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BackgroundThe short-coupled variant of torsade de pointes (sc-TdP) is a malignant arrhythmia that frequently presents with ventricular fibrillation (VF) electrical storm. Verapamil is considered the first-line therapy of sc-TdP while catheter ablation is not widely adopted. The aim of this study was to determine the origin of sc-TdP and to assess the outcome of catheter ablation using 3D-mapping.Methods and resultsWe retrospectively analyzed five patients with sc-TdP who underwent 3D-mapping and ablation of sc-TdP at five different institutions. Four patients initially presented with sudden cardiac arrest, one patient experienced recurrent syncope as the first manifestation. All patients demonstrated a monomorphic premature ventricular contraction (PVC) with late transition left bundle branch block pattern, superior axis, and a coupling interval of less than 300 ms. triggering recurrent TdP and VF. In four patients, the culprit PVC was mapped to the free wall insertion of the moderator band (MB) with a preceding Purkinje potential in two patients. Catheter ablation using 3D-mapping and intracardiac echocardiography eliminated sc-TdP in all patients, with no recurrence at mean 2.7 years (range 6 months to 8 years) of follow-up.Conclusion3D-mapping and intracardiac echocardiography demonstrate that sc-TdP predominantly originates from the MB free wall insertion and its Purkinje network. Catheter ablation of the culprit PVC at the MB free wall junction leads to excellent short- and long-term results and should be considered as first-line therapy in recurrent sc-TdP or electrical storm.

Introduction: Defibrillation testing (DFT) is recommended during subcutaneous implantable cardioverter‐defibrillator (S‐ICD) implantation. Previous studies analyzing the potential interference of propofol with defibrillation threshold are inconsistent. The purpose of this study was to analyze whether propofol affects DFT post S‐ICD placement. Methods: All patients with S‐ICD implantation between 01/2017 and 11/2020 at the University Heart Center Freiburg were retrospectively analyzed. Two groups were generated depending on the success of the first shock during DFT. Implantation characteristics and dose of anesthetics were analyzed. Results: In 12 of the included 80 (15%) patients, first shock during DFT failed. The absolute dose of propofol was significantly higher in patients with first shock failure (median 653 mg [IQR 503–855]) compared to patients with first shock termination (376 mg [200–600]; p = 0.027). Doses of opioids and midazolam as well as type of anesthesia did not differ between the groups. A multivariable binary logistic regression analysis confirmed an independent association of first shock termination and propofol dose (per 100 mg: OR 0.73 (95% CI: 0.56–0.95); p = 0.021). Conclusion: There is an independent association of propofol dose and first shock failure in routine S‐ICD defibrillation testing. [ABSTRACT FROM AUTHOR]

Combined implantation of cardiac contractility modulation (CCM) with subcutaneous implantable cardioverter‐defibrillator (S‐ICD) appears a suitable option to reduce the amount of intracardiac leads and complications for patients. Here we report on a patient with ischemic cardiomyopathy carrying an S‐ICD in which a CCM device was implanted. During crosstalk testing post‐CCM implantation, the S‐ICD misannotated QRS complexes and T waves. The problem was solved through reprogramming the CCM, while preserving S‐ICD functionality and improving heart failure symptoms. In conclusion, S‐ICD combined with CCM seems to be a good and safe option for patients when device interference is being ruled out. [ABSTRACT FROM AUTHOR]