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Introduction Endocardial catheter ablation (ECA) for atrial fibrillation (AF) has limited efficacy. Hybrid convergent procedure (HCP) with both epicardial and endocardial ablation is a novel strategy for AF treatment. In this meta‐analysis, we aimed to evaluate the efficacy and safety of HCP in AF ablation. Method We performed a comprehensive literature search for studies that evaluated the efficacy and safety of HCP compared with ECA for AF. The primary outcome was freedom of atrial arrhythmia (AA). The secondary outcome was the periprocedural complication rate. Pooled relative risk (RR) and corresponding 95% confidence intervals (CIs) were calculated using the random effects model. Results A total of eight studies, including 797 AF patients (mean age: 60.7 ± 9.8 years, 366 patients with HCP vs. 431 patients with ECA alone), were included. HCP showed a higher rate of freedom of AA compared with ECA (RR: 1.48, 95% CI: 1.13–1.94, p = .004). However, HCP was associated with higher rates of periprocedural complications (RR: 3.64, 95% CI: 2.06–6.43; p = .00001). Moreover, the HCP had a longer procedure time and postprocedural hospital stay. Conclusions Although hybrid ablation was associated with a higher success rate, this should be judged for increased periprocedural adverse events and extended hospital stay. Prospective large‐scale randomized trials are needed to validate these results., Graphical abstract showing the outcomes of our study. Although hybrid ablation was associated with a higher success rate, this should be judged for increased periprocedural adverse events and extended hospital stay.

Recent advances have been made in AF treatment, including the role of early rhythm control and landmark clinical trials using ablation therapy. However, some treatment gaps remain, including the creation of durable lesions outside the pulmonary veins and effective treatment of longstanding persistent AF. A novel epicardial-endocardial ablation approach – the hybrid convergent procedure – was developed to combine surgical and catheter ablation techniques into a collaborative, multidisciplinary approach to managing AF. In this review, the authors discuss recently published data on hybrid convergent ablation, including results of the CONVERGE clinical trial, in the context of current challenges to treatment of persistent and long-standing persistent AF. The review also aims to provide perspective on outstanding questions and future directions in this area.

Background and Design: Psoriasis is a chronic inflammatory skin condition associated with several systemic comorbidities including cardiovascular diseases (CVD). Epicardial fat pad (EFP) is defined as a visceral fat tissue surrounding the heart and coronary vessels. Recent studies revealed epicardial fat thickness, which is also increased in psoriasis, as an early sign of CVD. The aim of this study was to evaluate EFP prevalence and its associations in psoriasis patients. Materials and Methods: Two hundred thirty-seven psoriasis and 113 control patients were assessed for CVD risk factors, Psoriasis Area Severity Index, body composition parameters and laboratory work-up. Controls were chosen from outpatients who lack any chronic inflammatory skin disease and/or systemic inflammatory disease. Evaluation of chest X-rays were performed by a radiologist who was unaware of clinical data. Results: 42.2% of psoriasis patients (n=100) and 31% of controls (n=35) had EFP detected on chest X-ray revealing psoriasis patients had significantly more prevalent EFP than the controls (p=0.047). Prevalence of major CVD risk factors was statistically higher in psoriasis patients (60%, n=142) compared to controls (32%, n=36), (p

Background . The attention of many researchers is focused on studying the role of adipokines secreted by subcutaneous, visceral, epicardial, and perivascular adipose tissues in the pathogenesis of diseases of the cardiovascular system. At the same time, adipose tissue of retrosternal localization remains out of research focus. This pool of fat cells is formed at the site of the thymic involution and has a significant volume. However, their functional activity and participation in the development of cardiovascular pathology remain unexplored. Aim. To study the morphological characteristics of adipocytes of the retrosternal adipose tissue (RSAT) and their production of adipokines in comparison with epicardial (EAT) and subcutaneous adipose tissue (SCAT) and to investigate their relationships with arterial stiffness parameters in patients who underwent coronary artery bypass grafting. Materials and methods . The study included 17 patients (12 men/5 women aged 40–70 years) with the diagnosed coronary artery disease (CAD) who underwent coronary artery bypass grafting (CABG). Each patient underwent measurement of carotid-femoral pulse wave velocity (PWV) and aortic augmentation index (AIx) with the oscillometric device. Isolated adipocytes were obtained enzymatically from explants of SCAT, EAT and RSAT during coronary artery bypass grafting. The adipocytes were analyzed under the microscope at 200x magnification. The release of adiponectin, leptin and insulin was studied in the adipocyte supernatant after 1 hour incubation using ELISA. Results. It was found that adipocytes of the RSAT are smaller than adipocytes of SCAT: 83.96 ± 2.21 vs 98.62 ± 2.67 μm ( p = 0.00002), respectively, and comparable in size to adipocytes of EAT: 86.65 ± 1.33 μm. The release of adiponectin by adipocytes of the RSAT turned out to be comparable to the production of this adipokine in SCAT and EAT, however, adipocytes of the RSAT produce less leptin than SCAT and EAT: 0.26 (0.19; 0.27) ng/l vs 0.37 (0.28; 0.55) ( р = 0.01) and vs 0.32 (0.28; 0.44) ( р = 0.006) ng/ml, respectively. Furthermore, RSAT produce less insulin than SCAT and EAT: 1.56 (1.03; 2.08) vs 1.70 (0.99; 2.18) ng/ml, (р = 0.0022) and 1.76 (1.16; 2.40) ng/ml ( р = 0.006), respectively. A positive correlation was found between the secretion of leptin by adipocytes of the RSAT and the AIx ( r s = 0.52, p = 0.046). An inverse relationship was found between insulin secretion by retrosternal adipocytes and PWV r s = –0.55, p = 0.035). There was no relationship between the size of the retrosternal adipocyte or hypertrophy of the thymic adipocytes (more than 100 μm) and the production of leptin and insulin and arterial stiffness parameters. Conclusions . The data of our pilot study show that adipocyte hypertrophy of the retrosternal AT is not a significant marker of adipokine production disturbance . The observed relationships suggest that an increase in leptin production and reduced insulin secretion by retrosternal AT may contribute to the formation of adipokine-related arterial stiffness. Based on the data obtained, it can be assumed that adipokines produced by the retrosternal AT can participate in the formation of arterial stiffness in patients with coronary artery disease.

Introduction: Epicardial exit sites of ventricular tachycardia (VT) are frequently encountered during VT ablation requiring an epicardial ablation approach for successful elimination of VT. We sought to assess the utility of repolarization markers in identifying individuals requiring an epicardial ablation approach in addition to an endocardial approach. Methods: 32 patients who underwent successful ablation for scar mediated VT were included in the study. Fourteen patients who required a combined endocardial and epicardial VT ablation were defined as epicardial VT group (Epi) whereas 18 patients who were successfully ablated from the endocardium alone constituted the endocardial VT group (Endo). Repolarization markers during sinus rhythm were compared between the two groups. Results: A higher QTc max and QTc dispersion were seen in the Epi group compared to Endo group (479 ± 34 vs 449 ± 20, p = 0.008 and 63 ± 13 vs 38 ± 8, p = 0.001, respectively). Ts-p and Ts-p/Tp-e were higher in the Epi group (166 ± 23 vs 143 ± 23, p = 0.008 and 1.55 ± 0.26 vs 1.3 ± 0.21, p

Since their inception, percutaneous epicardial approaches have become increasingly common in clinical practice with the advent of new technology and the growth of catheter ablation for both ventricular and supraventricular arrhythmias. In addition to identifying the arrhythmogenic foci, there remain challenges to successful epicardial ablation such as the choice of energy source, optimizing irrigation during ablation, and anatomic barriers such as epicardial fat and coronary vessels. The performance of continued translational studies to understand how each of these factors contribute to lesion formation will be essential to guide future advances in the field of epicardial ablation.

Epicardial catheter ablation is most commonly performed following unsuccessful endocardial ablation. Given the frequency of epicardial substrates in certain cardiomyopathic disease states, however, a combined endocardial-epicardial approach should be considered as a primary treatment strategy. Although epicardial ablation is primarily deployed in patients with ventricular arrhythmias, the role of epicardial approaches in supraventricular tachycardias (eg, atrial fibrillation, inappropriate sinus tachycardia, and-rarely-accessory pathways) is growing, with continued advances being made.

Idiopathic premature ventricular contractions (PVCs) occur in structurally normal hearts and can be treated by ablation. Although most PVCs are ablated via an endocardial approach, some may have an epicardial origin which may require ablation via the coronary venous system or using a pericardial

Background Left atrial appendage occlusion (LAAO) represents a treatment alternative to anticoagulation in patients with atrial fibrillation. We evaluate a novel device for epicardial LAAO in a translational canine model. Methods Nine hounds (n = 9) were used to assess usability, safety, and efficacy of the TigerPaw Pro (TPP) device for epicardial LAAO. Following baseline imaging (intra-cardiac echocardiography (ICE) and angiography) and intraoperative visual inspection, usability was tested via a ``closure/re-opening`` maneuver followed by deployment of a total of twenty TPP devices (n = 20) on the left and right atrial appendages respectively. Procedural safety was evaluated by assessing for adverse-events via direct Epicardial inspection and endocardial imaging. Efficacy evaluation included assessment of device positioning, presence of residual stumps and completeness of closure. Post-mortem evaluation was performed to confirm safety and efficacy. Results Usability testing of all TPP devices was successful (n = 20;100%, delivery-time range 22–120 s) without any procedural adverse-events (tissue damage or tears, bleeding, vessel-impingement, structural impact). All devices fully traversed the ostium (n = 18) or appendage body (n = 2), and conformed smoothly to adjacent cardiac anatomy. In nineteen deployments (n = 19;95%), all device connector pairs were fully engaged, while in one TPP device the most distal pair remained unengaged. ICE and post-mortem inspections revealed complete closure of all appendage ostia (n = 18;100%) and only in one case a small residual stump was detected. Intraoperative safety findings were further confirmed post-mortem. Devices created a nearly smooth line of closure via symmetric endocardial tissue-coaptation. Conclusions In this preclinical model, the TPP demonstrated good ease of use for ostial access, ability to re-position (after engagement) and rapid deployment, while achieving safe and effective LAAO.

Introduction We present a case involving an initially unsuccessful ablation attempt of a right ventricular outflow tract (RVOT) ventricular tachycardia (VT) and the subsequent management that provided a definitive diagnosis and effective treatment. VT with left bundle branch block morphology and an inferior axis is often caused by focal tachycardia arising from the RVOT. The differential for this arrhythmia includes a macroreentrant VT. This can be due to arrhythmogenic right ventricular cardiomyopathy (ARVC),1 which is diagnosed using a combination of clinical cues and electrical and noninvasive imaging to meet the Task Force Criteria.2 This case demonstrates the difficulties with diagnosis in the early subclinical phase of ARVC and illustrates the pathophysiology of reentrant VT.

Purpose Epicardial pulmonary vein isolation has become an increasingly used therapy for medically resistant atrial fibrillation. The purpose of the present study was therefore to evaluate if epicardial pulmonary vein isolation combined with ganglionated plexi ablation affects the size and mechanical function of the left atrium, and whether the effects are dependent on the extensiveness of the ablation applications. Methods A total of 42 patients underwent an echocardiographic examination prior to and 6 months after a minimal invasive epicardial pulmonary vein isolation procedure for the assessment of the effects on left atrial size and function. In 27 patients, who had sinus rhythm both at baseline and follow-up, was a comparison of atrial size and function possible at these time intervals. Fractional area changes were obtained from the left atrial end-systolic and end-diastolic areas in the apical four-chamber view. Pulsed-Doppler was used to assess the transmitral flow velocities to evaluate mechanical function. Results Left atrial size and function at 6-month follow-up had not changed significantly from those at baseline as indicated by left atrial maximal area (17.1 ± 4.6 vs. 18.7 ± 5.3, p = 0.118), minimal area (12.5 ± 3.8 vs. 13.4 ± 4.7, p = 0.248), fractional area change (27.4 ± 8.2 vs. 28.7 ± 10.6, p = 0.670), and E/A ratio (1.49 ± 0.47 vs. 1.54 ± 0.67, p = 0.855). Conclusions Radiofrequency ablation for epicardial pulmonary vein isolation combined with ganglionated plexi ablation has no major effects on atrial function or size. A preserved atrial function for those maintaining sinus rhythm may have important implications for thromboembolic risk after surgery, but warrants confirmation in larger trials.

Ventricular tachycardia (VT) is a crucial cause of sudden cardiac death (SCD) and a primary cause of mortality and morbidity in patients with structural cardiac disease. VT includes clinical disorders varying from benign to life-threatening. Most life-threatening episodes are correlated with coronary artery disease, but the risk of SCD varies in certain populations, with various underlying heart conditions, specific family history, and genetic variants. The targets of VT management are symptom alleviation, improved quality of life, reduced implantable cardioverter defibrillator shocks, prevention of reduction of left ventricular function, reduced risk of SCD, and improved overall survival. Antiarrhythmic drug therapy and endocardial catheter ablation remains the cornerstone of guideline-endorsed VT treatment strategies in patients with structural cardiac abnormalities. Novel strategies such as epicardial ablation, surgical cryoablation, transcoronary alcohol ablation, pre-procedural imaging, and stereotactic ablative radiotherapy are an appealing area of research. In this review, we gathered all recent advances in innovative therapies as well as experimental evidence focusing on different aspects of VT treatment that could be significant for future favorable clinical applications.

Introduction Left atrial appendage (LAA) closure has become of major interest for patients with atrial fibrillation intolerant to oral anticoagulation therapy (OAC). Patients with a contraindication to both OAC and antiplatelet therapy are not eligible for percutaneous LAA closure. We aimed to find an alternative treatment for these specific patients. Methods From March 2014 until December 2015 five patients were referred for percutaneous LAA closure. Alternative treatment was necessary due to an absolute contraindication to OAC and antiplatelet therapy (n = 4) or after previous failed percutaneous device implantation (n = 1). A stand-alone full thoracoscopic closure of the LAA using the Atriclip PRO device (AtriCure Inc., Dayton, OH, USA) was performed under guidance of transoesophageal echocardiography (TEE). After three months all patients underwent a computed tomography scan. Mean follow-up was 7.2 months [range 4.5–9.8 months]. Results All procedures were achieved without the occurrence of complications. Complete LAA closure was obtained in all patients without any residual flow confirmed by TEE. Postoperative computed tomography confirmed persisting adequate clip positioning with complete LAA closure and absence of intracardial thrombi. During follow-up no thromboembolic events occurred. Conclusion For atrial fibrillation patients with an absolute contraindication to OAC and antiplatelet therapy a stand-alone, minimally invasive thoracoscopic closure of the LAA is a safe and feasible alternative treatment. This might be a solution to avoid serious bleeding complications while eliminating the thromboembolic risk originating from the LAA in patients who are not eligible for percutaneous LAA closure.

The epicardium and its derivatives provide trophic and structural support for the developing and adult heart. Here we tested the ability of human embryonic stem cell (hESC)-derived epicardium to augment the structure and function of engineered heart tissue in vitro and to improve efficacy of hESC-cardiomyocyte grafts in infarcted athymic rat hearts. Epicardial cells markedly enhanced the contractility, myofibril structure and calcium handling of human engineered heart tissues, while reducing passive stiffness compared with mesenchymal stromal cells. Transplanted epicardial cells formed persistent fibroblast grafts in infarcted hearts. Cotransplantation of hESC-derived epicardial cells and cardiomyocytes doubled graft cardiomyocyte proliferation rates in vivo, resulting in 2.6-fold greater cardiac graft size and simultaneously augmenting graft and host vascularization. Notably, cotransplantation improved systolic function compared with hearts receiving either cardiomyocytes alone, epicardial cells alone or vehicle. The ability of epicardial cells to enhance cardiac graft size and function makes them a promising adjuvant therapeutic for cardiac repair. Cell therapy in a rat model of heart attack is enhanced by stem-cell-derived epicardium.

Although electroanatomic mapping techniques have been previously applied to open chest epicardial ablation procedures, such efforts have often been limited by significant geometric distortions introduced by the need to use nonstandard mapping patch placements and by intrathoracic conductance changes introduced by having the pericardial space exposed. In this article, we present a case of a patient with recurrent hemodynamically unstable ventricular tachycardia who underwent a successful open chest epicardial ablation procedure with electroanatomic mapping in which geometric distortions were minimized by judicious placement of mapping patches and the use of a saline bath within the pericardial space.

Highlights • Assessment of epicardial fat volume is highly reproducible. • Epicardial fat volume and epicardial fat area have a good correlation to BMI. • Epicardial fat volume correlates best with DEXA-derived total body fat and trunk fat. • Epicardial fat volume should be considered over other CT assessment methods when quantifying epicardial fat in HIV patients., Purpose To assess the reproducibility of different epicardial fat measurement and their association with other adiposity measurements in HIV-infected and non-HIV-infected patients. Methods and materials In this cross-sectional study, 167 HIV-infected and 58 non-HIV-infected consecutive participants (200 males; mean age 56 years) with low/intermediate cardiovascular risk were recruited between 2012 and 2017 from a large prospective cohort and underwent non-contrast cardiac CT. Two independent observers measured epicardial fat volume, area and thickness in all participants. For intra-observer agreement, one observer did a second assessment in a subset of 40 patients. Agreement was assessed with the intraclass correlation coefficient (ICC). Pearson's correlation was estimated to assess the association between epicardial fat, body-mass index (BMI) and dual-energy x-ray absorptiometry (DEXA) derived percentage of body fat. Results Inter-observer agreement was excellent for epicardial fat volume (ICC 0.75) and area (ICC 0.95) and good for epicardial fat thickness (ICC near the left anterior descending artery (LAD) 0.64, ICC near right coronary artery (RCA) 0.64). Intra-observer agreement was excellent for epicardial fat volume (ICC 0.97), area (ICC 0.99), thickness at LAD (ICC 0.71) and good for epicardial fat thickness at RCA (ICC 0.68). Epicardial fat volume had a better correlation to total body fat (r = 0.28, p < 0.001) and trunk fat (r = 0.37, p < 0.001), in comparison to other epicardial fat indices. Conclusion Assessment of epicardial fat volume is highly reproducible in both HIV-infected and non-HIV-infected patients and shows a superior correlation with DEXA-based body and trunk fat measurements. Epicardial fat volume should be considered over other CT assessment methods when quantifying epicardial fat in HIV patients.

Background Mapping using a multipolar catheter with small and closely spaced electrodes has been shown to improve the validity of electrograms to identify endocardial critical sites of reentry isthmus and foci of earliest activation. However, the feasibility, safety, and clinical outcome of using such technology to guide epicardial ventricular tachycardia (VT) ablation has not been reported. Methods and Results Thirty‐three consecutive patients from 5 high‐volume centers were studied. These patients had 43 epicardial maps using a novel 64‐pole mini‐basket catheter to guide VT ablation. Activation maps with 17 832 points per map (interquartile range: 7621–32 497 points per map) were acquired in 11 patients with tolerated VT (7 focal, 4 reentry). Substrate maps with 40149 points per map (interquartile range: 20926–49391 points per map) were acquired in 30 patients. Local abnormal ventricular activities were consistently demonstrated at the substrate regions of interest. Epicardial ablation was performed in 31 of 33 patients, with acute VT termination in 10 of 11 patients (91%). Complete elimination of local abnormal ventricular activities was achieved in 25 of 31 patients. At a median follow‐up of 10 months (interquartile range: 4–14 months), 64% (7/11) of patients who had acute termination of VT and 55% (11/20) of those who had substrate modification alone were free of VT. There was no immediate complication following epicardial procedure. Conclusions Epicardial VT ablation guided by a mini‐basket catheter is feasible and safe. Complete reentry VT circuits and foci of earliest activation were identified in all inducible stable VT. The longer term clinical outcome of ablation guided by this novel mapping technology utilizing small and closely spaced electrodes will have to be determined with a larger study.

Background Soluble urokinase plasminogen activator receptor (su PAR ) is a proinflammatory biomarker associated with immune activation and fibrinolysis inhibition. Plasminogen activator inhibitor ( PAI ‐1) is associated with excessive fibrin accumulation, thrombus formation, and atherosclerosis. The relationship between cross‐coronary su PAR and PAI ‐1 production and endothelial dysfunction remains unknown. Methods and Results Seventy‐nine patients (age 53±10 years, 75% women) with angina and normal coronary arteries or mild coronary artery disease (20% after acetylcholine) and mircovascular endothelial dysfunction (coronary blood flow change PAR and PAI ‐1 levels were measured in each patient before acetylcholine administration, and cross‐coronary su PAR and PAI ‐1 production rates were calculated. Patients’ characteristics, except for age (51±10 versus 57±9, P =0.02), and resting coronary hemodynamics were not significantly different between patients with (26%) versus without (74%) epicardial endothelial dysfunction. Patients’ characteristics and resting coronary hemodynamics were not significantly different between those with (62%) and those without (38%) mircovascular endothelial dysfunction. Patients with mircovascular endothelial dysfunction demonstrated local coronary su PAR production versus su PAR extraction in patients with normal microvascular function (median 25.8 [interquartile range 121.6, −23.7] versus −12.7 [52.0, −74.8] ng/min, P =0.03). Patients with epicardial endothelial dysfunction had higher median coronary PAI ‐1 production rates compared with those with normal epicardial endothelial function (1224.7 [12 940.7, −1915.4] versus −187.4 [4444.7, −4535.8] ng/min, P =0.03). Conclusions su PAR is released in coronary circulation of patients with mircovascular endothelial dysfunction and extracted in those with normal microvascular function. Cross‐coronary PAI ‐1 release is higher in humans with epicardial endothelial dysfunction.

We report a case of a 69-year-old male with non-ischemic cardiomyopathy, having drug- and antitachycardia pacing-refractory ventricular tachycardia resulted in multiple ICD shocks. The sustained and intractable ventricular arrhythmia was mapped and ablated with the aid of the three-dimensional electroanatomic mapping system, initially performed but unsuccessful from the endocardial site then performed successfully from the epicardial site via the coronary sinus.

OBJECTIVES The aim of this study was to describe the procedural aspects and outcomes of retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) through ipsilateral collateral channels (ILCs). BACKGROUND Retrograde CTO PCI via ILCs is rarely performed, usually when no other retrograde options exist, and available evidence derives mostly from case reports. METHODS A large retrospective multinational registry was compiled, including all consecutive patients undergoing retrograde CTO PCI through ILCs at 6 centers between September 2011 and October 2016. Success rates, as well as procedural complications and in-hospital outcomes, were studied. RESULTS A total of 126 patients (17% of all retrograde CTO PCIs) were included. The mean age was 65.7 +/- 11.2 years, and the mean J-CTO (Multicenter CTO Registry in Japan) score was 2.36 +/- 1.13. The target vessel was the circumflex coronary artery in 42%, the left anterior descending coronary artery in 39%, and the right coronary artery in 19%. The ILCs used were epicardial in 76% and septal in 24%. ILC anatomy was very heterogeneous. One guiding catheter was used in 80%, whereas the ping-pong technique was used in 20%. A retrograde wire could be advanced to the distal cap in 81%. Technical and procedural success rates were 87% and 82%, respectively. ILC perforation with need for intervention was observed in 5.6% and tamponade due to ILC perforation in 2.4%. One patient (0.8%) died. CONCLUSIONS Retrograde CTO PCI through ILCs is a challenging intervention that can be performed in difficult occlusions with high success rates and reasonable rates of complications by experienced operators. (C) 2017 by the American College of Cardiology Foundation. Mr. Maeremans is a researcher for the Limburg Clinical Research Program UHasselt-ZOL-Jessa, supported by the foundation Limburg Sterk Merk, Hasselt University, Ziekenhuis Oost-Limburg, and Jessa Hospital. Dr. Azzalini has received honoraria from Guerbet; and has received research support from ACIST Medical Systems. Dr. Agostoni has received honoraria from Aquilant, Meril, Neovasc, Genae, and Angiodynamics. Dr. Dens has received consulting fees from Asahi, Boston Scientific, Medical Solutions, Orbus Neich, Terumo; and has received a scientific grant from Boston Scientific. Dr. Mashayekhi has received consulting fees from Asahi Intecc; and has received honoraria from Vascular Solutions.

Background The retrograde approach through epicardial collaterals (EC) for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is a challenging procedure. Our study aim was to evaluate the outcomes of patients undergoing CTO PCI using a retrograde approach through epicardial versus non-epicardial collaterals (NEC). Methods We collected data from our single-center registry of consecutive patients undergoing retrograde CTO PCI, performed by an experienced operator through EC and NEC (septals and bypass grafts). Clinical, angiographic and procedural data were recorded. The primary endpoint (major adverse cardiac events, MACE) was a composite of cardiac death, target-vessel myocardial infarction (MI) and target-vessel revascularization (TVR) on follow-up. Results During the study period, 318 CTO PCIs were performed. Of these, 81 procedures (25%) were performed retrogradely in 75 patients (38 using NEC [31 septals, 7 bypass grafts], 37 through EC [34 contralateral, 3 ipsilateral]). Clinical characteristics were balanced between EC and NEC. J-CTO score was 2.1±1.1 and 2.2±1.2, respectively (p=0.92). Collateral tortuosity was more marked in EC. Technical and procedural success was lower in EC (35% vs. 76%, p

Objectives This study investigated the impact on recurrences of 2 different substrate approaches for the treatment of these arrhythmias. Background Catheter ablation of electrical storms (ES) for ventricular arrhythmias (VAs) has shown moderate long-term efficacy in patients with ischemic cardiomyopathy. Methods Ninety-two consecutive patients (81% male, age 62 ± 13 years) with ischemic cardiomyopathy and ES underwent catheter ablation. Patients were treated either by confining the radiofrequency lesions to the endocardial surface with limited substrate ablation (Group 1, n = 49) or underwent endocardial and epicardial ablation of abnormal potentials within the scar (homogenization of the scar, Group 2, n = 43). Epicardial access was obtained in all Group 2 patients, whereas epicardial ablation was performed in 33% (14) of these patients. Results Mean ejection fraction was 27 ± 5. During a mean follow-up of 25 ± 10 months, the VAs recurrence rate of any ventricular tachycardia (VTs) was 47% (23 of 49 patients) in Group 1 and 19% (8 of 43 patients) in Group 2 (log-rank p = 0.006). One patient in Group 1 and 1 patient in Group 2 died at follow-up for noncardiac reasons. Conclusions Our study demonstrates that ablation using endo-epicardial homogenization of the scar significantly increases freedom from VAs in ischemic cardiomyopathy patients.

Permanent cardiac pacing in pediatric patients presents challenges related to small patient size, complex anatomy, electrophysiologic abnormalities, and limited access to cardiac chambers. Epicardial pacing currently remains the conventional technique for infants and patients with complex congenital heart disease. Pacemaker lead failure is the major source of failure for such epicardial systems. The authors hypothesized that a retrocostal surgical approach would reduce the rate of lead failure due to fracture compared with the more traditional subrectus and subxiphoid approaches. To evaluate this hypothesis, a retrospective chart review analyzed patients with epicardial pacemaker systems implanted or followed at Rady Children’s Hospital San Diego between January 1980 and May 2007. The study cohort consisted of 219 patients and a total of 620 leads with epicardial pacemakers. Among these patients, 84% had structural congenital heart disease, and 45% were younger than 3 years at time of the first implantation. The estimated lead survival was 93% at 2 years and 83% at 5 years. The majority of leads failed due to pacing problems (54%), followed by lead fracture (31%) and sensing problems (14%). When lead failure was adjusted for length of follow-up period, no significant differences in the rates of failure by pocket location were found.

Aims Transvenous pulmonary vein isolation (PVI) is the cornerstone of non-pharmacological rhythm control therapy in symptomatic atrial fibrillation (AF). Success and complications rates are, however, still not optimal. New techniques and energy sources are therefore being developed. Methods and results Fifteen patients with lone AF refractory for antiarrhythmic drugs (AADs) underwent PVI by minimal invasive epicardial off-pump monolateral right-sided video-assisted thoracic surgery (VATS) using the UltraCinch with high-intensity focused ultrasound (HIFU). Primary endpoint was successful ablation defined as absence of AF or atrial flutter/tachycardia after 6 months assessed by complaints, 12 lead electrocardiogram, and 96 h Holter monitoring. Secondary endpoints were ablation success at the end of follow-up irrespective of AADs use or re-ablation and complications related to the procedure. Mean age was 47 ± 10 years and 14 (93%) were male. Eleven (73%) had paroxysmal, and 4 (27%) patients had persistent AF. Median AF history was 5 (1–12) years. At 6 months, six (40%) patients had sinus rhythm after one epicardial PVI (four on AADs). After 1.3 ± 0.6 years, four (27%) patients had sinus rhythm after one epicardial PVI (two on AADs) and in six (40%) patients endocardial radiofrequency re-ablation was performed, which was successful in three patients (20%). Two patients (13%) were planned for re-ablation. Three others (20%) refused re-ablation. Two major complications occurred (one late tamponade and one bleeding during surgery, necessitating sternotomy). Conclusion Epicardial PVI using monolateral right-sided VATS with the UltraCinch delivering HIFU is feasible, but is associated with substantial complications. Furthermore, the success rate was low. More research is therefore warranted to assess optimal ablation techniques and energy sources to perform PVI. Trial Registration clinicaltrials.gov Identifier: NCT00448656.

Background: We investigated the efficacy and safety of strict voltage-based substrate mapping and radiofrequency catheter ablation (SV-substrate-map ablation) in patients with electrical storm. Methods and Results: SV-substrate-map ablation was performed in 15 patients suffering from multiple appropriate shocks (6.0 ± 3.8/day) from implantable cardioverter defibrillators (ICDs). Strict voltage criteria were defined as: non-arrhythmogenic areas, >0.6mV; low voltage areas, >0.1 to ≤0.6 mV; and scar, ≤0.1 mV. Using an electroanatomic mapping system, catheter ablation was performed at every possible arrhythmogenic region inside the low voltage areas. Further, we presented a review of the literature and investigated the published data on substrate-mapping guided ablation for electrical storm. After repeat endocardial ablation procedures in 4 patients and an epicardial approach in one, the targeted ventricular tachycardias (VTs) were successfully ablated, and the electrical storms were completely controlled in all. During a mean follow-up period of 801 ± 409 days, only one VT followed by an appropriate ICD shock was observed. No potential complications occurred during the procedure or follow-up. Our results were comparable or better than that of previous substrate-mapping guided ablation studies. Conclusion: SV-substrate-mapping ablation may be effective and safe for resolving serious clinical situations and prolonging the longevity of ICD devices in patients with electrical storms.

We report a patient with non-ischemic dilated cardiomyopathy and low left ventricular systolic function (28%) presenting with an electrical storm originated in epicardial scar and ablated by radiofrequency. This case report suggests that a strategy of epicardial catheter ablation is reasonable for the patient presenting with electrical storm related to structural disease with a low left ventricular ejection fraction.

Epicardial mapping and ablation via a percutaneous subxiphoid technique has been instrumental in improving the working understanding of complex myocardial scars in various arrhythmogenic substrates. Endocardial ablation alone may not be sufficient in patients with ischemic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, hypertrophic cardiomyopathy, and Chagas disease to prevent recurrent ventricular tachycardia. Multiple observational studies have demonstrated greater freedom from recurrence with adjunctive epicardial ablation compared with endocardial ablation alone. While epicardial ablation is performed predominantly at tertiary referral centers, knowledge of the technical approach, clinical indications, and potential complications is imperative to maximizing clinical success and patient safety. In 1996, Sosa and colleagues modified the pericardiocentesis technique to enable percutaneous access to the pericardial space for mapping and catheter ablation of ventricular tachycardia.1 Originally developed for patients with epicardial scarring due to chagasic cardiomyopathy and patients with ischemic cardiomyopathy refractory to endocardial ablationm,2,3 this approach has since become an essential part of the armamentarium for the treatment of ventricular tachycardia. Myocardial scars are three-dimensionally complex with varying degrees of transmurality, and the ability to map and ablate the epicardial surface has contributed to a greater understanding of scar-related VT in postinfarction cardiomyopathy and nonischemic substrates including idiopathic dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, hypertrophic cardiomyopathy, and chagasic cardiomyopathy. In this review, we highlight the percutaneous approach and discuss clinical indications and potential complications.

Background: Polycystic ovary syndrome (PCOS) is related to metabolic syndrome, insulin resistance, and cardiovascular metabolic syndromes. This is particularly true for individuals with central and abdominal obesity because visceral abdominal adipose tissue (VAAT) and epicardial adipose tissue (EAT) produce a large number of proinflammatory and proatherogenic cytokines. The present study aimed to determine whether there are changes in VAAT and EAT levels which were considered as indirect predictors for subclinical atherosclerosis in lean patients with PCOS. Methods: The clinical and demographic characteristics of 35 patients with PCOS and 38 healthy control subjects were recorded for the present study. Additionally, the serum levels of various biochemical parameters were measured and EAT levels were assessed using 2D-transthoracic echocardiography. Results: There were no significant differences in mean age (p = 0.056) or mean body mass index (BMI) (p = 0.446) between the patient and control groups. However, the body fat percentage, waist-to-hip ratio, amount of abdominal subcutaneous adipose tissue, and VAAT thickness were higher in the PCOS patient group than in the control group. The amounts of EAT in the patient and control groups were similar (p = 0.384). EAT was correlated with BMI, fat mass, waist circumference, and hip circumference but not with any biochemical metabolic parameters including the homeostasis model assessment of insulin resistance index or the levels of triglycerides, low-density lipoprotein cholesterol, and high-density lipoprotein (HDL) cholesterol. However, there was a small positive correlation between the amounts of VAAT and EAT. VAAT was directly correlated with body fat parameters such as BMI, fat mass, and abdominal subcutaneous adipose thickness and inversely correlated with the HDL cholesterol level. Conclusions: The present study found that increased abdominal adipose tissue in patients with PCOS was associated with atherosclerosis. Additionally, EAT may aid in the determination of the risk of atherosclerosis in patients with PCOS because it is easily measured. © 2015 Arpaci et al.

Background Specific 12-lead ECG criteria have been reported to predict an epicardial site of origin (SoO) of induced ventricular tachycardias (VTs) in left ventricular nonischemic cardiomyopathy. Objective The purpose of this study was to (1) determine the value of ECG criteria to predict an epicardial SoO of clinically documented VTs, (2) analyze the effect of VT cycle length (CL) and antiarrhythmic drugs on the accuracy of ECG criteria, and (3) assess interobserver variability. Methods In 36 consecutive patients with nonischemic left ventricular cardiomyopathy (age 58 ± 16 years, 75% male) who underwent combined endocardial/epicardial VT ablation, all clinically documented and induced right bundle branch block VTs were analyzed for previously reported ECG criteria to determine the SoO, as defined by ≥11/12 pace-map, concealed entrainment, and/or VT termination during ablation. Results In 21 patients with clinically documented (25 mm/s) right bundle branch block VT, none of the ECG criteria differentiated between patients with and those without an epicardial SoO. In induced VTs (100 mm/s), 2 of 4 interval criteria differentiated between an endocardial and epicardial SoO for slow VTs (CL >350 ms) and 2 of 4 criteria in patients on amiodarone, but none for fast VTs (CL ≤350 ms) or patients off amiodarone. The Q wave in lead I was the most accurate criterion for an epicardial SoO (sensitivity 88%, specificity 80%). In both clinically documented and induced VTs, interobserver agreement was poor for pseudodelta wave and moderate for other criteria. Conclusion When applied to clinically documented VTs, no ECG criterion could differentiate between patients with and those without an epicardial SoO. Published interval-based ECG criteria do not apply to fast VTs and patients off amiodarone.

It is well established that the cardiovascular (CV) risk of obesity is more strongly associated with visceral rather than subcutaneous adiposity.[1][1]–[3][2] Anthropometric variables that account for visceral adiposity, such as body mass index (BMI) and waist circumference (WC), have limited

Background Analysis of unipolar voltage maps has been used to detect epicardial scar, but data to define optimal parameters to identify scar remote from the recording site is limited. This study compares the characteristics of electrograms at endocardial sites adjacent to abnormal epicardial sites. Methods and Results Data obtained from endocardial and epicardial electroanatomical maps of 31 patients with scar‐related ventricular tachycardia were reviewed. Five hundred twenty‐three pairs of endo‐ and epicardial points were selected according to predefined criteria. The endocardial points adjacent to epicardial scar (bipolar voltage mV ) had smaller unipolar voltage than those distant from epicardial scar ( P P OR 0.94, 95% CI 0.93 to 0.97). An endocardial unipolar amplitude mV in the right ventricular (RV) (sensitivity 93%, specificity 76%) and mV in the left ventricular (LV) (sensitivity 91%, specificity 75%) was the optimal cutoff predicting epicardial scar. Applying these thresholds to electroanatomical maps, revealed a good match between endocardial unipolar abnormality and epicardial scar for 67% of LV and 75% of RV maps, respectively, but notably poor matches occurred in 8 (29%) maps (7 with nonischemic cardiomyopathy). Site‐by‐site correlations were better for ischemic than nonischemic cardiomyopathy. Conclusions This study supports the contention that unipolar electrograms are capable of indicating overlying epicardial scar during endocardial mapping, but illustrates limitations that appear to differ with nonischemic as compared to ischemic cardiomyopathy. The presence of epicardial arrhythmia substrate cannot be excluded by analysis of unipolar endocardial maps in some patients.

PURPOSE: To study the interatrial conduction times and atrial node performance in patients submitted to mitral valve surgery with the aid of temporary atrial epicardic electrodes. METHODS: The atriograms were carried out in the first postoperative day and before the hospital discharge of ten consecutive patients. RESULTS: Sixty percent of the patients could complete the post-operative study protocol. The main results were: a) Post-operative arrhythmias were detected in 50% of the patients; b) There were no statistical differences between the pre and post-operative 12 lead EKGs. c) The interatrial conduction time (IACT) ranged from 90 to 140ms in the first post-operative day, and from 110 to 130ms at hospital discharge; d) The sinus node recovery time (SNRT) ranged from 250 to 560 ms in the first post-operative day and from 180 to 360ms at hospital discharge; e) The sinus atrial conduction time (SACT) remained between 70 and 140ms, both in the first post-operative day and at hospital discharge, and; f) The IACT was normal in patients whose left atrium (LA) was less than 50mm in diameter but supra normal in the remaining cases. CONCLUSIONS: Sinus node function and inter-atrial conduction are not altered by mitral valve operation. Post-operative programmed epicardic atrial stimulation is easy and safe. OBJETIVO: Estudar os tempos de condução interatrial e a função do nó sinusal em pacientes submetidos a tratamento cirúrgico. MÉTODOS: Foram estudados 10 pacientes adultos consecutivos submetidos à operação de correção de valvopatia mitral. Registraram-se atriogramas usando eletrodos epimiocárdicos cirurgicamente implantados. Os atriogramas foram obtidos no primeiro dia do pós-operatório e antes da alta hospitalar. RESULTADOS: Os principais achados foram: a) A incidência de arritmias atriais até alta hospitalar foi de 50 %; b) O tempo de condução interatrial (TCIA) variou de 90 a 140 ms no 1°PO e 110 a130 ms antes da alta hospitalar; c) O tempo de recuperação do nó sinusal (TRNS) variou de 250 a 560 ms no 1°PO e180 a 360 ms antes da alta hospitalar; d) O tempo de condução sinoatrial (TCSA) variou de 70 a 140 ms tanto no 1ºPO, como antes da alta hospitalar e; d) O tempo de condução interatrial (TCIA) foi normal em pacientes com átrio esquerdo menores do que 50 mm e supranormal nos outros casos. CONCLUSÃO: As funções do nó sinusal e a condução interatrial não foram alteradas pelo tratamento cirúrgico da valvopatia mitral. A estimulação atrial epicárdica programada é segura de fácil realização.

The study was done to detect the optimal site of left anterior descending (LAD) artery for grafting and for the assessment of geometrical and anatomical characteristics of left internal mammary artery (LIMA)-to-LAD artery anastomosis in elective off-pump coronary artery bypass grafting surgery. Fifteen consecutive patients who underwent coronary artery bypass graft (CABG) were included in the study. All the operations were performed by a single surgeon. Epicardial ultrasound probe was placed at the site of grafting for scanning and the site of anastomosis selected. The anticipated target site selected by the surgeon was scanned for patency, size, septal perforator branches, and presence of plaque and calcification. The surgeon identified the LAD artery in 12 patients. In three patients, the LAD artery was not visible. However, with epicardial ultrasound, the LAD artery was identified in all patients. In 6 of 15 patients, the anticipated target anastomotic site was changed to a clear segment either due to the presence of perforators or plaques or calcifications. In all 15 patients, the surgeon scored the anastomosis as good, based on his or her experience independent of the ultrasound image. The anastomotic score by the cardiac anesthesiologist showed 5 anastomoses with satisfactory results and 10 anastomoses with good results. The study demonstrates that epicardial ultrasound scanning with a 10-MHz transducer provides reliable information in choosing the proper anastomotic site and allows proper visualization of LIMA-to-LAD anastomosis. All these measurements are easily obtained without risk of any complications and the method is not time consuming.

We describe a patient with nonischemic cardiomyopathy who underwent radiofrequency (RF) catheter ablation for a drug-refractory ventricular tachycardia (VT). RF ablation from a left ventricular (LV) endocardial site failed to eliminate the VT. Using a conventional ablation catheter with the temperature-controlled mode, RF ablation from the LV epicardium resulted in failed ablation because of low power due to a temperature limitation function. However, by using a pericardial pigtail catheter for manual infusion and removal of saline within the pericardial space, adequate energy could be delivered, and the ablation overlying the lowvoltage area successfully eliminated the VT.