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Aims Multiple re-entry circuits may operate simultaneously in the atria in the form of dual loop re-entry using a common isthmus, or multiple re-entrant loops without a common isthmus. When two or more re-entrant circuits coexist, ablation of an individual isthmus may lead to a seamless transition (without significant changes in surface electrocardiogram, coronary sinus activation or tachycardia cycle length) to a second rhythm, and the isthmus block can go unnoticed. Methods and results We hypothesize and subsequently illustrate in three patient cases, methods to rapidly identify a transition in the rhythm and isthmus block using local electrogram changes at the ablation site. Conclusion Local activation sequence changes, electrogram timing, and the behaviour of pre-existing double potentials can reveal isthmus block promptly when rhythm transitions occur during ablation of multiloop re-entry tachycardias.

Atrioventricular (AV) nodal conduction is decremental and very prone to alterations in autonomic tone. Conduction through the His-Purkinje system (HPS) is via fast channel tissue and typically not that dependent on autonomic perturbations. Applying these principles, when the sinus rate is stable and then heart block suddenly occurs preceded by even a subtle slowing of heart rate, it typically is caused by increased vagal tone, and block occurs in the AV node. Heart block with activity strongly suggests block in the HPS. Enhanced sympathetic tone and reduced vagal tone can facilitate induction of both AV and atrioventricular node reentry.

Delayed atrioventricular (AV) conduction most commonly occurs in the AV node, resulting from AH prolongation on an intracardiac electrocardiogram and PR prolongation on a surface electrocardiogram. AV conduction may be blocked in a 2:1 manner, with a normal PR interval and wide QRS suggesting infranodal disease, whereas a prolonged PR interval and narrow QRS are more suggestive of AV nodal disease. Block within the His is suspected when there is 2:1 AV block with normal PR and QRS intervals. Complete heart block occurs when the atrial rhythm is totally independent of a junctional or lower escape rhythm.

His-refractory premature ventricular complexes perturbing a supraventricular tachycardia (SVT) establish the presence of an accessory pathway (AP). Earlier premature ventricular complexes (ErPVCs) may perturb SVTs but are considered nondiagnostic.The purpose of this study was to test the hypothesis that an ErPVC will always show a difference35 ms in its advancement of the next atrial activation during atrioventricular nodal reentrant tachycardia (AVNRT). During atrioventricular reentrant tachycardia (AVRT), a PVC delivered close to the circuit can result in greater advancement of atrial activation due to retrograde conduction via an AP. Thus, an AP response, defined as ErPVC (HSixty-five consecutive patients with SVT were retrospectively evaluated. ErPVCs were defined when the ventricular pacing stimulus was35 ms ahead of the His during tachycardia.Among the 65 cases, 43 were AVNRT and 22 AVRT. Fourteen AVRT cases had an AP response with a mean HAn AP response to PVCs (A

Atrioventricular (AV) nodal conduction is decremental and very prone to alterations in autonomic tone. Conduction through the His-Purkinje system (HPS) is via fast channel tissue and typically not that dependent on autonomic perturbations. Applying these principles, when the sinus rate is stable and then heart block suddenly occurs preceded by even a subtle slowing of heart rate, it typically is caused by increased vagal tone, and block occurs in the AV node. Heart block with activity strongly suggests block in the HPS. Enhanced sympathetic tone and reduced vagal tone can facilitate induction of both AV and atrioventricular node reentry.

BACKGROUND Technical advances have improved the safety of cardiac implantable electronic device (CIED) insertion, but periprocedural complications persist. Despite ultrasound (US) guidance for vascular access being feasible and exhibiting shorter fluoroscopy times, it is not widely adopted for insertion of CIEDs. Thus, we studied the use of US for CIED insertion to (1) quantify the success rate of venous cannulation, (2) identify predictors of failed cannulation, and (3) quantify the rate of complications using US guidance. METHODS We studied 166 consecutive patients who underwent US-guided CIED implantation. Anatomic parameters of the axillary vein were measured. The primary outcome was success (group 1) or failure (group 2) to obtain vascular access utilizing US guidance. Secondary outcomes included pneumothorax and hematoma. RESULTS Successful US-guided cannulation occurred in 154 of 166 patients (93%). No patient had a pneumothorax. Hematoma occurred in 1 of 166 patients (0.01%). Group 2 exhibited higher male proportion at 11 of 12 (92%) compared with 94 of 154 (61%) in group 1 (P = .03), increased vein depth at 3.84 versus 2.85 cm (P = .003), more right-sided implants (P = .03), higher weight at 104.6 versus 85.3 kg (P = .017), higher body mass index at 35.6 versus 29.2 kg/m2 (P = .049), and higher body surface area at 2.24 versus 1.99 m2 (P = .013). Other parameters were statistically nonsignificant. In multivariate analysis, vein depth remained significantly associated with failure. CONCLUSION Using US guidance for CIED implantation is successful in the vast majority (93%) of patients. Rare cases of unsuccessful cannulation were associated with right-sided implants and increased venous depth.

BACKGROUND: Atrial fibrillation (AF) is a common comorbidity in patients with left ventricular assist devices (LVAD) with no defined guideline treatment strategy of rate versus rhythm control. The purpose of this study is to determine the effects of rate versus rhythm control for AF on the outcomes of patients with LVAD at our institution. METHODS: Consecutive patients who underwent LVAD implantation at St Vincent Hospital from January 1, 2015 to December 31, 2017 were retrospectively evaluated. Patients with AF were identified and divided into rate control or rhythm control groups. The primary outcome evaluated was a composite of death, heart failure admission, gastrointestinal bleed, ventricular tachycardia, cerebrovascular accident, hemolysis, and pump thrombosis. Secondary outcomes included the individual variables from the primary outcome. RESULTS: Out of 201 patients that underwent LVAD implantation, 81 had AF after implantation and were included with a median follow-up period of 384 days. The rate control group (n = 31; 38%) and the rhythm control group (n = 51; 62%) had no difference in composite outcomes (61% vs 59%, p = 0.83). When taken individually there was no difference in outcomes between the two groups. Thirteen patients underwent electrical cardioversion and successful conversion to normal sinus rhythm occurred in 71% of cases with a 60% recurrence rate. CONCLUSIONS: There was no difference in primary outcome between rate and rhythm control groups. These data suggest that maintenance of sinus rhythm may not be necessary in all patients with LVAD.

Background Electrophysiology study (EPS) is an important part of the diagnosis and workup for supraventricular tachycardia (SVT). Provocative medications are used to induce arrhythmias, when they are not inducible at baseline. The most common medication is the β1-specific agonist, isoproterenol, but recent price increases have resulted in a shift toward the nonspecific agonist, epinephrine. Objective We hypothesize that isoproterenol is a better induction agent for SVT during EPS than epinephrine. Methods We created a retrospective cohort of 131 patients, who underwent EPS and required medication infusion with either isoproterenol or epinephrine for SVT induction. The primary outcome was arrhythmia induction. Results Successful induction was achieved in 71% of isoproterenol cases and 53% of epinephrine cases (P = 0.020). Isoproterenol was significantly better than epinephrine for SVT induction during EPS (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.14-4.85; P = 0.021). There was no difference in baseline variables or complications between the two groups. Other variables associated with successful arrhythmia induction included a longer procedure duration and atrioventricular nodal re-entry tachycardia as the clinical arrhythmia. In a multivariable model, isoproterenol remained significantly associated with successful induction (OR, 2.57; 95% CI, 1.002-6.59; P = 0.05). Conclusions Isoproterenol was significantly better than epinephrine for SVT arrhythmia induction. However, epinephrine was safe and successfully induced arrhythmias in the majority of patients who received it. Furthermore, when atropine was added in epinephrine-refractory cases, in a post hoc analysis there was no difference in arrhythmia induction between medications. Cost savings could thus be significant without compromising safety.

A 25-year-old man with severe nonischemic dilated cardiomyopathy underwent subcutaneous implantable cardioverter defibrillator (S-ICD) implant and subsequently underwent HeartWare ventricular assist device (HVAD) placement. Postoperative interrogation revealed both primary and secondary S-ICD vectors inappropriately regarded sinus rhythm as "noise," and the alternate vector significantly undersensed sinus rhythm. The S-ICD was reinterrogated using high-resolution capture to visually confirm EMI with a dominant frequency in both the primary and secondary vectors of 46.67 Hz that fell within the S-ICD operational range of 9-60 Hz. The 46.67 Hz frequency correlated with the HVAD operational speed of 2,800 RPM. The HVAD pump speed was increased from 2,800 to 3,000 RPM, resulting in a dominant frequency of 50 Hz. The notch filter is nonprogrammable in S-ICDs. However, the built-in filter is 50 Hz for countries in European time zones as opposed to 60 Hz in US time zones due to differences in the anticipated noise from electrical sources within each continent. Thus, the S-ICD time zone was reprogrammed from EST to GMT, which reduced the notch filter from 60 to 50 Hz, resulting in S-ICD successfully eliminating EMI when the patient was in a supine position. The EMI interference was still intermittently present in the upright patient position. This case demonstrates the utility of high-resolution electrogram capture to identify the source and frequency of EMI in S-ICD and offers a potential avenue to troubleshoot dominant frequency oversensing by changing the device time zone.

A 55-year-old woman presented with severe dyspnea during acceleration-dependent left bundle branch block (LBBB). Metoprolol initially ameliorated symptoms by preventing the heart rate at which LBBB occurred. Over time LBBB presented at slower heart rates and the patient developed recurrent dyspnea during an activity that correlated with the development of LBBB on event monitors and exercise stress testing. A biventricular pacemaker was implanted, and the patient's symptoms remain resolved after a follow-up of over 4 years. More research is needed to define the use of cardiac resynchronization therapy in patients with normal heart function.

Background: Current maneuvers for differentiation of atrioventricular node reentry tachycardia (AVNRT) and atrioventricular reentry tachycardia (AVRT) lack sensitivity and specificity for AVRT circuits located away from the site of pacing. We hypothesized that a premature His complex (PHC) will always perturb AVRT because the His bundle is obligatory to the circuit. Further, AVNRT could not be perturbed by a late PHC (≤20 ms ahead of the His) due to the retrograde His conduction time. Earlier PHCs can advance the AVNRT circuit but only by a quantity less than the prematurity of the PHC. Methods: High-output pacing at the distal His location delivered PHCs. AVRT was predicted when late PHCs perturbed tachycardia or when earlier PHCs led to atrial advancement by an amount equal or greater than the degree of PHC prematurity. Results: Among the 73 supraventricular tachycardias, the test accurately predicted AVRT (n=29) and AVNRT (n=44) in all cases. Late PHC advanced the circuit in all 29 AVRTs and none of the AVNRTs (sensitivity and specificity, 100%). With earlier PHCs, the degree of atrial advancement was equal or greater than the PHC prematurity in 26/29 AVRTs and none of the AVNRTs (90% sensitivity and 100% specificity). The mean prematurity of the PHC required to perturb AVNRT was 48 ms (range, 28–70 ms) and the advancement less than the prematurity of the PHC (mean, 32 ms; range, 18–54 ms). Conclusions: The responses to PHCs distinguished AVRT and AVNRT with 100% specificity and sensitivity.

Introduction Focal impulse and rotor modulation (FIRM)-guided ablation has had mixed results of published success, and most studies have had a follow-up for a year or less. We aimed to study a consecutive group of patients followed for at least 1.5 years, subgrouped into those with an initial FIRM ablation and those with a previous, failed ablation who now received a FIRM guided one, to evaluate for success in each group and factors that might affect success. Methods Of 181 patients, 167 were available for analysis. Group 1 (n = 122) had a first or primary ablation (paroxysmal atrial fibrillation [PAF] 51; persistent atrial fibrillation [PeAF] 71) and group 2 (n = 45) had a redo ablation (PAF 18; PeAF 27). All patients were done under general anesthesia. FIRM mapping was done in the right atrium first and then the left, and only rotors consistently seen on multiple epochs were ablated, using 15 to 30 W. Rotor ablation was discontinued when remapping showed elimination of rotational activity at the site. Wide area catheter ablation was done for pulmonary vein isolation (PVI). Routine follow-up was at 3, 6, and 12 months of the first year, with a Holter monitor at 6 months, and then every 6 months thereafter. Event recorders were given to patients with potential arrhythmic symptoms. Results Mean follow-up was 16 months. Nearly 40% of patients had obstructive sleep apnea; mean body mass index was 32; and average left atrial size was 39.7 mm and 46.2 mm for PAF and PeAF patients, respectively. Freedom from atrial arrhythmia recurrence was: in group 1 patients, 82.4% for PAF and 67.6% for PeAF patients; in group 2 patients, 83.3% for PAF, but only 40.7% for PeAF patients. Comparing outcomes for the first 10 patients studied to the next 20 or more done by three operators showed no difference, suggesting no learning curve affecting the ablation results. Furthermore, the univariate analysis did not show any demographic factor to have an independent significance for ablation success or failure. Spontaneous termination during rotor ablation occurred in 76.8% of PAF and 27.6% of PeAF patients but did not affect the long-term outcomes for maintenance of sinus rhythm. Conclusions FIRM-guided atrial ablation plus PVI in our patient population resulted in good success from a recurrence of atrial arrhythmias in patients undergoing an initial ablation procedure. For those with persistent AF undergoing a second procedure now using FIRM guidance plus PVI, the results are lower. Further research is needed to define better the appropriate population for FIRM-guided ablation and the degree of ablation needed for success in these patients.

A report of the American College of Cardiology, American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for practice guidelines.

A 57-year-old man with a structurally normal heart and normal baseline ECG (Figure 1) underwent pulmonary vein isolation for atrial fibrillation. An electrophysiology study was then undertaken with an octapolar catheter positioned at the His bundle and an ablation catheter at the mid-right atrium. Figure 1. Baseline 12 lead ECG. See Editor’s Perspective p 985 At baseline, the sinus cycle length was 890 ms, the AH interval 48 ms, the HV interval 80 ms, and the QRS duration 80 ms. During extrastimulus atrial pacing, the HV interval shortened and the QRS complex widened with a left bundle branch block morphology (Figure 2). Atrial burst pacing at cycle length 330 ms demonstrates progressive shortening of the HV interval and widening of the QRS complex with left bundle branch block morphology (Figure 3A and 3B). On the final 3 beats in the figure, a His bundle electrogram seems after the QRS complex. On termination of pacing, a wide QRS complex tachycardia of identical morphology is noted (Figure 4). The atrial (A), His (H), and ventricular (V) electrograms are labeled. What is the mechanism of the tachycardia? Figure 2. Atrial extrastimulus pacing. Following S2, the QRS widens, the HV interval shortens and the His and right bundle activation sequence reverses. Dotted line and arrows provide reference for the anterograde to retrograde activation change. Preexcitation with a long AV interval, left bundle branch block morphology, and right bundle activation preceding ventricular activation suggest an atriofascicular accessory pathway. His 7 to 8 through 1 to 2 His bundle catheter recordings are proximal to distal; pacing intervals in milliseconds are marked. H indicates His; RA, right atrium; S1, drive train stimulus; and S2, extrastimulus. Legends …

A 15-year-old girl with a history of paroxysmal supraventricular tachycardia underwent an electrophysiology study (EPS) for diagnosis and ablation. Her baseline electrocardiogram and echocardiogram were normal. At EPS, she had dual atrioventricular nodal (AVN) conduction, but isoproterenol was needed to initiate the slow-fast form of AVN reentry. Before ablation without any isoproterenol, she began to have a spontaneous block in the fast pathway with continuous conduction over the slow pathway. After ablation of the slow pathway, all complexes conducted over the fast pathway during a 25-year follow-up. Possible electrotonic interaction between the slow and fast pathways is proposed as the mechanism for this phenomenon.

Background— Definitive diagnosis of bilateral bundle-branch delay/block may be made when catheter-induced right bundle-branch block (RBBB) develops in patients with baseline left bundle-branch (LBB) block. We hypothesized that a RBBB pattern with absent S waves in leads I and aVL will identify bilateral bundle-branch delay/block. Methods and Results— Fifty patients developing transient RBBB pattern in lead V1 during right heart catheterization were studied. Patients were grouped according to whether the baseline ECG demonstrated a normal QRS, left fascicular blocks, or LBB block pattern. The RBBB morphologies in each group were compared. The prevalence of bilateral bundle-branch delay/block pattern was examined in our hospital ECG database. All patients with baseline normal QRS complexes (n=30) or left fascicular blocks (4 anterior, 5 posterior) developed a typical RBBB pattern. Among the 11 patients with a baseline LBB block pattern, 7 developed an atypical RBBB pattern with absent S waves in leads I and aVL and the remaining 4 demonstrated a typical RBBB. The absence of S waves in leads I and aVL during RBBB was 100% specific and 64% sensitive for the presence of pre-existing LBB block. Among the consecutive 2253 hospitalized patients with RBBB, 34 (1.5%) had the bilateral bundle-branch delay/block pattern. Conclusions— An ECG pattern of RBBB in lead V1 with absent S wave in leads I and aVL indicates concomitant LBB delay. Pure RBBB and bifascicular blocks are associated with S waves in leads I and aVL.

The incidence and prevalence of atrial fibrillation (AF) are increasing globally, and the arrhythmia has profound impact on patient outcomes [(1)][1]. The precise reasons for the rising AF epidemic are unclear, and proposed causes include the aging population and increased incidence of risk factors

A 65-year-old man, with no significant past medical history, presented with an episode of sudden onset palpitations and lightheadedness. He was hemodynamically stable and the ECG revealed a left bundle branch block (LBBB) morphology tachycardia at 214 beats per minute (Figure 1A). The tachycardia terminated spontaneously with conversion to normal sinus rhythm and LBBB (Figure 1B). Further evaluation included a 2-dimensional echocardiogram showing a left ventricular ejection fraction of 40% to 45%, left heart catheterization showing angiographically normal coronaries, and cardiac magnetic resonance imaging revealing atypical septal motion with left ventricular ejection fraction of 60% to 65% and no scar or ischemia. The patient underwent an electrophysiology study. At baseline, the sinus cycle length was 890 ms, atrial-His interval was 64 ms, His-ventricular interval was 108 ms, and QRS duration was 120 ms. Spontaneous onset of the LBBB morphology tachycardia after a sinus beat is shown in Figure 2. The tachycardia cycle length is 306 ms, and the His-ventricular interval is 120 ms. The QRS while similar to the LBBB seen during sinus rhythm shows change in axis and the morphology in aVR is predominantly positive. There is no ventriculo-atrial conduction during the tachycardia. Attempts at entrainment from right ventricle (RV) led to termination of the tachycardia. His refractory premature ventricular complexes (PVCs) delivered from RV apex during tachycardia after the His depolarization advances the next H and V (Figure 3). What is the mechanism of the tachycardia? See Editor's Perspective by Asirvatham and Stevenson Figure 1. A , ECG showing wide complex tachycardia with left bundle branch block (LBBB) morphology. B , ECG showing sinus rhythm and LBBB. Figure 2. Spontaneous initiation of tachycardia during sinus rhythm. The first sinus complex does not conduct because of a premature ventricular complexes. The second sinus complex conducts with a His-ventricular (HV) interval of 108 …

Studies have established the superiority of atrial fibrillation ablation in controlling the rhythm compared with medical therapy. The procedure, however, has significant associated risks. Whether ablation therapy would improve the major outcomes of survival and stroke is not yet established. Until this information becomes available, ablation should continue to be used as a second-line option for most patient subgroups when one or more antiarrhythmic medications are ineffective.

Studies have established the superiority of atrial fibrillation ablation in controlling the rhythm compared with medical therapy. The procedure, however, has significant associated risks. Whether ablation therapy would improve the major outcomes of survival and stroke is not yet established. Until this information becomes available, ablation should continue to be used as a second-line option for most patient subgroups when one or more antiarrhythmic medications are ineffective.

Introduction Paroxysmal atrial fibrillation (AF) may progress to persistent AF. We studied the clinical correlates and the effect of rhythm-control strategy on AF progression. Methods RecordAF was a worldwide prospective survey of AF management. Consecutive eligible patients with recent-onset AF were included and allocated to rate or rhythm control according to patient/physician choice. A total of 2,137 patients were followed up for 12 months. Atrial fibrillation progression was defined as a change from paroxysmal to persistent/permanent AF. Results Progression of AF occurred in 318 patients (15%) after 1 year. Patients with AF progression were older; had a higher diastolic blood pressure; and more often had a history of coronary artery disease, stroke or transient ischemic attack, hypertension, or heart failure. Patients treated with rhythm control were less likely to show progression than those treated only with rate control (164/1542 [11%] vs 154/595 [26%], P