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INTRODUCTION: Device infections constitute a major complication of transvenous pacemakers. Mechanical heart valves (MHV) increase the risk of infective endocarditis (IE) and pacemaker infection, requiring lifelong vitamin K-antagonists (VKA), which may affect patient management. Leadless pacemakers (LP) are associated with low infection rates, posing an attractive option in MHV patients requiring permanent pacing.This study describes outcomes following LP implantation in patients with MHV. METHODS: This is a multicenter, observational, retrospective study including consecutive patients implanted with an LP at 5 centers between June 2015 and January 2020.Procedural outcomes, antithrombotic management, complications, performance during follow-up and episodes of bacteremia and IE were compared between patients with and without an MHV (MHV and non-MHV groups). RESULTS: Four hundred fifty-nine patients were included (74 in the MHV group, 16.1%, and 385 in the non-MHV group, 83.9%).Procedural outcomes and acute electrical performance were comparable between groups.Vascular complications and cardiac perforation occurred in 2.7 vs. 2.3% (p=1) and 0% vs. 0.8% (p=1) in the MHV group and non-MHV group.One case of IE occurred in the MHV group and 2 in the non-MHV group.In MHV patients, uninterrupted VKA was used in 83.8 %, whereas 16.2 % were heparin-bridged.Vascular complication or tamponade occurred in 1(8.3 %) MHV heparin-bridged patient vs. 1 (1.6 %) MHV uninterrupted VKA patient (p=0.3). CONCLUSION: LP implantation outcomes in MHV patients are comparable to the general LP population.Device-related infections are rare following LP implantation, including in patients with MHV.In the MHV group, periprocedural anticoagulation management was not associated with significantly different rates of tamponade or vascular complication. This article is protected by copyright. All rights reserved.

INTRODUCTION AND OBJECTIVES: The ADVANCE III trial showed that a delayed-detection strategy reduces implantable cardioverter-defibrillator (ICD) therapies. Here, we describe the adherence to and predictors of ADVANCE adoption and compare ICD therapy rates between patients with and without ADVANCE programming. METHODS: This observational retrospective study analyzed patients implanted with Medtronic ICDs included from 2005 to 2016 in a Spanish national multicenter registry (UMBRELLA database; ClinicalTrials.gov, NCT01561144). Changes in ADVANCE programming adoption were described in relation to a) publication of the ADVANCE trial, b) implementation of an "ADVANCE awareness" campaign, and c) publication of an expert consensus statement. Multivariate logistic regression identified predictors of adoption. Therapy incidence rates were compared between groups by estimating the adjusted incidence rate ratio (aIRR) using negative binomial regression. RESULTS: A total of 3528 patients were included. An ADVANCE strategy was used in 20% overall and in 44% at the end of the study. ADVANCE III adoption increased after trial publication, with less growth after an "ADVANCE awareness" campaign and after expert consensus statement publication. Predictors of ADVANCE adoption were as follows: ICD device with a nominal number of intervals to detect 30/40 (aOR, 4.4; 95%CI, 3.5-5.4), implantation by an electrophysiologist (aOR, 1.7; 95%CI, 1.4-2.2), and secondary prevention (aOR, 3.2; 95%CI, 2.6-3.9). Dual-chamber ICDs (aOR, 0.6; 95%CI, 0.5-0.8) and cardiac resynchronization-defibrillators (aOR, 0.5; 95%CI, 0.4-0.7) were associated with lower adoption. ADVANCE programming was associated with reduced total therapy burden (aIRR, 0.77; 95%CI, 0.69-0.86) and fewer inappropriate shocks (aIRR, 0.66; 95%CI, 0.52-0.85). CONCLUSIONS: ADVANCE adoption remains modest and can be improved through evidence-driven selection of nominal ICD settings. ADVANCE programming is associated with reduced therapy rates in real-world ICD recipients.

La tormenta eléctrica (TE) se caracteriza por episodios repetidos de taquicardia ventricular o fibrilación ventricular relacionados con mal pronóstico a corto y largo plazos. El objetivo fue evaluar la prevalencia, resultados y supervivencia de los pacientes sometidos a tratamiento intervencionista por TE en un centro de referencia.Estudio unicéntrico, observacional y retrospectivo. Se revisaron los procedimientos de ablación por TE y se evaluaron las características basales de los pacientes, tipo de procedimiento, mortalidad total, recurrencia de arritmia, mortalidad cardiovascular y necesidad de trasplante.Desde enero de 2009 hasta diciembre de 2016 se realizaron 67 procedimientos (38% de complejos: 19% de ablación endoepicárdica, 7.5% de crioablación epicárdica quirúrgica, 3% de simpatectomía, 3% de inyección coronaria con alcohol; 6% de apoyo con oxigenación con membrana extracorpórea) en 41 pacientes (61% de causa isquémica) por TE. La mortalidad intraprocedimiento fue del 1.5%. La mediana de seguimiento fue de 23.5 meses (RIQ, 14.2-52.7). Tras el primer ingreso por TE (uno o varios procedimientos), la mortalidad a un año fue de 9.8%. La incidencia acumulada de trasplante cardiaco por TE fue de 2.4%. En el análisis multivariado, el riesgo de recurrencias arrítmicas o muerte por cualquier causa fue significativamente mayor en pacientes con arritmias clínicas inducibles (HR, 9.03; p = 0.017).El tratamiento de pacientes con TE, instituido en un centro de referencia y con experiencia, se relacionó con una tasa baja de recurrencia y supervivencia elevada, con una tasa de trasplante cardiaco por TE muy baja. Ante una recurrencia temprana es recomendable practicar un nuevo procedimiento durante el ingreso.Electrical storm (ES) is characterized by repeated episodes of ventricular tachycardia or ventricular fibrillation, with poor short and long term prognosis. Our objective was to evaluate the prevalence, results of interventional treatment and survival of patients undergoing interventional treatment for ES in our center.Retrospective, unicentric and observational study. ES ablation procedures were revised and data regarding baseline characteristics of the patients, type of procedure, total mortality, recurrence of arrhythmia, cardiovascular mortality and the need for transplantation were evaluated.From January 2009 to December 2016, 67 procedures (38% complex procedures: 19% epicardial ablation, 7.5% surgical epicardial crioablation, 3% simpatectomy, 3% coronary alcohol injection, 6% extracorporeal membrane oxygenation support) were performed in 41 patients (61% Ischemic etiology) due to ES. Intraprocedural mortality was 1.5%. The median follow-up was 23.5 months (IQR [14.2-52.7]). After the first admission for ES (one or several procedures), 1-year mortality was 9.8%. The cumulative incidence of cardiac transplantation was 2.4%. The risk of arrhythmic recurrences or death was significantly higher in patients with inducible clinical arrhythmias after ablation (HR: 9.03, p = 0.017).The treatment of patients with ES, performed in a reference center, allows obtaining good rates of recurrence and survival, with very low rates of cardiac transplantation for ES. In the presence of an early recurrence, it is advisable to perform a new procedure during admission.

Introduction and objectives: The development of complete AV block and the need for pacemaker implantation (PM) is the most frequent complication after Transaortic valve replacement (TAVR). In other PM clinical contexts, a higher percentage of ventricular stimulation has been associated with worse prognosis. The objective was to study the existence of predictors of PM dependence. Methods: We identified 96 consecutive patients who had received a PM post-TAVR (all Core-Valve). We retrospectively analyzed this cohort with the aim of identifying predictors of a high and very high percentage of ventricular pacing (VP), PM dependency and survival. Results: The mean age was 82.3 years, with a mean logistic EuroSCORE of 17.1, 53% were women and 12% of patients had LVEF 50%, VP > 85% or PM dependence. In 73 patients PM rhythm was documented at the end of follow-up. Of these, 14 (19.2%) were considered dependent, and 37 (50.7%) presented VP > 50%. The post-TAVR complete AV block recovery rate was 67.8%. In multivariate analysis, female sex (HR = 5.6, p = 0.005), and indication of complete AV block vs. LBBB (HR = 15.7, p = 0.017) were independently associated with PM dependency. Conclusions: Female sex and indication due to complete AV block were independent predictors of PM dependency during follow up. In our series of patients with mostly normal LVEF, a high percentage of stimulation does not influence prognosis.

Resumen Introduccion y objetivos La ablacion con cateter es un metodo para tratar arritmias en poblacion pediatrica indicada en un creciente numero de casos. Hay poca evidencia sobre la experiencia en estos procedimientos en Espana. El objetivo es describir las caracteristicas y los resultados de una serie contemporanea de un hospital terciario de referencia nacional. Metodos Se revisaron los procedimientos de ablacion realizados entre 2004 y 2016 en menores de 17 anos en el momento de la indicacion. Se analizaron caracteristicas clinicas, metodologia de la ablacion y resultados agudos y a largo plazo. Resultados Se realizaron 291 procedimientos en 224 pacientes (mediana de edad, 12,2 anos; el 60% varones). El 46% de los pacientes venian derivados desde otras comunidades autonomas. Los sustratos mas frecuentemente abordados fueron las vias accesorias (VAC) (el 70,2%; mas del 50% septales) y la taquicardia intranodular (TIN) (15,8%). El 16,8% presentaba cardiopatia congenita, familiar o adquirida. El 35,5% de los casos se realizaron con crioablacion. El exito agudo general de los procedimientos primarios fue del 93,5% (el 93,8% en las VAC y el 100% en las TIN). Se repitieron procedimientos por recurrencia en el 18,9% de los casos, con un exito acumulado del 98,4% (el 99,3% en las VAC y el 100% en las TIN). Se registro un bloqueo auriculoventricular completo (0,37%), sin otras complicaciones mayores. Conclusiones El elevado porcentaje de exito con minimas complicaciones en una serie con alto nivel de complejidad reproduce los resultados publicados en otros paises y refrenda el uso de la ablacion con cateter en poblacion pediatrica en centros especializados de referencia.

Introduction and objectives Catheter ablation has become the treatment of choice in an increasing number of arrhythmias in children and adolescents. There is still limited evidence of its use at a national level in Spain. The aim was to describe the characteristics and results of a modern monocentric series form a referral tertiary care centre. Methods Retrospective register of invasive procedures between 2004 and 2016 performed in patients under 17 years and recorded clinical characteristic, ablation methodology and acute and chronic results of the procedure. Results A total of 291 procedures in 224 patients were included. Median age was 12.2 years, 60% male. Overall, 46% patients were referred from other autonomous communities. The most frequent substrates were accessory pathways (AP) (70.2%, > 50% septal AP localization) and atrioventricular nodal reentrant tachycardia (AVNRT) (15.8%). Congenital and acquired heart disease was frequent (16.8%). Cryoablation was used in 35.5% of the cases. Overall acute success of the primary procedure was 93.5% (AP 93.8%; AVNRT 100%). Redo procedures after recurrence were performed in 18.9% of all substrates, with a long-term cumulative efficacy of 98.4% (AP 99.3%; AVNRT 100%). One (0.37%) serious complication occurred, a case of complete atrioventricular block. Conclusions Our study replicated previous international reports of high success rates with scarce complications in a high complexity series, confirming the safety and efficacy of pediatric catheter ablation in our environment performed at highly experienced referral centers.

‘Gender ideology’ is a term used by many, but especially the Vatican, to chastise the view that sexual difference is more than just male and female, sexuality more than desire of the opposite. Each of the three books discussed in this article defends some version of this supposed ideology; each argues—though in different ways—for the need to move beyond a dimorphic account of sexual difference. Their arguments are taken up and deployed against what is here presented as the ideology of sexual dimorphism, as it is seen in the body theology of John Paul II. It is argued that such a theology dehumanises intersexed people, along with homosexuals, and undermines Christian soteriology. The church needs to acknowledge as fully human all who don’t conform to heterosexual dimorphism; it needs to embrace a ‘third sex’ without reserve.

Starting with the laying to rest of George Tyrrell’s body in an Anglican grave, outside the bounds of the Catholic Church, this article considers how Tyrrell could yet understood himself to be within the Church, within the body of Christ. Tyrrell developed a distinction between the visible and invisible Church in such a way that a person like himself could be included within the latter. In this, Tyrrell’s theology anticipated later ideas of the anonymous Christian and the Church as sacrament, his thinking incorporated within the body of more orthodox, conciliar theology.

Aims Radiofrequency ablation (RFA) of septal accessory pathways (APs) is associated with a significant rate of first procedure failures and complications. Cryoablation is an alternative energy source but there are no studies comparing both ablation techniques. We aimed to systematically review the literature and compare the efficacy and safety of cryoablation vs. RFA of septal APs. Methods and results We conducted two separate meta-analysis of cryoablation and RFA of septal APs and calculated the global estimates of the efficacy and safety. Sixty-four articles were included: 38 articles reporting RFA and 27 articles reporting cryoablation procedures. Additionally, we included the previously non-published cryoablation registry of septal APs performed at our institution. Overall, 4244 septal APs constitute our study population, 3495 in the RFA cohort and 749 in the cryoablation cohort. Acute procedural success rate of cryoablation was 86.0% (95% CI 81.6-89.4%) and RFA 89.0% (95% CI 86.8-91.0%). Recurrence rate of cryoablation was 18.1% (95% CI 14.8-21.8%) and RFA 9.9% (95% CI 8.2-12.0%). Long-term success rate after multiple ablation procedures of cryoablation was 75.9% (95% CI 68.2-82.3%) and RFA 88.4% (95% CI 84.7-91.3%). There were no reported cases of persistent atrioventricular block (AVB) with cryoablation and 2.7% (95% CI 2.2-3.4%) with RFA. Conclusion Studies of RFA for treatment of septal APs report higher efficacy rates than do studies using cryoablation, but a significantly higher rate of AVB.

INTRODUCTION Between 7% and 15% of patients with an indication for an implantable cardioverter-defibrillator (ICD) are not eligible for implantation of a subcutaneous implantable cardioverter-defibrillator (S-ICD) on the basis of the result of the conventional left parasternal electrocardiographic screening (LPES). Our objective was to determine the impact of systematically performing right parasternal electrocardiographic screening (RPES) in addition to conventional LPES, in terms of increasing both the total percentage of potentially eligible patients for S-ICD implantation and the number of suitable vectors per patient. METHODS AND RESULTS Consecutive patients from the outpatient device clinic who already had an implanted ICD, and no requirement for pacing were enrolled. Conventional left parasternal electrode position and right parasternal electrode positions were used. The automatic screening tool was used to analyze the recordings. Screenings were performed in the supine and standing positions. Overall, 209 patients were included. The mean age was 63.4 ± 13 years, 59.8% had ischemic heart disease, mean QRS duration was 100 ± 31 ms, and 69.9% had a primary prevention ICD indication. Based on conventional isolated LPES, 12.9% of patients were not eligible for S-ICD compared with 11.5% based on RPES alone (P = .664). Considering LPES and RPES together, only 7.2% of patients were not eligible for S-ICD (P

Many centers perform catheter ablation for atrial fibrillation (AF) with periprocedural interruption of oral vitamin K antagonists. In this scenario, the optimal post-procedural anticoagulation strategy is still under debate. We sought to compare the incidence of major complications associated with post-procedural use of low molecular weight heparin (LMWH) versus unfractioned heparin (UFH) as a bridge to reinitiation of oral anticoagulation after an AF ablation procedure. We retrospectively reviewed medical history data of all patients undergoing catheter ablation for AF at three Spanish referral centers between January 2009 and January 2014. A total of 702 patients were included in the analysis. We compared the incidence of major complications (a combination of major bleeding and thromboembolic events) between patients receiving UFH (291) and those receiving LMWH (411) after the procedure. The overall incidence of major complications was 4.1 %, including five thromboembolic events (0.7 %) and 24 major bleeding events (3.4 %), with no significant differences in patients treated with LMWH vs. UFH (2.9 vs. 4.1 %; P = NS). The presence of peripheral vascular disease emerged as the only independent predictor of major complications (adjusted odds ratio (OR) 9.1; confidence interval (CI) 95 % 1.7–49.3; P

Little is known about the role of time to initiation of therapeutic hypothermia and time to target temperature (TTT) in the prognosis of patients resuscitated from cardiac arrest.A retrospective analysis was performed in 145 survivors of cardiac arrest who underwent therapeutic hypothermia between January 2003 and January 2013. The objective was to identify predictors of survival free from significant neurological sequelae (Cerebral Performance Categories Scale (CPC):2) six months after cardiac arrest. We evaluated the effect of faster and earlier cooling.Overall survival at six months was 42.1% (61 patients); 59 of these were considered to have a good neurological status (CPC ≤ 2), and in whom therapeutic hypothermia was initiated earlier (87 ± 17 min vs. 111 ± 14 min; p=0.042), and the target temperature was reached at an earlier time (TTT: 316 ± 30 min vs. 365 ± 27 min; p=0.017). Multivariate analysis selected longer duration of cardiac arrest (odds ratio (OR) = 1.06 per min), a non-shockable initial rhythm (OR=13.8), severe acidosis (OR=0.009 per 0.01 unit), older age (OR=1.04 per year) and longer TTT (OR=1.005 per min) as associated with poor prognosis.The most important prognostic factors for death or lack of neurological recovery in patients with cardiac arrest treated with therapeutic hypothermia are initial-rhythm, time from cardiac arrest to return of spontaneous circulation and arterial-pH at admission. Although the speed of cooling initiation and the time to reach target temperature may play a role, its influence on prognosis seems to be less important.

Evaluation of mitral regurgitation (MR) severity remains complex and challenging. An integrative approach to grading MR is recommended. The use of multiple Doppler methods should be used to help discriminate between grades of severity. Importantly, MR severity should always be considered in the context of clinical data. The emerging inclusion of 3-dimensional echocardiography may provide complementary data for MR quantification and better anatomic and pathophysiological detail of the mitral valve. This article summarizes recommendations for MR assessment and highlights the importance of an integrated approach, using anatomic information as well as qualitative and quantitative Doppler measures.

Echocardiography is undoubtedly one of the main tools used in assessment of mitral regurgitation (MR) because it allows characterization of valvular morphology, assessment of the severity of the regurgitation, and its secondary effects. In this article we present an overview of the echocardiographic assessment of MR.

This article examines the place of wonder in Newman's account of university education. It pays particular attention to Newman's ‘Rise and Progress of Universities’ (1872) rather than to his better known The Idea of a University (1873). The article first introduces some ideas about wonders and wondering, as found in medieval thought and in Newman's writings, before proceeding to the wonder that was Newman's attempt to establish a university in Dublin, and that is his history (historia) of the university: a story (fabula) that is every bit as marvellous as any medieval tale. Newman's educational romance involves the islands of Britannia and Hibernia, and the cities of Athens, Rome and Dublin. The article also considers the place of personal encounter and the written word in Newman's idea and practice of education, before finally offering some brief reflections on the diversity of modern society and university education. The article closes by suggesting the necessity of wonder for the gaining of knowledge.

This article invokes Giorgio Agamben's discussion of messianic time in his 2005 book The Time That Remains in order to explore Andrei Tarkovsky's late film, Nostalghia (1983). Agamben is wandering in a foreign land, as also Tarkovsky; Agamben in Christian theology and Tarkovsky in Italy. In St Paul Agamben finds an event without precedent and the arrival of a time that is time beside itself, an excess of temporality that opens possibility. Tarkovsky similarly defeats mere succession by realizing a screen time that makes time itself present in the duration of the film's long takes. In waiting on the film we wait on that which arrives in our waiting. The film is a kind of prayer, a patience and yearning for the time in which the “time of the end” arrives, transfiguring the present.

This article discusses various uses of ‘queer’ in theology, from the queerness of theology itself to queer as insult, and as insult turned. But it is chiefly concerned with queer as what David Halperin calls an ‘identity without an essence’. As such, queer is a movement, a deployment, which unsettles all attempts to fix theology—and God—within the contingent lineaments of heteropatriarchy. Queer is what all theology should be.

I offer a brief outline of The Beauty of the Infinite, pointing up its similarities with and differences from John Milbank'sTheology and Social Theory (1990), and the violence of its rhetoric. I then take issue with Hart's reading of Nicholas Lash on the death and resurrection of Christ. I argue that not only is Lash closer to Hart than Hart allows, but that Lash recognizes the necessarily unfinished nature of Christian story telling. Hart is led by his rhetoric of out-narration to affirm an unsustainable completeness that elides the terrors of suffering and death, the very fault for which Hart chides Lash. Having noted Hart's misdirection I conclude with an appreciation of his aesthetics.

Aims Cardiac resynchronization therapy (CRT) reduces the incidence of sudden cardiac death and the use of appropriate implantable cardioverter-defibrillator (ICD) therapies (AICDTs); however, this antiarrhythmic effect is only observed in certain groups of patients. To gain insight into the effects of CRT on ventricular arrhythmia (VA) burden, we compared the incidence of AICDT use in four groups of patients: patients with ischaemic cardiomyopathy vs. non-ischaemic dilated cardiomyopathy (NIDC) and patients implanted with an ICD vs. CRT-ICD. Methods and results We analysed 689 consecutive patients (mean follow-up 37 +/- 16 months) included in the Umbrella registry, a multicentre prospective registry including patients implanted with ICD or CRT-ICD devices with remote monitoring capabilities in 48 Spanish Hospitals. The primary outcome was the time to first AICDT. Despite a worse clinical risk profile, NIDC patients receiving a CRT-ICD had a lower cumulative probability of first AICDT use at 2 years compared with patients implanted with an ICD [24.7 vs. 41.6%, hazard ratio (HR): 0.49, P = 0.003]; on the other hand, there were no significant differences in the incidence of first AICDT use at 2 years in ischaemic patients (22.6 vs. 21.9%, P = NS). Multivariate analysis confirmed the association of CRT with lower AICDT rates amongst NIDC patients (Adjusted HR: 0.55, CI 95% 0.35-0.87). Conclusions These data suggest that CRT is associated with significantly lower rates of first AICDT use in NIDC patients, but not in ischaemic patients. This study suggests that ICD patients with NIDC and left bundle branch block experiencing VAs may benefit from an upgrade to CRT-ICD despite being in a good functional class.

Introduction: Post myocardial infarction (MI) patients are at risk of scar related ventricular tachycardia (VT). Hypothesis: Stem cell therapy reduces post-MI scar size, potentially leading to a reduction in the risk of ventricular arrhythmias (VA). Methods: A post-MI scar model of VT was created by transient occlusion of the mid left anterior descending artery in 56 swine. Five weeks after infarct creation 29 subjects were treated with allogeneic cardiac stem cells (CSC): 10 underwent transcoronary delivery of CSC, 9 direct transepicardial delivery (via a minithoracotomy) and 10 underwent a combined transcoronary and VT substrate guided (late potentials) direct transendocardial CSC delivery procedure using an electroanatomic mapping system. Of the remainder, 8 subjects underwent a “sham” transepicardial procedure and 19 served as controls. Seventeen weeks after infarct creation an electrophysiological study was performed in each subject to assess for ventricular arrhythmia inducibility. VA inducibility was compared in each group vs. the control group. Results: Of the 19 control subjects, 17 were inducible (89,5 %). As presented in the figure, CSC delivery with a combined transcoronary/transendocardial approach was associated with a significant reduction in VT inducibility rates compared to controls (20 % vs. 89,5 %; p value 0,001). Subjects treated with transcoronary CSC also experienced significantly lower VA inducibility rates (40 % vs. 89,5 %; p value 0,009). There were no differences in VA inducibility compared with controls in patients in the “sham” (62,5 % vs 89,5 %; p value 0,136) or the transepicardial group (66,7 % vs 89,5 %; p value 0,290). Conclusions: Combined transcoronary and VT substrate-guided transendocardial CSC delivery is associated with a significant reduction in VA inducibility in a post-MI swine model. Future human studies should evaluate the effects of allogeneic CSC therapy on ventricular arrhythmia burden in post-MI patients.

Sinus histiocytosis with massive lymphadenopathy, or Rosai-Dorfman disease (RDD), is commonly characterized by painless cervical lymphadenopathy. Exclusively cutaneous Rosai-Dorfman disease is rare. In the absence of massive lymphadenopathy, the nonspecific skin lesions may complicate the diagnosis. To our knowledge, the case reported herein is the youngest case of extranodal cutaneous RDD.

We read with interest the paper by Yokokawa et al. [(1)][1] and wanted to congratulate the authors for its valuable contributions. The ideal endpoint of ventricular tachycardia (VT) ablation procedures has not been definitively established [(2,3)][2]. This study provides relevant data suggesting

Objectives The aim of this study was to determine if noninvasive measurement of scar by contrast-enhanced magnetic resonance imaging (MRI)–based signal intensity (SI) mapping predicts ventricular tachycardia (VT) recurrence after endocardial ablation. Background Scar extension on voltage mapping predicts VT recurrence after ablation procedures. Methods A total of 46 consecutive patients with previous myocardial infarction (87% men, mean age 68 ± 9 years, mean left ventricular ejection fraction 36 ± 10%) who underwent VT substrate ablation before the implantation of a cardioverter-defibrillator were included. Before ablation, contrast-enhanced MRI was performed, and areas of endocardial and epicardial scarring and heterogeneous tissue were measured; averaged subendocardial and subepicardial signal intensities were projected onto 3-dimensional endocardial and epicardial shells in which dense scar, heterogeneous tissue, and normal tissue were differentiated. Results During a mean follow-up period of 32 ± 24 months 17 patients (37%) had VT recurrence. Patients with recurrence had larger scar and heterogeneous tissue areas on SI maps in both endocardium (81 ± 27 cm 2 vs. 48 ± 21 cm 2 [p = 0.001] and 53 ± 21 cm 2 vs. 30 ± 15 cm 2 [p = 0.001], respectively) and epicardium (76 ± 28 cm 2 vs. 51 ± 29 cm 2 [p = 0.032] and 59 ± 25 cm 2 vs. 37 ± 19 cm 2 [p = 0.008]). In the multivariate analysis, MRI endocardial scar extension was the only independent predictor of VT recurrence (hazard ratio: 1.310 [per 10 cm 2 ]; 95% confidence interval: 1.051 to 1.632; p = 0.034). Freedom from VT recurrence was higher in patients with small endocardial scars by MRI ( 2 ) than in those with larger scars (≥65 cm 2 ) (85% vs. 20%, log-rank p = 0.018). Conclusions Pre-procedure endocardial scar extension assessment by contrast-enhanced MRI predicts VT recurrence after endocardial substrate ablation. This information may be useful to select patients for ablation procedures.

Methods 71 consecutive patients (p) with DCM, left ventricular systolic dysfunction (LVEF

Physicians cannot rely solely on the angiographic appearance of epicardial coronary artery stenosis when evaluating patients with myocardial ischemia. Instead, sound knowledge of coronary vascular physiology and of the methods currently available for its characterization can improve the diagnostic and prognostic accuracy of invasive assessment of the coronary circulation, and help improve clinical decision-making. In this article we summarize the current methods available for a thorough assessment of coronary physiology.