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Background— The purpose of this study was to conduct a worldwide survey investigating the methods, efficacy, and safety of catheter ablation (CA) of atrial fibrillation (AF). Methods and Results— A detailed questionnaire was sent to 777 centers worldwide. Data relevant to the study purpose were collected from 181 centers, of which 100 had ongoing programs on CA of AF between 1995 and 2002. The number of patients undergoing this procedure increased from 18 in 1995 to 5050 in 2002. The median number of procedures per center was 37.5 (range, 1 to 600). Paroxysmal AF, persistent AF, and permanent AF were the indicated arrhythmias in 100.0%, 53.0%, and 20.0% of responding centers, respectively. The most commonly used techniques were right atrial compartmentalization between 1995 and 1997, ablation of the triggering focus in 1998 and 1999, and electrical disconnection of multiple pulmonary veins between 2000 and 2002. Of 8745 patients completing the CA protocol in 90 centers, of whom 2389 (27.3%) required >1 procedure, 4550 (52.0%; range among centers, 14.5% to 76.5%) became asymptomatic without drugs and another 2094 (23.9%; range among centers, 8.8% to 50.3%) became asymptomatic in the presence of formerly ineffective antiarrhythmic drugs over an 11.6±7.7-month follow-up period. At least 1 major complication was reported in 524 patients (6.0%). Conclusions— The findings of this survey provide a picture of the variable and evolving methods, efficacy, and safety of CA for AF as practiced in a large number of centers worldwide and may serve as a guide to clinicians considering therapeutic options in patients suffering from this arrhythmia.

This trial will significantly advance our understanding of the prognostic and therapeutic usefulness of electrophysiologic studies in patients with coronary artery disease. Several features of this trial are worth emphasizing. First, the protocol for performing programmed stimulation and serial drug testing is designed to mirror those currently in use by many practicing electrophysiologists. While practice patterns vary, the procedures used in the trial reflect what is considered "usual and standard" practice. Second, because half of the patients with inducible sustained ventricular tachycardia will be given no antiarrhythmic therapy, we will be able to ascertain the true risk of sudden death in this patient population without the influence of these agents. Third, this trial will assess the usefulness of a method of guiding antiarrhythmic therapy (electrophysiologic testing) to reduce mortality in this high-risk population. It will not evaluate the efficacy of a specific type of antiarrhythmic therapy.

Ablation procedures for atrial fibrillation are being performed with increasing frequency. One of the most serious complications is the development of pulmonary vein stenosis, which occurs in 1% to 3% of current series. The presentation of pulmonary vein stenosis varies widely. The majority of patients are symptomatic although specific referral bias patterns can affect this. Symptoms may include dyspnea or hemoptysis or may be consistent with bronchitis. These symptoms are affected by the number of stenotic veins as well as the severity of the stenosis. The more severe the stenosis and the greater number of stenosed veins result in more symptoms. Because of the variability in symptoms, clinicians must have heightened sensitivity to the presence of the condition. Diagnostic tests of value include magnetic resonance angiography and computed tomography. Although echocardiography has been used, it does not usually provide adequate assessment. Progression of stenosis is unpredictable and may be rapid. The specific anatomy of the stenosis varies widely and affects management. Because of the presence of antral fusion of the origin of the left superior and left inferior pulmonary vein, a stenosis involving 1 or the other can impinge and affect outcome. In this setting, bifurcation techniques familiar to interventional cardiology are very helpful. Controversy currently exists about the optimal treatment approach. The use of balloons and larger stents (approximately 10 mm) results in more optimal results than just balloon angioplasty alone; however, even with stent implantation, recurrent restenosis may occur in 30% to 50% of patients. Follow-up of these patients typically involves computed tomography imaging to document restenosis. If significant restenosis is identified, it should be treated promptly because of the potential for progression to total occlusion.

The outcome of congestive heart failure (CHF) patients with syncope is understood incompletely.We analyzed data from patients enrolled in the SCD-HeFT (Sudden Cardiac Death Heart Failure Trial) to determine whether syncope predicted outcomes in patients with CHF.We compared outcomes (and associated clinical characteristics) in patients with and without syncope enrolled in SCD-HeFT.In SCD-HeFT, 162 (6%) patients had syncope before randomization, 356 (14%) had syncope after randomization (similar incidence in each randomized arm), and 46 (2%) had syncope before and after randomization. A QRS durationor=120 ms and absence of beta-blocker use predicted syncope during follow-up (hazard ratio [HR] 1.30 and 95% confidence interval [CI] 1.06 to 1.61, p = 0.014 and HR 1.25, 95% CI 1.01 to 1.56, p = 0.048, respectively). Syncope recurrence did not differ by randomization arm. However, in the implantable cardioverter-defibrillator (ICD) arm, syncope, before and after randomization, was associated with appropriate ICD discharges (HR 1.75, 95% CI 1.10 to 2.80, p = 0.019 and HR 2.91, 95% CI 1.89 to 4.47, p = 0.001, respectively). Post-randomization syncope predicted total and cardiovascular death (HR 1.41, 95% CI 1.13 to 1.76, p = 0.002 and HR 1.55, 95% CI 1.19 to 2.02, p = 0.001, respectively). The elevated relative risk of mortality for syncope versus non-syncope patients did not vary significantly across treatment arms (ICD, HR 1.54, 95% CI 1.04 to 2.27; amiodarone, HR 1.33, 95% CI 0.91 to 1.93; and placebo, HR 1.39, 95% CI 0.96 to 2.02, test for difference p = 0.86).For CHF patients with ICDs, syncope was associated with appropriate ICD activations. Syncope was associated with increased mortality risk in SCD-HeFT regardless of treatment arm (placebo, amiodarone, or ICD).

Venice Chart International Consensus Document on Atrial Fibrillation Ablation ANDREA NATALE, M.D.,∗ ANTONIO RAVIELE, M.D.,† THOMAS ARENTZ, M.D.,‡ HUGH CALKINS, M.D.,¶ SHIH-ANN CHEN, M.D.,∗∗ MICHEL HAISSAGUERRE, M.D.,†† GERHARD HINDRICKS, M.D.,‡‡ YEN HO, M.D.,¶¶ KARL HEINZ KUCK, M.D.,∗∗∗ FRANCIS MARCHLINSKI, M.D.,††† CARLO NAPOLITANO, M.D.,‡‡‡ DOUGLAS PACKER, M.D.,¶¶¶ CARLO PAPPONE, M.D.,∗∗∗∗ ERIC N. PRYSTOWSKY, M.D.,†††† RICHARD SCHILLING, M.D.,‡‡‡‡ DIPEN SHAH, M.D.,¶¶¶¶ SAKIS THEMISTOCLAKIS, M.D.,† and ATUL VERMA, M.D.,∗∗∗∗∗ for the Venice Chart members From the ∗Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, USA; †Department of Cardiology, Arrhythmologic Section, Umberto I Hospital, Venice-Mestre, Italy; ‡Arrhythmia Service, Herz-Zentrum, Bad Krozingen, Germany; ¶Department of Cardiology, The Johns Hopkins Hospital, Baltimore, USA; ∗∗Division of Cardiology, Department of Medicine, National Yang-Ming University School of Medicine and Taipei Veterans General Hospital, Taipei, Taiwan; ††Hospital du Haut Leveque, CHU Bordeaux, Bordeaux, France; ‡‡University Leipzig, Heart Center, Department of Cardiology, Leipzig, Germany; ¶¶National Heart and Lung Institute, Imperial College and Royal Brompton & Harefield Hospitals, London, UK; ∗∗∗Second Medical Department, St Georg General Hospital, Hamburg, Germany; †††Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA; ‡‡‡Molecular Cardiology Laboratory, University of Pavia, Salvatore Maugeri Foundation, Pavia, Italy; ¶¶¶Department of Clinical Cardiac Electrophysiology and Internal Medicine, Mayo Clinic, Rochester, USA; ∗∗∗∗Department of Cardiology, Electrophysiology and Cardiac Pacing Unit, San Raffaele University Hospital, Milan, Italy; ††††St. Vincent Hospital and Health Care Center Program, Indianapolis, USA; ‡‡‡‡St. Bartholomew’s Hospital, London, UK; ¶¶¶¶Cardiology Cantonal Hospital of Geneva, Geneva, Switzerland; ∗∗∗∗∗University of Toronto, Toronto, Canada.