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While sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) is due to arrhythmias, the guidelines for prediction of SCD are based solely on non-electrophysiological methods. This study aims to stimulate thinking about whether the interests of patients with HCM are better served by using current, ‘risk factor’, methods of prediction or by further development of electrophysiological methods to determine arrhythmic risk. Five published predictive studies of SCD in HCM, which contain sufficient data to permit analysis, were analysed to compute receiver operating characteristics together with their confidence bounds to compare their formal prediction either by bootstrapping or Monte Carlo analysis. Four are based on clinical risk factors, one with additional MRI analysis, and were regarded as exemplars of the risk factor approach. The other used an electrophysiological method and directly compared this method to risk factors in the same patients. Prediction methods that use conventional clinical risk factors and MRI have low predictive capacities that will only detect 50–60% of patients at risk with a 15–30% false positive rate [area under the curve (AUC) = ∼0.7], while the electrophysiological method detects 90% of events with a 20% false positive rate (AUC = ∼0.89). Given improved understanding of complex arrhythmogenesis, arrhythmic SCD is likely to be more accurately predictable using electrophysiologically based approaches as opposed to current guidelines and should drive further development of electrophysiologically based methods.

Epicardial access for mapping and ablation of the epicardial substrate may be required in catheter ablation of ventricular tachycardias (VT). However, high complication rates are associated with the standard epicardial access approach. Recently, a novel method of intentional coronary vein (CV) exit with pericardial COPatients undergoing epicardial VT ablation between 1 February 2021 to 31 May 2022 at the Royal Prince Alfred Hospital, Sydney, NSW, were included in this study. Via femoral venous access, a branch of the coronary sinus was sub-selected and intentional CV exit was performed with a high tip load coronary angioplasty wire. A microcatheter was then advanced over the wire into the pericardial space, followed by pericardial COFive (5) patients underwent epicardial access for VT mapping and ablation. All patients had successful intentional CV exit and COThis is the first case series of epicardial access facilitated by CO

Objectives This multicenter registry aimed to assess the reproducibility and safety of intentional coronary vein exit and carbon dioxide insufflation to facilitate subxiphoid epicardial ac...

Background: The majority of data regarding tissue substrate for post myocardial infarction (MI) VT has been collected during hemodynamically tolerated VT, which may be distinct from the substrate responsible for VT with hemodynamic compromise (VT-HC). This study aimed to characterize tissue at diastolic locations of VT-HC in a porcine model.Methods: Late Gadolinium Enhancement (LGE) cardiovascular magnetic resonance (CMR) imaging was performed in eight pigs with healed antero-septal infarcts. Seven pigs underwent electrophysiology study with venous arterial-extra corporeal membrane oxygenation (VA-ECMO) support. Tissue thickness, scar and heterogeneous tissue (HT) transmurality were calculated at the location of the diastolic electrograms of mapped VT-HC.Results: Diastolic locations had median scar transmurality of 33.1% and a median HT transmurality 7.6%. Diastolic activation was found within areas of non-transmural scar in 80.1% of cases. Tissue activated during the diastolic component of VT circuits was thinner than healthy tissue (median thickness: 5.5 mm vs. 8.2 mm healthy tissue, p < 0.0001) and closer to HT (median distance diastolic tissue: 2.8 mm vs. 11.4 mm healthy tissue, p < 0.0001). Non-scarred regions with diastolic activation were closer to steep gradients in thickness than non-scarred locations with normal EGMs (diastolic locations distance = 1.19 mm vs. 9.67 mm for non-diastolic locations, p < 0.0001). Sites activated late in diastole were closest to steep gradients in tissue thickness.Conclusions: Non-transmural scar, mildly decreased tissue thickness, and steep gradients in tissue thickness represent the structural characteristics of the diastolic component of reentrant circuits in VT-HC in this porcine model and could form the basis for imaging criteria to define ablation targets in future trials.

AIMS: The aim of this study was to determine whether revascularisation of an infarct-related artery chronic total occlusion (IRA-CTO) has a modulatory effect on myocardial scar composition. METHODS AND RESULTS: This is a unique, first-time report of three consecutive patients presenting with myocardial scar-related recurrent ventricular tachycardia (rVT) on a background of ischaemic cardiomyopathy. Electro-anatomic mapping of the left ventricular endocardium was performed before and immediately after IRA-CTO percutaneous coronary intervention (PCI) to assess for changes in scar composition and size. There were substantial percentage reductions in the low voltage area of scar compared to baseline after IRA-CTO PCI (Patient 1: −12.8%, Patient 2: −27.0%, and Patient 3: −15.3%). Interval remapping ≥6 months after the index procedure demonstrated extensive net reductions in all areas of myocardial scar (Patient 1: dense scar =−7.5%, border zone scar =−54.9%, low voltage area =−32.7%, and Patient 2: dense scar =−38.6%, border zone scar =−59.6%, low voltage area =−51.7%). Patient 3 declined interval remapping but has remained free of rVT at one-year follow-up. CONCLUSIONS: IRA-CTO PCI may positively modify the size and composition of myocardial scar associated with rVT in the context of ischaemic cardiomyopathy.

This multicenter registry aimed to assess the reproducibility and safety of intentional coronary vein exit and carbon dioxide insufflation to facilitate subxiphoid epicardial access in the setting of ventricular tachycardia ablation.Epicardial ablation for ventricular tachycardia is not a widespread technique due to the significant potential complications associated with subxiphoid puncture. The first experience in 12 patients showed that intentional coronary vein exit and carbon dioxide insufflation was technically feasible.A branch of the coronary sinus was cannulated by means of a diagnostic JR4 coronary catheter. Intentional perforation at the distal portion of that branch was performed with a high tip load 0.014-inch angioplasty wire. A microcatheter was advanced over the wire into the pericardial space. Carbon dioxide was then insufflated into the pericardial space, allowing direct visualization of the anterior pericardial space to facilitate subxiphoid puncture.Intentional coronary vein exit was attempted in 102 consecutive patients in 16 different centers and successfully completed in 101 patients. Significant pericardial adhesions were confirmed in 3 patients, preventing carbon dioxide insufflation and epicardial ablation. None of the punctures were complicated with inadvertent right ventricular puncture or damage to a coronary artery. Significant bleeding (80 ml) due to coronary vein exit occurred in 5 patients, without hemodynamic compromise. None of the patients required surgery.Coronary vein exit and carbon dioxide insufflation can be safely and reproducibly achieved to facilitate subxiphoid pericardial access in the setting of ventricular tachycardia ablation.

High-density automated mapping of complex atrial tachycardias (ATs) requires accurate assessment of activation maps. A new local activation display module (HD coloring, Biosense Webster®) provides higher map resolution, a better delineation of potential block reducing color interpolation, and a new propagation display. We evaluated the accuracy of a dedicated local activation display compared with standard algorithm. High-density maps from 10 AT were collected with a multipolar catheter and were displayed with standard activation or HD coloring. Six expert operators retrospectively analyzed activation maps and were asked to define (1) the tachycardia mechanism, (2) ablation target, and (3) level of difficulty to interpret those maps. Using HD coloring, operators were able to reach a correct diagnosis in 93% vs. 63%, p

Objectives: This study assessed the feasibility of intentional coronary venous perforation and exit with subsequent pericardial carbon dioxide (CO2) insufflation as a novel method for assis...

Aims In persistent atrial fibrillation (PsAF), success rates for pulmonary vein isolation (PVI) alone are limited and additional substrate modification is often performed. The two most widely used substrate-based strategies are the ablation of complex fractionated atrial electrograms (CFAE) and left atrial linear ablation (LALA) at the roof and mitral isthmus. However, it is unclear whether adjunctive CFAE ablation or LALA add significant benefit to PVI alone. We performed a meta-analysis to better gauge the benefit of adjunctive CFAE ablation and LALA in PsAF. Methods and results Electronic databases were systematically searched. We included studies that examined the impact of CFAE ablation or LALA in addition to a PVI-based strategy on clinical outcomes in PsAF. We included both randomized and non-randomized studies. Totally 10 studies ( n = 1821) were included: 6 evaluating CFAE ablation, 3 LALA, and 1 both approaches. In comparison with PVI alone, the addition of CFAE ablation [RR 0.86; 95% confidence intervals (CI) 0.64, 1.16; P = 0.32] or LALA (RR 0.64; 95% CI 0.37, 1.09; P = 0.10) offered no significant improvement in arrhythmia-free survival. However, adjunctive CFAE ablation was associated with significant increases ( P < 0.05) and LALA non-significant increases in procedure and fluoroscopy times. Conclusion In PsAF, the addition of CFAE ablation or LALA, in comparison with PVI alone, offers no significant improvement in arrhythmia-free survival. Furthermore, they are associated with increases in both procedural and fluoroscopy times. The optimal ablation strategy for PsAF is currently unclear and needs further refinement.

Magnetic resonance imaging (MRI) is the gold standard for defining myocardial substrate in 3D and can be used to guide ventricular tachycardia ablation. We describe the feasibility of using a prototype magnetic resonance-guided electrophysiology (MR-EP) system in a pre-clinical model to perform real-time MRI-guided epicardial mapping, ablation, and lesion imaging with active catheter tracking.Experiments were performed in vivo in pigs (n = 6) using an MR-EP guidance system research prototype (Siemens Healthcare) with an irrigated ablation catheter (Vision-MR, Imricor) and a dedicated electrophysiology recording system (Advantage-MR, Imricor). Following epicardial access, local activation and voltage maps were acquired, and targeted radiofrequency (RF) ablation lesions were delivered. Ablation lesions were visualized in real time during RF delivery using MR-thermometry and dosimetry. Hyper-acute and acute assessment of ablation lesions was also performed using native T1 mapping and late-gadolinium enhancement (LGE), respectively. High-quality epicardial bipolar electrograms were recorded with a signal-to-noise ratio of greater than 10:1 for a signal of 1.5 mV. During epicardial ablation, localized temperature elevation could be visualized with a maximum temperature rise of 35 °C within 2 mm of the catheter tip relative to remote myocardium. Decreased native T1 times were observed (882 ± 107 ms) in the lesion core 3-5 min after lesion delivery and relative location of lesions matched well to LGE. There was a good correlation between ablation lesion site on the iCMR platform and autopsy.The MR-EP system was able to successfully acquire epicardial voltage and activation maps in swine, deliver, and visualize ablation lesions, demonstrating feasibility for intraprocedural guidance and real-time assessment of ablation injury.

Background— Successful late potential (LP) abolition and postprocedural ventricular tachycardia (VT) noninducibility constitute significant end points after catheter ablation for VT. We investigated the prognostic impact of a combined procedural end point of VT noninducibility and LP abolition in a large series of post–myocardial infarction patients with VT. Methods and Results— A total of 160 (154 men, 94% with implantable cardioverter defibrillators) consecutive post–myocardial infarction patients undergoing first-time ablation procedures from 2010 to 2012 were included. Of the 159 patients surviving the procedure, 137 (86%) were either inducible or in VT at baseline and 103 (65%) had baseline LP presence, of which 79 (77%) underwent successful LP abolition. The combined end point was assessable in 155 (97%) patients. There were 50 (32%) patients with VT recurrences and 17 (11%) cardiac deaths during follow-up. Patients who fulfilled the combined end point of VT noninducibility and LP abolition compared with inducible patients exhibited a significantly lower incidence of VT recurrence (16.4% versus 47.4%; log-rank P P P P P =0.001). Conclusions— Achieving a combined catheter ablation procedural end point of VT noninducibility and LP abolition reduces VT recurrence rates to low levels (16%). The overall strategy was associated with a significant impact on cardiac survival.

Background Programming long arrhythmia detection times can reduce the incidence of implantable cardioverter-defibrillator (ICD) shock therapy. However, potential concerns exist regarding the impact on mortality and incidence of syncope. Objective The purpose of this study was to perform a meta-analysis to better gauge the impact of prolonged arrhythmia detection times on the rates of ICD shock therapy and other adverse outcomes. Methods Electronic databases were systematically searched. We included only prospective studies that examined the impact of programming longer vs shorter ICD arrhythmia detection times on clinical outcomes. Studies that were retrospective, did not have a control group, used historical controls, or did not specifically state the programmed detection times were excluded. Summary estimates of the relative risk (RR) of death, syncope, and appropriate and inappropriate shocks were calculated using random effects models. Results Four studies enrolling 4896 patients were identified. During a mean/median follow-up of 12 to 17 months, there were 305 deaths, 106 patients experienced syncope, 264 received an appropriate shock, and 253 an inappropriate shock. In the long detection group there were significant reductions in mortality (RR 0.77, 95% confidence interval [CI] 0.62, 0.96), and inappropriate shocks (RR 0.50, 95% CI 0.39, 0.65), without significant increase in syncope (RR 1.23, 95% CI 0.84, 1.79). Conclusion Programming long arrhythmia detection times is an important strategy for improving outcomes from ICD therapy. The use of long detection times can significantly decrease the burden of inappropriate shock therapy and all-cause mortality in ICD recipients, without significant increase in syncope.

We describe a patient presenting with incessant ectopic atrial tachycardia during a high risk twin pregnancy. Tachycardia was resistant to escalating doses of beta-blockade with digoxin. Because of increasing left ventricular dysfunction early in the third trimester, catheter ablation was performed successfully at 30 weeks gestation. Electro-anatomic mapping permitted the entire procedure to be conducted without the use of ionizing radiation. The pregnancy proceeded to successful delivery near term and after three years the patient remains recurrence free with normal left ventricular function, off all medication.

This study assessed the feasibility of intentional coronary venous perforation and exit with subsequent pericardial carbon dioxide (COWidespread adoption of first-line endoepicardial ventricular tachycardia ablation has not been taken up because of the risk of lacerating coronary vessels and puncturing the right ventricle with direct subxiphoid puncture.A lateral branch of the coronary sinus was subselected using a diagnostic JR4 coronary catheter inside a steerable sheath, via femoral access, and a distal branch then perforated intentionally using a high tip load 0.014-inch angioplasty wire. Either a microcatheter or over-the-wire balloon was then passed over this into the pericardial space, allowing up to 150 ml of pericardial COIntentional coronary vein exit was achieved in all 12 patients. In 1 patient, this confirmed widespread pericardial adhesions and therefore only endocardial VT ablation was undertaken. The other patients underwent successful pericardial COWe report the first human transcoronary vein exit procedure. Coronary vein exit and subsequent percutaneous subxiphoid anterior access using a microneedle puncture after CO

Background— We report the experience in a cohort of consecutive patients receiving extracorporeal membrane oxygenation during catheter ablation of unstable ventricular tachycardia (VT) at our center. Methods and Results— From 2010 to 2015, extracorporeal membrane oxygenation was initiated in 64 patients (average age: 63±15 years; left ventricular ejection fraction in 27±9%; cardiogenic shock in 23%, and electrical storm in 62% of patients) undergoing 74 unstable VT catheter ablation procedures. At least one VT was terminated in 81% of procedures with baseline inducible VT, and VT noninducibility was achieved in 69%. Acute heart failure occurred in 5 patients: 3 underwent emergency heart transplantation, 1 had left ventricular assist device (LVAD) implantation, and 1 patient eventually died because of subsequent mesenteric ischemia. All other patients were discharged alive. After a median follow-up of 21 months (13–28 months), VT recurrence was 33%; overall survival was 56 out of 64 patients (88%). Extracorporeal membrane oxygenation–supported ablation was the bridge to LVAD in 6.9% and to heart transplantation in 3.5% of patients. VT recurrence was related to ablation success (after 180 days of follow up: 19% when VT was noninducible, 42% if nonclinical VT was inducible, 75% when clinical VT was inducible, and 75% in untested patients, P P P =0.001) and left ventricular ejection fraction (hazard ratio 0.916; P =0.008) correlated with all-cause death, LVAD, and heart transplantation. Conclusions— Ablation of unstable VTs can be safely supported by extracorporeal membrane oxygenation, which allows rhythm stabilization with low procedure mortality, bridging decompensated patients to permanent LVAD or heart transplantation. Successful ablation is associated with better outcomes than unsuccessful ablation.

Background: Interval training is recommended for chronic heart failure patients (CHF), but specific guidelines on setting appropriate workloads have not been fully established. The aim of this study was to compare a traditional method of interval training prescription with a protocol specifically designed for CHF. Methods: Ten CHF and 7 healthy controls performed 2 maximal incremental cycle tests to determine interval training workload; a standard test (10 W min −1 ) and a steep test (25 W.10 −s ). Peak work rate and oxygen uptake (VO2peak) were determined. Training workloads were defined as 100% standard test and 50% steep test peak work rate. Results: Training workload determined from the standard test was higher than from the steep test in healthy controls (151±17 W vs 118± 13 W; Pb0.01), whereas in CHF there was no significant difference between methods (88±10 W vs 96±9 W; PN0.05). Steep test VO2peak reached 91±5% of standard test VO2peak in controls, and 99±4% in CHF, with no significant differences between tests in either group. Conclusion: Prescribing interval training from a standard test results in higher workloads than from a steep test in healthy individuals, but in CHF both methods prescribe similar workloads. However it should not be assumed that the two tests can be used interchangeably for CHF. This small-sized study raises issues about interval training prescription that may be hypothesis-generating for future larger-scale studies.

Summary Introduction: Repeat cardioversion may be necessary in over 50% of patients with persistent atrial fibrillation (AF), but identifying responders remains challenging. This study evaluates the long-term success of direct current cardioversion (DCCV) and the clinical and echocardiographical parameters that influence them, in over 1000 sedation-cardioversion procedures undertaken at Eastbourne General Hospital between 1996 and 2006. Methods: A total of 770 patients of mean age (SD) 70.1(10.1) underwent 1013 DCCVs (first n = 665, repeat n = 348) for atrial tachyarrhythmias from 1996 to 2006. Time to persistent arrhythmia recurrence was compared between first and multiple DCCV, and the effect of age, gender, presence of heart disease, left atrial size, fractional shortening, arrhythmia duration, anti-arrhythmic drug therapy (AAD) and other concomitant cardiac medication was evaluated using the Kaplan–Meier method and Cox’s Proportional-hazards model. Results: In all, 33% of first and 29% of repeat DCCVs were in sinus rhythm (SR) at 12 months (m). There was no difference in median time to arrhythmia recurrence (SE) between first and multiple procedures: 1.5 ± 0.1 m (1.3–1.7) and 1.5 ± 0.0 m (1.4–1.6) respectively, p = 0.45. AAD use was significantly higher, arrhythmia duration shorter and more diabetic patients underwent repeat procedures. Amiodarone, OR 0.56, p = 0.04, sotalol, OR 0.61, p = 0.02 and arrhythmia duration

The beneficial effects of atrial pacing on the incidence, duration and symptomatology of paroxysmal atrial fibrillation (PAF) may be negated by increased ventricular pacing. This prospective randomised study evaluates the effect of pacing algorithms that minimise ventricular pacing (MinVP) with and without anti-AF algorithms, on AF burden (AFB) in patients with symptomatic PAF. Patients implanted with pacemakers with MinVP capability with AFB 1–70% were enrolled. Three different DDDRP devices were assessed. Following a 1-month induction phase, patients were randomised to MinVP with and without preventive AF algorithms or dual chamber rate adaptive pacemaker (DDDR) (AV delay (AVD) 150 ms) for 2 months per study phase. The primary outcome measure was AFB. One hundred and ten patients were enrolled; of these, 66 (mean age 74.3 ± 7.9, 56% males) had an AFB of 1–70% during the induction phase and completed all study phases. There was no significant difference in AFB between the control phase DDDR, 13.8% (95% CI 8.7 to 18.8), and MinVP, 14.4% (95% CI 9.4 to 19.4), or MinVP with AF algorithms enabled, 14.7% (95% CI 9.7 to 19.7), (p = 0.65 and p = 0.49, respectively). Median ventricular pacing was significantly higher during the control phase, 86.0% (IQR 72.8, 97.3), than in MinVP 2.0% (IQR 0.0, 14.1) and MinVP + algorithms 3.0% (IQR 0.4, 15.6), p =

Aims Right ventricular pacing increases the risk of persistent atrial fibrillation (AF) in the long term. The effects of right ventricular pacing on paroxysmal AF (PAF) are unknown. The aim was to examine the effect of right ventricular pacing on AF burden (AFB) in patients with symptomatic drug-resistant PAF. Pooled analysis of pacemaker-derived counters and AF diagnostic data from the Atrial Fibrillation Therapy (AFT) and Pacemaker Atrial Fibrillation Suppression (PAFS) randomized anti-AF pacemaker algorithm trials were used. Methods and results Five hundred and fifty-four patients from the AFT ( n = 372) and PAFS ( n = 182) were studied. The individual percentages of pacing, Atrial Sense Ventricular Pace (ASVP), Atrial Pace Ventricular Pace (APVP), and Atrial Pace Ventricular Sense (APVS) as well as total ventricular pacing during synchronous rhythm (VPinSR, %) were examined for an effect on AFB. Three hundred and twenty-one (AFT, age 64 ± 11, 55% male) and 79 (PAFS, age 71 ± 8, 54% male) patients had complete data for analysis. Increased VPinSR was weakly associated with an increased AFB (effect size—10% VPinSR increased AFB by only 0.03%) in AFT ( P = 0.04) but not PAFS ( P = 0.98) or the pooled analysis ( P = 0.95). None of the synchronous paced modalities (ASVP, APVP, APVS) significantly increased AFB compared with sinus rhythm (Atrial Sense Ventricular Sense) ( P = ns). Conclusion No pacing modality, atrial or ventricular, had a significant effect on AFB. On the basis of these data, the detrimental effect of high-frequency right ventricular pacing on AFB in paced PAF patients, unlike with persistent AF, appears to be minimal in the short term.

The purpose of this study is to identify the electrophysiological factors affecting symptoms in paroxysmal atrial fibrillation (PAF) using patients with paroxysmal atrial fibrillation and pacemakers with advanced atrial fibrillation (AF) diagnostics. Seventy-nine patients (age 71.0 ± 8.2, 54.4% male) with symptomatic PAF and AF burden of 1% to 50% with DDDRP pacemakers implanted were assessed for 6 months. Patients recorded symptom onset and duration and these were correlated with device-derived electrophysiological data. Of 2,638 AF episodes, 333 were symptomatic and 2,305 asymptomatic, with 194 non-atrial tachyarrhythmia symptomatic episodes giving a sensitivity of 12.6% and a positive predictive value of 63.2% for specific AF symptoms. Symptomatic AF episodes were 3.8 times more common diurnally than nocturnally (p

Summary Aims: AngioSeal and StarClose are vascular closure devices (VCDs) that can be used following cardiac catheterisation via the femoral artery to achieve haemostasis. Both devices have been demonstrated to be superior to conventional manual pressure, which reduce time to haemostasis and time to patient ambulation. We sought to compare these devices in a prospective, randomised trial. Methods: Patients undergoing elective coronary angiography were randomised to receive either AngioSeal VIP or StarClose VCD with immediate postprocedure mobilisation. Bruising was recorded at 30 min, 60 min and at 1 week postprocedure. Patient satisfaction surveys were taken at 1 h and 1 week postprocedure. Complications for both groups were compared. Results: Four hundred and one patients were included. Arteriotomy closure was achieved in 144 of 208 (69.2%) patients randomised to AngioSeal and 134 of 193 (69.3%) patients randomised to StarClose (p = ns). There was no significant bruising in either group at either 30 or 60 min postprocedure. However, at 1 week, there was significantly more bruising in the AngioSeal group than the StarClose group (63.1 vs. 38.5cm2, p = 0.02). Patient satisfaction and pain perception with the procedure at closure were not significantly different between the groups. Deployment success and instant mobilisation rates were significantly lower for junior, as compared with senior, operators. Conclusion: Achievement of haemostasis is similar with both AngioSeal and StarClose. The StarClose vascular closure device results in significantly less bruising at 1 week postprocedure as compared with AngioSeal, with no significant differences in complication rates. Patients’ pain perception and satisfaction are similar with both VCDs.

Aims Arrhythmogenic right ventricular (RV) cardiomyopathy (ARVC) is associated with ventricular arrhythmias, even without RV structural disease. We aimed to characterize the RV substrate using electroanatomical mapping and to define outcomes following ventricular tachycardia (VT) ablation in patients with and without RV structural abnormalities. Methods and results Twenty-nine patients with definite or suspected ARVC undergoing VT ablation were classified as 'electrical' and 'structural' cardiomyopathy based on the absence or presence of major structural criteria. Right ventricular (RV) endocardial and epicardial mapping with assessment of bipolar and unipolar voltages, distribution of late potentials (LPs), and inducible VT morphologies were performed. The endpoints for VT ablation were VT non-inducibility and LP abolition. Fourteen patients were categorized as electrical RV cardiomyopathy and 15 were categorized as structural RV cardiomyopathy. In patients with electrical cardiomyopathy, scar was limited to the epicardial surface (epicardium 13 cm2vs. endocardium 1 cm2, P < 0.05), primarily in the outflow tract, whereas patients with structural disease had greater involvement of the endocardium. During a mean follow-up of 22 ± 11 months, the VT recurrence rate was 27%, with LP abolition being a predictor of VT-free survival (HR 0.075 (0.008-0.661), P = 0.020). There was a trend towards higher recurrence rates in structural RV cardiomyopathy (40%) compared with the electrical cardiomyopathy (15%, P = 0.17). Conclusion The development of RV structural disease in patients with ARVC is associated with extensive epicardial and endocardial scar. Conversely those patients without RV structural disease have identifiable epicardial scar limited to the RV outflow tract. Ventricular tachycardia (VT) ablation in both groups targeting LP abolition is effective in preventing VT recurrence.

Introduction: We analyzed the endo-epicardial electroanatomical mapping (EAM) characteristics, their association with clinical data and their prognostic value in a large cohort of post-myocardial infarction (MI) patients. Methods: We performed analysis of voltage (bipolar dense scar-DS and low voltage-LV areas, unipolar LV and penumbra areas) and morphology characteristics (presence of abnormal late-LPs and early potentials-EPs) in 100 post-MI patients undergoing EAM-based ventricular tachycardia (VT) ablation (26 endo-epicardial procedures). We defined as unipolar LV areas those with voltage Results: Mean endocardial surface area was 236.1 cm2. Of that, 10.2% was bipolar DS, 21.8% was bipolar LV and 46.7% was unipolar LV. Endocardial penumbra was present in all but one patients and mean area was 51.6 cm2 (24.9%). There was no endocardial bipolar DS in 18% of the patients. Endocardial bipolar DS area >22.5 cm2 (sensitivity 61.1% and specificity 87.5%) best predicted scar transmurality. Endocardial LPs were recorded in 66% of the patients and epicardially in 17/26 (65.4%). Endocardial bipolar DS area >7 cm2 (sensitivity 88.2% and specificity 66.7%) and endocardial bipolar scar density >0.35 (sensitivity 52.9% and specificity 100%) predicted epicardial LPs. Abolition of endocardial LPs was achieved in 51/66 (77.3%) and of epicardial LPs in 10/17 (58.8%) patients. As a primary strategy, LPs and VT-mapping ablation occurred in 48%, only VT-mapping ablation in 27%, only LPs ablation in 17% and EPs ablation (in the absence of LPs) in 6%. After a median follow-up time of 628 days, endocardial LP abolition was associated (HR 0.274, p=0.01) with reduced VT recurrence (32%). Endocardial LP presence (HR 0.177, p=0.041) acted as a prophylactic predictor while increased endocardial penumbra area (HR=1.028, p=0.044) as an adverse predictor of cardiac death (7%). Conclusions: Endocardial scar extension and density predicted scar transmurality and endo-epicardial presence of LPs, although DS is not always identified in post-MI patients. LPs were abolished in 51% resulting in improved outcome.

Background— Catheter ablation is an important therapeutic option in postmyocardial infarction patients with ventricular tachycardia (VT). We analyzed the endo–epicardial electroanatomical mapping (EAM) voltage and morphology characteristics, their association with clinical data and their prognostic value in a large cohort of postmyocardial infarction patients. Methods and Results— We performed total and segmental analysis of voltage (bipolar dense scar [DS] and low voltage areas, unipolar low voltage and penumbra areas) and morphology characteristics (presence of abnormal late potentials [LPs] and early potentials [EPs]) in 100 postmyocardial infarction patients undergoing electroanatomical mapping–based VT ablation (26 endo–epicardial procedures) from 2010–2012. All patients had unipolar low voltage areas, whereas 18% had no identifiable endocardial bipolar DS areas. Endocardial bipolar DS area >22.5 cm 2 best predicted scar transmurality. Endo–epicardial LPs were recorded in 2/3 patients, more frequently in nonseptal myocardial segments and were abolished in 51%. Endocardial bipolar DS area >7 cm 2 and endocardial bipolar scar density >0.35 predicted epicardial LPs. Isolated LPs are located mainly epicardially and EPs endocardially. As a primary strategy, LPs and VT-mapping ablation occurred in 48%, only VT-mapping ablation in 27%, only LPs ablation in 17%, and EPs ablation in 6%. Endocardial LP abolition was associated with reduced VT recurrence and increased unipolar penumbra area predicted cardiac death. Conclusions— Endocardial scar extension and density predict scar transmurality and endo–epicardial presence of LPs, although DS is not always identified in postmyocardial infarction patients. LPs, most frequently located in nonseptal myocardial segments, were abolished in 51% resulting in improved outcome.

This study sought to develop a novel automated technique, simultaneous amplitude frequency electrogram transformation (SAFE-T), to identify ventricular tachycardia (VT) isthmuses by analysis of sinus rhythm arrhythmogenic potentials (AP).Substrate ablation is useful for patients with scar-related hemodynamically unstable VT; however, the accuracy of different approaches remains inadequate, varying from targeting late potentials to full scar homogenization.High-density ventricular mapping was performed in 3 groups: 1) 18 normal heart control subjects; 2) 10 ischemic patients; and 3) 8 nonischemic VT patients. In VT patients, isthmus sites were characterized using entrainment responses. Sinus rhythm right ventricle/left ventricle endocardial and epicardial electrograms underwent Hilbert-Huang spectral analysis and were displayed as 3-dimensional SAFE-T maps. AP and their relation to the VT isthmus sites were studied.AP were defined by a cutoff value of 3.08 Hz mV using normal heart control subjects. Receiver-operating characteristics showed that VT isthmus sites were best identified using SAFE-T mapping (p 0.001) as compared with bipolar and unipolar scar and late potential mapping with an optimal cutoff value of 3.09 Hz mV, allowing identification of 100% of the 34 mapped VT isthmuses, compared with 68% using late potentials. There was no significant difference between sinus rhythm and paced SAFE-T values. Abnormal SAFE-T areas involved about one-quarter of the scar total area.Automated electrogram analysis using 3-dimensional SAFE-T mapping allows rapid and objective identification of AP that reliably detect VT isthmuses. The results suggest that SAFE-T mapping is good alternative strategy to late potential mapping in identifying VT isthmuses and allows reduced ablation as compared to scar homogenization.

Patients with non-ischaemic cardiomyopathy (NICM) and ventricular tachycardia can be categorized as anteroseptal (AS) or inferolateral (IL) scar sub-types based on imaging and voltage mapping studies. The aim of this study was to correlate the baseline electrocardiogram (ECG) with endo-epicardial voltage maps created during ablation procedures and identify the ECG characteristics that may help to distinguish the scar as AS or IL.We assessed 108 baseline ECGs; 72 patients fulfilled criteria for dilated cardiomyopathy whereas 36 showed minimal structural abnormalities. Based on the unipolar low-voltage distribution, the scar pattern was classified as predominantly AS (n = 59) or IL (n = 49). Three ECG criteria (PR interval 170 ms or an r ? 0.3 mV in V3 having 92 and 81% of sensitivity and specificity, respectively, in predicting AS scar pattern. A significant negative correlation was found between the extension of the endocardial unipolar low voltage area and left ventricular EF (rs = -0.719, P

Single site left ventricular (LV) pacing in the absence of intrinsic ventricular activity can be as detrimental to LV function as right ventricular apical pacing. This report describes a patient with complete heart block who developed significant dyssynchrony and cardiomyopathy secondary to single site lateral LV pacing. The process was reversed by placement of a second anterior LV lead. (PACE 2013; 36:e35–e37)

Background— The mechanism of cardiac resynchronization therapy (CRT)–induced proarrhythmia remains unknown. We postulated that pacing from a left ventricular (LV) lead positioned on epicardial scar can facilitate re-entrant ventricular tachycardia. The aim of this study was to investigate the relationship between CRT-induced proarrhythmia and LV lead location within scar. Methods and Results— Twenty-eight epicardial and 63 endocardial maps, obtained from 64 CRT patients undergoing ventricular tachycardia ablation, were analyzed. A positive LV lead/scar relationship, defined as a lead tip positioned on scar/border zone, was determined by overlaying fluoroscopic projections with LV electroanatomical maps. CRT-induced proarrhythmia occurred in 8 patients (12.5%). They all presented early with electrical storm (100% versus 39% of patients with no proarrhythmia; P P P =0.03 on epicardial bipolar scar, 80% versus 17% P =0.02 on epicardial unipolar scar, and 80% versus 17% P =0.02 on any-epicardial scar). Ablation was performed within epicardial scar, close to the LV lead, and allowed CRT reactivation in all patients. Conclusions— CRT-induced proarrhythmia presented early with electrical storm and was associated with an LV lead positioning within epicardial scar. Catheter ablation allowed for resumption of biventricular stimulation in all patients.

Background: Resting echocardiographic measures of cardiac function such as left ventricular ejection fraction correlate poorly with exercise capacity. Assessment during exercise using measures less dependent on hemodynamic loading conditions, such as tissue Doppler imaging (TDI), may more accurately characterize the relationship between cardiac function and exercise capacity. Methods and Results: One hundred one subjects with various cardiac diagnoses underwent exercise stress echocardiography with simultaneous cardiopulmonary gas exchange analysis. Standard two-dimensional, Doppler and spectral TDI parameters were assessed at both rest and peak exercise. Across all subjects the strongest relationship with peak oxygen uptake (pVO2) was with peak left ventricular systolic tissue velocity (S′) during exercise (r=0.84, P

Aims In patients requiring permanent pacemaker implantation for sinus node disease (SND) or atrioventricular (AV) block, right ventricular (RV) pacing has been demonstrated to increase the risk of developing atrial fibrillation (AF). The effects of RV pacing in patients with paroxysmal AF are less well defined. Short- and medium-term studies have suggested no significant correlation between RV pacing and atrial fibrillation burden (AFB) measurement; we sought to assess for an effect in the long-term. Methods and results Sixty-six patients were randomized to receive either conventional dual chamber pacing (DDDR, n = 33), or dual chamber minimal ventricular pacing (MinVP, n = 33), for a period of at least 1 year. Patients were reviewed every 6 months and all pacemaker data were downloaded. The primary outcome measures were device-derived AFB and progression to persistent AF. The mean duration of study follow-up was 1.4 ± 0.6 years. Mean ventricular pacing was less in the MinVP cohort compared with the DDDR cohort (5.8 vs. 74.0%, P < 0.001). At follow-up, the device-derived AFB was significantly lower in the MinVP cohort when compared with the DDDR cohort (12.8 ± 15.3% vs. DDDR 47.6 ± 42.2%, P < 0.001). Kaplan–Meier estimates of time to onset of persistent AF showed significant reductions in the rates of persistent AF for MinVP pacing (9%) when compared with conventional DDDR pacing (42%), P = 0.004. Conclusion Right ventricular pacing induces increased AFB in patients with paroxysmal AF in the long term. Dual chamber MinVP algorithms result in reduced AFB and reduced disease progression from paroxysmal to persistent AF in the long term.

Single site left ventricular (LV) pacing in the absence of intrinsic ventricular activity can be as detrimental to LV function as right ventricular apical pacing. This report describes a patient with complete heart block who developed significant dyssynchrony and cardiomyopathy secondary to single site lateral LV pacing. The process was reversed by placement of a second anterior LV lead.

Introduction:Accurate atrial arrhythmia discrimination is important for dual chamber pacemakers and defibrillators. The aim was to assess the accuracy of atrial arrhythmia recording using modern devices and relate this to atrial tip-to-ring (TTR) distance. Methods:One hundred eighty-two patients (72 ± 9 years, 55% male) with paroxysmal atrial fibrillation were enrolled and were included in the study if they had an atrial fibrillation (AF) burden of 1–50% during a monitoring phase. Seventy-nine patients fulfilled these criteria and were followed for at least 5 months. Electrodes were classified as having short (

The study aim was to validate the closed loop stimulation (CLS) vs. accelerometer (ACC) rate-responsive sensors with electrodes placed in the right ventricular high septal (RVHS) or right ventricular apical (RVA) lead positions in patients following 'ablate and pace' therapy for persistent atrial fibrillation.'Ablate and pace' patients were randomised to either RVHS or RVA electrode placement with a dual sensor device. A double-blind crossover study comparing CLS vs. ACC rate-response pacing modes was undertaken. Subjects undertook cardiopulmonary testing with constant workload light exercise followed by a ramp protocol in addition to activity of daily living assessments.Twenty subjects (14 male; age, 74 +/- 8 years) were studied. Heart rate increase was greater from lying to sitting with ACC. With mental stress, heart rate increase was greater with CLS. Peak heart rates were similar for stair ascent and descent in ACC mode. With CLS mode, however, the peak heart rate was significantly lower for stair descent. There was no difference between modes in mean response time, oxygen deficit, peak VO(2), VO(2) at anaerobic threshold, peak heart rate, total exercise time and total workload. CLS function was equally optimal at both electrode sites.CLS rate adaptive pacing is appropriate for 'ablate and pace' patients, and this sensor functions equally well using RVA or RVHS lead positions.

Aims ATI-2042 (budiodarone) is a chemical analogue of amiodarone with a half life of 7 h. It is electrophysiologically similar to amiodarone, but may not have metabolic and interaction side effects. The sophisticated electrocardiograph logs of advanced DDDRP pacemakers were used to monitor the efficacy of ATI-2042. The aim of this study was to determine the preliminary efficacy and safety of ATI-2042 in patients with paroxsymal atrial fibrillation (PAF) and pacemakers.\ud \ud Methods and results Six women with AF burden (AFB) between 1 and 50% underwent six sequential 2-week study periods. Patients received 200 mg bid of ATI-2042 during Period 2 (p2), 400 mg bid during p3, 600 mg bid during p4, 800 mg bid during p5, and no drug during baseline and washout (p1 and p6). Pacemaker data for the primary outcome measure AFB were downloaded during each period. Mean AFB decreased between baseline and all doses: AFB at baseline (SD) was 20.3 ± 14.6% and mean AFB at 200 mg bid was 5.2 ± 4.2%, at 400 mg bid 5.2 ± 5.2%, at 600 mg bid 2.8 ± 3.4%, and at 800 mg bid 1.5 ± 0.5%. The mean reductions in AFB at all doses of ATI-2042 were statistically significant (P < 0.005). Atrial fibrillation burden increased in washout. Atrial fibrillation episodes tended to increase with ATI-2042, but this was offset by substantial decreases in episode duration. ATI-2042 was generally well tolerated.\ud \ud Conclusion ATI-2042 effectively reduced AFB over all doses studied by reducing mean episode duration. A large-scale study will be required to confirm this effect.

Objective Exercise-induced changes in the synchrony of left ventricular contraction may be an important therapeutic target in heart failure. There are limited data to support the feasibility of exercise assessments. In addition, the effect of exercise on synchrony in healthy individuals is undetermined. Methods Eleven healthy young men underwent tissue Doppler assessments before and immediately after maximal cardiopulmonary exercise. Left ventricular synchrony was assessed using pulsed wave tissue Doppler of the lateral, septal, inferior, and anterior walls. The maximal dispersion times between the walls for onset and peak systolic velocities were used as synchrony indices. Results The proportion of the cardiac cycle taken between Q wave and time to onset or peak systolic motion was constant at rest and peak exercise. There was no significant exercise-induced change seen in either interventricular or intraventricular synchrony. Conclusion Exercise synchrony assessment is technically feasible. Synchronization of cardiac contraction is maintained after maximal exercise in healthy individuals.

A 75-year-old woman presented with left ventricular apical ballooning syndrome mimicking acute anterior myocardial infarction. She had a long history of chest tightness and was undergoing a contrast stress echocardiogram because of frequent re-admissions with chest pain, all with normal ECGs and troponins. A standard dobutamine/atropine protocol had been used. The patient developed central crushing chest pain, marked ST elevation, transient slowing of heart rate and left ventricular apical ballooning. She was admitted to the coronary care unit and received thrombolysis. Echocardiography showed no mitral regurgitation, normal pulmonary artery systolic pressure and no intraventricular gradient. Immediate troponin T was significantly raised and peaked at 6 h. The patient underwent coronary angiography the next day. This showed systolic left ventricular apical ballooning and no coronary lesions or vasospasm. A further contrast echo 2 weeks later showed complete resolution of the wall motion abnormalities. Left ventricular apical ballooning or takotsubo syndrome can lead to cardiogenic shock but has a favourable prognosis compared to myocardial infarction. This patient was noted to be unusually anxious about having a stress echocardiogram and mental stress might be a precipitating factor, furthermore, this response during dobutamine stress echocardiography favours a catecholamine related disease mechanism.

Background Implantable cardiac defibrillator (ICD) therapy reduces mortality in selected patients at high risk of sudden cardiac death. However, patients at high risk of non-sudden cardiac death, whose risk of short-term mortality following device implantation is high, may gain no significant benefit from an ICD. A number of approaches have been proposed to identify these high-risk patients, including single clinical markers and more complex scoring systems. The aims of this study were to use the proposed scoring systems to: (1) establish how many current ICD recipients may be too high risk to derive significant benefit from ICD therapy and (2) evaluate how well the proposed scoring systems predict short-term mortality in an unselected cohort of ICD recipients. Methods We performed asingle-centre retrospective observational study of all new ICD implants over 5years (2009–2013). We used 3 published scoring systems (Kramer et al 1 ; Barsheshet et al 2 ; Parkash et al 3 ) to identify new ICDrecipients whose short-term risk of death following ICD implantation waspredicted to be high. We then evaluated how well the scoring systems predicteddeath during follow-up. Results Over 5 years there were 406 new implants (79% male, age 67 ± 13 years). The majority (58%) were primary prevention implants and 45% were cardiac resynchronisation therapy-defibrillator devices. During a mean follow-up of 936 ± 560 days, 77 patients died. Using the published scoring systems, the proportion of ICD recipients predicted to be at high risk of short-term mortality were 4% (Kramer), 36% (Barsheshet) and 23% (Parkash). Three-year mortality rates in these high-risk groups were 76%, 32% and 36% respectively; in the overall study population 3-year mortality was 20%. In univariate Cox regression analyses, all 3 scoring systems predicted death (p Conclusions Using published scoring systems, a significant proportion of current ICD recipients are at high risk of short-term mortality following device implantation. Although all 3 scoring systems predicted mortality during follow-up, only the Kramer model added predictive accuracy compared to renal function alone. RENCES Kramer DB, Friedman PA, Kallinen LM, Morrison TB, Crusan DJ, Hodge DO, Reynolds MR, Hauser RG. Development and validation of a risk score to predict early mortality in recipients of implantable cardioverter-defibrillators. Heart Rhythm 2012; 9 :42–6 Barsheshet A, Moss AJ, Huang DT, McNitt S, Zareba W, Goldenberg I. Applicability of a risk score for prediction of the long-term (8-year) benefit of the implantable cardioverter-defibrillator. J Am Coll Cardiol 2012; 59 :2075–9 Parkash R, Stevenson WG, Epstein LM, Maisel WH. Predicting early mortality after implantable defibrillator implantation: a clinical risk score for optimal patient selection. Am Heart J 2006; 151 :397–403

Atrial fibrillation is the most common sustained cardiac arrhythmia and is increasing in prevalence with an ageing population. As the arrhythmia is often asymptomatic the true prevalence is likely even higher. Largely because of stroke this arrhythmia places a huge financial burden on the health economy. Despite this, large studies assessing rate versus rhythm control have been equivocal. Because of the ineffectiveness of pharmacological therapy much research effort has been undertaken in device and ablative approaches to rhythm management. Although catheter ablation has gained favour because of the high success rates the technique requires considerable expertise and still has a significant complication profile maintaining interest in pacing therapies for atrial fibrillation. Dual chamber versus single-chamber ventricular pacing has been shown to significantly reduce the incidence of atrial fibrillation. Research is currently underway to see if minimising the deleterious effects of right ventricular apical pacing could further increase the benefits of atrioventricular synchronous pacing. Several studies show some (albeit variable) reduction in AF burden with anti-AF algorithms in the setting of bradycardia. Antitachycardia pacing, on the other hand, has not been shown to treat AF in a randomised trial despite the successful termination of co-existent atrial tachycardias. There is increasing evidence that alternative atrial pacing sites may treat AF by improving atrial function. Furthermore, these strategies coupled with other therapies in a ‘hybrid approach’ have also showed promising results.

Evidence from randomized trials indicates that the clinical benefits of dual-chamber (DDD) pacing are modest: (i) no significant differences exist between physiological pacing and single-chamber pacing in mortality and stroke; (ii) ventricular desynchronization resulting from chronic right-ventricular pacing in DDD mode, induces a significantly increased incidence of atrial fibrillation (AF) and heart failure hospitalizations; (iii) AF pacing prevention and therapy algorithms have shown a modest to minimal or absent efficacy; (iv) the widespread use of physiological pacemakers is not an economically attractive strategy. Thus, these data provide a reliable body of evidence on which to make more rationale clinical decisions for individual patients and policy decisions for health costs saving. The cheaper single-chamber AAI(R) or VVI(R) has been shown to satisfy both conditions in most cases of sinus node disease and AV block.