous revascularization) were included. Mean LVEF was 35 ± 8%. At a mean follow-up of 24 ± 9 months, a significant benefit in survival-free from appropriate ICD therapies was observed in all patients undergoing first-line catheter ablation compared to medical management (RR 0.70, 95% CI 0.56-0.86). In patients with moderately depressed LVEF (>30-50%), first line VT ablation was associated with a statistically significant reduction in the composite endpoint of survival-free VT/VF and appropriate ICD therapies (HR: 0.52, 95% CI: 0.36-0.76), whereas there was no difference in patients with severely depressed LVEF (30-50%).

Direct oral anticoagulants (DOACs) are contraindicated in patients with atrial fibrillation (AF) and mechanical cardiac valves. However, safety and efficacy are controversial in patients with biological cardiac valves. We report the safety and feasibility of periprocedural and long-term treatment with DOACs in patients with biological valves undergoing ablation for AF. A total of 127 patients with AF and biological cardiac valve undergoing CA on uninterrupted DOAC were matched by gender and age with 127 patients with AF and biological cardiac valves undergoing CA on uninterrupted warfarin. All patients were anticoagulated for at least 3–4 weeks prior to ablation with either rivaroxaban (70%) or apixaban (30%), which were continued for at least 3 months and subsequently based on CHA2DS2-VASc score. Mean age of the study population was 63.0 ± 10.9 with 66% being male. The majority of patients on NOACs had aortic valve replacement (59%), while mitral valve was replaced in 41% of patients, which did not differ from the matched cohort on coumadin (aortic valve 57% and mitral valve 43%, (p = 0.8) (p = 0.8), respectively). The CHADS2 score was ≥ 2 in 90 patients (71.0%) on DOAC and 86 patients in (68%) the control (p = 0.6) group. Patients underwent ablation predominantly with uninterrupted rivaroxaban [89 (70%)], while the remaining 38 patients (30%) underwent ablation while on apixaban. Two groin hematomas were observed periprocedurally in both groups. No stroke/transient ischemic attack (TIA) was observed both periprocedurally and at long-term follow-up in either group. Periprocedural and long-term administration of DOACs in patients with biological cardiac valves undergoing AF ablation appears as safe as warfarin therapy.

Background Pulmonary vein isolation (PVI) is the mainstay of catheter ablation (CA) for paroxysmal atrial fibrillation (AF). However, for persistent and long-standing persistent AF, there are no established strategies to improve the success rate of CA. Despite studies indicating that prophylactic cavotricuspid isthmus (CTI) ablation provides no or limited incremental benefit in patients with AF, it is still routinely performed worldwide. Objective We sought to examine whether CTI ablation for AF is associated with improvement in recurrence of all-atrial arrhythmias, compared with PVI alone in patients with and without typical atrial flutter (AFL). Methods A systematic review of PubMed, Cochrane, and Embase was performed for clinical studies including AF patients, reporting outcomes of CTI + PVI versus PVI alone. The primary efficacy endpoint was recurrence of all-atrial arrhythmias. Results Five studies comprising 1400 patients undergoing CTI + PVI versus PVI alone were included; 1110 patients had AF without AFL, and 290 patients had coexistent AF and AFL. After a mean follow-up of 14.4 ± 4.8 months, CTI + PVI was not associated with improvement in recurrence of all-atrial arrhythmias when compared with PVI alone (risk ratio [RR]: 1.29; 95% confidence interval [CI]: 0.93-1.79;p = .13). In the subgroup analysis, there were no differences between both groups in patients with AF without AFL (RR: 1.55; 95% CI: 0.96-2.48; p = .07), and in patients with AF and AFL (RR: 0.91; 95% CI: 0.6-1.39; p = .68). Conclusion In AF patients, irrespective of the presence of typical AFL, additional CTI ablation is not associated with improvement in recurrence of all-atrial arrhythmias, compared with PVI alone.

Background: Data characterizing structural changes of arrhythmogenic right ventricular (RV) cardiomyopathy are limited. Methods: Patients presenting with left bundle branch block ventricular tachycardia in the setting of arrhythmogenic RV cardiomyopathy with procedures separated by at least 9 months were included. Results: Nineteen consecutive patients (84% males; mean age 39±15 years [range, 20–76 years]) were included. All 19 patients underwent 2 detailed sinus rhythm electroanatomic endocardial voltage maps (average 385±177 points per map; range, 93–847 points). Time interval between the initial and repeat ablation procedures was mean 50±37 months (range, 9–162). No significant progression of voltage was observed (bipolar: 38 cm 2 [interquartile range (IQR), 25–54] versus 53 cm 2 [IQR, 25–65], P =0.09; unipolar: 116 cm 2 [IQR, 61–209] versus 159 cm 2 [IQR, 73–204], P =0.36) for the entire study group. There was a significant increase in RV volumes (percentage increase, 28%; 206 mL [IQR, 170–253] versus 263 mL [IQR, 204–294], P P =0.006; unipolar: Spearman ρ, 0.5743, P =0.03). Most patients with progressive RV dilatation (8/14, 57%) had moderate (2 patients) or severe (6 patients) tricuspid regurgitation recorded at either initial or repeat ablation procedure. Conclusions: In patients with arrhythmogenic RV cardiomyopathy presenting with recurrent ventricular tachycardia, >10% increase in RV endocardial surface area of bipolar voltage consistent with scar is uncommon during the intermediate term. Most recurrent ventricular tachycardias are localized to regions of prior defined scar. Voltage indexed scar area at baseline but not changes in scar over time is associated with progressive increase in RV size and is consistent with adverse remodeling but not scar progression. Marked tricuspid regurgitation is frequently present in patients with arrhythmogenic RV cardiomyopathy who have progressive RV dilation.

This is a case of a patient with high burden PVCs causing cardiomyopathy. The PVC features on 12-lead ECG was suggestive of a LVOT PVC origin (R/L cusp origin). We initially mapped the RVOT and coronary sinus (AIV/GCV junction) and both had late PVC activation. Single ablation at the R/L aortic cusps suppressed the PVC where the activation and pace-mapping was excellent.

A 73 years-old male was referred for catheter ablation of left ventricular summit (LVS) arrhythmias. Typical LVS arrhythmias have a right bundle branch block configuration in lead V1 or a left bundle branch block configuration with early precordial transition (V3 or earlier). The axis is always inferior. Our initial approach to LVS PVCs is to map the coronary venous system. If ablation is unsuccessful or deemed risky in this region, adjacent cardiac structures should be mapped, including the sinuses of Valsalva, left ventricular endocardium, and right ventricular outflow tract.

A 29 year-old male was noted with symptomatic high burden premature ventricular contractions (PVC) despite therapy with betablockers. An electrophysiology study was done. Activation map and pacemapping localized the PVC to the tip of the papillary muscle. Ablation of papillary muscle PVCs is often challenging because of the anatomical variability, potentially deep intramural site of arrhythmia origin, and the stability issues related to the ablation of a mobile target.

Objectives This study reports outcomes of bailout atrial balloon septoplasty (ABS) to overcome challenging left atrial (LA) access in patients undergoing atrial fibrillation (AF) ablation. Background Transseptal puncture (TSP) and LA access for AF ablation can be challenging in patients with prior atrial septal surgery, percutaneous closure, or scarred septum due to multiple prior TSPs. Methods The study identified patients who underwent AF ablation at 2 ablation centers from 2011 to 2017 with challenging TSP in whom bailout percutaneous ABS was performed to allow LA access. Following TSP, the transseptal sheath could not be advanced to the LA despite multiple attempts or approaches including use of a stiff wire sequentially in the left and right pulmonary veins, use of a stiff pigtail exchange wire advanced in the LA or left ventricle, or sequential dilation with progressively larger diameter long dilators. ABS was performed using a noncompliant balloon (diameter 4 to 10 mm) advanced over a stiff wire deployed in the left superior pulmonary vein, allowing passage of the transseptal sheaths for completion of the AF ablation procedure. Results Fifteen patients (mean age 54.4 ± 15.5 years, 9 women) with challenging TSP (7 patients with prior surgical ASD repair, 2 with percutaneous ASD closure devices, and 13 with ≥1 previous TSP) underwent bailout ABS for AF ablation. After TSP (radiofrequency assisted in 10 cases), ABS was successful and permitted access to the LA for ablation in all patients. Mean time required to perform ABS was 21.3 ± 19.4 min, and mean total procedure time was 241.1 ± 114.6 min (fluoroscopy time 62.0 ± 29.9 min). There were no procedural complications. Conclusions In patients undergoing AF ablation with difficult transseptal access due to scarred, surgically, or percutaneously repaired atrial septum, ABS is a safe and effective bailout strategy to obtain transseptal access.

Objectives This was a meta-analysis of published studies to examine the impact of early referral on outcomes after catheter ablation for ventricular tachycardia (VT) in patients with structural heart disease. Background Patients are frequently referred for VT ablation after failure of antiarrhythmic drugs to control VT. Some studies have suggested that early referral might confer better outcomes. Methods An electronic search was performed using major databases. The primary outcomes were long-term VT recurrence and total mortality. Secondary outcomes were acute procedural success and acute complications. Results Three studies were included with a total of 980 patients (mean age 64 ± 12 years, 71% males). Mean follow-up was 29 ± 27 months. Early referral for VT ablation was associated with decreased VT recurrence and acute complications compared with late referral (relative risk: 0.69 [95% confidence interval: 0.58 to 0.82], p Conclusions Late referral for VT ablation was associated with worse outcomes (VT recurrence and acute complications) in patients with structural heart disease, which suggests that early referral for VT ablation might be a reasonable consideration in this patient population.

The CABANA trial reported that catheter ablation, when compared with drug therapy, did not significantly reduce the primary composite end point of death, disabling stroke, serious bleeding, or cardiac arrest in patients with atrial fibrillation. Despite multiple limitations in study design, the CABANA trial still confirmed that catheter ablation of atrial fibrillation led to clinically important and significant improvements in quality of life at 12 months without increasing the risk of complications.

Background Atrioventricular nodal reentry tachycardia (AVNRT) is common in adults and often involves reentry through ≥2 atrioventricular nodal-atrial connections. Although AVNRT can be a trigger for atrial fibrillation (AF), we have observed new-onset AVNRT after AF ablation procedures. Objective The purpose of this study was to determine whether ablation involving the septum or proximal coronary sinus (CS) during AF ablation may create a substrate favorable for AVNRT. Methods Cases of ablation for persistent AF who required a repeat ablation procedure between 2009 and 2016 were reviewed for diagnosis of AVNRT. Results Nine patients were identified; the mean age was 54 years, 7 (78%) were men, 2 with prior Cox-MAZE procedures, 5 had radiofrequency ablation (RFA) for AF, and 2 patients had both RFA and Cox-MAZE procedure. None of the patients with prior RFA had dual atrioventricular node physiology at baseline. All patients had evidence of atrial fibrosis in the septum or proximal CS, and 6 had undergone ablation either at the septum or the CS ostium/body, and the other 3 had received inferior mitral lines at a surgical MAZE procedure. All had typical AVNRT inducible that was abolished by slow pathway ablation, but 5 required ablation in the roof of the CS or on the mitral valve annulus. Conclusion Ablation involving the septum or proximal CS may create a substrate favorable for AVNRT. These findings are consistent with the theory that the posteroseptal left atrium and its connections to the CS are critical for some forms of AVNRT.

Atrial fibrillation (AF) is a cause of significant morbidity and mortality. Catheter ablation for AF (CAAF) has emerged as an effective treatment option of rhythm control for patients with symptomatic AF. However, the risk of thromboembolism and bleeding in the periprocedural period represent a worrisome complication of this therapy. The reported incidence of thromboembolic and bleeding events associated with CAAF varies from 0.9% to 5% depending on the CAAF strategy and the anticoagulation regimen used in the periprocedural period. Areas covered: The different anticoagulation regimens used prior to, during, and after CAAF to minimize the risk of thromboembolic and bleeding events are reviewed. The use of uninterrupted oral anticoagulation and appropriate heparin dosing to achieve safe activated clotting time levels are also detailed. A comprehensive approach with assessment of individual risk for thromboembolic and bleeding complications, and understanding the pharmacokinetics of the anticoagulant agents available is also reviewed. Expert opinion: The key advances done in the periprocedural anticoagulation field include the use of uninterrupted anticoagulation strategies in patients undergoing AF ablation and efforts to simplify the selection of patients who need LAA thrombus screening prior to ablation.

Lower socioeconomic status (SES) is associated with a higher risk of cardiovascular disease. However, the association between SES and mortality in patients with atrial fibrillation (AF) is not clear. We examined whether SES predicts all-cause mortality in patients hospitalized with AF. This is a retrospective study of patients aged >18 years, admitted with a primary diagnosis of AF to Montefiore Medical Center between 2000 and 2010. Multivariable logistic regression models were used to determine predictors of survival adjusted for age, gender, heart failure, diabetes mellitus, chronic kidney disease, previous myocardial infraction, chronic obstructive pulmonary disease, hypertension, peripheral vascular disease, and SES. SES was determined using the New York City Department of Health Standardized Score (a log composite score of household income, value of housing units, net rental income, household occupations, and educational level). The cohort was divided into quartiles based on SES score, with Q4 the highest and Q1 the lowest SES score. There were 4,503 patients identified with a mean follow up of 4.5 years in the following SES quartiles: Q1 (n = 1,132), Q2 (n = 1,119), Q3 (n = 1,126), and Q4 (n = 1,126). The unadjusted mortality varied across quartiles (Q1 to Q4), 54%, 58%, 56%, and 59%, respectively (p = 0.004). After controlling for other variables in the multivariable analysis, patients with the lowest SES (Q1) had a significantly higher mortality than patients in the quartile with the highest (Q4) SES (odds ratio 1.3, CI 1.1 to 1.5). In conclusion, patients admitted to the hospital with AF have varying mortality based on their SES. After controlling for co-morbidities, patients with AF and lower SES scores had higher mortality. Further research studies are warranted to study this risk of increased mortality in AF population.

Ventricular arrhythmias are a frequent cause of mortality in patients with ischemic cardiomyopathy and nonischemic cardiomyopathy. Scar-related reentry represents the most common arrhythmia substrate in patients with recurrent episodes of sustained ventricular tachycardia (VT). Initial mapping of scar-related VT circuits is focused on identifying arrhythmogenic tissue. The substrate-based strategies include targeting late potentials, scar dechanneling, local abnormal ventricular activities, core isolation, and homogenization of the scar. Even though substrate-based strategies for VT ablation have shown promising outcomes for patients with structural heart disease related to ischemic cardiomyopathy, the data are scarce for patients with nonischemic substrates.

This study describes the technique and outcomes of atrial fibrillation (AF) ablation via a superior approach in patients with interrupted or absent inferior vena cavas (IVCs).In patients with interrupted or absent IVCs, transseptal access cannot be obtained via standard femoral venous access. In these patients, alternative strategies are necessary to permit catheter ablation in the left atrium (LA). This study reports on the outcomes of AF ablation from a superior venous access with a radiofrequency (RF)-assisted transseptal puncture (TSP) technique.This study identified patients with interrupted or absent IVCs who underwent AF ablation via a superior approach at 2 ablation centers from 2010 to 2019.Fifteen patients (mean age: 50.8 ± 11.2 years; 10 men; 10 with paroxysmal AF) with interrupted or absent IVCs underwent AF ablation with transseptal access via a superior approach. Successful TSP was performed either with a manually bent RF transseptal needle (early cases: n = 4) or using a RF wire (late cases: n = 11); this approach permitted LA mapping and ablation in all patients. Mean time required to perform single (n = 8) or double (n = 7) TSP was 16.1 ± 4.8 min, and mean total procedure time was 227.9 ± 120.7 min (fluoroscopy time: 57.0 ± 28.5 min). LA mapping and ablation were successfully performed in all patients.In patients with AF undergoing catheter ablation and who had a standard transseptal approach via femoral venous approach is impossible due to anatomic constraints, RF-assisted transseptal access via a superior approach can be an effective alternative strategy to permit LA mapping and ablation.

Background The slow pathway region (SPR) is commonly targeted during ablation of atrioventricular nodal reentrant tachycardia. However, its role in idiopathic ventricular arrhythmias (IVAs) remains unknown. Objective The purpose of this study was to describe the electrocardiographic and electrophysiological characteristics of IVAs that were successfully ablated from the SPR. Methods Medical records of consecutive patients undergoing ablation of IVAs in the para-Hisian region between 2010 and 2018 were reviewed to identify subjects whose ventricular arrhythmias were targeted from the SPR. Results Among 63 patients with para-Hisian IVAs undergoing ablation, the SPR was targeted in 12 (20%; mean age 64 ± 7 years; 9 men). All patients presented with ventricular premature depolarizations manifesting left bundle branch block morphology with variable precordial transition (leads V2–V5) and a mean QRS duration of 131 ± 11 ms. In all cases, leads I and aVL had positive forces (R or Rs) and lead aVR had negative forces (QS or Qr). In the majority of cases, lead II had positive forces (R or Rs; n = 9 [75%]) and lead III had negative forces (rS or QS; n = 9 [75%]). Mean activation at the SPR was 31 ± 5 ms pre-QRS. All patients had initial ablation with radiofrequency, resulting in junctional rhythm in 9 (75%); 3 (25%) patients required additional cryoablation. Ablation was successful in 11 patients (92%). One patient required a permanent pacemaker for heart block but subsequently recovered intrinsic conduction. Conclusion The SPR can be a source of IVAs, which can be safely and successfully ablated in most cases using radiofrequency energy. IVAs arising from this location manifest unique electrocardiographic features.

Idiopathic ventricular arrhythmias may arise from anywhere in the heart, and the majority of them can be effectively treated with catheter ablation. The 12-lead electrocardiogram (ECG) is the initial mapping tool to predict the most likely site of origin and is valuable to choose the appropriate ablation strategy. Crucial to ECG interpretation is understanding the attitudinal orientation of the heart within the chest and the relationship between the different cardiac structures. In this review, we provide a stepwise anatomical approach for the localization of idiopathic ventricular arrhythmias based on sequential analysis of the most relevant ECG features.