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Introduction: Catheter ablation is an effective treatment of scar-related ventricular tachycardia (VT), but the overall complexity of the procedure has precluded its widespread use. Remote magnetic navigation (RMN) has been shown to facilitate cardiac mapping and ablation of VT in a retrospective series. STOP-VT is the first multicenter, prospective, single-arm and single-procedure study evaluating RMN-based mapping and ablation of post-infarction VT., Methods: Patients with documented VT and prior MI, in whom an ICD was implanted either for primary or secondary prevention, were recruited from four EU and US centers. Either a transseptal (48 patients) or transaortic (5 patients) approach was employed to gain access for ventricular endocardial mapping/ablation during VT (entrainment mapping, activation mapping) and/or substrate mapping in sinus rhythm (elimination of fractionated/late potentials, variable extent of substrate modification) with RMN and irrigated RF ablation. The primary endpoints were as follows: (i) non-inducibility of the target VT or any other sustained VT; (ii) elimination of sustained VT/VF during ICD follow-up of up to 12 months., Results: The cohort included 53 consecutive patients (median age 67 years, 49 men, median LVEF 31%). One hemodynamically unstable patient was excluded at the onset of mapping. Inducibility of sustained VT was achieved an average of 2.2 times per patient (1-8), with mean tachycardia cycle length (TCL) 374 milliseconds (179-510). Mean total procedure and fluoroscopy times were 223 minutes and 8.7 minutes, respectively; mean cumulative fluoroscopy time during mapping and ablation was 0.95 minutes; maximum power averaged 42.3 W with nominal saline 30 cc/min irrigation; mean cumulative RF time was 38 minutes. Non-inducibility of the target VT was achieved in 49/52 patients (94.2%) and non-inducibility of any VT was achieved in 38/52 patients (73.1%). A combination of RMN and manual ablation was performed in two patients, rendering one non-inducible. During the 12-month ICD follow-up period, freedom from any sustained VT/VF was observed in 30 patients (62%), of which 19 (63%) were off antiarrhythmic medications. Five patients expired during follow-up: one presented with a VT storm, but for the others, death was not related to VT/VF (MI-cardiogenic shock, pulmonary embolism, bronchogenic carcinoma, end stage heart failure). No procedural complications were reported., Conclusions: This first prospective, single-procedure, multicenter study indicates that remote magnetic navigation is a safe and effective method for catheter ablation of post-infarction VT., (© 2016 Wiley Periodicals, Inc.)

Introduction: Effectiveness of antral pulmonary vein isolation (PVAI) and ablation of non-PV triggers (non-PVTA) in controlling longstanding persistent atrial fibrillation (AF) has not been reported. We sought to describe clinical outcomes with this ablation strategy in patients (pts) followed for at least 1 year., Methods: Two hundred pts underwent PVAI for longstanding persistent AF and were followed for recurrence. Thirty-three pts with <1-year follow-up and 37 pts with additional RF atrial ablation were excluded, leaving 130 pts for analysis., Results: All 130 pts (108 men, mean LA 4.7 ± 0.6 cm, mean AF duration of 38 ± 44 months) underwent PVAI with entrance/exit block. In addition, 24 pts (15 pts during the initial procedure and 9 additional pts at repeat ablations) had 40 non-PVTA, including 3 with AVNRT. During follow-up, atrial flutter (AFL) was noted in 7 (5%) pts. The AF-free survival after single procedure without antiarrhythmic drugs (AAD) was 38%. Repeat AF or AFL ablation was performed in 37 pts (28%) with PV reconnection uniformly identified (3.7 ± 0.5 veins/pt). During mean follow-up of 41.1 ± 23.8 months (range 12-103 months), 85/130 pts (65%) were in sinus rhythm with 65 pts (50%) off AAD, 20 pts (15%) on AAD. Additionally, 9 pts (7%) have had rare episodes of AF such that 72% of pts have had good long-term clinical outcome. Of the 36 pts with recurrent AF, 20 pts have not had a repeat procedure., Conclusions: PVAI with non-PVTA for longstanding persistent AF provides good long-term AF control in over 70% of patients with infrequent (5%) AFL. AAD therapy and repeat PVAI may be required for this optimal outcome., (© 2012 Wiley Periodicals, Inc.)

Introduction: The number of elderly patients with atrial fibrillation (AF) is increasing rapidly, and the safety and efficacy of catheter ablation in this demographic group has not been established., Methods: Over a 7-year period we studied 1,165 consecutive patients undergoing 1,506 AF ablation procedures using a consistent ablation protocol that included proximal ostial pulmonary vein (PV) isolation and focal ablation of non-PV AF triggers. Outcome was analyzed for three distinct age groups: <65 years (group 1; n = 948 patients), 65-74 years (group 2; n = 185 patients), and > or =75 years (group 3; n = 32 patients) based on the age at the initial procedure., Results: There was no significant difference in AF control (89% in group 1, 84% in group 2, and 86% in group 3, P = NS) during a mean follow-up of 27 months. Major complication rates were also comparable (1.6% in group 1, 1.7% in group 2, 2.9% in group 3, P = NS) between the three groups. There was no difference in the left atrial size, percentage with left ventricular ejection fraction <50%, or percentage with paroxysmal versus more persistent forms of atrial fibrillation. However, older patients were more likely to be women (20% in group 1, 34% in group 2, and 56% in group 3, P < 0.001) and have hypertension and/or structural heart disease (56% in group 1 vs 68% in group 2 vs 88% in group 3; P < 0.001). There was a strong trend demonstrating that older patients were less likely to undergo repeat ablation (26% vs 27% vs 9%) to achieve AF control and more likely to remain on antiarrhythmic drugs (20% vs 29% vs 37%; P < 0.05)., Conclusions: Elderly patients with AF undergoing catheter ablation therapy are represented by a higher proportion of women and have a higher incidence of hypertension/structural heart disease. To achieve a similar level of AF control, there appears to be no increased risk from the ablation procedure, but elderly patients are more likely to remain on antiarrhythmic drugs.

Recurrent ventricular tachycardia (VT) in the setting of coronary artery disease is frequently a life-threatening electrophysiologic emergency. Even in patients with an implantable defibrillator, recurrent VT is frequently accompanied by repeated and disabling shock therapy. Catheter ablative therapy offers the ability to provide immediate control of recurrent VT. Long-term elimination of VT should be anticipated in most patients. This article reviews the strategies, tools, techniques, and expected outcome for catheter ablation of stable and unstable ventricular arrhythmias in the setting ischemic heart disease.

Introduction: Ablative therapy for atrial fibrillation (AF) by targeting initiating triggers, usually in or around the pulmonary veins, has been reported by several centers. Evidence for an overall improvement in quality of life (QOL) and amelioration of symptoms is lacking., Methods and Results: Seventy-one patients undergoing attempted ablation of focal AF were followed for 60+/-33 weeks. QOL and symptom questionnaires were completed 1 month before and 6 months after electrophysiologic study. Twenty-three patients (32%) underwent electrophysiologic mapping but no ablation because of either insufficient or multifocal ectopy; the other 48 patients (68%) underwent attempted ablation. Sixteen of 48 patients (33%) undergoing ablation, or 16 (23%) of 71 on an intention-to-treat basis, were found at last follow-up to have persistent sinus rhythm without antiarrhythmic drugs. Patients who underwent mapping without ablation reported no improvements in any QOL or symptom score, whereas patients who had long-term successful ablation had significant improvements in all six QOL measures. Interestingly, patients who developed AF recurrence after ablation still reported significant improvements in 4 of 6 QOL measures. Four of 48 patients (8.3%) undergoing ablation developed pulmonary vein stenosis., Conclusion: Paroxysmal AF can be treated successfully in some patients by ablating initiating triggers in the pulmonary veins; however, in our experience the recurrence rate (32/48 [68%]) and risk of pulmonary vein stenosis (8%) after ablation are high. Patients with recurrent AF after ablation of focal AF triggers have significant improvement in QOL and symptoms compared with before ablation. Patients and their physicians should carefully balance the risks and benefits before considering ablation.