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Ventricular arrhythmia (VA) is the primary mechanism of sudden death in patients with structural heart disease. Cardiac stereotactic body radiation therapy (SBRT) delivered to the scar in the left ventricle significantly reduces the burden of VA. The goal of this study was to investigate the impact of SBRT on scar morphology and VA inducibility in a porcine infarct model. Myocardial infarction (MI) was created in 10 Yorkshire pigs involving the left anterior descending artery territory. Cardiac positron emission tomography and computed tomography were performed for targeted SBRT. Alternative pigs received SBRT at 25 Gy in a single fraction. The terminal experiment included endocardial mapping, programmed ventricular stimulation, and tissue harvesting. Of the 10 pigs infarcted, 2 died prematurely after MI and 8 (4 MI and 4 MI+SBRT) survived. Mean time from MI to SBRT was 48 ± 12 days, and mean time from SBRT to harvest was 32 ± 12 days. Scar was localized on intracardiac mapping in all pigs, and the scar was denser in the MI+SBRT compared with the MI-only group (33% ± 20% vs 14% ± 11%; P =.07). All 4 MI pigs had inducible VA during programmed stimulation, whereas only 1 of 4 pigs had inducible VA in the MI+SBRT arm (100% vs 25%; P =.07). No myocardial fibrosis was seen in the remote areas in either group. SBRT reduced VA inducibility in pigs with scarring after MI. Endocardial mapping revealed denser scar in pigs receiving SBRT compared with those that did not, suggesting that SBRT suppresses VA inducibility through better scar homogenization. [Display omitted] [ABSTRACT FROM AUTHOR]

There are limited real-world data on the extended prognosis of patients with drug-induced type 1 Brugada electrocardiogram (ECG). We assessed the clinical outcomes and predictors of life-threatening arrhythmias in patients with drug-induced type 1 Brugada ECG. This multicenter retrospective study, conducted at 21 Italian and Swiss hospitals from July 1997 to May 2021, included consecutive patients with drug-induced type 1 ECG. The primary outcome, a composite of appropriate ICD therapies and sudden cardiac death, was assessed along with the clinical predictors of these events. A total of 606 patients (mean age 49.7 ± 14.7 years; 423 [69.8%] men) were followed for a median of 60.3 months (interquartile range 23.0–122.4 months). Nineteen patients (3.1%) experienced life-threatening arrhythmias, with a median annual event rate of 0.5% over 5 years and 0.25% over 10 years. The SCN5A mutation was the only predictor of the primary outcome (hazard ratio 4.54; P =.002), whereas a trend was observed for unexplained syncope (hazard ratio 3.85; P =.05). In patients who were asymptomatic at presentation, the median annual rate of life-threatening arrhythmias is 0.24% over 5 years and increases to 1.2% if they have inducible ventricular fibrillation during programmed ventricular stimulation. In patients with drug-induced type 1 Brugada ECG, the annual risk of life-threatening arrhythmias is low, with the SCN5A mutation as the only independent predictor. Unexplained syncope correlated with worse clinical outcomes. Ventricular fibrillation inducibility at programmed ventricular stimulation significantly increases the median annual rate of life-threatening arrhythmias from 0.24% to 1.2% over 5 years. [Display omitted] [ABSTRACT FROM AUTHOR]

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Aims Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) detects myocardial scarring, a risk factor for ventricular arrhythmias (VAs) in hypertrophic cardiomyopathy (HCM). The LGE-CMR distinguishes core, borderzone (BZ) fibrosis, and BZ channels, crucial components of re-entry circuits. We studied how scar architecture affects inducibility and electrophysiological traits of VA in HCM. Methods and results We correlated scar composition with programmed ventricular stimulation-inducible VA features using LGE intensity maps. Thirty consecutive patients were enrolled. Thirteen (43%) were non-inducible, 6 (20%) had inducible non-sustained, and 11 (37%) had inducible sustained mono (MMVT)- or polymorphic VT/VF (PVT/VF). Of 17 induced VA, 13 (76%) were MMVT that either ended spontaneously, persisted as sustained monomorphic, or degenerated into PVT/VF. Twenty-seven patients (90%) had LGE. Of these, 17 (57%) had non-sustained or sustained inducible VA. Scar mass significantly increased (P = 0.002) from non-inducible to inducible non-sustained and sustained VA patients in both the BZ and core components. Borderzone channels were found in 23%, 67%, and 91% of non-inducible, inducible non-sustained, and inducible sustained VA patients (P = 0.003). All 13 patients induced with MMVT or monomorphic-initiated PVT/VF had LGE. The origin of 10/13 of these VTs matched scar location, with 8/10 of these LGE regions showing BZ channels. During follow-up (20 months, interquartile range: 7–37), one patient with BZ channels and inducible PVT had an ICD shock for VF. Conclusion Scar architecture determines inducibility and electrophysiological traits of VA in HCM. Larger studies should explore the role of complex LGE patterns in refining risk assessment in HCM patients. [ABSTRACT FROM AUTHOR]

Background: Programed ventricular stimulation (PVS) is a risk stratification tool in patients at risk for adverse arrhythmia outcomes. Patients with negative PVS may yet be at risk for adverse arrhythmia‐related events, particularly in the presence of symptomatic ventricular arrhythmias (VA). Objective: To investigate the long‐term outcomes of real‐world patients with symptomatic VA without indication for device therapy and negative PVS, and to examine the role of cardiac scaring on arrhythmia recurrence. Methods: Patients with symptomatic VA, and late gadolinium enhancement cardiac magnetic resonance imaging (LGE‐CMR), and negative PVS testing were included. All patients underwent placement of implantable cardiac monitors (ICM). Survival analysis was performed to investigate the impact of LGE‐CMR findings on survival free from adverse arrhythmic events. Results: Seventy‐eight patients were included (age 60 ± 14 years, women n = 36 (46%), ejection fraction 57 ± 9%, cardiomyopathy n = 26 (33%), mitral valve prolapse [MVP] n = 9 (12%), positive LGE‐CMR scar n = 49 (62%), history of syncope n = 23 (29%)) including patients with primarily premature ventricular contractions (n = 21) or nonsustained VA (n = 57). Patients were followed for 1.6 ± 1.5 years during which 14 patients (18%) experienced VA requiring treatment (n = 14) or syncope due to bradycardia (n = 2). Four/9 patients (44%) with MVP experienced VA (n = 3) or syncope (n = 1). Baseline characteristics between those with and without adverse events were similar (p > 0.05); however, the presence of cardiac scar on LGE‐CMR was independently associated with an increased risk of adverse events (hazard ratio: 5.6 95% confidence interval: [1.2–27], p = 0.03, log‐rank p = 0.03). Conclusions: In a real‐world cohort with long‐term follow‐up, adverse arrhythmic outcomes occurred in 18% of patients with symptomatic VA despite negative PVS, and this risk was significantly greater in patients with positive DE‐CMR scar. Long term‐monitoring, including the use of ICM, may be appropriate in these patients. [ABSTRACT FROM AUTHOR]

Sudden cardiac death (SCD) is one of the leading causes of cardiovascular death in general population. SCD primary prevention requires the correct selection of patients at increased risk who may benefit from implantable cardioverter-defibrillator (ICD). Despite several noninvasive arrhythmic risk indexes are available, their ability to stratify the SCD risk among asymptomatic patients with cardiac disease at increased arrhythmic risk is debated. The programmed ventricular stimulation (PVS) is an invasive approach historically used for SCD risk stratification in patients with acquired or inherited cardiac disease and is currently included in international guidelines. Aim of this review is to summarize all available data about the role of PVS for the SCD risk stratification in different clinical settings. [ABSTRACT FROM AUTHOR]

Background: Ventricular fibromas frequently present with life-threatening ventricular tachycardia (VT) or ventricular fibrillation (VF) in children. The long-term risk of sustained ventricular arrhythmias after surgical resection is unknown.Objectives: The aims of this study were to quantify the VT/VF risk after surgical resection and to examine the results of early (during index surgical hospitalization) and late (≥3 months after surgery) postoperative ventricular stimulation (V-stim) studies.Methods: We performed a retrospective cohort study of all patients with ventricular fibromas who underwent surgical resection at our institution (2000-2020). The primary outcome was defined as recurrent VT/VF ≥3 months after index surgical resection.Results: Forty-six patients with a median age at surgery of 2 years (range 0.3-18.9 years) formed our study cohort. Indications for surgery included cardiac arrest in 11 (24%), sustained VT in 16 (35%), premature ventricular contractions/nonsustained VT in 10 (22%), and hemodynamic abnormalities in 9 (20%). Of the 11 patients who presented with cardiac arrest, 4 underwent pre-resection implantable cardioverter-defibrillator (ICD) implantation, all of which were explanted at the time of surgery. An early postoperative V-stim study was performed in 26 (57%) patients, and all were negative for inducible VT/VF. Of the 13 late postoperative V-stim studies, 3 were positive: 2 underwent ICD implantation and 1 was initiated on amiodarone and underwent loop recorder implantation. At the time of last follow-up (median 1.5 years; range 0.3-16.5 years), 45 (98%) were free of clinical VT/VF and no patient with an ICD has received an appropriate shock.Conclusion: Surgical resection of ventricular fibromas significantly reduces the risk of life-threatening arrhythmias in children; however, a small number of patients remain vulnerable. [ABSTRACT FROM AUTHOR]

Background: Ventricular arrhythmia inducibility is one of the ideal endpoints of ventricular tachycardia (VT) ablation. However, it may be challenging to implement programmed electrical stimulation (PES) at the end of the procedure under several circumstances. The long-term outcome of patients who did not undergo PES after VT ablation remains largely unknown. Purpose: To investigate the details and long-term outcome of VT ablation in patients who did not undergo PES at the end of the ablation procedure. Methods: Among 183 VT ablation procedures in patients with structural heart disease who underwent VT ablation using an irrigated catheter, we enrolled those who did not undergo PES after VT ablation. VT ablation strategy involved targeting clinical VT plus pacemap-guided substrate ablation if inducible. When VT was not inducible, substrate-based ablation was performed. The primary endpoint was VT recurrence. Results: In 58 procedures, post-ablation VT inducibility was not assessed. The causes were non-inducibility of sustained VT before ablation (27/58, 46.6%), long procedure time (27.6%, mean 392 min), complications (10.3%), intolerant hemodynamic state (10.3%), and inaccessible or unsafe target (6.9%). With regard to the primary endpoint, 23 recurrences (39.7%) were observed during a mean follow-up period of 2.5 years. Patients with non-inducibility before ablation showed less VT recurrences (4/27, 14.8%) during follow-up than patients with other causes of untested PES after ablation (19/31, 61.2%) (Log-rank < 0.001). Conclusions: VT recurrence was not observed in approximately 60% of the patients who did not undergo PES at the end of the ablation procedure. PES after VT ablation may be not needed among patients with pre-ablation non-inducibility. [ABSTRACT FROM AUTHOR]

Sudden cardiac death (SCD) in patients with ischemic heart disease remains a leading cause of death. Prediction of who is at risk is based on the left ventricular ejection fraction (EF). However, the majority of victims of SCD have a normal EF, and the majority of patients implanted with an implantable cardioverter- defibrillator based on their EF are never treated by their device. Several parameters could allow better prediction of SCD. Several signs on the ECG and Periodic Repolarization Dynamics have been associated with increased risk. Elevated serum biomarkers such as pro-B type natriuretic peptides and serum soluble suppression of tumorigenicity 2 protein (sST2) are predictive of SCD. On the echocardiogram, global longitudinal strain, speckle tracking and relative wall thickness have been implicated. Programmed ventricular stimulation studies and cardiac magnetic resonance are promising modalities that could be further investigated. In conclusion, the EF is an imperfect tool for predicting SCD. Using the modalities reviewed, a model could be created for better prediction of patients at risk. [ABSTRACT FROM AUTHOR]

We report the case of drug-induced type 1 Brugada syndrome at high arrhythmic risk associated with Lamin A/C gene mutation.

Aims: Myotonic dystrophy type 1 (DM1) predisposes to the development of life-threatening arrhythmias and sudden cardiac death. Our study aimed to evaluate the prognostic value of programmed ventricular stimulation (PVS) in DM1 patients with conduction system disease.Methods and Results: Arrhythmic CArdiac DEath in MYotonic dystrophy type 1 patients (ACADEMY 1) is a double-arm non-randomized interventional prospective study. Myotonic dystrophy type 1 patients with permanent cardiac pacing indication were eligible for the inclusion. The study population underwent to pacemaker (PM) or implantable cardioverter-defibrillator (ICD) implantation according to the inducibility of ventricular tachyarrhythmias at PVS. Primary endpoint of the study was a composite of appropriate ICD therapy and cardiac arrhythmic death. The secondary study endpoint was all-cause mortality. Seventy-two adult-onset DM1 patients (51 ± 12 years; 39 male) were enrolled in the study. A ventricular tachyarrhythmia was induced in 25 patients (34.7%) at PVS (PVS+) who underwent dual chambers ICD implantation. The remaining 47 patients (65.3%) without inducible ventricular tachyarrhythmia (PVS-) were treated with dual-chamber PM. During an average observation period of 44.7 ± 10.2 months, nine patients (12.5%) met the primary endpoint, four in the ICD group (16%) and five (10.6%) in the PM group. Thirteen patients died (18.5%), 2 in the ICD group (8%) and 11 in PM group (23.4%). The Kaplan-Meier analysis did not show a significantly different risk of both primary and secondary endpoint event rates between the two groups.Conclusions: The inducibility of ventricular tachyarrhythmias has shown a limited value in the arrhythmic risk stratification among DM1 patients. [ABSTRACT FROM AUTHOR]

Sudden cardiac death (SCD) is one of the leading causes of cardiovascular death in general population. SCD primary prevention requires the correct selection of patients at increased risk who may benefit from implantable cardioverter-defibrillator (ICD). Despite several non-invasive arrhythmic risk indexes are available, their ability to stratify the SCD risk among asymptomatic patients with cardiac disease at increased arrhythmic risk is debated. The programmed ventricular stimulation (PVS) is an invasive approach historically used for SCD risk stratification in patients with acquired or inherited cardiac disease and is currently included in international guidelines. Aim of this review is to summarize all available data about the role of PVS for the SCD risk stratification in different clinical settings.

Abstract Background Although some post myocardial infarction (post‐MI) and dilated cardiomyopathy (DCM) patients with mid‐range ejection fraction heart failure (HFmrEF/40%‐49%) face an increased risk for arrhythmic sudden cardiac death (SCD), current guidelines do not recommend an implantable cardiac defibrilator (ICD). We risk stratified hospitalized HFmrEF patients for SCD with a combined non‐invasive risk factors (NIRFs) guiding to programmed ventricular stimulation (PVS) two‐step approach. Methods Forty‐eight patients (male = 83%, age = 64 ± 14 years, LVEF = 45 ± 5%, CAD = 69%, DCM = 31%) underwent a NIRFs screening first‐step with electrocardiogram (ECG), SAECG, Echocardiography and 24‐hour ambulatory ECG (AECG). Thirty‐two patients with presence of one of three NIRFs (SAECG ≥ 2 positive criteria for late potentials, ventricular premature beats ≥ 240/24 hours, and non‐sustained ventricular tachycardia [VT] episode ≥ 1/24 hours) were further investigated with PVS. Patients were classified as either low risk (Group 1, n = 16, NIRFs−), moderate risk (Group 2, n = 18, NIRFs+/PVS−), and high risk (Group 3, n = 14, NIRFs+/PVS+). All in Group 3 received an ICD. Results After 41 ± 18 months, 9 of 48 patients, experienced the major arrhythmic event (MAE) endpoint (clinical VT/fibrillation = 3, appropriate ICD activation = 6). The endpoint occurred more frequently in Group 3 (7/14, 50%) than in Groups 1 and 2 (2/34, 5.8%). Logistic regression model adjusted for PVS, age, and LVEF revealed that PVS was an independent MAE predictor (OR: 21.152, 95% CI: 2.618‐170.887, P = .004). Kaplan‐Meier curves diverged significantly (log rank, P

Electrophysiologic testing with programmed ventricular stimulation (PVS) has been utilized to induce ventricular tachycardia (VT), thereby improving risk stratification for patients with ischemic and nonischemic cardiomyopathies and determining the effectiveness of antiarrhythmic therapies, especially catheter ablation. A variety of procedural aspects can be modified during PVS in order to alter the sensitivity and specificity of the test including the addition of multiple baseline pacing cycle lengths, extrastimuli, and pacing locations. The definition of a positive result is also critically important, which has varied from exclusively sustained monomorphic VT (>30 seconds) to any ventricular arrhythmia regardless of morphology. In this review, we discuss the history of PVS and evaluate its role in sudden cardiac death risk stratification in a variety of patient populations. We propose an approach to future investigations that will capitalize on the unique ability to vary the sensitivity and specificity of this test. We then discuss the application of PVS during and following catheter ablation. The strategies that have been utilized to improve the efficacy of intraprocedural PVS are highlighted during a discussion of the limitations of this probabilistic strategy. The role of noninvasive programmed stimulation is also reviewed in predicting recurrent VT and informing management decisions including repeat ablations, modifications in antiarrhythmic drugs, and implantable cardioverter-defibrillator programming. Based on the available evidence and guidelines, we propose an approach to future investigations that will allow clinicians to optimize the use of PVS for risk stratification and assessment of therapeutic efficacy., Competing Interests: Funding Support and Author Disclosures This research was supported by the F. Harlan Batrus EP Research Fund and the Mark Marchlinski EP Research and Education Fund. Dr Markman has reported that he has no relationships relevant to the contents of this paper to disclose. Dr Marchlinski has received research funding from Biosense Webster; and lecture honoraria from Abbott, Boston Scientific, and Medtronic. Dr Callans has received consulting fees and lecture honoraria from Abbott, Biosense Webster, Biotronik, and Boston Scientific. Dr Frankel has received research support from Biosense Webster; and lecture honoraria from Abbott., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Sudden cardiac death (SCD) in patients with ischemic heart disease remains a leading cause of death. Prediction of who is at risk is based on the left ventricular ejection fraction (EF). However, the majority of victims of SCD have a normal EF, and the majority of patients implanted with an implantable cardioverter- defibrillator based on their EF are never treated by their device. Several parameters could allow better prediction of SCD. Several signs on the ECG and Periodic Repolarization Dynamics have been associated with increased risk. Elevated serum biomarkers such as pro-B type natriuretic peptides and serum soluble suppression of tumorigenicity 2 protein (sST2) are predictive of SCD. On the echocardiogram, global longitudinal strain, speckle tracking and relative wall thickness have been implicated. Programmed ventricular stimulation studies and cardiac magnetic resonance are promising modalities that could be further investigated. In conclusion, the EF is an imperfect tool for predicting SCD. Using the modalities reviewed, a model could be created for better prediction of patients at risk.

Introduction: The dST-Tiso is a newly proposed electrocardiographic (ECG) marker during Brugada (BrS) type I pattern, that predicts the likelihood of ventricular arrhythmia (VA) inducibility in patients with ajmaline-induced pattern. The objective of this study was to validate the effectiveness of this criterion using an independent data set., Methods: Consecutive patients exhibiting a BrS type I ECG pattern following ajmaline administration underwent programmed ventricular stimulation (PVS). dST-Tiso interval was measured in all patients and tested as a predictor for positive VA inducibility., Results: Among 128 patients (median age 43 years, 59% male) with drug-induced BrS type I ECG pattern who underwent PVS, 32 (25.0%) had VA inducibility that required defibrillation. Compared to noninducible subjects, those with positive PVS were more commonly male (81% vs. 51%, p = 0.003), had longer PQ (165 vs. 160 ms, p = 0.016) and dST-Tiso (310 vs. 230 ms, p < 0.001) intervals, and shorter QT interval (412 vs. 420 ms, p = 0.022). When treated as a continuous variable, dST-Tiso confirmed significant association with VA inducibility, with an adjusted odds ratio of 1.02 (95% confidence interval: 1.01-1.03, p < 0.001) for each 1 ms increase in duration. A dST-Tiso interval >300 ms yielded a sensitivity of 75%, a specificity of 86%, and positive and negative predictive values of 69% and 91%, respectively., Conclusion: The validation of the model based on the dST-Tiso interval >300 ms confirmed its high accuracy in predicting VA inducibility in drug-induced BrS type I pattern. This straightforward ECG marker might be linked to the extent of the electrical substrate of the disease., (© 2024 Wiley Periodicals LLC.)

Introduction: Left ventricular noncompaction (LVNC) is associated with ventricular arrhythmias (VA) including premature ventricular complexes, and ventricular tachycardia (VT). The value of imaging with delayed enhancement cardiac magnetic resonance (DE‐CMR) and programmed ventricular stimulation (PVS) for risk stratification in patients with VA and LVNC is unknown. The purpose of this study was to determine whether DE‐CMR and PVS are beneficial for risk stratification and whether CMR helps to identify VA target sites. Methods and Results: Consecutive patients with LVNC undergoing ablation for VAs were included, all patients had preprocedure DE‐CMR. A total of 23 patients (7 women, 46 ± 14 years, ejection fraction 35 ± 14) were included and followed for 2.9 ± 2.2 years. DE‐CMR scar was present in 12/23 patients (52%). PVS was performed in 20/23 patients, 8/10 patients (80%) with scar were inducible for VT compared to 0/10 (0%) patients without scar (p <.001). VA target sites in patients with scarring were located adjacent to areas of scarring in all but 1 patient and ablation was successful in 15/23 patients (65%). Patients with scar had worse survival free of VT than those without scar (log rank p =.01) and patients with inducible VT had worse survival free of VT than those who were noninducible (log rank p <.001). Conclusions: The presence of CMR defined scar in patients with LVNC was associated with inducible VT and worse outcomes. Inducibility for VT was associated with VT recurrence. Furthermore, CMR is beneficial in localizing the arrhythmogenic substrate in LVNC and therefore can aid in procedural planning. [ABSTRACT FROM AUTHOR]

Aims: Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) detects myocardial scarring, a risk factor for ventricular arrhythmias (VAs) in hypertrophic cardiomyopathy (HCM). The LGE-CMR distinguishes core, borderzone (BZ) fibrosis, and BZ channels, crucial components of re-entry circuits. We studied how scar architecture affects inducibility and electrophysiological traits of VA in HCM., Methods and Results: We correlated scar composition with programmed ventricular stimulation-inducible VA features using LGE intensity maps. Thirty consecutive patients were enrolled. Thirteen (43%) were non-inducible, 6 (20%) had inducible non-sustained, and 11 (37%) had inducible sustained mono (MMVT)- or polymorphic VT/VF (PVT/VF). Of 17 induced VA, 13 (76%) were MMVT that either ended spontaneously, persisted as sustained monomorphic, or degenerated into PVT/VF. Twenty-seven patients (90%) had LGE. Of these, 17 (57%) had non-sustained or sustained inducible VA. Scar mass significantly increased (P = 0.002) from non-inducible to inducible non-sustained and sustained VA patients in both the BZ and core components. Borderzone channels were found in 23%, 67%, and 91% of non-inducible, inducible non-sustained, and inducible sustained VA patients (P = 0.003). All 13 patients induced with MMVT or monomorphic-initiated PVT/VF had LGE. The origin of 10/13 of these VTs matched scar location, with 8/10 of these LGE regions showing BZ channels. During follow-up (20 months, interquartile range: 7-37), one patient with BZ channels and inducible PVT had an ICD shock for VF., Conclusion: Scar architecture determines inducibility and electrophysiological traits of VA in HCM. Larger studies should explore the role of complex LGE patterns in refining risk assessment in HCM patients., Competing Interests: Conflict of interest: P.F. received speaker fees from Boston Scientific and research grants from Abbott and Boston Scientific. A.B. is stockholder of Galgo Medical. D.S.-I. and P. F.-O. are employees of Biosense Webster Inc. All other authors declared no conflicts of interest., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Programmed ventricular stimulation (PVS), a clinical tool introduced in the early 1980s, aims to prove the electrical vulnerability of the heart and, independent of spontaneous arrhythmia variability, to trigger arrhythmias under controlled conditions. A specific response is the inducibility of monomorphic sustained ventricular tachycardia. This depends on the underlying heart disease, e.g., only for coronary artery disease but not for nonischemic diseases. The value of pharmacologic arrhythmia control as serial electrical testing is uncertain. Up to now there seems to be no prognostic value of PVS concerning sudden cardiac death. PVS is used as a tool to monitor the results of ventricular tachycardia (VT)-catheter ablation in patients who were primarily inducible., (© 2024. The Author(s).)

Background: Although some post myocardial infarction (post‐MI) and dilated cardiomyopathy (DCM) patients with mid‐range ejection fraction heart failure (HFmrEF/40%‐49%) face an increased risk for arrhythmic sudden cardiac death (SCD), current guidelines do not recommend an implantable cardiac defibrilator (ICD). We risk stratified hospitalized HFmrEF patients for SCD with a combined non‐invasive risk factors (NIRFs) guiding to programmed ventricular stimulation (PVS) two‐step approach. Methods: Forty‐eight patients (male = 83%, age = 64 ± 14 years, LVEF = 45 ± 5%, CAD = 69%, DCM = 31%) underwent a NIRFs screening first‐step with electrocardiogram (ECG), SAECG, Echocardiography and 24‐hour ambulatory ECG (AECG). Thirty‐two patients with presence of one of three NIRFs (SAECG ≥ 2 positive criteria for late potentials, ventricular premature beats ≥ 240/24 hours, and non‐sustained ventricular tachycardia [VT] episode ≥ 1/24 hours) were further investigated with PVS. Patients were classified as either low risk (Group 1, n = 16, NIRFs−), moderate risk (Group 2, n = 18, NIRFs+/PVS−), and high risk (Group 3, n = 14, NIRFs+/PVS+). All in Group 3 received an ICD. Results: After 41 ± 18 months, 9 of 48 patients, experienced the major arrhythmic event (MAE) endpoint (clinical VT/fibrillation = 3, appropriate ICD activation = 6). The endpoint occurred more frequently in Group 3 (7/14, 50%) than in Groups 1 and 2 (2/34, 5.8%). Logistic regression model adjusted for PVS, age, and LVEF revealed that PVS was an independent MAE predictor (OR: 21.152, 95% CI: 2.618‐170.887, P =.004). Kaplan‐Meier curves diverged significantly (log rank, P <.001) while PVS negative predictive value was 94%. Conclusions: In hospitalized HFmrEF post‐MI and DCM patients, a NIRFs guiding to PVS two‐step approach efficiently detected the subgroup at increased risk for MAE. [ABSTRACT FROM AUTHOR]

Introduction: Intramural scarring is a risk factor for sudden cardiac death. The objective of this study was to determine the value of scar quantification for risk stratification in patients with nonischemic cardiomyopathy (NICM) undergoing ablation procedures for ventricular arrhythmias (VA). Methods and Results: Cardiac late gadolinium‐enhanced magnetic resonance imaging was performed in patients with NICM referred for ablation of premature ventricular complexes or ventricular tachycardia (VT). Only patients with intramural delayed enhancement were included. Scar volume was measured and correlated with immediate and long‐term outcomes. Receiver operator curves, Wilcoxon signed‐rank testing, and logistic regression were used to compare patient characteristics. The study consisted of 99 patients (74 males, mean age: 59.6 [54.0‐68.1] years, ejection fraction [EF]: 46.0 [35.0‐60.0]%). Patients without clinical VT or inducible VT had smaller total and core scar size compared to patients with a history of VT or inducible VT (total scar 1.12 [0.74‐1.79] cm3 vs 7.45 [4.16‐12.21] cm3, P <.001). A total scar volume of greater than or equal to 2.78 cm3 was associated with inducibility of VT (AUC 0.94, 95% CI [0.89‐0.98], sensitivity 85%, specificity 90%). Scar volume was associated with VT inducibility independent of a prior history of VT or the preprocedure EF (adjusted OR 1.67 [1.24‐2.24]/cm3, P <.01). Conclusion: Quantification of scar size in patients with intramural scarring is useful for risk stratification in patients with NICM and VA independent of the EF or a prior history of VT. Scar characteristics of patients without a history of VT who have inducible VT are similar to patients with a history of VT. [ABSTRACT FROM AUTHOR]

Aims: To establish the indication for programmed ventricular stimulation (PVS) for asymptomatic patients with Brugada syndrome (BrS), we evaluated the prognostic significance of PVS based on abnormal electrocardiogram (ECG) markers.Methods and Results: One hundred and twenty-five asymptomatic patients with BrS were included. We performed PVS at two sites of the right ventricle with up to three extrastimuli [two pacing cycle lengths and minimum coupling interval (MCI) of 180 ms]. We followed the patients for 133 months and evaluated ventricular fibrillation (VF) events. Fragmented QRS (fQRS) and Tpeak-Tend (Tpe) interval were evaluated as ECG markers for identifying high-risk patients. Fragmented QRS and long Tpe interval (≥100 ms) were observed in 66 and 37 patients, respectively. Ventricular fibrillation was induced by PVS in 60 patients. During follow-up, 10 patients experienced VF events. Fragmented QRS, long Tpe interval, and PVS-induced VF with an MCI of 180 ms or up to two extrastimuli were associated with future VF events (fQRS: P = 0.015, Tpe ≥ 100 ms: P = 0.038, VF induction: P < 0.001). However, PVS-induced VF with an MCI of 200 ms was less specific (P = 0.049). The frequencies of ventricular tachyarrhythmia events during follow-up were 0%/year with no ECG markers and 0.1%/year with no VF induction. The existence of two ECG factors with induced VF was strongly associated with future VF events (event rate: 4.4%/year, P < 0.001), and the existence of one ECG factor with induced VF was also associated (event rate: 1.3%/year, P = 0.011).Conclusion: We propose PVS with a strict protocol for asymptomatic patients with fQRS and/or long Tpe interval to identify high-risk patients. [ABSTRACT FROM AUTHOR]

Introduction: No studies so far addressed the role of invasive programmed ventricular stimulation (PVS) in myocarditis patient's arrhythmic risk stratification. Methods and Results: We present a single‐center prospective study on 96 consecutive adult patients (44 ± 13 years, 70.1% males) with myocarditis and ventricular arrhythmias (VA) at index hospitalization. Depending on baseline endomyocardial biopsy (EMB) and cardiac magnetic resonance, patients were divided into two groups: active (A) vs nonactive (NA) myocarditis. All of the patients underwent PVS at index hospitalization. Medical treatment and implantable cardioverter‐defibrillator (ICD) implantation were clinically‐driven. Malignant VA episodes (MVA = ventricular tachycardias [VT], ventricular fibrillation [VF], appropriate ICD therapy) were evaluated at 54 ± 18 months follow‐up (FU). Patients who underwent VT ablation or with myocarditis recurrence (n = 9) were excluded. Of 87 patients, 41 (47.2%) were in group A. PVS was positive in 32 cases (36.8%), 16 A vs 16 NA (P = NS), with no associations with VA type at presentation. Before discharge, 55 patients (63.2%) underwent ICD implant. In FU, MVA occurred in 27 patients (31.0%), 13 A vs 14 NA (P = NS), 18 PVS+ vs 9 PVS‐ (P <.001). The association between PVS result and FU MVA was maximal in group NA (high rule‐out performance with negative predictive value = 90.0%, P <.001) and minimal in group A (low rule‐in performance with PPV = 43.8%, P =.302). In the whole population, three independent factors for major VA were identified: major arrhythmic onset by sustained VT or VF (HR 2.8, 95% CI, 1.0‐7.4, P =.042), presence of fibrosis at EMB (HR 5.8, 95% CI, 1.1‐30.0, P =.038), and PVS positivity (HR 4.2, 95% CI, 1.7‐10.7, P =.003). Conclusion: In myocarditis patients presenting with VA, PVS is associated with FU MVA in NA patients, but not in A ones. Overall, risk stratification of arrhythmic myocardits is still complex and multifactorial. [ABSTRACT FROM AUTHOR]

Background: Frequent premature ventricular complexes (PVCs) can be an indicator of structural heart disease.Objective: The purpose of this study was to determine the prevalence of scarring detected by delayed enhancement cardiac magnetic resonance (DE-CMR) imaging in patients with frequent PVCs without apparent structural heart disease and to determine the value of programmed ventricular stimulation (PVS) for risk stratification in patients with frequent PVCs and myocardial scarring.Methods: DE-CMR imaging was performed in patients without apparent heart disease who had frequent PVCs and were referred for ablation. In the presence of scarring, scar volume was measured and correlated with outcome variables. All patients underwent PVS and were monitored for the occurrence of ventricular arrhythmias. Logistic regression was used to compare imaging and procedural findings with long-term outcomes, with adjustment for postablation ejection fraction (EF).Results: The study consisted of 272 patients (135 men; mean age 52 ± 15 years; EF 52% ± 12%). DE-CMR scar was found in 67 patients (25%), and 7 (3%) were found to have inducible ventricular tachycardia (VT). The presence and amount of DE-CMR were related to the risk of long-term VT independent of EF (hazard ratio 18.8 [95% confidence interval] [2.0-176.6], P = .01; and hazard ratio 1.4 [1.1-1.7] per cm3 scar, P <.001, respectively). The positive predictive value and negative predictive value of PVS for VT during long-term follow-up were 71% and 100%, respectively.Conclusion: Preprocedural cardiac DE-CMR and PVS can be used to identify patients with frequent PVCs without apparent heart disease who are at risk for VT. [ABSTRACT FROM AUTHOR]

Aims Sudden cardiac death (SCD) annual incidence is 0.6–1% in post-myocardial infarction (MI) patients with left ventricular ejection fraction (LVEF)≥40%. No recommendations for implantable cardioverter-defibrillator (ICD) use exist in this population. Methods and results We introduced a combined non-invasive/invasive risk stratification approach in post-MI ischaemia-free patients, with LVEF ≥ 40%, in a multicentre, prospective, observational cohort study. Patients with at least one positive electrocardiographic non-invasive risk factor (NIRF): premature ventricular complexes, non-sustained ventricular tachycardia, late potentials, prolonged QTc, increased T-wave alternans, reduced heart rate variability, abnormal deceleration capacity with abnormal turbulence, were referred for programmed ventricular stimulation (PVS), with ICDs offered to those inducible. The primary endpoint was the occurrence of a major arrhythmic event (MAE), namely sustained ventricular tachycardia/fibrillation, appropriate ICD activation or SCD. We screened and included 575 consecutive patients (mean age 57 years, LVEF 50.8%). Of them, 204 (35.5%) had at least one positive NIRF. Forty-one of 152 patients undergoing PVS (27–7.1% of total sample) were inducible. Thirty-seven (90.2%) of them received an ICD. Mean follow-up was 32 months and no SCDs were observed, while 9 ICDs (1.57% of total screened population) were appropriately activated. None patient without NIRFs or with NIRFs but negative PVS met the primary endpoint. The algorithm yielded the following: sensitivity 100%, specificity 93.8%, positive predictive value 22%, and negative predictive value 100%. Conclusion The two-step approach of the PRESERVE EF study detects a subpopulation of post-MI patients with preserved LVEF at risk for MAEs that can be effectively addressed with an ICD. Clinicaltrials.gov identifier NCT02124018 Open in new tab Download slide Open in new tab Download slide [ABSTRACT FROM AUTHOR]

The authors discuss a study on the utility of programmed ventricular stimulation in patients with active versus prior arrhythmic myocarditis. Highlights include the use of endomyocardial biopsy as a risk-stratification tool, pathophysiology of ventricular arrhythmia in myocarditis, and the lack of T2-mapping techniques with cardiovascular magnetic resonance and the timing of electrophysiologic imaging before biopsy results.

Abstract Background Although large randomized clinical trials have found that primary prevention use of an implantable cardioverter-defibrillator (ICD) improves survival in patients with cardiomyopathy and heart failure symptoms, patients who receive ICDs in practice are often older and have more comorbidities than patients who were enrolled in the clinical trials. In addition, there is a debate among clinicians on the usefulness of electrophysiological study for risk stratification of asymptomatic patients with Brugada syndrome. Aim Our analysis has 2 objectives. First, to evaluate whether ventricular arrhythmias (VAs) induced with programmed electrostimulation in asymptomatic patients with Brugada syndrome identify a higher risk group that may require additional testing or therapies. Second, to evaluate whether implantation of an ICD is associated with a clinical benefit in older patients and patients with comorbidities who would otherwise benefit on the basis of left ventricular ejection fraction and heart failure symptoms. Methods Traditional statistical approaches were used to address 1) whether programmed ventricular stimulation identifies a higher-risk group in asymptomatic patients with Brugada syndrome and 2) whether ICD implantation for primary prevention is associated with improved outcomes in older patients (>75 years of age) and patients with significant comorbidities who would otherwise meet criteria for ICD implantation on the basis of symptoms or left ventricular function. Results Evidence from 6 studies of 1138 asymptomatic patients were identified. Brugada syndrome with inducible VA on electrophysiological study was identified in 390 (34.3%) patients. To minimize patient overlap, the primary analysis used 5 of the 6 studies and found an odds ratio of 2.3 (95% CI: 0.63–8.66; p=0.2) for major arrhythmic events (sustained VAs, sudden cardiac death, or appropriate ICD therapy) in asymptomatic patients with Brugada syndrome and inducible VA on electrophysiological study versus those without inducible VA. Ten studies were reviewed that evaluated ICD use in older patients and 4 studies that evaluated unique patient populations were identified. In our analysis, ICD implantation was associated with improved survival (overall hazard ratio: 0.75; 95% confidence interval: 0.67–0.83; p<0.001). Ten studies were identified that evaluated ICD use in patients with various comorbidities including renal disease, chronic obstructive pulmonary disease, atrial fibrillation, heart disease, and others. A random effects model demonstrated that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.72; 95% confidence interval: 0.65–0.79; p<0.0001), and a second "minimal overlap" analysis also found that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.61–0.82; p<0.0001). In 5 studies that included data on renal dysfunction, ICD implantation was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.60–0.85; p<0.001). [ABSTRACT FROM AUTHOR]

Background: Although large randomized clinical trials have found that primary prevention use of an implantable cardioverter-defibrillator (ICD) improves survival in patients with cardiomyopathy and heart failure symptoms, patients who receive ICDs in practice are often older and have more comorbidities than patients who were enrolled in the clinical trials. In addition, there is a debate among clinicians on the usefulness of electrophysiological study for risk stratification of asymptomatic patients with Brugada syndrome.Aim: Our analysis has 2 objectives. First, to evaluate whether ventricular arrhythmias (VAs) induced with programmed electrostimulation in asymptomatic patients with Brugada syndrome identify a higher risk group that may require additional testing or therapies. Second, to evaluate whether implantation of an ICD is associated with a clinical benefit in older patients and patients with comorbidities who would otherwise benefit on the basis of left ventricular ejection fraction and heart failure symptoms.Methods: Traditional statistical approaches were used to address 1) whether programmed ventricular stimulation identifies a higher-risk group in asymptomatic patients with Brugada syndrome and 2) whether ICD implantation for primary prevention is associated with improved outcomes in older patients (>75 years of age) and patients with significant comorbidities who would otherwise meet criteria for ICD implantation on the basis of symptoms or left ventricular function.Results: Evidence from 6 studies of 1138 asymptomatic patients were identified. Brugada syndrome with inducible VA on electrophysiological study was identified in 390 (34.3%) patients. To minimize patient overlap, the primary analysis used 5 of the 6 studies and found an odds ratio of 2.3 (95% CI: 0.63-8.66; p=0.2) for major arrhythmic events (sustained VAs, sudden cardiac death, or appropriate ICD therapy) in asymptomatic patients with Brugada syndrome and inducible VA on electrophysiological study versus those without inducible VA. Ten studies were reviewed that evaluated ICD use in older patients and 4 studies that evaluated unique patient populations were identified. In our analysis, ICD implantation was associated with improved survival (overall hazard ratio: 0.75; 95% confidence interval: 0.67-0.83; p<0.001). Ten studies were identified that evaluated ICD use in patients with various comorbidities including renal disease, chronic obstructive pulmonary disease, atrial fibrillation, heart disease, and others. A random effects model demonstrated that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.72; 95% confidence interval: 0.65-0.79; p<0.0001), and a second "minimal overlap" analysis also found that ICD use was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.61-0.82; p<0.0001). In 5 studies that included data on renal dysfunction, ICD implantation was associated with reduced all-cause mortality (overall hazard ratio: 0.71; 95% confidence interval: 0.60-0.85; p<0.001). [ABSTRACT FROM AUTHOR]

Background Sudden cardiac death (SCD) risk stratification in hypertrophic cardiomyopathy (HCM) in the context of primary prevention remains suboptimal. The purpose of this study was to examine the additional contribution of programmed ventricular stimulation (PVS) on established risk assessment. Methods Two-hundred-and-three consecutive patients with diagnosed HCM and ≥ 1 noninvasive risk factors were prospectively enrolled over 19 years. Patients were risk stratified, submitted to PVS and received an implantable cardioverter-defibrillator (ICD) according to then-current American Heart Association (AHA) guidelines and inducibility. Participants were prospectively followed-up for primary endpoint occurrence (appropriate ICD therapy or SCD). Contemporary (2015) AHA and European Society of Cardiology (ESC) guidelines were retrospectively assessed. Results During a median follow-up period of 60 months the primary endpoint occurred in 20 patients, 19 of whom were inducible and received an ICD. Overall, 79 patients (38.9%) were inducible and 92 patients (45.3%) received an ICD (PVS sensitivity = 95%, specificity = 67.2%, positive predictive value = 24%, negative predictive value = 99.2%). AHA and ESC guidelines application misclassified 3 and 9 primary endpoint-meeting patients, respectively. Inducibility was the most important determinant of event-free survival in multivariate Cox regression (hazard ratio = 33.3). A combined approach of ESC score ≥ 6% or AHA indication for ICD with PVS inducibility yielded absolute sensitivity and negative predictive value, the former at a more cost-effective and specific way. Conclusions Inducibility at PVS predicts SCD or appropriate device therapy in HCM. Non-inducibility is associated with prolonged event-free survival, while the procedure was proven safe. Reintegration of PVS into established risk stratification models in HCM may improve patient assessment. [ABSTRACT FROM AUTHOR]

According with the new European and American guidelines, the role of an electrophysiology study (EPS) remains small for risk stratification for sudden cardiac death (SCD), limited to patients with an LVEF >35%, mostly indicated when evaluating symptoms suggestive of ventricular tachyarrhythmias, including palpitations, presyncope and syncope, mainly in those with underlying structural heart disease, particularly coronary artery disease in the setting of a remote myocardial infarction rather than non-ischemic cardiomyopathy. Importantly, there is no indication or need of EPS as a prerequisite for any of the standard indications of implantable cardioverter defibrillator (ICD) for secondary or primary prevention of SCD. [ABSTRACT FROM AUTHOR]

Background: Frequent premature ventricular complexes (PVCs) have been associated with increased mortality. However, the optimal approach to the risk stratification of these patients is unclear.Objective: The purpose of this study was to prospectively assess the use of cardiac magnetic resonance imaging (MRI) and programmed ventricular stimulation to identify patients with PVCs undergoing radiofrequency ablation at risk for adverse long-term outcomes.Methods: A total of 321 consecutive patients (52 ± 15 years; 157 men [49%]; left ventricular ejection fraction 51% ± 12%) underwent PVC ablation between 2004 and 2015, preceded by cardiac MRI to assess for structural heart disease (SHD). Programmed stimulation was performed at the time of the ablation procedure. If ventricular tachycardia (VT) was induced in the presence of SHD, an implantable cardioverter-defibrillator (ICD) was implanted.Results: SHD was identified by MRI in 64 patients (20%), and sustained monomorphic VT was inducible in 15 patients (5%). Fourteen patients had both SHD and inducible VT, and received an ICD after the procedure. The primary endpoint of VT/ventricular fibrillation or death was met in 15 patients after a median 20 months of follow-up. The combination of SHD by MRI and VT inducibility conferred independently an increased risk of adverse outcome (multivariate hazard ratio 25.73, 95% confidence interval 6.74-98.20; P <.001).Conclusion: Preablation cardiac MRI and programmed stimulation can be useful for risk stratification in patients with frequent PVCs. Patients with inducible VT in the setting of SHD may benefit from ICD implantation after ablation regardless of left ventricular ejection fraction. [ABSTRACT FROM AUTHOR]

Background: Primary prevention of sudden cardiac death by means of implantable cardioverter-defibrillators constitutes the holy grail of arrhythmology. However, current risk stratification algorithms lead to suboptimal outcomes, by both allocating ICDs to patients not deriving any meaningful survival benefit and withholding them from those erroneously considered as low-risk for arrhythmic mortality.Methods: In the present review article we will attempt to present shortcomings of contemporary guidelines regarding sudden death prevention in ischemic and dilated cardiomyopathy patients and present available data suggesting encouraging results following implementation of multifactorial approaches, by using multiple modalities, both noninvasive and invasive. Invasive electrophysiological testing, namely programmed ventricular stimulation, will be discussed in greater length to highlight both its potential usefulness and currently ongoing multicenter studies aiming to provide evidence necessary to make the next step in sudden death risk stratification.Results: Promising findings have been reported by multiple study groups regarding novel strategies for both negative selection of low and positive selection of relatively preserved ejection fraction patients as candidates for ICD implantation.Conclusions: The era of ejection fraction as the sole risk stratifier for arrhythmic risk in heart failure appears to be drawing to an end, especially if current underway large studies validate previous findings. [ABSTRACT FROM AUTHOR]

The article offers a case study of a 45-year old woman with no structural heart disease presented with recurrent episodes of paroxysmal palpitation whose baseline electrocardiogram had not shown preexcitation. It mentions the differential diagnosis for an left bundle branch block (LBBB) tachycardia includes supraventricular tachycardia and atrial tachycardia.

A case of a patient with Brugada pattern on ECG is presented with dubious symptoms whose management was guided by an electrophysiology (EP) study where programmed ventricular stimulation easily induced ventricular fibrillation with only two ventricular extrastimuli and facilitated a decision to implant a defibrillator for sudden death protection. Images of the EP tracings are provided that illustrate the findings and the pros and cons of such an approach are herein discussed. [ABSTRACT FROM AUTHOR]

Background: The results of programmed ventricular stimulation (PVS) may change after myocardial infarction (MI). The objective was to study the factors that could predict the results of a second PVS.Methods: Left ventricular ejection fraction (LVEF) and QRS duration were determined and PVS performed within 3 to 14 years of one another (mean 7.5±5) in 50 patients studied systematically between 1 and 3 months after acute MI.Results: QRS duration increased from 120±23 ms to 132±29 (p 0.04). LVEF did not decrease significantly (36±12 % vs 37±13 %). Ventricular tachycardia with cycle length (CL) > 220ms (VT) was induced in 11 patients at PVS 1, who had inducible VT with a CL > 220 ms (8) or < 220 ms (ventricular flutter, VFl) (3) at PVS 2. VFl or fibrillation (VF) was induced in 14 patients at PVS 1 and remained inducible in 5; 5 patients had inducible VT and 4 had a negative 2nd PVS. 2. 25 patients had initially negative PVS; 7 had secondarily inducible VT, 4 a VFl/VF, 14 a negative PVS. Changes of PVS were related to initially increasing QRS duration and secondarily changes in LVEF and revascularization but not to the number of extrastimuli required to induce VFl.Conclusions: In patients without induced VT at first study, changes of PVS are possible during the life. Patients with initially long QRS duration and those who developed decreased LVEF are more at risk to have inducible monomorphic VT at 2nd study, than other patients.

Background: Brugada syndrome is an arrhythmogenic disease characterized by an ECG pattern of ST-segment elevation in the right precordial leads and an increase risk of sudden cardiac death. Risk stratification for the life-threatening arrhythmic events in Brugada syndrome is not yet established. In the present study, we report our experience in patients with Brugada syndrome, following an ICD implantation.Methods and Results: A total of 12 patients (11 men, 1 woman) with a mean age of 46.5±11.8 were studied. At diagnosis, 7 patients had syncope of unknown origin, 2 patients were asymptomatic, 2 patients were survivors of cardiac arrest, and 1 had documented clinical VT requiring direct cardioversion for termination. Age was similar between the symptomatic and asymptomatic patients (46.6±13 vs. 46±2.8, respectively). Two patients reported a family history of sudden cardiac death. In 3 patients, spontaneous coved-type ECG was found at baseline. In 9 patients, a class I antiarrhythmic drug administration unmasked the characteristic type I ECG. In 4 patients (2 symptomatic with syncope at presentation and 2 asymptomatic), who underwent PES, sustained polymorphic VT or VF was induced. VF was induced by single extrastimuli in 2 symptomatic patients (1 from RV apex and 1 from RVOT). In 2 asymptomatic patients, VF was induced by two and triple ventricular extrastimli (1 from RV apex and 1 from RVOT). None of them experienced an event during follow-up. No significant difference was found between symptomatic and asymptomatic patients (p=NS). The mean follow-up period for the entire study population was 27.83±11.25 months. During follow-up, 2 patients (one with prior cardiac arrest and another with syncope) had VF. Both of them had a type I ECG after provocation with a class I antiarrhythmic drug. None of them had undergone programmed ventricular stimulation. Five patients (41.7 %) had inappropriate ICD interventions during follow-up. The cause of inappropriate therapy was sinus tachycardia in 2 patients, AF in 2 patients and T wave oversensing in 1 patient. Conclusions: Knowledge about Brugada syndrome is steadily progressing but there are still unanswered issues dealing with the risk stratification and the management of patients.

Introduction: Robotically guided radiofrequency (RF) ablation offers greater catheter stability that may improve lesion depth. We performed a non-randomised comparison of patients undergoing ventricular tachycardia (VT) ablation either manually or robotically using the Hansen Sensei system for recurrent implantable defibrillator (ICD) therapy. Methods: Patients with infarct-related scar underwent VT ablation using the Hansen system to assess feasibility compared with patients undergoing manual VT ablation during a similar time period. Power delivery during robotic ablation was restricted to 30 W at 60 s. VT inducibility was checked at the end of the procedure. Pre-ablation ICD therapy burdens over 6 months were compared with post-ablation therapy averaged to a 6-month period. Results: Twelve consecutive patients who underwent robotic VT ablation were compared to 12 consecutive patients undergoing a manual ablation. Patient demographics and comorbidities were similar in the two groups. A higher proportion of robotic cases were urgent (9/12 (75 %)) vs. manual (4/12 (33 %)) ( p = 0.1). Post-ablation VT stimulation did not induce clinical VT in 11/12 (92 %) in each group. There were no peri-procedural complications related to ablation delivery. Patients were followed up for approximately 2 years. Averaged over 6 months, robotic ICD therapy burdens fell from 32 (5-400) events to 2.5 (0-11) ( p = 0.015). Therapy burden fell from 14 (10-25) to 1 (0-5) ( p = 0.023) in the manual group. There was no difference in long-term outcome ( p = 0.60) and mortality (4/12 (33 %), p = 1.0). Conclusion: Robotically guided VT ablation is both feasible and safe when compared to manual ablation with good acute and long-term outcomes. [ABSTRACT FROM AUTHOR]