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Background: Recurrent ventricular tachycardia (VT) after prior endocardial catheter ablation(s) presents challenges in the setting of prior cardiac surgery where percutaneous epicardial access may not be feasible., Objective: The purpose of this study was to compare the outcomes of cryothermal vs radiofrequency ablation in direct surgical epicardial access procedures., Methods: We performed a retrospective study of consecutive surgical epicardial VT ablation cases. Surgical cases using cryothermal vs radiofrequency ablation were analyzed and outcomes were compared., Results: Between 2009 and 2022, 43 patients underwent either a cryothermal (n = 17) or a radiofrequency (n = 26) hybrid epicardial ablation procedure with direct surgical access. Both groups were similarly matched for age, sex, etiology of VT, and comorbidities with a high burden of refractory VT despite previous endocardial and/or percutaneous epicardial ablation procedures. The surgical access site was lateral thoracotomy (76.5%) in the cryothermal ablation group compared with lateral thoracotomy (42.3%) and subxiphoid approach (38.5%) in the radiofrequency group, with the remainder in both groups performed via median sternotomy. The ablation time was significantly shorter in those undergoing cryothermal ablation vs radiofrequency ablation (11.54 ± 15.5 minutes vs 48.48 ± 23.6 minutes; P < .001). There were no complications in the cryothermal ablation group compared with 6 patients with complications in the radiofrequency group. Recurrent VT episodes and all-cause mortality were similar in both groups., Conclusion: Hybrid surgical VT ablation with cryothermal or radiofrequency energy demonstrated similar efficacy outcomes. Cryothermal ablation was more efficient and safer than radiofrequency in a surgical setting and should be considered when surgical access is required., (Copyright © 2023 Heart Rhythm Society. All rights reserved.)

Background: Autonomic modulation is finding an increasing role in the treatment of ventricular arrhythmias. Renal denervation (RDN) has been described as a treatment modality for refractory ventricular tachycardia (VT) in case series., Objective: The purpose of this study was to evaluate RDN as an adjunctive therapy to cardiac sympathetic denervation (CSD) for ablation refractory VT., Methods: Patients who underwent RDN after radiofrequency ablation and CSD procedures at our center from 2012 to 2019 were evaluated., Results: Ten patients underwent RDN after CSD (9 bilateral and 1 left-sided only) with a median follow-up of 23 months. The mean age was 59.9 ± 10.4 years, and 9/10 (90%) were men. All had cardiomyopathy with a mean ejection fraction of 33% ± 11% (20% ischemic). Four (40%) underwent CSD during the same hospitalization as that for RDN. Patients who underwent RDN as adjunctive therapy to CSD had a decrease in all implantable cardioverter-defibrillator therapies (shocks + antitachycardia pacing [ATP]) from 29.5 ± 25.2 to 7.1 ± 10.1 comparing 6 months pre-RDN to 6 months post-RDN (P = .028). Implantable cardioverter-defibrillator shocks were significantly decreased from 7.0 ± 6.1 to 1.7 ± 2.5 comparing 6 months pre-RDN to 6 months post-RDN (P = .026). This benefit was driven by a decrease in therapies for 6 patients who had a staged procedure, not performed during the same hospitalization (28.5 ± 24.3 to 1.0 ± 1.2; P = .043)., Conclusion: RDN demonstrates the potential benefit when VT recurs after radiofrequency ablation and CSD. The benefit is seen in patients who undergo a staged procedure. The need for acute RDN after CSD portends a poor prognosis., (Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Purpose: Fluoroscopically guided interventional (FGI) procedures often have lower complication rates compared with alternative surgical procedures, providing an option for patients with a high risk of perioperative mortality. Although severe radiation injuries are rare, patients receiving peak skin doses exceeding 3 Gy can suffer from radiation-induced tissue injuries, ranging from transient erythema to nonhealing wounds. As these iatrogenic injuries may manifest weeks to months postprocedure, proper diagnosis and timely medical intervention are less likely. Clinically, the lack of situational awareness for monitoring air kerma continues to be a challenge despite the recommendations of numerous organizations on ways to achieve fluoroscopy safety. For patient safety efforts, this study aimed to identify and mitigate systematic gaps associated with potentially high-radiation dose fluoroscopic procedures in US Department of Veterans Affairs (VA) and non-VA medical institutions., Methods: In this study, a multi-institutional team utilized Healthcare Failure Mode and Effect Analysis (HFMEA) on an example implantable cardioverter defibrillator lead extraction procedure., Results: With this approach, 29 interventions were devised and prioritized by feasibility, cost-effectiveness, and expected clinical impact. Five of the 29 interventions were recommended for immediate implementation or piloting., Conclusions: This work demonstrates the application of formal risk-based analysis techniques in FGI procedures. These high priority interventions may be valuable for other facilities to consider when performing potentially high-radiation dose procedures and conducting risk-benefit analyses. Formal risk analysis techniques such as the HFMEA process are recommended for other facilities to use to improve safety for their high-risk procedures., (Copyright © 2019 American College of Radiology. All rights reserved.)

Background: There is limited experience of surgical epicardial access in the contemporary era of ventricular tachycardia ablation after cardiac surgery., Objectives: The purpose of this study was to describe our institutional experience with surgical epicardial access and the influence of surgical approach and compare outcomes with those of a propensity-matched percutaneous epicardial access control group., Methods: We performed a retrospective study of consecutive surgical epicardial ventricular tachycardia (VT) ablation cases from a single center. Surgical cases were propensity-matched to percutaneous epicardial ablation controls and short-term and long-term outcomes were compared., Results: Between 2004 and 2016, 38 patients underwent 40 surgical epicardial access procedures (subxiphoid, n = 22; thoracotomy, n = 18). The commonest indication was prior coronary artery bypass grafting (45%), valve surgery (22%), or ventricular assist device (VAD) (10%). The mean procedure time was 444 minutes (standard deviation, 107 minutes). Mapped epicardial geometry area was 149 cm 2 (interquartile range 182 cm 2 ), which comprised 36% of the mapped epicardial geometric area of a percutaneous control group. Subxiphoid access gave preferential access to the inferior and inferolateral left ventricular segments and was less frequently able to access the anterior, anterolateral, and apical segments compared with a thoracotomy approach. When compared with results from a propensity-matched percutaneous-access group, short-term outcomes, complication rates, and 1-year survival free from a combined end point of VT recurrence, death, or transplantation were not statistically different., Conclusions: Surgical epicardial access after cardiac surgery for ablation of VT in patients with careful preprocedure evaluation can be performed with acceptable safety with no statistical difference in long-term outcomes compared with a propensity-matched percutaneous epicardial cohort. The region of left ventricular epicardium that can be mapped is limited compared with that of percutaneous cases and is determined by the surgical approach., (Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Magnetic resonance imaging (MRI) has been performed safely in patients without MRI-conditional cardiac implantable electronic devices (CIEDs), but experience specifically with cardiac magnetic resonance imaging (CMR) is limited in this patient population., Objective: Evaluate the safety of CMR in non-MRI-conditional CIEDs and the interpretability of images using wideband sequences., Methods: We performed 114 consecutive CMR studies in 111 patients (mean age 59 ± 14 years, with 12 pacemakers, 73 implantable cardioverter defibrillators, 29 biventricular defibrillators) using a wideband pulse sequence for late gadolinium enhancement (LGE) imaging. A standardized protocol for device management and patient monitoring was followed. Patients were evaluated for major clinical adverse events and device parameter changes immediately after CMR and at clinical follow-up., Results: In total, 111 CMR studies were completed successfully. There were no patient deaths, new arrhythmias, immediate generator or lead failures, electrical resets, or pacing capture failures in dependent patients. Right atrial, right ventricular, and left ventricular lead impedances were significantly lower post CMR, with median differences -7 Ω (interquartile range [IQR] -20 to 0 Ω; P < .0001), 0 Ω (IQR -19 to 0 Ω; P = .0001), and -10 Ω (IQR -30 to 0 Ω; P = .023), respectively. These changes persisted through the follow-up period, with median differences -18.5 Ω (IQR -41 to -66 Ω; P = .007), -19 Ω (IQR -44 to -7 Ω; P = .006), and -30 Ω (IQR -130 to 0 Ω; P = .003), respectively. Ninety-seven studies (87%) had no artifact limiting interpretation., Conclusions: CMR can be performed safely in non-MRI-conditional CIEDs using a standardized protocol. Use of a wideband pulse sequence for LGE imaging yields a high rate of studies unaffected by artifact., (Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Infrequent intraprocedural premature ventricular complexes (PVCs) may impede radiofrequency catheter ablation (RFA) outcome, and pharmacologic induction is unpredictable., Objective: The purpose of this study was to determine whether PVC circadian variation could help predict drug response., Methods: Consecutive patients referred for RFA with detailed Holter monitoring and frequent monomorphic PVCs were included. Patients were divided into 3 groups based on hourly PVC count relationship to corresponding mean heart rate (HR) during each of the 24 hours on Holter: fast-HR-dependent PVC (F-HR-PVC) type for a positive correlation (Pearson, P <.05), slow-HR-dependent PVC (S-HR-PVC) type for a negative correlation, and independent-HR-PVC (I-HR-PVC) when no correlation was found., Results: Fifty-one of the 101 patients (50.5%) had F-HR-PVC, 39.6% I-HR-PVC, and 9.9% S-HR-PVC; 30.7% had infrequent intraprocedural PVC requiring drug infusion. The best predictor of infrequent PVC was number of hours with PVC count <120/h on Holter (area under the curve 0.80, sensitivity 83.9%, specificity 74.3%, for ≥2 h). Only F-HR-PVC patients responded to isoproterenol. Isoproterenol washout or phenylephrine infusion was successful for the 3 S-HR-PVC patients, and no drug could increase PVC frequency in the 12 I-HR-PVC patients. Long-term RFA success rate in patients with frequent PVCs at baseline (82.9%) was similar to those with infrequent PVC who responded to a drug (77.8%; P = .732) but significantly higher than for those who did not respond to any drug (15.4%; P <.0001)., Conclusion: A simple analysis of Holter PVC circadian variability provides incremental value to guide pharmacologic induction of PVCs during RFA and predict outcome. Patients with infrequent I-HR-PVC had the least successful outcomes from RF ablation., (Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Pericardial adhesions can prevent epicardial access and restrict catheter movement during mapping and ablation of ventricular tachycardia (VT). The incidence of adhesions in patients without prior cardiac surgery or clinically evident pericarditis is not known., Objective: To describe the incidence of pericardial adhesions and explore their impact in patients without prior cardiac surgery or pericarditis., Methods: A retrospective search of our ablation database containing patients who underwent epicardial ablation for VT was undertaken. Adhesions were diagnosed with routine contrast pericardiography after pericardial entry. Demographics and long-term outcomes were compared between patients with and without adhesions., Results: Between 2004 and 2016, successful epicardial entry was achieved in 188 of 192 attempts (98%). In 155 first-time epicardial access attempts, pericardial adhesions were diagnosed in 13 (8%). When comparing baseline demographics, there was no significant difference. However, adhesions tended to occur more frequently with severe renal impairment (2% of patients without adhesions vs 15% of patients with adhesions, P = .07). No patient with a structurally normal heart had adhesions present. Adhesions were associated with limited epicardial mapping (3% of patients without adhesions vs 85% of patients with adhesions, P < .001) and lower short-term procedural success (68% of patients without adhesions vs 46% of patients with adhesions, P = .02), but complication rates were similar. The presence of adhesions did not translate into lower VT-free survival (P = .64) or freedom from a combined end point of VT recurrence, death, or transplant at 1 year (P = .93)., Conclusion: Adhesions may be unexpectedly encountered in patients without prior cardiac surgery or pericarditis. When present, they can limit mapping and may be associated with lower short-term success. Larger studies are required to determine their impact on long-term outcomes., (Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to determine the temporal trends in utilization of catheter ablation of accessory pathways in the United States., Methods: All patients from the Nationwide Inpatient Sample (NIS) ≥18years of age with a primary diagnosis of anomalous atrioventricular excitation syndrome (International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] code 426.7) were included in the study. Patients who underwent catheter ablation were identified using ICD-9-CM procedure code 37.34. Patients with a concomitant diagnosis of atrial fibrillation, atrial flutter, atrial tachycardia or ventricular arrhythmias were excluded from the analysis. Annual hospital volume was identified using unique hospital identification number and was divided into tertiles for further analysis., Results: A total of 11,601 catheter ablations for anomalous atrioventricular excitation syndrome were studied from 1998 to 2011. The mean length of stay was 1.8days (median 1day). The utilization trends of accessory pathway ablation have steadily declined from 3.9 ablation procedures/million US population in 1998-1999 to 2.5 ablation procedures/million US population in 2010-2011. The second tertile (adjusted OR 0.41; 95% CI 0.20-0.83, p=0.01) and third tertile (adjusted OR 0.39; 95% CI 0.18-0.85, p=0.02) of hospital volume were associated with reduction in cardiac complications as compared to first tertile of hospital volume. Advanced age (OR 1.02, 95% CI 1.01-1.04, p=0.002) was independent predictor of cardiac complications. There were no in-hospital deaths., Conclusion: Despite decline in ablation trends, it still remains a relatively safe procedure associated with low morbidity and no mortality., (Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.)

Background: Accessory pathways can lie near or within the coronary sinus (CS). Radiofrequency catheter ablation of accessory pathways is a well-established treatment option, but this procedure can cause damage to adjacent coronary arteries., Objective: The purpose of this study was to evaluate the anatomic relationship between the coronary arteries and the CS., Methods: Retrospective data of patients who underwent catheter ablation of supraventricular tachycardia between June 2011 and August 2013 was reviewed. In addition, detailed analysis of coronary computed tomographic angiography (CTA) data from 50 patients was performed., Results: Between June 2011 and August 2013, 427 patients underwent catheter ablation of supraventricular tachycardia, of whom 105 (age 28 ± 17 years, 60% male) had accessory pathway-mediated tachycardia. Of these, 23 patients had accessory pathways near the CS, and 60% (N = 14) underwent concurrent coronary angiography. In 4 patients, the posterolateral (inferolateral) branch (PLA) of the right coronary artery was in close proximity to the CS, and 2 patients (18%) had stenosis of the PLA at the site of ablation. On CTA at their closest proximity, the PLA was 1.9 ± 1.3 mm and the left circumflex artery (LCx) was 2.0 ± 0.8 mm from the body of the CS, in right and left coronary artery-dominant patients, respectively. CS ostium and PLA were 3.6 ± 1.9 mm apart. In left-dominant patients, LCx and CS ostium were 3.8 ± 1.2 mm apart., Conclusion: The PLA and LCx are in close proximity to the anteroinferior aspect of the CS ostium and proximal CS. The relationship of the CS and coronary arteries should be evaluated before ablation at these sites., (Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Patient monitors in modern hospitals have become ubiquitous but they generate an excessive number of false alarms causing alarm fatigue. Our previous work showed that combinations of frequently co-occurring monitor alarms, called SuperAlarm patterns, were capable of predicting in-hospital code blue events at a lower alarm frequency. In the present study, we extend the conceptual domain of a SuperAlarm to incorporate laboratory test results along with monitor alarms so as to build an integrated data set to mine SuperAlarm patterns. We propose two approaches to integrate monitor alarms with laboratory test results and use a maximal frequent itemsets mining algorithm to find SuperAlarm patterns. Under an acceptable false positive rate FPRmax, optimal parameters including the minimum support threshold and the length of time window for the algorithm to find the combinations of monitor alarms and laboratory test results are determined based on a 10-fold cross-validation set. SuperAlarm candidates are generated under these optimal parameters. The final SuperAlarm patterns are obtained by further removing the candidates with false positive rate>FPRmax. The performance of SuperAlarm patterns are assessed using an independent test data set. First, we calculate the sensitivity with respect to prediction window and the sensitivity with respect to lead time. Second, we calculate the false SuperAlarm ratio (ratio of the hourly number of SuperAlarm triggers for control patients to that of the monitor alarms, or that of regular monitor alarms plus laboratory test results if the SuperAlarm patterns contain laboratory test results) and the work-up to detection ratio, WDR (ratio of the number of patients triggering any SuperAlarm patterns to that of code blue patients triggering any SuperAlarm patterns). The experiment results demonstrate that when varying FPRmax between 0.02 and 0.15, the SuperAlarm patterns composed of monitor alarms along with the last two laboratory test results are triggered at least once for [56.7-93.3%] of code blue patients within an 1-h prediction window before code blue events and for [43.3-90.0%] of code blue patients at least 1-h ahead of code blue events. However, the hourly number of these SuperAlarm patterns occurring in control patients is only [2.0-14.8%] of that of regular monitor alarms with WDR varying between 2.1 and 6.5 in a 12-h window. For a given FPRmax threshold, the SuperAlarm set generated from the integrated data set has higher sensitivity and lower WDR than the SuperAlarm set generated from the regular monitor alarm data set. In addition, the McNemar's test also shows that the performance of the SuperAlarm set from the integrated data set is significantly different from that of the SuperAlarm set from the regular monitor alarm data set. We therefore conclude that the SuperAlarm patterns generated from the integrated data set are better at predicting code blue events., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Ablation has become an important option for treatment of ventricular tachycardia (VT). The influence of procedure duration on outcomes remains unexamined., Objective: The purpose of this study was to determine the influence of procedure duration on outcomes and complications over an 8-year period, Methods: Patients referred for scar-mediated VT ablation from 2004 to 2011 were retrospectively analyzed. Procedure duration was defined as the time from the insertion of catheters through the femoral vein to the time of their withdrawal. Procedure duration was analyzed in relationship with baseline and intraoperative covariates, acute procedural outcomes, complications, and 6-month clinical outcomes., Results: One hundred forty-eight patients underwent VT ablation with mean procedure duration of 5.7 ± 1.8 hours. VT recurrence and survival at 6 months were 46% and 82%, respectively, and were not associated with procedure duration. Hospital mortality increased with intraoperative intraaortic balloon pump insertion (adjusted odds ratio [OR] 13.7, 95% confidence interval [CI] 2.35-79.94, P = .004) and was improved with successful ablation of the clinical VT as a procedural end-point (adjusted OR 0.13, 95% Cl 0.03-0.54, P = .005). The association between procedure duration and hospital mortality remained after adjusting for significant baseline variables (adjusted OR 1.75, 95% CI 1.14-2.68, P = .0098) and intraoperative variables (adjusted OR 1.6, 95% CI 1.12-2.29, P = .0104)., Conclusion: Hospital mortality was significantly increased by unsuccessful clinical VT ablation as a procedural end-point and intraoperative intraaortic balloon pump insertion. However, after adjusting for significant baseline and intraoperative covariates, procedure duration still was associated with increased hospital mortality. Procedure duration had no impact on VT recurrence and survival at 6 months., (Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Electroanatomic mapping systems are an important tool to identify cardiac chamber voltage and assess channels of slow conduction., Objective: To assess the correlation between electroanatomic mapping voltage maps obtained during macroreentrant tachycardia compared to sinus rhythm (SR) with a contact mapping system., Methods: We retrospectively evaluated patients with atrial flutter (AFL) referred for radiofrequency ablation with electroanatomic voltage maps obtained during AFL and SR. The atrium was divided into predetermined segments. Overall atrial and segmental peak-to-peak bipolar voltages in AFL and SR were assessed. To directly compare a region within the same patient, tissue voltage differences during AFL and SR were assessed on the basis of mean voltage difference., Results: Sixteen patients (87% men) had available voltage maps. Eighty-one percent had typical cavotricuspid isthmus-dependent right AFL. A mean of 441.7±153.9 vs 398.1±125.4 total points (P = .22) were sampled during AFL and SR, with a mean of 99.5±58.9 vs 91.2±60.4 points (P = .45) sampled per region. Overall right atrial mean voltage was significantly higher during AFL than SR (0.554±0.092mV vs 0.473±0.079mV; P≤.001), with the lateral wall (0.707±0.120mV vs 0.573±0.097mV; P = .0004) and the cavotricuspid isthmus (0.559±0.100mV vs 0.356±0.066mV; P<.0001) also showing higher mean voltage during AFL. When compared within an individual patient, 19% (14 of 75) of the patient regions had a>0.5mV mean voltage difference and 40% (30 of 75) had a>0.25mV mean voltage difference., Conclusions: These data suggest that voltage maps performed during macroreentrant atrial arrhythmias often vary significantly from maps obtained during SR., (Copyright © 2013 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Definition of myocardial scars as identified by electroanatomic mapping is integral to catheter ablation of ventricular tachycardia (VT). Myocardial imaging can also identify scars prior to ablation. However, the relationship between imaging and voltage mapping is not well characterized., Objective: The purpose of this study was to verify the anatomic location and heterogeneity of scars as obtained by electroanatomic mapping with contrast-enhanced MRI (CeMRI) and histopathology, and to characterize the distribution of late potentials in a chronic porcine infarct model., Methods: In vivo 3-dimensional cardiac CeMRI was performed in 5 infarcted porcine hearts. High-density electroanatomic mapping was used to generate epicardial and endocardial voltage maps. Scar surface area and position on CeMRI were then correlated with voltage maps. Locations of late potentials were subsequently identified. These were classified according to their duration and fractionation. All hearts underwent histopathological examination after mapping., Results: The total dense scar surface area and location on CeMRI correlated to the total epicardial and endocardial surface scar on electroanatomic maps. Electroanatomic mapping (average of 1,532 ± 480 points per infarcted heart) showed that fractionated late potentials were more common in dense scars (<0.50 mV) as compared with border zone regions (0.51 to 1.5 mV), and were more commonly observed on the epicardium., Conclusion: In vivo, CeMRI can identify areas of transmural and nontransmural dense scars. Fractionated late diastolic potentials are more common on the epicardium than the endocardium in dense scar. These findings have implications for catheter ablation of VT and for targeting the delivery of future therapies to scarred regions., (Copyright © 2011 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Late potential (LP) electrograms represent areas of slow conduction and are often sites critical to reentrant tachycardia circuits. The distribution of LPs within infarct scar is not known., Objective: The purpose of this study was to delineate infarct heterogeneity using ultra high-density mapping and to determine the location of LPs with respect to scar architecture., Methods: Detailed endocardial (n = 21) and epicardial (n = 8) ultra high-density mapping was performed to delineate the substrate for ventricular tachycardia (VT) in 21 patients with ischemic cardiomyopathy. LP was defined as a low-voltage electrogram (< 1.5 mV) with distinct onset after the QRS. Very late potentials (vLPs) were classified as LPs with onset > 100 ms after the QRS., Results: A mean of 787 ± 391 and 810 ± 375 points in the LV endocardium and epicardium were sampled. Multipolar mapping identified heterogeneous islets (HIs) with relatively preserved electrogram amplitudes (≥ 0.51 mv) within dense scar (8.5 ± 4.9/4.5 ± 2.6 HIs per endocardium/epicardium) in all patients. In maps on which putative VT isthmuses were identified (25/29), 57% of vLP were recorded in or adjacent to HI. An LP-targeted ablation strategy combined with pace mapping achieved acute success in all patients (complete success in 52% and partial success in 48%). After 15 ± 7 months, 65% of patients remained free of VT episodes., Conclusion: Ultra high-density mapping with a multipolar catheter facilitates the delineation of heterogeneous scar architecture at higher resolution. Electrograms within and adjacent to HIs have a higher incidence of vLP, and these sites are frequently critical to reentry. These findings have important implications for substrate-based ablation strategies., (Copyright © 2010 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Prior chest surgery limits the ability to obtain epicardial access in patients referred for catheter ablation of ventricular tachycardia (VT)., Objective: The purpose of this study was to describe the utility of different surgical approaches to access the epicardium for VT ablation., Methods: Clinical data of 14 patients with drug-refractory VT who underwent hybrid surgical epicardial access for catheter mapping and ablation in the electrophysiology lab were reviewed. Baseline patient and procedural characteristics including access, exposure, mapping techniques, and ablation were analyzed., Results: Of a total of 14 patients (age 63.2 ± 10.3 years), 11 had a subxiphoid window performed, and three patients underwent limited anterior thoracotomy to access the epicardium. The indication for surgical access was prior cardiac surgery (n = 12), previous failed epicardial access (n = 1), and ablation in close proximity to the coronary arteries and phrenic nerve (n = 1). Mapping in patients with subxiphoid surgical access was limited to the inferior and diaphragmatic surface of the heart extending posteriorly to the basal lateral wall. With limited anterior thoracotomy, access to the apex, anterior, and mid to apical anterolateral walls was obtained. In these regions, adhesions were more severe and repeat entry into the epicardial region at a different intercostal level was needed in two of three patients., Conclusion: Surgical access with subxiphoid window and limited anterior thoracotomy in the electrophysiology lab is feasible and safe. The surgical approach can be tailored to the region of interest in the ventricle to be mapped and ablated., (Copyright © 2010. Published by Elsevier Inc.)

Background: Catheter ablation of the left atrium (LA) is associated with potential collateral injury to surrounding structures, especially the esophagus and the right phrenic nerve (PN)., Objectives: The purpose of this study was to evaluate the efficacy and feasibility of intrapericardial balloon placement (IPBP) for the protection of collateral structures adjacent to the LA., Methods: Electroanatomic mapping was performed in porcine hearts using a transseptal endocardial approach in eight swine weighing 40-50 kg. An intrapericardial balloon was inflated in the oblique sinus, via percutaneous epicardial access, to displace the esophagus. Similarly, with the balloon positioned in the transverse sinus, IPBP was used to displace the right PN. Esophageal temperature was monitored while endocardial radiofrequency (RF) energy was delivered to the distal inferior PV., Results: In all cases, balloon placement was successful with no significant effects on hemodynamic function. Balloon inflation increased the distance between the esophagus and posterior LA by 12.3 +/- 4.0 mm. IPBP significantly attenuated increases in luminal esophageal temperature during endocardial RF application (6.1 +/- 2.4 degrees C vs. 1.2 +/- 1.1 degrees C; P<.0001). High-output endocardial pacing from the right superior pulmonary vein ostium stimulated PN activity. After displacement of the right PN with IPBP, PN capture was abolished in 30 (91%) of 33 sites., Conclusions: These findings demonstrate that in an animal model, IPBP is feasible in the setting of catheter ablation procedures and has the potential to decrease the risk of collateral damage to the esophagus and PN during LA ablation.

Nonpharmacologic approaches for the management of atrial fibrillation are rapidly emerging as the mainstay for definitive management of this arrhythmia. Over the past several years, numerous studies reported in the literature have highlighted various aspects of the pathophysiologic mechanisms underlying atrial fibrillation. The purpose of this review is to place the current approaches being used for arrhythmia management in the context of the current knowledge of about arrhythmia mechanisms.

Atrial fibrillation (AF) and congestive heart failure are common conditions and each predisposes to the development of the other. Basic research using animal models of the two conditions continues to yield insights that may improve therapies. The role of medical therapies aimed at the underlying structural changes in AF continues to be a subject of ongoing studies. Cardiac resynchronization therapy is effective in appropriately selected patients with both sinus rhythm and AF. Catheter ablation is emerging as a potential alternative to antiarrhythmic drug therapy, but large randomized trials will be needed to assess its role.

Background: Many patients with appropriate indications fail to respond to cardiac resynchronization therapy (CRT)., Objective: The purpose of our study was to determine the relationship between CRT response and preimplantation apical wall motion abnormality., Methods: We analyzed data from 83 patients with ischemic cardiomyopathy who underwent CRT. All patients had New York Heart Association class III or IV symptoms despite maximal medical therapy, left ventricular ejection fraction (LVEF) < or =35%, and QRS duration > or =130 ms or <130 ms with left ventricular dyssynchrony. CRT responders at 6 months were defined as surviving patients with: (1) no hospitalization for heart failure, and (2) improvement of New York Heart Association classification. Patients underwent echocardiography before and 6 months after implantation to assess changes in regional wall motion and LVEF., Results: At baseline, CRT responders (n = 39) and nonresponders (n = 44) had similar LVEF (22.9% +/- 6.9% vs 23.1% +/- 8.3%), QRS duration (159 +/- 43 ms vs 159 +/- 36 ms), and medical treatment. CRT nonresponders had a higher prevalence of preimplantation apical wall motion abnormality (68% vs 33%, P = .003). Patients with baseline apical wall motion abnormalities (n = 43) were less likely than others (n = 40) to show improvement in wall motion at 6 months (30% vs 81%, P < .001) or clinical response to CRT (31% vs 64%, P = .003)., Conclusion: The presence of a preimplantation apical wall motion abnormality was associated with a lower rate of CRT response in patients with ischemic cardiomyopathy.

Background: The impact of cardiac resynchronization therapy (CRT) on dispersion of repolarization is controversial. The benefit of CRT on sudden cardiac death has been demonstrated only after 3 years follow-up., Objective: The purpose of this study was to explore the immediate effect of CRT on dispersion of repolarization and to define the value of dispersion of repolarization parameters as predictors of appropriate implantable cardioverter-defibrillator (ICD) therapy., Methods: Data from 100 patients who underwent CRT-ICD placement were analyzed retrospectively. Patients had symptoms of New York Heart Association functional class III or IV heart failure, left ventricular ejection fraction < or =35%, and QRS duration >130 ms or QRS < or =130 ms with left intraventricular dyssynchrony. ECG indices of dispersion of repolarization before and immediately after CRT implantation (QT dispersion, Tpeak-Tend [Tp-e], and Tp-e dispersion) were measured., Results: In patients who were upgraded to a biventricular system, Tp-e did not increase significantly after CRT. However, Tp-e increased significantly after CRT in patients with left bundle branch block or narrow QRS at baseline. After 12-month follow-up, 22 patients had received appropriate ICD therapy. ICD therapy and no ICD therapy groups had similar baseline characteristics, such as secondary prevention and ischemic cardiomyopathy. Postimplantation Tp-e was the only independent predictor of future ICD therapy (P = .02)., Conclusion: Immediately after CRT, Tp-e did not increase in patients who received a biventricular upgrade; however, Tp-e did increase in patients with preimplantation left bundle branch block or narrow QRS. Postimplantation Tp-e was the only independent predictor of appropriate ICD therapy.

Background: Percutaneous pericardial access, epicardial mapping, and ablation have been used successfully for catheter ablation procedures., Objectives: The purpose of this study was to evaluate the safety and feasibility of closed-chest direct epicardial ultrasound imaging for aiding cardiac catheter ablation procedures., Methods: An intracardiac ultrasound catheter was used for closed-chest epicardial imaging of the heart in 10 patients undergoing percutaneous epicardial access for catheter ablation. All patients underwent concomitant intracardiac echocardiography and preprocedural transesophageal echocardiography. Using a double-wire technique, two sheaths were placed in the pericardium, and a phased-array ultrasound catheter was manipulated within the pericardial sinuses for imaging., Results: Multiple images from varying angles were obtained for catheter navigation. Notably, image stability was excellent, and structures such as the left atrial appendage were seen in great detail. No complications resulting from use of the ultrasound catheter in the pericardium occurred, and no restriction of movement due to the presence of the additional catheter in the pericardial space was observed. Wall motion was correlated to voltage maps in five patients and showed that areas of scars correlated with wall-motion abnormalities. Normal wall-motion score correlated to sensed signals of 4.2 +/- 0.3 mV (normal myocardium >1.5 mV), and scores >1 correlated to areas with signals <0.5 mV in that territory)., Conclusion: Intrapericardial imaging using an ultrasound catheter is feasible and safe and has the potential to provide additional valuable information for complex ablation procedures.

Background: Percutaneous epicardial mapping has been used for ablation of recurrent ventricular tachycardia (VT)., Objectives: The purpose of this study was to use a combined epicardial and endocardial mapping strategy to delineate the myocardial substrate for recurrent VT in both ischemic (n = 12) and nonischemic cardiomyopathy (n = 8), and to define the role of epicardial ablation., Methods: Electroanatomic mapping was performed in 20 patients. High-density voltage maps were obtained by acquiring both endocardial and epicardial electrograms. Electrograms derived from six patients with structurally normal hearts were used as controls. A total of 26 VTs were targeted in the 20 patients., Results: Most VTs (23/26 [88.5%]) were hemodynamically unstable. In patients with ischemic cardiomyopathy, the extent of endocardial scar was greater than epicardial scar. A definable pattern of scar could not be demonstrated in nonischemic cardiomyopathy. Pathologic examination of explanted hearts in two patients with nonischemic cardiomyopathy demonstrated that low-voltage areas were not always predictive of scarred myocardium. A substrate-based approach was used for catheter ablation. Catheter ablation was performed on the endocardium in all patients; additional epicardial delivery of radiofrequency energy was required in 8 (40%) of 20 patients for successful ablation. During follow-up (12 +/- 4 months), 15 (75%) of 20 patients have been arrhythmia-free., Conclusion: Patients with ischemic cardiomyopathy tend to have a larger endocardial than epicardial scar. Use of epicardial and endocardial electroanatomic mapping to define the full extent of myocardial scars allows successful catheter ablation in patients with hemodynamically unstable VTs.

Background: Delivery of radiofrequency energy in proximity of a pulmonary vein can cause vein stenosis. A sudden decrease in impedance as the catheter is moved from the vein into the left atrium (LA) has been used to define the pulmonary vein-LA transition during ablation procedures., Objectives: The purpose of this study was to define the variables affecting impedance measurement., Methods: In vitro analysis of impedance was performed in a saline bath using sheaths and a plastic stereolithographic model of the LA. Impedance was continuously monitored during a calibrated pullback from the pulmonary vein into the LA in 37 veins of 10 patients referred for catheter ablation. Location of the catheter was confirmed by the following imaging modalities: intracardiac echocardiography, contrast venography, electroanatomic mapping, and computed tomography/magnetic resonance imaging (offline) in all patients., Results: Larger cross-sectional areas containing the catheter correlated with lower impedance in an exponential manner both with respect to sheath size (R(2) = 0.99) and in the stereolithographic model (R(2) = 0.91). In vivo, the impedance in the pulmonary veins decreased in an exponential manner as the catheter was pulled back into the LA. However, impedance at the vein orifice was not significantly higher than the LA. A defined cutoff value for defining the pulmonary vein-LA transition could not be identified., Conclusion: The primary determinant of impedance is the cross-sectional area of the space containing the catheter. Impedance monitoring alone does not guarantee a catheter tip position outside the pulmonary vein. Intraprocedural imaging confirmation should be considered to avoid radiofrequency application within pulmonary veins.