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Purpose: In patients with paroxysmal atrial fibrillation (PAF), functional changes are observed in the left atrium (LA) after pulmonary vein isolation (PVI) procedure. Although previous studies have investigated the altered mechanical functions of the LA with radiofrequency (RF) ablation, changes in the LA functions in the early period after cryoablation (CB-2) have not been clearly demonstrated. This study aims to explore the early periodical changes in mechanical functions of the LA in patients with PAF who underwent CB-2 based ablation through the help of echocardiographic methods which contain Doppler and strain parameters. Methods: Consecutive seventy-seven patients (mean age: 57.5±11.2; 57% men) with PAF underwent CB-2 were prospectively analyzed. All patients were in sinus rhythm before and after the procedure. The LA dimensions, the LA reservoir strain, the LA atrial contractile strain and the LA conduit strain and left ventricular diastolic function parameters were evaluated by Doppler echocardiography before and 3 months after the procedure. Results: Acute procedural success was achieved in all cases. No major complications were observed. LA reservoir strain and LA contractile strain showed significant recovery after the procedure. (28.3±12.8 vs 34.6±13.8, pConclusion: Significant improvement in mechanical functions may occur even in the early period after cryoballoon ablation in patients with PAF.

We compared the efficacy and safety of cardioneuroablation (CNA) vs. permanent pacing (PM) for recurrent cardioinhibitory vasovagal syncope (CI-VVS).One hundred sixty-two patients (CNA = 61, PM = 101), age 36 + 11 years) with syncope frequency of 6.7 ± 3.9/year were included in this multicenter study. All patients with CNA were provided by a single center, while patients with PM were provided by 4 other centers. In the CNA arm, an electroanatomic mapping guided approach was used to detect and ablate ganglionated plexus sites. Dual chamber rate drop response (RDR) or close loop stimulation (CLS) transvenous and leadless pacemakers were implanted using standard technique. The primary endpoint was freedom from syncope.Of 101 patients in the PM group, 39 received dual-chamber pacemaker implants with the CLS algorithm, 38 received dual-chamber pacemakers with the RDR algorithm, and 24 received a leadless pacemaker. At 1-year follow-up, 97% and 89% in the CNA and PM group met the primary endpoint (adjusted HR = 0.27, 95% CI 0.06-1.24, p = 0.09). No significant differences in adverse events were noted between groups. There was no significant association between age (HR:1.01, 95% CI 0.96-1.06, p = 0.655), sex (HR:1.15, 95% CI 0.38-3.51, p = 0.809), and syncope frequency in the past year (HR:1.10, 95% CI 0.97-1.25, p = 0.122) and the primary outcome in univariable analyses.After adjustment for patient characteristics, the medium-term syncope recurrence risk of CI-VVS patients who underwent CNA was similar to that of a population of patients undergoing pacemaker implantation with a similar safety profile.

Congenital anomalies of the venous system including superior (SVC) and inferior vena cava are not uncommon. Failure of certain vessels embryogenesis results in numerous caval variations and anomalies. Anomalies of systemic venous circulation are frequently seen in patients with congenital heart disease and are sometimes incidentally recognized. However, these are usually without significant clinical implications, detection of these anomalies is necessary to avoid diagnostic pitfalls and for planning vascular interventions. We present a rare caval anomaly, a left-sided IVC with hemiazygos continuation to left SVC and coronary sinus.

The impact of cardioneuroablation (CNA) on ventricular repolarization by using corrected QT interval (QTc) measurements has been recently demonstrated. The effects of cardiac pacing (CP) on ventricular repolarization have not been studied in patients with vasovagal syncope (VVS). We sought to compare ventricular repolarization effects of CNA (group 1) with CP (group 2) in patients with VVS.We enrolled 69 patients with age 38 ± 13 years (53.6% male), n = 47 in group 1 and n = 22 in group 2. Clinical diagnosis of cardioinhibitory type was supported by cardiac monitoring or tilt testing. QTc was calculated at baseline (time-1), at 24 h after ablation (time-2), and at 9-12 months (time-3) in the follow-up.In the group 1, from time-1 to time-2, a significant shortening in QTcFredericia (from 403 ± 27 to 382 ± 27 ms, p0.0001), QTcFramingham (from 402 ± 27 to 384 ± 27 ms, p0.0001), and QTcHodges (from 405 ± 26 to 388 ± 24 ms, p0.0001) was observed which remained lower than baseline in time-3 (373 ± 29, 376 ± 27, and 378 ± 27 ms, respectively). Although the difference between measurements in time-1 and time-2 was not statistically significant for QTcBazett, a significant shortening was detected between time-1 and time-3 (from 408 ± 30 to 394 ± 33, p = 0.005). In the group 2, there was no time-based changes on QTc measurements. In the linear mixed model analysis, the longitudinal reduction tendency in the QTcFredericia and QTcFramingham was more pronounced in group 1.Our results demonstrate that CNA reduces QTc levels through neuromodulation effect whereas CP has no effect on ventricular repolarization in patients with VVS.

Sudden cardiac death (SCD) is a common disorder and an unsolved issue for health care providers. Despite several risk factors for SCD, some cases experience SCD as an initial presentation of cardiovascular disease. Prediction of individuals at increased risk for SCD is important for implementing community-based approaches and individual-based therapies with high costs, such as implantable defibrillators. This chapter discusses the potential role of biomarkers in predicting SCD in different cardiovascular diseases.

Annotation of earliest depolarization which depends on maximum dV/dt of unipolar-electrograms and unipolar QS morphology identify site of origin for ventricular premature contractions (VPC). However, identification of unipolar QS morphology has limitations due to low spatial resolution. This study aims to compare electrogram characteristics at successful ablation site in patients with outflow tract (OT) VPC.Local activation time (LAT), duration, and voltage data of each bipolar- and unipolar-electrogram at the successful ablation sites from the right ventricle OT (RVOT) and the left ventricle OT (LVOT) cases were analyzed.Forty-four of 60 (73%) of patients were ablated from RVOT and in 16/60 (27%) required ablation from both sides. All patients had acute VPC suppression. Bipolar-electrogram-QRS onset was earlier (36.4 ± 14.5 ms vs 26.3 ± 7.4 ms, p = 0.01), duration of bipolar-electrogram was shorter (56.9 ± 18.9 ms vs 78.9 ± 21.8 ms, p = 0.002), and bi-voltage amplitude was higher (3.2 ± 2.3 mV vs 1.4 ± 1.1 mV, p = 0.07) for patients with RVOT-only ablation. Mean bipolar-unipolar-electrogram difference was 4.4 ± 4.5 ms in the RVOT group vs 12.8 ± 4.9 ms in RVOT + LVOT group (p 0.001). Unipolar QS morphology was recorded in 3.0 ± 3.9 vs 3.6 ± 1.8 cmQS in unipolar-electrogram was not a perfect predictor for successful ablation sites. Analysis of bipolar voltage amplitude and duration with bipolar-unipolar-electrogram time difference may identify presence of a deeper source.

Ganglionated plexi (GP) ablation may be associated with improved syncope or arrhythmia-free survival arrhythmia patients with vasovagal syncope (VVS) and atrial fibrillation (AF), respectively. We aimed to compare the characteristics of vagal response (VR) and clarify the effect on heart rate after GP ablation based on clinical diagnosis.A total of 83 consecutive patients undergoing GP ablation were divided following two groups: (1) GP ablation for VVS (VVS group, n = 43) and (2) GP ablation in addition to pulmonary vein isolation (AF group, n = 40). We examined VR characteristics during RF ablation and high frequency stimulation, respectively, in the VVS and AF groups. To evaluate immediate and long-term heart rate response, a standard 12-lead ECG was obtained at baseline at 24 h after ablation and at the last follow-up visit.In the VVS group, the superior and inferior left atrial GPs were the most common GP sites at which a VR was observed. No VR was seen during radiofrequency application in the superior and inferior right atrial GPs in the VVS group. On the contrary, VR was more prevalent in the right-sided GPs during high-frequency stimulation in the AF group. VR was observed during ablation in only one patient with AF. Although the heart rate increased significantly after ablation in both groups, the effect was more prominent and durable in the VVS group.The autonomic response during GP ablation is different in VVS compared to AF, suggesting that VVS and AF may represent distinct forms of autonomic hyperactivity.

AimsCryoballoon (CB)-based pulmonary vein isolation (PVI) is an effective treatment for atrial fibrillation (AF). The most frequent complication during CB-based PVI is right-sided phrenic nerve injury (PNI) which is leading to premature abortion of the freeze cycle. Here, we analysed reconnection rates after CB-based PVI and PNI in a large-scale population during repeat procedures.Methods and resultsIn the YETI registry, a total of 17 356 patients underwent CB-based PVI in 33 centres, and 731 (4.2%) patients experienced PNI. A total of 111/731 (15.2%) patients received a repeat procedure for treatment of recurrent AF. In 94/111 (84.7%) patients data on repeat procedures were available. A total of 89/94 (94.7%) index pulmonary veins (PVs) have been isolated during the initial PVI. During repeat procedures, 22 (24.7%) of initially isolated index PVs showed reconnection. The use of a double stop technique did non influence the PV reconnection rate (P = 0.464). The time to PNI was 140.5 ± 45.1 s in patients with persistent PVI and 133.5 ± 53.8 s in patients with reconnection (P = 0.559). No differences were noted between the two populations in terms of CB temperature at the time of PNI (P = 0.362). The only parameter associated with isolation durability was CB temperature after 30 s of freezing. The PV reconnection did not influence the time to AF recurrence.ConclusionIn patients with cryoballon application abortion due to PNI, a high rate of persistent PVI rate was found at repeat procedures. Our data may help to identify the optimal dosing protocol in CB-based PVI procedures.Clinical Trial Registrationhttps://clinicaltrials.gov/ct2/show/NCT03645577?term=YETI&cntry=DE&draw=2&rank=1 ClinicalTrials.gov Identifier: NCT03645577.

BACKGROUND Ventricular scars due to myocardial infarction provide a substrate for ventricular arrhythmias, and cardiac magnetic resonance (CMR) is the golden standard for the quantification of scar tissue magnitude. CMR has still limitations with patients with ICD despite ICD's becoming MR-compatible. We investigated the association between calibrated integrated backscatter (cIBS) and arrhythmia frequency in patients with ICD. METHODS Thirty-two ischemic dilated cardiomyopathy (ICM) patients with VVI-ICD (mean age 66.56 ± 9.05, 28 male, and four female) were divided into three groups according to their arrhythmia frequency (ventricular arrhythmia-[VA -], VA + [VA +], and arrhythmia storm [AS]). Then with transthoracic echocardiography (TTE), all patients' cIBS values were calculated and these values were compared with the patients' arrhythmia frequency. RESULTS cIBS values of patients with VA + and AS were significantly higher in the apical-septal (0.66 ± 0.11 vs. 0.50 ± 0.16, p = .008) and apical-lateral (0.62 ± 0.19 vs. 0.46 ± 0.18, p = .041) segments compared to those of patients with VA -. The cIBS values of apical-septal (0.50 ± 0.16 vs. 0.65 ± 0.08 vs. 0.66 ± 0.13 respectively, p = .032) and apical-anterior (0.53 ± 0.22 vs. 0.48 ± 0.17 vs. 0.79 ± 0.23 respectively, p = .03) segments were significantly different between the groups. Furthermore, in the post hoc analysis, the difference was significantly higher in VA + than VA - in the apical-septal segment and higher in AS than VA + in apical-anterior segments. CONCLUSION Our findings suggest an association between the cIBS values and arrhythmia frequency in the study group.

The anatomical basis underlying the neuromodulation effects seen with pulmonary vein (PV) isolation (PVI) is not fully understood. Left atrial (LA) electro-anatomical maps of 38 patients who underwent catheter cardioneuroablation for vagally mediated bradycarrhythmias (VMB) were studied. During the procedure, LA ganglionic plexi (GPs) were systematically identified and ablated. Design PVI lines were created on these maps by a blinded observer, and the degree of overlap between 4 GPs and individual PVs was assessed. 1.7±7 (35.5±17.0%) of the total 31.6±10 GP ablation sites per patient were found to overlap with the design PVI lines. The overlap was higher for the right-sided GPs, P< 0.001. The degree of GP-PV overlap varied: 1 PV in 5 (13.2%) patients, 2 PVs in 15 (39.2%), 3 PVs in 16 (42.1%), and all 4 PVs in 2 (5.3%). No patient had zero GP-PV overlap. A vagal response was most commonly observed during ablation at the left superior GP (89.5%), while a sympathetic response was observed most often during the right superior GP ablation (97.4%). Some degree of GP-PV antral overlap is the norm, and this is more pronounced for the right-sided PVs. There is significant individual variability in the degree of overlap which may explain why neuromodulation effects are not seen universally following PVI. This article is protected by copyright. All rights reserved.

BACKGROUND In previous studies, patients undergoing ablation of ganglionated plexi (GPA) for vagally mediated bradyarrhythmias were noted to have shortening of their corrected QT interval (QTc). AIMS To compare the effects of GPA (group 1) to pulmonary vein isolation + GPA (group 2) on QTc. MATERIAL AND METHODS We enrolled 39 patients, n = 25 in group 1 and n = 14 in group 2. QTc was calculated at baseline, at 24 h after ablation, and at 9-12 months in the follow-up. Recurrent syncope, asystole >2 s, and/or second- or third-degree AVB episodes were carefully documented as the primary outcome in group 1. Any atrial arrhythmia ≥30 seconds documented on 24-h Holter monitoring was defined as the primary outcome in group 2. RESULTS The mean follow-up time was 14.9 ± 4 months. Acute success was achieved in all cases. In whole cohort, a significant shortening on QTcBazett, QTcFramingham, QTcFredericia, and QTcHodges was observed [416 vs 398ms (p = .002), 411vs 378 ms (p

Clinicians should have a basic understanding of the working principle of the instruments they use to avoid potential pitfalls caused by post-processing of the acquired biological signals. An electrocardiogram (ECG) is no exception; many different errors can arise during the acquisition or the processing of the ECG data, which may result in dangerous misdiagnoses. We present a case where the use of an inappropriate high-pass filter led to a false diagnosis of ST-elevation myocardial infarction. In addition, this report discusses the basic mechanisms of this frequently overlooked phenomenon and methods to avoid it.

Ablation of ganglionated plexuses (GPs) is a relatively new technique in patients with vasovagal syncope. Due to individual variation of GP settlement, reproducible GP detection methods are needed to during electrophysiologic study. In the present case, fractionation mapping software of Ensite system was tested to detect localization of GPs and first compared with previously validated fractionated electrograms based strategy.

Cardioneuroablation (CNA) is an endocardial ablation technique aiming to prevent the autonomic imbalance occurring in vasovagal syncope (VVS). A 46-year-old female was referred to our center for pacemaker implantation due to recurrent syncopal episodes despite conventional treatments. A 22-s asystole was detected on head-up tilt testing. After a discussion with the patient and her family, we decided to perform CNA. Positive response was confirmed, and procedural endpoints were defined using pre-procedural atropine response test. Ganglionated plexus (GP) sites were detected and ablated by using fractionated electrogram (FE)-based strategy. During baseline electrophysiological study, AA and PR intervals were calculated as 810 ms and 164 ms, respectively. Based on our ablation order, radiofrequency ablation (RFA) was started from the left inferior and left superior GPs, respectively. A significant vagal response with sinus pauses and atrioventricular (AV) block was detected during RFA. Ablation of the right superior GP caused a significant increase of sinus rate with continuing AV block. After completion of ablation on the right superior and inferior GPs, PR interval was still 164 ms although AA interval decreased to 640 ms. After RFA on the posteromedial left GP which provides mainly vagal innervation of AV node, PR interval and cycle length of sinus node were detected as 134 ms and 540 ms, respectively. Selective parasympathetic innervation principles of the sinus node and AV node were previously demonstrated. We described a case of successful parasympathetic denervation of the sinus node and AV nodes using CNA.

Pulmonary vein isolation (PVI) may cause vagal response during radiofrequency application or increase on heart rate after ablation. All those responses are related to inadvertent ablation effect on ganglionated plexi. In the present case, we aimed to explain why vagal response effects of PVI are not same in all cases.

Objective: The usage of synthetic cannabinoids (SCs) has increased both in Turkey and all worldwide. Here, we evaluate if SCs cause ventricular repolarization abnormalities using initial and after 12th-hour electrocardiograms in patients with acute intoxication of SCs. We examined changes in the QTc and cTp-e parameters to demonstrate ventricular repolarization effects of the usage of SCs. Material and Methods: We used a prospective study design. Twenty patients were included who visited the emergency department, complaining of clouding of consciousness after using SCs. The QT, QTc and Tp-e intervals and several other electrocardiographic parameters were measured at baseline and 12 hours after the usage of SCs. Results: The QRS duration was significantly decreased (102.1 ± 15.5 ms vs 95.0 ± 10.7 ms; p = 0.022). We noted a significant decrease in cQT measurements at the end of the 12th hour (426.6 ± 47.2 ms vs 390.4 ± 42.9 ms; p = 0.002). Similarly, the Tp-e and cTp-e values decreased significantly when SCs lost its acute effect (93.4 ± 21.1 ms vs 77.4 ± 21.0 ms; p = 0.014, 105.3 ± 28.5 ms vs 88.1 ± 21.5 ms; p = 0.01). Conclusions: The usage of SCs affects ventricular repolarization heterogeneity based on QTc and Tp-e intervals

Supplemental Digital Content is available in the text., Background: Cryoballoon-based pulmonary vein isolation (PVI) has emerged as an effective treatment for atrial fibrillation. The most frequent complication during cryoballoon-based PVI is phrenic nerve injury (PNI). However, data on PNI are scarce. Methods: The YETI registry is a retrospective, multicenter, and multinational registry evaluating the incidence, characteristics, prognostic factors for PNI recovery and follow-up data of patients with PNI during cryoballoon-based PVI. Experienced electrophysiological centers were invited to participate. All patients with PNI during CB2 or third (CB3) and fourth-generation cryoballoon (CB4)-based PVI were eligible. Results: A total of 17 356 patients underwent cryoballoon-based PVI in 33 centers from 10 countries. A total of 731 (4.2%) patients experienced PNI. The mean time to PNI was 127.7±50.4 seconds, and the mean temperature at the time of PNI was −49±8°C. At the end of the procedure, PNI recovered in 394/731 patients (53.9%). Recovery of PNI at 12 months of follow-up was found in 97.0% of patients (682/703, with 28 patients lost to follow-up). A total of 16/703 (2.3%) reported symptomatic PNI. Only 0.06% of the overall population showed symptomatic and permanent PNI. Prognostic factors improving PNI recovery are immediate stop at PNI by double-stop technique and utilization of a bonus-freeze protocol. Age, cryoballoon temperature at PNI, and compound motor action potential amplitude loss >30% were identified as factors decreasing PNI recovery. Based on these parameters, a score was calculated. The YETI score has a numerical value that will directly represent the probability of a specific patient of recovering from PNI within 12 months. Conclusions: The incidence of PNI during cryoballoon-based PVI was 4.2%. Overall 97% of PNI recovered within 12 months. Symptomatic and permanent PNI is exceedingly rare in patients after cryoballoon-based PVI. The YETI score estimates the prognosis after iatrogenic cryoballoon-derived PNI. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03645577. Graphic Abstract: A graphic abstract is available for this article.

Macroscopic T-wave alternans (TWA) is the beat-to-beat variation in the amplitude or shape of the T wave on a surface electrocardiogram (ECG) and known to be a harbinger of impending malignant ventricular arrhythmias such as polymorphic ventricular tachycardia. We herein report a case with hepatic encephalopathy, who developed TWA, followed by polymorphic ventricular tachycardia.

Pulmonary vein (PV) automaticity is an established trigger for paroxysmal atrial fibrillation (PAF), making PV isolation (PVI) the cornerstone of catheter ablation. However, data on triggers for atrial fibrillation (AF) and catheter ablation strategy in very young patients aged 30 seconds after a 3-month blanking period. A total of 2 patients with atrioventricular nodal reentrant tachycardia, 1 with left atrial appendage tachycardia, experienced AF recurrence within the first 3 months and received PVI. After the 3-month blanking period, during a median follow-up of 17.0 +/- 10.1 months, 44 of 51 patients (86.2%) were free of ATA recurrence. In the PVI group, 33 of 39 patients (84.6%) experienced no ATA recurrence. In conclusion, SVT substrate is identified in around a quarter of young adult patients with history of AF, and targeted ablation without PVI may be sufficient in the majority of these patients. PVI is needed in the majority and is safe and effective in this population. (C) 2021 Published by Elsevier Inc.

Background Studies have shown that increased body weight and obesity may be associated with an increased risk of arrhythmic events. However, studies conducted in patients with implantable cardioverter-defibrillator (ICD) have found that low body mass index (BMI) is associated with higher mortality. The aim of this study is to evaluate the effect of obesity on the risk of arrhythmic events, hospitalization and death in patients receiving ICD therapy for primary or secondary prevention. Methods The study was designed as a single-center prospective and observational. Patients with BMI Results Among the total of 340 patients, 78.2% were male, 21.8% were female, and the mean age of the patients was 60.9 years. Among all patients, there were 30.6% normal weight, 47.4% overweight and 22.1% obese patients. AF recording was significantly higher in obese patients compared to the normal weight patient group (p=0.02). Shock, appropriate shock, and liquid load sensing were statistically higher in obese than non-obese patients (p=0.042, p=0.011 and p=0.007). In the primary prevention group, all-cause mortality and cardiac mortality rates were lower in the obesity group (p=0.022, p=0.037). Conclusion Our findings showed that although cardiac arrhythmic events are more common in obese patients, mortality and hospitalization events are less common in obese patients. These findings are consistent with the reverse epidemiology that has been demonstrated previously between obesity and mortality Funding Acknowledgement Type of funding sources: None. Events obtained from device controlSurvival normal weight and overweight

INTRODUCTION Single-center observational studies have shown promising results with fragmented electrogram (FE)-guided ganglionated plexus (GP) ablation in patients with vagally mediated bradyarrhythmia (VMB). We aimed to compare the acute procedural characteristics during FE-guided GP ablation in patients with VMB performed by first-time operators and those of a single high-volume operator. METHODS AND RESULTS This international multicenter cohort study included data collected over 2 years from 16 cardiac hospitals. The primary operators were classified according to their prior GP ablation experience: a single high-volume operator who had performed > 50 GP ablation procedures (Group 1), and operators performing their first GP ablation cases (Group 2). Acute procedural characteristics and syncope recurrence were compared between groups. Forty-seven consecutive patients with VMB who underwent FE-guided GP ablation were enrolled, n = 31 in Group 1 and n = 16 in Group 2. The mean number of ablation points in each GP was comparable between groups. The ratio of positive vagal response during ablation on the left superior GP was higher in Group 1 (90.3% vs. 62.5%, p = .022). Ablation of the right superior GP increased heart rate acutely without any vagal response in 45 (95.7%) cases. The procedure time was longer in group 2 (83.4 ± 21 vs. 118.0 ± 21 min, respectively, p

Background: The contribution of autonomic influences to atrioventricular block (AVB) is unclear. Although cardioneuroablation has been used to treat cardioinhibitory vasovagal syncope, its role in treating functional paroxysmal and persistent AVB has not been formally evaluated. Methods: We used a stepwise protocol in 241 consecutive patients presenting with symptomatic AVB to identify 31 (12.9%) patients with functional or vagally mediated AVB. All patients had episode(s) of syncope in previous 12 months, and AVB was persistent in 17 (54.8%) patients. All 31 patients received targeted catheter-based cardioneuroablation, and their follow-up outcomes were evaluated with serial Holter monitoring. Results: Twenty-eight patients received biatrial or left-sided cardioneuroablation while 3 received only right-sided cardioneuroablation because of structural factors that precluded safe attempts at transseptal puncture. Procedural success, as defined as acute reversal of AVB and complete abolition of atropine response, was achieved in 30 (96.7%) cases, while the remaining patient received a pacemaker. Over a mean follow-up of 19.3±15 months, AVB episodes were observed in 2 (6.7%) of 30 cases, and 3 (9.6%) patients required pacemaker implantation during follow-up. Conclusions: Functional AVB can be identified in a minority of patients presenting with high-grade AVB. Cardioneuroablation for these patients results in encouraging medium-term outcomes.

Parasympathetic overactivity may cause functional atrioventricular block episodes and necessitate pacemaker implantation in symptomatic cases and those refractory to conventional therapies. In these patients, if it can be clearly demonstrated that there is no structural damage in the conduction system, elimination of the vagal activity based on radiofrequency catheter ablation of main ganglionated plexi around the heart, which is called as cardioneuroablation, might be a rational approach. In this review article, we try to discuss patient selection and procedural steps suitable for cardioneuroablation based on two patients with functional atrioventricular block.

Patient: Female, 85 Final Diagnosis: Ischemic cardiomyopathy with electrical storm Symptoms: Dyspnea Medication: — Clinical Procedure: Ablation of ventricular tachycardia Specialty: Cardiology Objective: Unusual clinical course Background: Response to cardiac resynchronization therapy (CRT) is variable among patients. Extensive scar tissue burden has been characterized as a negative predictor of significant response. Whereas mid-term and long-term response has been thoroughly investigated in randomized clinical trials; however, little is known about acute hemodynamic effects of biventricular pacing. Case Report: We report a case of an elderly female patient with severe ischemic cardiomyopathy and a large anterior wall aneurysm, who received right ventricular and biventricular pacing during ablation of incessant pleomorphic ventricular tachycardia. During the procedure, biventricular pacing was associated with a 20% acute increase in systolic blood pressure compared to right ventricular pacing, although there was no acute or long-term effect on left ventricular function. Conclusions: The acute hemodynamic effect of CRT in our patient suggests an effect of CRT even in patients with negative predictors of CRT response such as severe ischemic cardiomyopathy with a large aneurysm. Although no marked increase in left ventricular function might be observed, the acute effect of CRT might contribute to stabilization of heart failure in these patients.

PubMed ID: 30170919 Second generation cryoballoon (CB) has been shown to be effective for treatment of paroxysmal and persistent atrial fibrillation (AF). However, the fixed size of the non-compliant balloon may limit its use in patients with pulmonary vein (PV) abnormalities. In this study we investigated the acute success, procedural complications and long term outcome of CB based PV isolation (PVI) in patients with PV abnormality. A total of 238 patients [64.8 ± 11.1 years; 91 paroxysmal (38.2%), 147 persistent AF (61.8%)] underwent PVI using the second generation CB without preprocedural imaging. In 43/238 (18.1%) patients PV abnormality (left common PV in 26, right middle PV in 20) was observed. All targeted veins including abnormal PVs were isolated (100%). Transient phrenic nerve palsy (PNP) occurred in one (2.3%) patient in the PV anomalous group and 6 (3.0%) in the control group (p = NS). There was no other adverse event including PV stenosis, atrio-esophageal fistula or cerebrovascular events related to the procedure. During mean follow-up of 11.8 ± 5.4 month a total of 59 patients (24.7%) had atrial tachyarrhythmia (ATA) recurrence [27 (11.3%) had AT recurrence]. In the PV anomalous group, 20/43 (46.5%) patients had ATA recurrence compared to 39/195 (20%) in the control group (p < 0.001). AT recurrence was observed in 27 (11.3) patients [11 (25.5%) in the PV anomalous group and 16 (8.2%) in controls respectively, p = 0.003]. In patients with PV abnormality CB-based AF ablation results in a similar acute PVI rate but a higher ATA recurrence rate during follow up as compared to patients without PV abnormality. © 2018 Elsevier B.V. Türk Kardiyoloji Derneği, TKD K. Yalin received research and educational grant from Turkish Society of Cardiology . E. Lyan received travel grants and Speaker's Bureau Honoraria from Biosense Webster, Medtronic, Boston Scientific. R. Tilz received travel grants from St. Jude Medical, Topera, Biosense Webster, Daiichi Sankyo, Sentrheart and Speaker's Bureau Honoraria from Biosense Webster, Biotronik, P zer, Topera, Bristol-Myers Squibb; Bayer, Sano Aventis.

INTRODUCTION We aimed to determine the effects of conscious and deep sedation on vagal response (VR) characteristics during ganglionated plexus (GP) ablation. METHODS Forty consecutive patients undergoing GP ablation for vasovagal syncope were divided to receive conscious sedation with midazolam (Group 1, n = 29) or deep sedation with the midazolam-propofol combination (Group 2, n = 11). VR was defined on three levels. R-R interval increase of >50% (Level 1); R-R interval increase of 20%-50% (Level 2); and R-R interval increase of

Funding Acknowledgements Type of funding sources: None. Background Cardiac ganglionated plexi (GPs) of the autonomic system are primarily located in major epicardial fat pads adjacent to the left atrium and pulmonary vein junctions. These structures may play a central role in both the initiation and maintenance of atrial fibrillation (AF). Previous studies reported modification of GPs during pulmonary vein isolation (PVI) may increase rate of sinus node and AF-free survival. However, a deficiency certainly existed why is modification of GPs observed in some patients during PVI but not in others? Purpose We aimed to evaluate ratio of ablation points within classical antral circumferential ablation lines for PVI and distribution of 4 major atrial ganglionated plexus. Methods Thirty-eight consecutive patients undergoing ablation of GP for vagally mediated bradyarrhythmias were evaluated. All GP sites were detected by using previously defined fragmented electrogram based strategy which is a validated tool when compared with a combination of spectral analysis and high frequency stimulation to detect GPs. Estimated ablation lines for antral circumferential ablation was defined as a circumferential isolation line performed ≥1 cm away from the pulmonary vein ostium as identified by 3D electroanatomical reconstruction (Figure 1). The total number of ablation points in each GP sites and ratio of ablation points within estimated antral circumferential ablation lines were recorded. Results The great majority of ablation points were detected at the insertion of the right pulmonary veins. Number of ablation points in each GP site in descending order is as follows: (1) the right superior GP = 13.6 ± 6; (2) the left superior GP = 10.5 ± 5; (3) the right inferior GP = 5.9 ± 4; and (4) the left inferior GP = 2.5 ± 3. The ratio of ablation points within estimated antral circumferential ablation lines was higher in right-sided GPs (50.5%±24 for the right superior GP and 30.2%±31 for the right inferior GP vs 18.3%±24 for the left superior GP and 11.6%±26 for the left inferior GP. Figure 2 demonstrates total number of ablation points and the ratio of ablation points within estimated antral circumferential ablation lines in each GP site. Conclusions The present study shows that individual variability of distribution of GPs and how antral ablation was done during PVI might be the main contributors of neuromodulation effect. Further randomized, controlled and multicenter studies should be performed to confirm these findings. Abstract Figure 1

Funding Acknowledgements Type of funding sources: None. Background The effect of different anesthetics on the function of the autonomic nervous system (ANS) is not well known. As a relatively new treatment option, ganglionated plexus (GP) ablation aims to modify the behavior of the cardiac ANS to prevent some/all of the autonomic processes occurring in vasovagal syncope (VVS) by using endocardial ablation techniques. Purpose The purpose of this study was to determine the effects midazolam and propofol on the vagal response (VR) characteristics during GP ablation in patients with vasovagal syncope (VVS). Methods Forty consecutive patients undergoing GP ablation for VVS were divided to receive local anesthesia with midazolam (group 1, n = 29) or general anesthesia with propofol (group EA, n = 11). All GP sites were detected by using previously defined fragmented electrogram based strategy. VR was defined on 3 levels: 1) R-R interval increased by 50% (level 1); 2) R-R interval increased by 20-50% (level 2); and 3) R-R interval increase lower than 20% (level 3). Results Baseline characteristics and mean follow-up times were comparable between groups. In both groups, the left superior GP (LSGP) was the most common GP site at which a VR was observed. However, there was a significant difference between groups for level of VR. While ablation on the LSGP caused a level 1 VR in 89.6% of cases in group 1, level 1 VR was seen in 22.2% of cases in group 2 (p Conclusions The autonomic nervous tone might be affected in different ways by local and general anesthesia. Propofol may reveal a shift in the sympathovagal balance toward sympathetic predominance which may cause a blunting on VR during GP ablation. Further randomized, controlled and multicenter studies should be performed to confirm these findings.

Funding Acknowledgements Type of funding sources: None. Introduction Pulmonary vein automaticity is an established trigger of paroxysmal atrial fibrillation (PAF) making pulmonary vein isolation (PVI) the cornerstone for catheter ablation. However, data on triggers of AF and catheter ablation strategy in very young ( Methods and results: Sixteen young patients (mean age 25.2 ± 4.9 years; 75% men) with recurrent drug refractory PAF underwent EP study and ablation at 3 EP centers. None of the patients had structural heart disease or family history of AF. EP study revealed degeneration of induced supraventricular tachycardia (SVT) into AF in 5 patients (n = 5, 31.2%). Induced SVTs were left lateral concealed accessory pathway mediated orthodromic AVRT in two patients, typical AVNRT in two patients, and left superior PV tachycardia in one patient respectively. In patients with induced SVTs, SVT ablation without PVI was performed as an index procedure. Remaining patients underwent second generation cryoballoon (CB-2) based PVI (n = 11, 68.7%). There were no major complications related to ablation procedures. Follow-up was based on outpatient visits including 24-h Holter-ECG at 3, 6 and, 12 months post ablation, or additional Holter-ECG was ordered in case of symptoms suggesting recurrence. Recurrence was defined as any atrial tachyarrhythmia (ATA) episode >30s following a 3-month blanking period. After a median follow-up of 18.3 ± 6.2 months, 13 of 16 (81.2%) patients were free of ATA recurrence. None of the patients belonging to SVT ablation only group experienced ATA recurrence. Three patients with previous CB-2 PVI recurred, one had typical atrial flutter and underwent CTI ablation, remaining 2 patients had AF recurrence and medically followed. Conclusion In a considerable fraction of young adult patients with history of PAF SVTs may be responsible and SVT ablation without PVI may be sufficient as an index procedure. Catheter ablation AF seems to be safe and effective in this population.

Adequate and effective therapy for resistant vasovagal syncope patients is lacking and the benefit of cardioneuroablation (CNA) in this cohort is still debated. The aim of this study is to assess the long-term effect of CNA versus conservative therapy (CT) in a retrospectively followed cohort.A total of 2874 patients underwent head-up tilt test (HUT) and 554 (19.2 %) were reported as positive, with VASIS type 2B response or3 s asystole in 130 patients. After exclusion of 29 patients under 18 years and over 65 years of age, 101 patients were included final analysis. Fifty-one patients (50.4%) underwent CNA and 50 (49.6%) patients received CT. After propensity score matching, 19 pairs of patients were successfully matched. The recurrence rate of syncope was compared between groups.During a median follow-up of 22 months (IQR, 13-35), syncope was seen in 12 (11.8%) cases. In the 19 propensity-matched patients, recurrent syncope was observed in 8 patients in the CT group and in 2 patients in the CNA group, respectively. In mixed effect Cox regression analysis, CNA was associated with less syncope recurrence risk at follow-up (HR 0.23, 95% CI 0.03-0.99, p = 0.049). The 4-year Kaplan-Meier syncope free rate was 0.86 (95% CI, 0.63-1.00) for CNA group and 0.50 (95% CI, 0.30-0.82) for CT group in the matched cohort.In highly selected patients with HUT-induced cardioinhibitory response, CNA is associated with a significant reduction in syncope recurrence during follow-up when compared to CT.

A significant shortening of the corrected QT interval (QTc) in addition to parasympathetic denervation after cardioneuroablation (CNA) was recently demonstrated in patients with vagally mediated bradyarrhythmias and normal QTc range. This study assessed the effects of CNA on ventricular repolarization and heart rate by using QTc measurements in 2 patients with long QT syndrome (LQTS). The case series included 2 consecutive patients with significant sinus bradycardia and refractory paroxysmal atrial fibrillation (AF). All atrial ganglionated plexus (GP) sites in addition to pulmonary vein isolation were successively targeted by using electrogram-guided strategy. QTc was calculated on 12-lead ECG before the procedure (time point 1), at post-ablation 24 h (time point 2), and at the last follow-up visit (time point 3), respectively. In the first case, QTc (Bazett) shortened from 612 to 551 msec between time points 1 and 2 and was 419 msec in time point 3. Similarly, QTc (Bazett) shortened from 480 to 401 msec between time points 1 and 3 in the second case. In both cases, minimum and mean heart rates were significantly increased after ablation. The parameters of which are used to estimate both sympathetic and parasympathetic changes in heart rate variability were significantly decreased after ablation. There were no arrhythmia-related symptoms during follow-up. The present case series reports a new ablation strategy systematically targeting autonomic GPs in LQTS patients. CNA shortens QTc (through sympathetic modulation) and increases heart rate. Although promising, these preliminary results need to be confirmed in the larger prospective study.

We aimed to define the role of extended pulmonary vein isolation (PVI), posterior wall isolation, and mitral isthmus lines to eliminate electrograms exhibiting fractionation pattern during stepwise ablation on acute atrial fibrillation (AF) termination rate in patients with long-standing persistent AF (LSPAF). Twelve patients with LSPAF underwent ablation during AF. Using the fractionation mapping tool of the Ensite™ (Abbott Medical, Chicago, USA) system, sites exhibiting discrete atrial complexes and consistent activation sequence were mapped. The areas with a fractionation score above 4 were accepted as potential drivers for AF. During stepwise ablation consisting of circumferential PVI, roof and floor lines for posterior wall isolation, and mitral isthmus lines, ablation lines were extended toward potential AF drivers on the fractionation map as much as possible until sinus was achieved by ablation. Fractionation-guided ablation caused acute AF termination in 8 of 12 patients. In 6 of 12 cases, AF returned to sinus rhythm during the extended ablation. In 2 patients, AF shifted to sinus after cavotricuspid isthmus ablation. Sinus was achieved by cardioversion in 3 of cases. Procedural failure was seen in one case with significant scar tissue. During a mean follow-up of 31.5 ± 11 months, overall arrhythmia-free survival was 92% with 2 procedures. This pilot study demonstrates that fractionation mapping–guided ablation may provide an adjunctive benefit in terms of acute AF termination in patients with LSPAF. These results should be confirmed by larger, randomized, comparison studies between linear ablation and extended ablation without elimination of electrograms (EGMs) with fractionation.