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The implantable cardioverter defibrillator (ICD) is able to reduce sudden arrhythmic death in patients who are considered to be at high risk. However, the arrhythmic risk may be increased only temporarily as long as the proarrhythmic conditions persist, left ventricular ejection fraction remains low, or heart failure prevails. The wearable cardioverter defibrillator (WCD) represents an alternative approach to prevent sudden arrhythmic death until either ICD implantation is clearly indicated or the arrhythmic risk is considered significantly lower or even absent. The WCD is also indicated for interrupted protection by an already implanted ICD, temporary inability to implant an ICD, and lastly refusal of an indicated ICD by the patient. The WCD is not an alternative to the ICD, but a device that may contribute to better selection of patients for ICD therapy. The WCD has the characteristics of an ICD, but does not need to be implanted, and it has similarities with an external defibrillator, but does not require a bystander to apply lifesaving shocks when necessary. The WCD was introduced into clinical practice about 8 years ago, and indications for its use are currently expanding. This article describes the technological aspects of the WCD, discusses current indications for its use, and reviews the clinical studies with the WCD. Additionally, data are reported on the clinical experience with the WCD based on 354 patients from Germany hospitalized between 2000 and 2008 who wore the WCD for a mean of 3 months. (PACE 2010; 33:353-367) [ABSTRACT FROM AUTHOR]

Introduction: Radiofrequency (RF) catheter ablation currently is used for treatment of cardiac arrhythmias. Although the success rate is high for almost all supraventricular tachycardias (SVT), this technique has some drawbacks, especially when pulmonary veins (PV) are targeted for treatment of atrial fibrillation (AF). Additionally, new techniques for isolation of the PVs have the drawback that they can be used only for PV isolation and not for routine treatment of other SVTs. The aim of this study was to report on the safety and efficacy of a new cryoablation system for treatment of all SVTs. Methods and Results: Forty-nine patients with SVT (38 men; age 48 years, range 23-76) were enrolled in the study. Five patients were withdrawn from the study before they underwent cryoablation. The remaining 44 patients were treated with cryoablation (22 AF, 15 atrial flutter, 3 accessory pathway, 2 AV nodal reentrant tachycardia, 1 AV junction ablation for permanent AF, 1 atrial tachycardia). Cryoablation was performed with the CryoCor[TM] cryoablation system, which uses a precooling system and N2O as a refrigerant. The number of freezes applied varied according to the index arrhythmia treated. Successful isolation of PVs was performed in 20 of (96%) 21 AF patients and 53 of 55 veins. The overall acute success was 98% (43/44). Fifty-three PVs were isolated (2.5/patient). The success rate was 100% (23/23) for right-sided procedures. The average and nadir temperatures reached in right-sided and left-sided procedures were -77°C and -80°C and -75°C and -78°C, respectively. No acute PV stenosis was seen. Conclusion: This novel cryoablation system appears to be safe and can successfully treat different types of SVTs, including AF. Isolation of PVs is possible without producing stenosis. Despite the high blood flow in the right atrial isthmus and PVs, bidirectional conduction block can be achieved. [ABSTRACT FROM AUTHOR]

Primary prevention of sudden arrhythmic death in patients with organic heart disease with poor left ventricular function and/or heart failure is currently a major challenge in cardiology. Amiodarone (with or without beta blockers) and the implantable cardioverter defibrillator (ICD) are considered the 2 major therapeutic tools to prevent sudden arrhythmic death in these patients. Two large trials have been launched to define the prophylactic benefit of the ICD or amiodarone on total mortality in patients that receive optimal heart failure and anti-ischemic treatment but remain at high risk of dying suddenly. The Sudden Cardiac Death in Heart Failure Trial (SCD-Heft) is designed to determine whether amiodarone or the ICD will decrease overall mortality in patients with coronary artery disease or nonischemic cardiomyopathy who are in heart failure New York Heart Association (NYHA) class II or III and have a left ventricular ejection fraction < 35%. The primary endpoint is total mortality; secondary objectives are comparison of arrhythmic and nonarrhythmic mortality and morbidity in the 3 arms as well as quality of life, cost-effectiveness, and incidence of episodes of ventricular tachyarrhythmias. The Multicenter Automatic Defibrillator Implantation Trial (MADIT) II is a follow-up study to the MADIT trial. It examines the prophylactic benefit in coronary artery disease patients with a left ventricular ejection fraction of < 30%, who have had at least 1 myocardial infarction but require no further risk stratification. MADIT II is a sequential design trial that compares ICD versus no ICD therapy. Programmed electrical stimulation to test inducibility of ventricular tachycardia is performed during ICD implantation, and various noninvasive risk markers are tested after randomization. Primary endpoint is total mortality, and secondary objectives are quality-of-life issues as well as cost-effectiveness ratio. [ABSTRACT FROM AUTHOR]

The findings of our initial study demonstrate for the first time the ability to terminate induced VT/VF reliably (100% of all episodes) by a single, monophasic 230-J shock delivered by the Wearable Cardioverter-Defibrillator (WCD). Although limited by sample size, our data suggest the WCD could be used as a feasible bridge to definitive implantation of an implantable cardioverter-defibrillator in patients in whom risk stratification for sudden death is not completed. [ABSTRACT FROM AUTHOR]

Aims: This case series was completed to determine the effectiveness of an interdisciplinary (occupational and physical therapy) approach to treating constipation and fecal incontinence in children. Non-pharmacological therapies for treating constipation and incontinence are showing potential benefits, especially for children not responding to standard medical treatment, which involves oral laxatives for fecal dis-impaction (cleanout) and maintenance dosing to prevent further impaction., Methods: A retrospective chart review, surface electromyography (sEMG) biofeedback, and parent and child reports of progress was completed for two children ages 4 and 10 years old. Progress toward goals was measured using a therapy plan of care and progress updates every 60 days. Focus of goals included, pelvic floor muscle coordination and activation, education of anatomy and physiology of digestive system, emotional regulation, functional training in the bathroom, and hygiene., Results: Notable improvements in pelvic floor function, emotional regulation, and defecation dynamics contributed to decreased constipation and fecal incontinence as well as improved emotional regulation and confidence in both participants over a 6-month period., Conclusion: A coordinated physical therapy and occupational therapy approach to treating children with constipation and fecal incontinence can be successful in reaching full continence and support children have not responded to standard medical treatment.

Background: The wearable cardioverter defibrillator (WCD) uses surface electrodes to detect arrhythmia before initiating a treatment sequence. However, it is also prone to inappropriate detection due to artefacts., Objective: The aim of this study is to assess the alarm burden in patients and its impact on clinical outcomes., Methods: Patients from the nationwide Swiss WCD Registry were included. Clinical characteristics and data were obtained from the WCDs. Arrhythmia recordings ≥30 s in length were analysed and categorized as VT/VF, atrial fibrillation (AF), supraventricular tachycardia (SVT) or artefact., Results: A total of 10653 device alarms were documented in 324 of 456 patients (71.1%) over a mean WCD wear-time of 2.0 ± 1.6 months. Episode duration was 30 s or more in 2996 alarms (28.2%). One hundred and eleven (3.7%) were VT/VF episodes. The remaining recordings were inappropriate detections (2736 (91%) due to artefacts; 117 (3.7%) AF; 48 (1.6%) SVT). Two-hundred and seven patients (45%) had three or more alarms per month. Obesity was significantly associated with three or more alarms per month ( p = 0.01, 27.7% vs. 15.9%). High alarm burden was not associated with a lower average daily wear time (20.8 h vs. 20.7 h, p = 0.785) or a decreased implantable cardioverter defibrillator implantation rate after stopping WCD use (48% vs. 47.3%, p = 0.156)., Conclusions: In patients using WCDs, alarms emitted by the device and impending inappropriate shocks were frequent and most commonly caused by artefacts. A high alarm burden was associated with obesity but did not lead to a decreased adherence.

The Swiss Ablation Registry provides a national database for electrophysiologic studies and catheter ablations. We analyzed the database to provide an in-depth look at changing trends over the last 20 years. During the study period a total of 78622 catheter ablations (age 61.0 ± 1.2 years; 63.7% male) were performed in 29 centers. The number of ablations increased by approximately ten-fold in 20 years. Ablation for atrial fibrillation (AF) was the main driver behind this increase, with more than hundred-fold (39.7% of all ablations in 2019). Atrioventricular-nodal-reentrant-tachycardia (AVNRT) and accessory pathways, being the main indications for ablation in 2000 (44.1%/25.1%, respectively), made up of only a small proportion (15.2%/3.5%,) respectively in 2019. Fluoroscopy, ablation, and procedure durations were reduced for all ablations over time. The highest repeat ablations were performed for ventricular tachycardia and AF (24.4%/24.3%). The majority of ablations (63.0%) are currently performed in private hospitals and non-university public hospitals whereas university hospitals had dominated (82.4%) at the turn of the century. A pronounced increase in the number of catheter ablations in Switzerland was accompanied by a marked decrease in fluoroscopy, ablation, and procedure durations. We observed a shift toward more complex procedures in older patients with comorbidities.

Introduction: Sudden cardiac death caused by malignant arrhythmia can be prevented by the use of defibrillators. Although the wearable cardioverter defibrillator (WCD) can prevent such an event, its role in clinical practice is ill defined. We investigated the use of the WCD in Switzerland with emphasis on prescription rate, therapy adherence and treatment rate., Materials and Methods: The Swiss WCD Registry is a retrospective observational registry including patients using a WCD. Patients were included from the first WCD use in Switzerland until February 2018. Baseline characteristics and data on WCD usage were examined for the total study population, and separately for each hospital., Results: From 1 December 2011 to 18 February 2018, a total of 456 patients (67.1% of all WCDs prescribed in Switzerland and 81.1% of all prescribed in the participating hospitals) were included in the registry. Up to 2017 there was a yearly increase in the number of prescribed WCDs to a maximum of 271 prescriptions per year. The mean age of patients was 57 years (&plusmn; 14), 81 (17.8%) were female and mean left ventricular ejection fraction (EF) was 32% (&plusmn; 13). The most common indications for WCD use were new-onset ischaemic cardiomyopathy (ICM) with EF &le;35% (206 patients, 45.2%), new-onset nonischaemic cardiomyopathy (NICM) with EF &le;35% (115 patients, 25.2%), unknown arrhythmic risk (83 patients, 18.2%), bridging to implantable cardioverter-defibrillator implantation or heart transplant (37 patients, 8.1%) and congenital/inherited heart disease (15 patients, 3.3%). Median wear duration was 58 days (interquartile range [IQR] 31&ndash;94) with a median average daily wear time of 22.6 hours (IQR 20&ndash;23.2). Seventeen appropriate therapies from the WCD were delivered in the whole population (treatment rate: 3.7%) to a total of 12 patients (2.6% of all patients). The most common underlying heart disease in patients with a treatment was ICM (13/17, 76.5%). There were no inappropriate treatments., Conclusion: The use of WCDs has increased in Switzerland over the years for a variety of indications. There is high therapy adherence to the WCD, and a treatment rate comparable to previously published registry data. &nbsp.

Introduction: The wearable cardioverter-defibrillator (WCD) has established itself in treatment of potentially life-threatening ventricular arrhythmias, when implantation of an implantable cardioverter-defibrillator (ICD) is not warranted. Careful patient selection for this therapy is crucial, but unfortunately very little information from randomised controlled trials is available to guide clinical decision-making. Consequently, data from real-world patient registries play a more important role in this context., Materials and Methods: A retrospective observational study was conducted at the University Hospital of Zurich and the GZO Regional Healthcare Centre in Wetzikon. Clinical databases were screened for patients with a history of WCD use from the time of its approval in Switzerland in July 2014 until February 2018. Baseline characteristics, WCD data and outcome data, with an emphasis on ICD implantation and ICD therapies, were collected and analysed., Results: Two-hundred and seven patients were included in the primary analysis. Eighty-six percent were male and the mean age was 58 &plusmn; 13 years. The underlying heart disease was ischaemic cardiomyopathy (ICM), non-ischaemic cardiomyopathy (NICM) and congenital/inherited heart diseases in 60, 35 and 5%, respectively. The most common indication for WCD use was heart failure with an ejection fraction (EF) &lt;35% due to ICM or NICM (43 and 27%, respectively). Three of the 207 patients received an appropriate shock over a median WCD wear-time of 62 days (interquartile range [IQR] 35&ndash;95). No inappropriate shocks were registered. Median average daily wear-time was 22.6 hours (IQR 19.9&ndash;23.2) and was significantly shorter for patients for whom WCD discontinuation was due to comfort issues (17 patients, p = 0.003). After the end of WCD therapy, 48% were implanted with an ICD. In those receiving an ICD, the rate of appropriate ICD therapies (either shock or antitachycardia pacing) was 8% during a median follow-up of 110 days (IQR 23&ndash;421)., Conclusion: The WCD is safe and effective in terminating malignant ventricular arrhythmias. A substantial subgroup of patients, however, discontinued WCD use prematurely because of comfort issues. This subset of patients deserves further attention in clinical practice to ensure therapy adherence. &nbsp.

Background: Wearable cardioverter-defibrillators (WCD, LifeVest, ZOLL) can protect from sudden cardiac death bridging a vulnerable period until a decision on implantable cardioverter-defibrillator (ICD) implantation can be reached. WCD is commonly used for 3 months or less. It is unknown, which patients use WCD longer and which patients are most likely to benefit from it., Hypothesis: Extended use of WCD is reasonable in selected cases based on underlying heart disease and overall patient risk profile., Methods: We conducted a systematic and comprehensive research of all published clinical studies on PubMed reporting on the use of the WCD. Only original articles reporting on wear times and time to appropriate shocks were included in our analysis., Results: The search resulted in 127 publications. 14 parameters were reported necessary for inclusion in our analysis. Median wear times ranged from 16 to 394 days. The median wear time was especially long for patients suffering from nonischemic cardiomyopathy (NICM) (range: 50-71 days) and specifically peripartum cardiomyopathy (PPCM) (120 days) and for heart transplant candidates. There was a large variation of appropriate shocks according to indication for WCD use. In contrast to NICM in general, the number of appropriate shocks was particularly high in patients with PPCM (0 in 254 patients and 5 in 49 patients, respectively). The median and maximal time periods to the first appropriate shock were longest in patients with PPCM (median time to the first appropriate shock: 68 days)., Conclusions: Prolonged use of WCD is not uncommon in available literature. Patients suffering from NICM and specifically PPCM seem most likely to have longer therapy duration with WCD with success. Careful patient selection for prolonged use may decrease the need for ICD implantation in the future; however, prospective data are needed to confirm this hypothesis.

The wearable cardioverter-defibrillator has been available for over a decade and now is frequently prescribed for patients deemed at high arrhythmic risk in whom the underlying pathology is potentially reversible or who are awaiting an implantable cardioverter-defibrillator. The use of the wearable cardioverter-defibrillator is included in the new 2015 ESC guidelines for the management of ventricular arrhythmias and prevention of sudden cardiac death. The present review provides insight into the current technology and an overview of this approach., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.)

Purpose of Review: The wearable cardioverter-defibrillator has been available for over a decade. In recent years, the device has been prescribed increasingly for a wide range of indications. The purpose of this review is to describe the technical and clinical aspects of the wearable cardioverter-defibrillator. The available literature on safety, efficacy and cost-effectiveness is reviewed, and indications for use will be discussed., Recent Findings: The wearable cardioverter-defibrillator has been used successfully in more than 100 000 patients for a variety of indications. These include high-risk patients after myocardial infarction or revascularization or with heart failure and newly diagnosed cardiomyopathy. It has also been used to bridge the time period of postponed implantable cardioverter-defibrillator implantation or reimplantation, or until heart transplantation. It has been shown that the device safely and effectively terminates ventricular tachycardia and fibrillation with high first shock success. Patient compliance has been high. Although no randomized trial has been published yet, several guidelines recommend wearable cardioverter-defibrillator use in different patient populations and clinical scenarios., Summary: The wearable cardioverter-defibrillator effectively bridges a limited time period in patients with a real or perceived high risk for sudden cardiac arrest and may become a helpful tool for risk stratification to better select patients for primary prevention implantable cardioverter-defibrillator placement.

It is well established that implantable cardioverter defibrillator (ICD) is a life saving device ensuring protection against life threatening ventricular arrhythmias. But there are certain situations like a recent myocardial infarction where the standard guidelines do not recommend the implantation of an ICD while the patient can still be at a risk of demise due to a life threatening ventricular arrhythmia. There could also be a temporary indication for protection while explanting an infected ICD system. The wearable cardioverter defibrillator (WCD) is a device which comes to the rescue in such situations. In this brief review, we discuss the historical aspects of the development of a WCD, technical aspects as well as the clinical trial data and real world scenario of its use., (Copyright © 2013 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Background: An important determinant of successful cardiac resynchronization therapy for heart failure is the position of the left ventricular (LV) pacing lead. The aim of this study was to analyze the impact of the LV lead position on outcome in patients randomized to cardiac resynchronization-defibrillation in the Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT) study., Methods and Results: The location of the LV lead was assessed by means of coronary venograms and chest x-rays recorded at the time of device implantation. The LV lead location was classified along the short axis into an anterior, lateral, or posterior position and along the long axis into a basal, midventricular, or apical region. The primary end point of MADIT-CRT was heart failure (HF) hospitalization or death, whichever came first. The LV lead position was assessed in 799 patients, (55% patients ≥65 years of age, 26% female, 10% LV ejection fraction ≤25%, 55% ischemic cardiomyopathy, and 71% left bundle-branch block) with a follow-up of 29±11 months. The extent of cardiac resynchronization therapy benefit was similar for leads in the anterior, lateral, or posterior position (P=0.652). The apical lead location compared with leads located in the nonapical position (basal or midventricular region) was associated with a significantly increased risk for heart failure/death (hazard ratio=1.72; 95% confidence interval, 1.09 to 2.71; P=0.019) after adjustment for the clinical covariates. The apical lead position was also associated with an increased risk for death (hazard ratio=2.91; 95% confidence interval, 1.42 to 5.97; P=0.004)., Conclusion: LV leads positioned in the apical region were associated with an unfavorable outcome, suggesting that this lead location should be avoided in cardiac resynchronization therapy. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique identifier: NCT00180271.

Age-related physiologic changes, a higher prevalence of chronic illness, and concomitant (often multiple) medication account for a higher susceptibility of elderly patients to syncope. Although elderly patients are the largest group with syncope, the causes frequently remain unclear. Multifactorial causes, lack of witnesses, overlap with falls, and additional cognitive impairment often confound the assessment of syncope in the elderly. Thus, strategic investigation is often needed to establish the diagnosis and to unmask the cause. In addition to a comprehensive medical history (by both patient and witnesses), a thorough physical examination including supine and standing blood pressure measurements and a standard 12 lead ECG remain the mainstay of diagnosis. The decision whether additional tests are needed depends on indications whether organic heart disease is present or not. Without evidence of structural heart disease, tilt table testing and studies of autonomic function are the next steps. In contrast, additional cardiac investigation (including invasive studies) is needed in patients with suspected or documented cardiac disease. External or implantable loop recorders represent a significant improvement in the diagnosis of rare episodes of (brady- or tachy)-arrhythmias. Prognosis is determined by the underlying (heart) disease.

Although novel cryoablation systems have recently been introduced into clinical practice for catheter ablation of supraventricular tachycardia, the feasibility of catheter cryoablation of VT is unknown. Thus, the present study evaluates catheter cryoablation of the ventricular myocardium (1) in healthy sheep and (2) of VT in chronic myocardial infarction (MI). In three healthy sheep, 21 ventricular lesions (12 left and 9 right ventricle) were created with a catheter cryoablation system. Different freeze/thaw characteristics were used for lesion creation. The mean nadir temperature was -84.1 degrees C +/- 0.9 degrees C, mean lesion volume was 175.8 +/- 170.3 mm3, and 5 of 21 lesions were transmural. Lesion dimensions were 7.5 +/- 3.1 mm (width) and 4.2 +/- 2.5 mm (depth). Left ventricular lesions were significantly larger than right ventricular lesions (262 +/- 166 vs 60.5 +/- 91.6 mm3, P=0.0025). There was no difference in lesion volume with respect to different freeze/thaw characteristics. Anatomically (n=3) or electrophysiologically (n=3) guided catheter cryoablation was attempted in six sheep 105 +/- 56 days after MI, three of six animals had reproducibly inducible VT with a mean cycle length of 215 +/- 34 ms prior to ablation. In these animals, five VTs were targeted for ablation. A mean of 6 +/- 3 applications for nine left ventricular lesions were applied, six of nine lesions were transmural. The mean lesion volume was 501 +/- 424 mm3. No VT was inducible in two of three animals after cryoablation using an identical stimulation protocol. Therefore, catheter cryoablation of VT in healed MI is feasible, and no acute complications were observed.

Introduction: Direct injection of ethanol into myocardium has been shown to create large, well-demarcated lesions with transmural necrosis in normal ventricular myocardium and in regions of healed myocardial infarction. The aim of this study was to investigate the effects of direct ethanol injection on the inducibility of ventricular tachycardia (VT) in an animal model of chronic myocardial infarction., Methods and Results: Eight sheep with reproducibly inducible VT underwent an electrophysiologic study 139 +/- 65 days after myocardial infarction. Noncontact mapping was used to analyze induced VT. Fifteen different VTs were targeted for catheter ablation. Ablation was achieved by catheter-based intramyocardial injection of a mixture of 96% ethanol, glycerine, and iopromide (ratio 3:1:1). Direct intramyocardial ethanol injection resulted in noninducibility of any VT 20 minutes after ablation in 7 of 8 animals. Four of 5 animals with initially successful ablation remained noninducible for any VT at follow-up study at least 2 days after the ablation procedure. Microscopic examination revealed homogeneous lesions with interstitial edema, intramural hemorrhage, and myofibrillar degeneration at the lesion border. The lesions were well demarcated from the surrounding tissue by a border zone of neutrophilic infiltration., Conclusion: Catheter ablation of VT by direct intramyocardial injection of ethanol during the chronic phase of myocardial infarction is feasible. It may be a useful tool for catheter ablation when the area of interest is located deep intramyocardially or subepicardially or when a more regional approach requires ablation of larger amounts of tissue.

Objectives: To evaluate the long-term outcome with an implantable atrial defibrillator (IAD) in patients with recurrent atrial fibrillation (AF)., Background: Maintenance of sinus rhythm using repeated internal cardioversion shocks has been shown to be effective and safe in short-term studies but long term follow-up is unknown., Methods: Since 1995, 136 patients (30 women) with symptomatic, drug-refractory atrial fibrillation were implanted with an IAD (METRIX, InControl). This analysis was performed after a median of 40 (range 7-66) months after implantation., Results: In 26 patients, the programmed mode was not documented during last follow-up, four patients had died. Of the remaining 106 patients (mean age 58+/-10, range 34 - 79 years), 39 were actively delivering therapy with the device, in 14 patients the device was used to monitor the arrhythmia but no shocks were delivered, and in 53 patients it was turned off or explanted. Increases in defibrillation thresholds (n=7), patient intolerance of multiple cardioversion shocks (n=15), and significant bradycardia requiring dual-chamber pacing (n=12) were the main reasons for discontinuation of therapy in addition to battery depletion (n=19). After explantation, efforts to maintain sinus rhythm were continued in 17 patients whereas rate control was attempted in 36 patients., Conclusions: A strategy of maintaining sinus rhythm long-term with an IAD is feasible in a proportion of patients. However, patient selection is critical, and technical improvements (i.e. higher shock energies, dual-chamber pacing and additional preventive and anti-tachycardia pacing algorithms) are required to increase the number of patients having long term benefit, and frequent arrhythmia recurrences and patient intolerance to repeated cardioversion shocks remain a major limitation.

Treatment of ventricular tachyarrhythmias in the setting of chronic myocardial infarction requires accurate characterization of the arrhythmia substrate. New mapping technologies have been developed that facilitate identification and ablation of critical areas even in rapid, hemodynamically unstable ventricular tachycardia. A noncontact mapping system was used to analyze induced ventricular tachycardia in a closed-chest sheep model of chronic myocardial infarction. Twelve sheep were studied 96 +/- 10 days after experimental myocardial infarction. During programmed stimulation, 15 different ventricular tachycardias were induced in nine animals. Induced ventricular tachycardia had a mean cycle length of 190 +/- 30 ms. In 12 ventricular tachycardias, earliest endocardial activity was recorded from virtual electrodes, preceding the surface QRS onset by 30 +/- 7 ms. Noncontact mapping identified diastolic activity in ten ventricular tachycardias. Diastolic potentials were recorded over a variable zone, spanning more than 30 mm. Timing of diastolic potentials varied from early to late diastole and could be traced back to the endocardial exit site. Entrainment with overdrive pacing was attempted in nine ventricular tachycardias, with concealed entrainment observed in seven. Abnormal endocardium in the area of chronic myocardial infarction identified by unipolar peak voltage mapping was confirmed by magnetic resonance imaging. These data suggest that induced ventricular tachycardia in the late phase of myocardial infarction in the sheep model is due to macroreentry involving the infarct borderzone. The combination of this animal model with noncontact mapping technology will allow testing of new strategies to cure and prevent ventricular tachycardia in the setting of chronic myocardial infarction.

The Wearable Cardioverter Defibrillator (WCD) automatically detects and treats ventricular tachyarrhythmias without the need for assistance from a bystander, while at the same time allowing the patient to ambulate freely. It represents an alternative to emergency medical services for outpatient populations with a temporary risk of sudden cardiac death. While the original devices used a monophasic truncated exponential waveform for cardioversion/defibrillation shocks, a new, biphasic shock was developed for the next device generation. In 12 patients undergoing electrophysiological testing for ventricular tachyarrhythmias, termination of electrically induced ventricular fibrillation (VF) was attempted via the WCD. In 22 episodes, induced VF was promptly terminated by the first 70 J (n=12) or 100 J (n=10) biphasic shocks. Time between arrhythmia initiation and shock delivery was 22 +/- 6 seconds (70 J) and 21 +/- 6 seconds (100 J) (P=NS). The measured transthoracic impedance was 71 +/- 5 Ohms (64-79 Ohms) for the 70 J shock and 64 +/- 8 Ohms (47-72 Ohms) for the 100 J shock. The present study demonstrates that a single low energy biphasic shock delivered by the WCD, reliably terminates electrically induced VF (100% of episodes). The results of this study suggest that there is an acceptable safety margin to the maximum output of the device (150 J). Despite our promising data, we recommend that programming all shocks for maximum energy output should be done when using the WCD in ambulatory patients.

Objectives: We sought to evaluate the efficacy and safety of pulmonary vein (PV) isolation using transvenous cryoablation for the treatment of atrial fibrillation (AF)., Background: Although electrical isolation of PVs with radiofrequency energy for the treatment of AF is feasible, it is associated with a significant risk of PV stenosis. Cryoablation is a new alternative therapy allowing ablation of tissue while preserving its underlying architecture., Methods: In 52 patients with paroxysmal (n = 45) or persistent (n = 7) AF, PV isolation using the CryoCor cryoablation system (CyroCor Inc., San Diego, California) with a 10F deflectable transvenous catheter was performed as guided by ostial PV potentials. Cryoablation was applied twice at each targeted site (2.5 to 5 min/application). Computed tomography (CT) of the thorax was performed at baseline and at 3 and 12 months to evaluate for PV stenosis., Results: All targeted PVs were completely isolated in 49 (94%) of 52 of patients. Of 152 PVs targeted, 147 (97%) were successfully isolated (mean 3.0 PVs isolated per patient). After a mean period of 12.4 +/- 5.5 months of follow-up, 37 (71%) of 52 patients had no recurrence of AF or were clinically improved, including 29 patients (56%) who had no recurrence of AF with (n = 11) or without the use of anti-arrhythmic drugs. At 3 and 12 months, the CT scan showed no evidence of PV stenosis associated with cryoablation in any patients., Conclusions: Transvenous catheter cryoablation is an effective method to create PV electrical isolation for the treatment of AF. A clinically satisfactory result can be achieved in 71% of patients with AF, without the risk of PV stenosis.

ICD implantation is standard therapy for malignant ventricular arrhythmias. The advantage of dual and single coil defibrillator leads in the successful conversion of arrhythmias is unclear. This study compared the effectiveness of dual versus single coil defibrillation leads. The study was a prospective, multicenter, randomized study comparing a dual with a single coil defibrillation system as part of an ICD using an active pectoral electrode. Seventy-six patients (64 men, 12 women; age 61 +/- 11 years) were implanted with a dual (group 1, n = 38) or single coil lead system (group 2,n = 38). The patients represented a typical ICD cohort: 60% presented with ischemic cardiomyopathy as their primary cardiac disease, the mean left ventricular ejection fraction was 0.406 +/- 0.158. The primary tachyarrhythmia was monomorphic ventricular tachyarrhythmia in 52.6% patients and ventricular fibrillation in 38.4%. There was no significant difference in terms of P and R wave amplitudes, pacing thresholds, and lead impedance at implantation and follow-up in the two groups. There was similarly no difference in terms of defibrillation thresholds (DFT) at implantation. Patients in group 1 had an average DFT of 10.2 +/- 5.2 J compared to 10.3 +/- 4.1 J in Group 2, P = NS. This study demonstrates no significant advantage of a dual coil lead system over a single coil system in terms of lead values and defibrillation thresholds. This may have important bearing on the choice of lead systems when implanting ICDs.

The Wearable Cardioverter Defibrillator (WCD) is an external defibrillator that automatically detects and treats ventricular tachyarrhythmias without the need for assistance from a bystander while at the same time allowing the patient to ambulate freely. The main components of the system are the defibrillator unit and a chest belt with electrodes for arrhythmia detection and therapy delivery. Between December 1998 and October 2001, 84 patients used the device at our institution. The majority of patients had a history of acute myocardial infarction or coronary artery bypass surgery with an increased risk for sudden cardiac death or were awaiting heart transplantation. During a mean follow-up of 116+/-90 days, 7 episodes of ventricular tachyarrhythmias were detected and terminated successfully by the WCD in 5 patients. In 9720 days, there was one inappropriate shock due to oversensing of electrical noise. Four patients died during follow-up; none of them had a cardiac arrest while wearing the device. Five patients were excluded because of irregularities in device use. An ICD was implanted in 24 patients at the end of the follow-up period. The WCD is effective in detecting and treating ventricular tachyarrhythmias in patients with an intermittently increased risk for sudden cardiac death. Further use of the system in larger patient populations is needed to confirm its safety and cost effectiveness.