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Ventricular arrhythmias in cardiac channelopathies are linked to autonomic triggers, which are sub-optimally targeted in current management strategies. Improved molecular understanding of cardiac channelopathies and cellular autonomic signalling could refine autonomic therapies to target the specific signalling pathways relevant to the specific aetiologies as well as the central nervous system centres involved in the cardiac autonomic regulation. This review summarizes key anatomical and physiological aspects of the cardiac autonomic nervous system and its impact on ventricular arrhythmias in primary inherited arrhythmia syndromes. Proarrhythmogenic autonomic effects and potential therapeutic targets in defined conditions including the Brugada syndrome, early repolarization syndrome, long QT syndrome, and catecholaminergic polymorphic ventricular tachycardia will be examined. Pharmacological and interventional neuromodulation options for these cardiac channelopathies are discussed. Promising new targets for cardiac neuromodulation include inhibitory and excitatory G-protein coupled receptors, neuropeptides, chemorepellents/attractants as well as the vagal and sympathetic nuclei in the central nervous system. Novel therapeutic strategies utilizing invasive and non-invasive deep brain/brain stem stimulation as well as the rapidly growing field of chemo-, opto-, or sonogenetics allowing cell-specific targeting to reduce ventricular arrhythmias are presented. [ABSTRACT FROM AUTHOR]

Accessing the pericardial space safely and efficiently is an important skill for interventional cardiac electrophysiologist. With the increased recognition of the complexity of the 3‐dimensional arrhythmogenic substrate due to advances in imaging and mapping technologies there has been an expansion of epicardial procedures in recent years. Equally, minimally invasive implantation of epicardial pacing, cardiac resynchronization, or defibrillation leads is expanding in specific patients where transvenous systems are contraindicated or their long term sequelae should be ideally avoided. Selective delivery of intrapericardial pharmacological antiarrhythmic therapy is yet another potential indication, albeit still investigational. The expanding indications for percutaneous epicardial procedures is contrasted by the still substantial risk and challenges associated with accessing the pericardial space. Myocardial perforation, coronary artery laceration, and damage to the surrounding organs are all recognized and feared complications. A number of innovative epicardial access techniques have been proposed to overcome the difficulties and risks of traditional dry subxiphoid punctures and may allow for more widespread use of epicardial access in the future. We review 10 different established and novel subxiphoidal epicardial access techniques describing procedural success rates, safety profile and overall experience. The technical aspects as well as access times and costs for extra equipment will be reviewed. Finally, an outlook of reported preclinical techniques awaiting in‐human feasibility studies is provided. [ABSTRACT FROM AUTHOR]

Contemporary cardiac imaging allows for detailed non-invasive assessment of structural alterations of the atria implicated in the initiation and maintenance of atrial arrhythmias. Left atrial wall thickness (LAWT) may be an important parameter reflecting atrial remodelling as it is thought that LAWT increases in the presence of AF and may further promote its perpetuation. Tissue thickness may also be important to success and safety of AF ablation given the importance of creating durable, transmural lesions without causing collateral damage. Different calculation methods for quantifying local LAWT exist. An understanding of quantitative differences between estimation methods is relevant if LAWT-guided ablation strategies are pursued. We aimed to compare the results of LAWT measurement within the same cohort using a semi-automated eikonal-equation based workflow against a proprietary automated nearest-point LAWT estimation approach. In a prospective case-control study, patients with AF and controls without AF but with clinical indication for cardiac computed tomographic angiography (CCTA) were recruited. Prospective, ECG-gated CCTAs were acquired and the best diastolic sequence identified. 42 AF patients (35.7% female, mean age 64.6 +/- 10.2, CHA2DS2-VASc 2.48 +/- 1.5, 69.0% paroxysmal AF, 31% persistent AF, mean LVEF 57.9 +/- 10.5%) and 37 controls (35.1% female, mean age 56.6 +/- 7.2, CHA2DS2-VASc 1.54 +/- 1, mean LVEF 60.4 +/- 4.9%) were recruited. A total of 76 contrast enhanced CTs (37 Control, 39 AF) were acquired. Mean wall thickness between the two methods showed moderate, statistically significant correlation (r 0.499 p < 0.001). Mean LAWT was higher using ADAS LAWT estimation in all groups (total, AF and control) with a mean difference of 0.39mm (p 0.001). Both methods identified a statistically significant increase in LAWT in AF patients when compared to controls. There was no significant difference in standard derivation between estimation methods. In conclusion, fully automated nearest point LAWT estimation and semi-automated eikonal based LAWT estimation method yield a moderate, statistically significant correlation with mean difference in the sub-millimetre range. Even though the latter is statistically significant, for clinical ablation procedures these differences are likely to be of negligible clinical relevance. Available local expertise and software for LAWT estimation may determine the preferred employed approach. [ABSTRACT FROM AUTHOR]

Background: Epicardial ICD systems and CRT‐Ds using high voltage coils represent an alternative to transvenous systems in patients without central venous access and prior device complications including infection. Objective: We present a case series in the adult population of epicardial ICD/CRTD systems using high voltage epicardial coils. We summarize the existing data regarding techniques, efficacy, and safety. Methods: A retrospective board approved medical record review was conducted for all patients undergoing epicardial ICD/CRTD placement at our institution between January 2010 and May 2020. The literature was reviewed for prior published trials, case reports, and case series of epicardial high voltage coil insertions. Results: Eleven patients (six female, mean age 48 years) underwent epicardial ICD/CRTD implant including 5/11 completely epicardial CRTD systems. The procedure was performed via median sternotomy in eight patients, left anterior thoracotomy in two patients, and sub‐xiphoid approach in one patient. After a mean follow up of 35 months, appropriate successful shocks were delivered in two (18%) patients and no patients received an inappropriate shock. Three of five (60%) patients had volumetric remodeling with CRT with significant improvement of LV EF. Device‐related complications requiring a surgical/percutaneous revision or another DFT test occurred in six patients (54%). One patient died during follow up due to refractory heart failure. No cases of epicardial device infection, coronary artery compression, constrictive pericarditis, or erosion of defibrillator coils into intrathoracic organs were reported. No randomized studies comparing safety and efficacy of traditional transvenous or subcutaneous ICD systems and epicardial ICD systems using contemporary high voltage coils were found nor any studies directly comparing epicardial defibrillator patches versus epicardial coils. Thirteen case series and 24 single case reports published between 2004 and 2020 were identified describing in total a heterogenous group of 188 patients with ICD systems incorporating one or more epi‐ or pericardially positioned shock coils. Conclusion: The use of epicardial defibrillation coils for ICD/CRT‐D is a feasible treatment option for patients with either failed or contraindicated transvenous ICD systems. Dedicated epicardial high voltage leads with integrated pace‐sense electrodes and specialized delivery tools for minimal invasive implantations may improve longer term outcomes. [ABSTRACT FROM AUTHOR]

The use of the "inside-out" approach with an infraclavicular exit site with a dedicated system in the presence of complex central venous occlusion is feasible and safe for the implantation of complex cardiac devices. [ABSTRACT FROM AUTHOR]

Cardiac involvement in the rare monogenic autosomal recessive Alström syndrome (ALMS) may manifest as infantile, juvenile or adult dilated or restrictive cardiomyopathy. Case reports have described ventricular arrhythmias and conduction system disease, though little is known about atrial arrhythmia burden and management in these patients. This case presents a possible underreported atrial phenotype of the ALMS with exceptionally advanced structural remodelling with atrial scar encompassing nearly the entire left atrium in a young patient. It highlights the difficulties in managing these patient with medical rate and rhythm control due to frequent multi-organ involvement and concomitant conduction system disease, as well as the challenges faced during invasive activation mapping in an exceptionally disease atrial myocardium with ubiquitous complex low amplitude EGMs undermining the value of high density mapping with automated annotation algorithms. [ABSTRACT FROM AUTHOR]

The high prevalence of atrial fibrillation (AF) in the overall population and its association with substantial morbidity, increased mortality and health care cost has instigated significant basic and clinical research efforts over recent years. The publication of multiple new high-quality randomized multi-center trials in the area of AF management and the rapidly evolving technological progress in terms of diagnostic possibilities and catheter ablation in recent years demanded a revision of the previous ESC AF Guidelines from 2016. The 2020 guidelines provide up-to-date, evidence-based guidance for the management of AF. One of the most important innovations is the presentation of a new concept for structural characterization of AF (the "4S AF scheme") replacing the traditional classification based on its temporal pattern alone (paroxysmal-persistent-permanent). The 4S-AF-scheme highlights the importance of systematic assessment of stroke risk, severity of symptoms, total AF burden and underlying substrate as the foundation for effective and individualized AF treatment for each and every patient. Further novelties relate to the presentation of an easy and intuitive management pathway ("ABC pathway") and strengthening the recommendations for early rhythm control, in particular the role of first line catheter ablation in heart failure. Another core component of the guidelines is the focus on patient involvement to achieve optimal outcomes. Patient education, shared decision making and incorporation of patient values and patient reported outcome of treatment interventions as well as integrated care by a multidisciplinary team all have a central role in the proposed management pathway for AF. [ABSTRACT FROM AUTHOR]