Cardiovasc Electrophysiol Research Articles

Effective ablation of atrial tachycardia with an epicardial circuit-insights from endocardial scars sites: a case study.

A previous study reported primary macroreentrant atrial tachycardia (AT) in the left atrium (LA), including the epicardial circuit on a left atrial anterior wall (LAAW) scar, without any prior cardiac intervention (Miyazawa et al. in J Cardiovasc Electrophysiol 2019; 30: 263-264). However, determining the target for terminating macroreentrant ATs is challenging. The mapping revealed a centrifugal pattern but did not fully elucidate the AT circuit. The reentrant mechanism of these ATs was confirmed using entrainment pacing. The earliest excitation site (EES) was traditionally selected as the ablation site, typically located in healthy tissue. However, our two cases provide new insights into AT termination, including the epicardial bridge across the endocardial LAAW scar, using minimum ablation points, without the need to ablate the healthy EES.

Right ventricular cardiac resynchronization therapy in patients with right ventricular conduction delay and heart failure

Right ventricular cardiac resynchronization therapy in patients with right ventricular conduction delay and heart failure

Repetitive multiform narrow complex tachycardia

A 73-year-old man presented to the emergency department with palpitations. After experiencing transient exertional palpitations and dyspnea a few months earlier, investigation revealed moderate left ventricular dysfunction and extensive coronary artery disease with evidence of prior inferior infarction. He underwent bypass grafting and remained symptom free with normalization of his ejection fraction until the current presentation. Figure 1 demonstrates his presenting rhythm that did not respond to adenosine but terminated with intravenous diltiazem. What is the most likely mechanism of the tachycardia? Figure 1 shows a regular narrow complex tachycardia with 3 distinct alternating QRS morphologies: (1) right bundle branch block (RBBB), V1 R 120 ms, V4 precordial transition, left superior axis; (2) RBBB, V1 rsRʹ 100 ms, positive precordial concordance, left superior axis; and (3) RBBB, V1 R 100 ms, positive precordial concordance, left superior axis. The RBBB and left superior axis of all 3 morphologies suggest that the ventricles are activated via the left posterior fascicle, or at the very least, there is early engagement of this fascicle. While supraventricular tachycardia with aberrant conduction is theoretically possible, varying ventricular morphologies in this fashion, lack of termination with adenosine, and the relatively narrow QRS duration (<130 ms) would make this less likely. Together with the response to diltiazem, the overall evidence suggests ventricular tachycardia involving the left posterior fascicle. The classic form of idiopathic fascicular ventricular tachycardia involves the left posterior fascicle, in which there is slow antegrade conduction along abnormal Purkinje fibers in the mid-septum (resulting in P1 potentials) and conduction over the left posterior fascicle (resulting in P2 potentials).1Nogami A. Naito S. Tada H. et al.Demonstration of diastolic and presystolic Purkinje potentials as critical potentials in a macroreentry circuit of verapamil-sensitive idiopathic left ventricular tachycardia.J Am Coll Cardiol. 2000; 36: 811-823Crossref PubMed Scopus (218) Google Scholar In any individual patient, variable relationships of the abnormal Purkinje fiber to the left posterior fascicle can result in a more basal or apical site of breakout to the left ventricle; these differences can often be suggested on the surface electrocardiogram by the width of the QRS complex and the precordial transition.2Liu Q. Shehata M. Jiang R. et al.Macroreentrant loop in ventricular tachycardia from the left posterior fascicle: new implications for mapping and ablation.Circ Arrhythm Electrophysiol. 2016; 9e004272Crossref Scopus (7) Google Scholar,3Ma W. Lu F. Shehata M. et al.Catheter ablation of idiopathic left posterior fascicular ventricular tachycardia: predicting the site of origin via mapping and electrocardiography.Circ Arrhythm Electrophysiol. 2017; 10e005240Crossref PubMed Scopus (1) Google Scholar Sung et al4Sung R.K. Kim A.M. Tseng Z.H. et al.Diagnosis and ablation of multiform fascicular tachycardia.J Cardiovasc Electrophysiol. 2013; 24: 297-304Crossref PubMed Scopus (29) Google Scholar described multiform fascicular QRS complexes due to alternate conduction over the left anterior fascicle and the left posterior fascicle from the septal fascicle, but the QRS forms described in the present report are different. Idiopathic fascicular ventricular tachycardia typically occurs in patients with structurally normal hearts, which was not the case in the present report. However, abnormal Purkinje fibers have also been implicated in a minority of patients with ischemic ventricular tachycardia and extension of inferoposterior scar to the left posterior fascicle.5Bogun F. Good E. Reich S. et al.Role of Purkinje fibers in post-infarction ventricular tachycardia.J Am Coll Cardiol. 2006; 48: 2500-2507Crossref PubMed Scopus (121) Google Scholar In this case, it was hypothesized that different QRS morphologies were due to varying sites of left ventricular breakout (Figure 2). The patient underwent electrophysiology study, where multiple episodes of ventricular tachycardia were able to be induced with ventricular extrastimuli similar to those seen on presentation. Ablation of the left posterior fascicle was undertaken, with subsequent noninducibility and no further episodes after 12 months of follow-up.

Using a smartwatch for the detection of loss of left ventricular capture in patients receiving cardiac resynchronization therapy

Pilot studies showed promising applications for smartwatches (SWs) beyond the detection of atrial fibrillation. 1 Cobos Gil M.Á. Standard and precordial leads obtained with an Apple watch. Ann Intern Med. 2020; 172: 436 Crossref PubMed Scopus (23) Google Scholar Ammann et al 2 Ammann P. Sticherling C. Kalusche D. et al. An electrocardiogram-based algorithm to detect loss of left ventricular capture during cardiac resynchronization therapy. Ann Intern Med. 2005; 142: 968-973 Crossref PubMed Google Scholar developed a readily applicable algorithmClick or tap here to enter text. for detecting loss of left ventricular (LV) capture in patients with heart failure receiving cardiac resynchronization therapy (CRT) using leads I and V1 of the standard 12-lead electrocardiogram (ECG) (Figure 1). 3 Cao Y.-Y. Su Y.-G. Bai J. et al. The roles of the Q (q) wave in lead I and QRS frontal axis for diagnosing loss of left ventricular capture during cardiac resynchronization therapy. J Cardiovasc Electrophysiol. 2015; 26: 64-69 Crossref PubMed Scopus (4) Google Scholar We hypothesized that recording lead I and modified lead V1 ECGs with a SW allows the validation of the Ammann algorithm for detecting loss of LV capture.

Left atrial appendage occlusion should be offered only to select atrial fibrillation patients.

Left atrial appendage occlusion should be offered only to select atrial fibrillation patients.

Structure and function of the ventricular tachycardia isthmus.

Catheter ablation of postinfarction reentrant ventricular tachycardia (VT) has received renewed interest owing to the increased availability of high-resolution electroanatomic mapping systems that can describe the VT circuits in greater detail, and the emergence and need to target noninvasive external beam radioablation. These recent advancements provide optimism for improving the clinical outcome of VT ablation in patients with postinfarction and potentially other scar-related VTs. The combination of analyses gleaned from studies in swine and canine models of postinfarction reentrant VT, and in human studies, suggests the existence of common electroanatomic properties for reentrant VT circuits. Characterizing these properties may be useful for increasing the specificity of substrate mapping techniques and for noninvasive identification to guide ablation. Herein, we describe properties of reentrant VT circuits that may assist in elucidating the mechanisms of onset and maintenance, as well as a means to localize and delineate optimal catheter ablation targets.

PERIPROCEDURAL HEMOTHORAX AFTER WATCHMAN LEFT ATRIAL APPENDAGE CLOSURE IMPLANTATION

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Left atrial appendage occlusion with the WATCHMAN device has had decreasing periprocedural complications since its approval by the Food and Drug Administration [1]. Hemothorax is a rare complication after WATCHMAN device deployment. Here a case is presented of a left sided hemothorax occurring within 24 hours of device deployment. CASE PRESENTATION: A 77-year-old male with a history of persistent atrial fibrillation on warfarin developed an abdominal hematoma when his INR was supratherapeutic, so he was evaluated for WATCHMAN (Boston Scientific Corporation, Marlborough, MA) left atrial appendage occlusion. Transesophageal echocardiography (TEE) showed an adequately sized left atrial appendage so a 27mm WATCHMAN device was deployed. Angiogram showed the device in good position and TEE showed no peri-device leak or pericardial effusion. He was placed on a continuous heparin infusion which was maintained in the therapeutic range based on anti-Xa assay. The following morning, he was confused, clammy, and short of breath. Shortly thereafter the patient went into cardiac arrest. During arrest it was noted that the patient had a 4g drop in hemoglobin and intra-arrest bedside ultrasound revealed a complex left pleural effusion, so he was transfused with protamine sulfate, vitamin K, fresh frozen plasma, packed red blood cells, and incompatible platelets. Return of spontaneous circulation was achieved after 16 minutes. Post-arrest a CT angiogram of the chest revealed a large left pleural effusion without evidence of perforation of any large arteries. Transthoracic echocardiogram showed no evidence of pericardial effusion. A left chest tube was placed with drainage of 2200 cc of frank blood in the first 12 hours. Endoscopy showed a superficial ulcer of the mid-esophagus but no evidence of esophageal perforation or tear. The patient was stabilized but ultimately had poor neurologic recovery due to anoxic brain injury and palliatively extubated and discharged home to family on comfort measures. DISCUSSION: Left atrial appendage closure with a WATCHMAN device has similar bleeding rates compared to warfarin alone, with a majority of major bleeding events occurring in the periprocedural period[2]. Although periprocedural bleeding after device implantation is not uncommon, hemothorax is a very rare complication occurring in only 0.1% of cases[1]. In this case rupture of the left atrial appendage or other perforation of cardiac structures was ruled out by the absence of a pericardial effusion, as well as bleeding from esophageal rupture after TEE. It is unclear whether dissections or perforations of smaller arterial or venous structures lead to the hemothorax or whether it was a spontaneous event related to heparin infusion. CONCLUSIONS: Hemothorax is a rare bleeding complication of WATCHMAN device implantation but needs to be considered as a potential major bleeding event after device deployment. REFERENCE #1: 1. Munir MB, Khan MZ, Darden D, Pasupula DK, Balla S, Han FT, Reeves R, Hsu JC. Contemporary procedural trends of Watchman percutaneous left atrial appendage occlusion in the United States. J Cardiovasc Electrophysiol. 2021 Jan;32(1):83-92. REFERENCE #2: 2. Price MJ, Reddy VY, Valderrábano M, Halperin JL, Gibson DN, Gordon N, Huber KC, Holmes DR. Bleeding outcomes after left atrial appendage closure compared with long-term warfarin: a pooled, patient-level analysis of the WATCHMAN randomized trial experience. JACC Cardiovasc Interv. 2015; 8:1925–1932. DISCLOSURES: no disclosure on file for Michael Caniglia; No relevant relationships by John Cox, source=Web Response No relevant relationships by Thomas Maloney, source=Web Response

NON-CARDIOGENIC PULMONARY EDEMA FOLLOWING CARDIAC ABLATION: WILL THE REAL CULPRIT PLEASE STAND UP?

TOPIC: Diffuse Lung Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Non-cardiogenic pulmonary edema (NCPE) is an entity with a variety of etiologies and pathology that include alveolar damage due to direct toxicity or catecholamine surge. We present a case of non-cardiogenic pulmonary edema 48 hours following ablation for atrial fibrillation. CASE PRESENTATION: A 72-year-old woman with a history of atrial fibrillation, coronary artery disease with bypass grafting, and heart failure with preserved ejection fraction presented with sudden onset shortness of breath for a few hours. She had undergone cardiac ablation with pulmonary vein isolation and cavotricuspid isthmus line 2 days prior, with no periprocedural complications. She was tachypneic and hypoxic (oxygen saturation 51% on room air), with reduced breath sounds on auscultation but no peripheral edema or jugular venous distension. Laboratory workup was notable for leukocytosis, elevated N-terminal proBNP (9,853 pg/mL), elevated C-reactive protein (257 mg/L), with normal procalcitonin and negative viral panel, including SARS-CoV-2. Electrocardiography showed no acute abnormalities. Computed tomography (CT) of the chest did not show pulmonary embolism but demonstrated bilateral ground glass opacities. Oxygen was administered via high-flow nasal cannula, and diuresis was initiated in the inpatient setting. Echocardiography revealed mild left ventricular diastolic dysfunction, with left atrial enlargement and mild pulmonary hypertension (39 mm of Hg). Right heart catheterization demonstrated normal filling and pulmonary artery pressures (pulmonary capillary wedge pressure (PCWP) of 6 mm Hg and mean pulmonary artery pressure or 16 mm Hg). Systemic corticosteroids were empirically initiated for suspicion of an inflammatory etiology. The combination of steroids and diuresis produced symptomatic and radiographic improvement, and she was discharged with supplemental oxygen. Her oxygen was unable to be completely weaned off as of follow-up 6 weeks later. DISCUSSION: Catheter ablation for atrial fibrillation is a widely adopted rhythm control strategy with a favorable safety profile. NCPE appears to be an exceedingly rare complication of ablation, with only a few cases being reported in our literature review. The diagnosis of NCPE can be challenging to make, as it must be distinguished for cardiogenic edema. The lack of peripheral edema or jugular venous distension in our patient suggested the absence of cardiac etiology, but a right heart catheterization demonstrating normal PCWP definitively excluded it. Hypotheses for mechanisms for this reaction include a systemic inflammatory response syndrome, autoimmune reaction to ablation, and vagus nerve injury with consequent dysregulation of immunomodulation. Treatment is primarily supportive, including adequate ventilation, with consideration for diuresis and corticosteroids. CONCLUSIONS: NCPE is a rare adverse effect of ablation, and treatment is primarily supportive. REFERENCE #1: Weber R, Minners J, Restle C, et al. Pulmonary edema after extensive radiofrequency ablation for atrial fibrillation. J Cardiovasc Electrophysiol. 2008 Jul;19(7):748-52. DISCLOSURES: No relevant relationships by Dan Kazmierski, source=Web Response No relevant relationships by jacob miller, source=Web Response No relevant relationships by Pius Ochieng, source=Web Response No relevant relationships by NISHANT SHARMA, source=Web Response

Left Atrial Appendage Electrical Isolation Reduces Atrial Fibrillation Recurrences: A Simulation Study.

Left Atrial Appendage Electrical Isolation Reduces Atrial Fibrillation Recurrences: A Simulation Study.

Ruptured Popliteal Artery Aneurysm Complicated with Acute Respiratory Distress Syndrome Secondary to SARS-CoV-2 Infection

We herein report a rare case of the ruptured popliteal artery aneurysm in an 89-year-old man, whose recovery after surgical treatment was complicated with acute respiratory distress syndrome secondary to confirmed infection with SARS-CoV-2. Presenting symptoms, patient's comorbidities, and postoperative course complicated with cardiac and respiratory failure leading to adverse outcome are discussed in this case report.

Cryoablation for atrial fibrillation.

Cryoballoon ablation for the treatment of atrial fibrillation has established itself as an effective and efficient modality for achieving pulmonary vein isolation. Over the past 13 years more than 100,000 Cryoballoon ablation procedures have been performed with the first to fourth generation cryoballoons. Over that time there have been significant advances in our understanding regarding the optimal procedural techniques. The purpose of this "topic in review" is to focus on the practical aspects of performing a Cryoballoon ablation procedure, within the context of the contemporary literature. Specifically there is a focus on how contemporary studies can inform clinical decision making and ensure operators are able to perform a safe and effective procedure.

His-bundle pacing is the best approach to physiological pacing.

His-bundle pacing is the best approach to physiological pacing.

How to use intracardiac echocardiography to guide catheter ablation of outflow tract ventricular arrhythmias

The anatomy of the ventricular outflow tracts and semilunar valves as it pertains to catheter ablation of outflow tract ventricular arrhythmias (OTVAs) has been described. 1 Asirvatham S.J. Correlative anatomy for the invasive electrophysiologist: outflow tract and supravalvar arrhythmia. J Cardiovasc Electrophysiol. 2009; 20: 955-968 Crossref PubMed Scopus (114) Google Scholar Assessment of semilunar valve and regional anatomy by fluoroscopy and angiography has limitations. Coronary arteries may be subject to damage from catheter ablation near the semilunar valves due to their proximity to sites of origin of OTVAs. Detailed intracardiac echocardiographic (ICE) views of the semilunar valves may be useful to understand the anatomy, catheter location, and coronary artery proximity and variations. 2 Enriquez A. Saenz L.C. Rosso R. et al. Use of intracardiac echocardiography in interventional cardiology: working with the anatomy rather than fighting it. Circulation. 2018; 137: 2278-2294 Crossref PubMed Scopus (104) Google Scholar We describe in detail the application of ICE for this purpose during catheter ablation of OTVAs.

Fascicular Tachycardia: The Great Masquerader

SESSION TITLE: Cardiovascular Disease SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Hemodynamically stable tachycardia in a young seemingly healthy individual is generally assumed to be supraventricular in origin. However there is a type of ventricular tachycardia (VT) that has a relatively narrow complex that presents in young healthy individuals and is frequently misdiagnosed as supraventricular ventricular tachycardia (SVT). We present such a case and demonstrate the consequence of delayed diagnosis. CASE PRESENTATION: Our case is a 39 year old male with no past medical history who presented to our emergency department with one day of palpitations and diaphoresis. He first noted these symptoms in adolescence, which were of shorter duration and therefore medical attention was never sought. On arrival to our institution the patient was hemodynamically stable on presentation with an unremarkable physical exam other than a pulse rate of 200 bpm with an EKG showing wide complex tachycardia (figure 1). In addition his blood chemistries were all within normal limits. Despite receiving multiple rounds of adenosine (6mg, 12mg, 12mg) followed by electrical cardioversion, patient remained in wide complex tachycardia. Patient was then given Diltiazem 20mg IVP, which resulted in conversion to normal sinus rhythm (figure 2). Closer investigation of the presenting ECG revealed a leftward (northwest) axis and an incomplete RBBB pattern with RSR’ complexes, a finding highly specific for ventricular tachycardia (VT). An Echocardiogram at our institution revealed no structural heart disease with normal ventricular systolic function. Patient was taken for further electrophysiological testing which confirmed Left Fascicular VT. Patient underwent radiofrequency catheter ablation without any complications. DISCUSSION: Fascicular tachycardia typically originates in the region of the left posterior fascicle and has a RBBB, left superior axis morphology and AV disassociation. In most, a resting EKG is normal and there is no evidence of structural heart disease evidenced by echocardiography and coronary angiography. The narrow QRS complex (typically 0.12 to 0.14 sec) morphology distinguishes fascicular VT from most VTs, but it also resembles SVT frequently leading to misdiagnosis. CONCLUSIONS: Our goal is to help clinicians, especially those who first encounter patients’ with this presentation, be cognizant about the subtle important features of fascicular tachycardia. When it comes to wide complex tachyarrhythmias’ clinicians often have a sense of uneasiness, further clouding their clinical judgment. It is therefore imperative to recognize cases of Idiopathic VT, precisely fascicular tachycardia so they can be differentiated from svt and treated appropriately. Reference #1: Brooks R, Burgess JH. Idiopathic ventricular tachycardia. A review. Medicine (Baltimore) 1988; 67:271. Reference #2: Belhassen B, Viskin S. Idiopathic ventricular tachycardia and fibrillation. J Cardiovasc Electrophysiol 1993; 4:356. DISCLOSURE: The following authors have nothing to disclose: Shahab Khan, Ravi Mann, Fawzi Ameer, David Slotwiner No Product/Research Disclosure Information

Pericardial adhesions as a consequence of cryoballoon ablation detected during the hybrid AF ablation procedure

Pericardial adhesions as a consequence of cryoballoon ablation detected during the hybrid AF ablation procedure

MO‐F‐CAMPUS‐I‐02: Occupational Conceptus Doses From Fluoroscopically‐Guided Interventional Procedures

Purpose:The aim of this method was to provide dosimetric data on conceptus dose for the pregnant employee who participates in fluoroscopically‐guided interventional procedures.Methods:Scattered air‐kerma dose rates were obtained for 17 fluoroscopic projections involved in interventional procedures. These projections were simulated on an anthropomorphic phantom placed on the examination table supine. The operating theater was divided into two grids relative to the long table sides. Each grid consisted of 33 cells spaced 0.50 m apart. During the simulated exposures, at each cell, scatter air‐kerma rate was measured at 110 cm from the floor i.e. at the height of the waist of the pregnant worker. Air‐kerma rates were divided by the dose area product (DAP) rate of each exposure to obtain normalized data. For each projection, measurements were performed for 3 kVp and 3 filtration values i.e. for 9 different x‐ray spectra. All measurements were performed by using a modern C‐arm angiographic system (Siemens Axiom Artis, Siemens, Germany) and a radiation meter equipped with an ionization chamber.Results:The results consist of 153 iso‐dose maps, which show the spatial distribution of DAP‐normalized scattered air‐kerma doses at the waist level of a pregnant worker. Conceptus dose estimation is possible using air‐kerma to embryo/fetal dose conversion coefficients published in a previous study (J Cardiovasc Electrophysiol, Vol. 16, pp. 1–8, July 2005). Using these maps, occupationally exposed pregnant personnel may select a working position for a certain projection that keeps abdominal dose as low as reasonably achievable. Taking into consideration the regulatory conceptus dose limit for occupational exposure, determination of the maximum workload allowed for the pregnant personnel is also possible.Conclusion:Data produced in this work allow for the anticipation of conceptus dose and the determination of the maximum workload for a pregnant worker from any fluoroscopically‐guided interventional procedure.This study was supported by the Greek Ministry of Education and Religious Affairs, General Secretariat for Research and Technology, Operational Program ‘Education and Lifelong Learning’, ARISTIA (Research project: CONCERT).

53 Coarse Fibrillatory Waves in Atrial Fibrillation Predict Success of Electrical Cardioversion

<h3>Introduction</h3> Electrical cardioversion (ECV) is an established therapy for the management of persistent atrial fibrillation (AF). Although ECV is initially successful, recurrence rates of 70–80% have been reported at follow-up at 1 year.¹ Fibrillatory waves (Fw) can often been seen on the surface ECG in AF and can be characterised simply and reliably based on their amplitude.² Amplitudes of ≥0.1 mV are classified as coarse, whilst &lt;0.1 mV are classified as fine (Figure 1). Recent invasive human electrophysiological studies have suggested that AF initiates via organised mechanisms.³ We hypothesised that coarse Fw reflected more ‘early’ organised AF and were therefore a predictor of maintenance of sinus rhythm (SR) after ECV. <h3>Methods</h3> We conducted a single centre retrospective observation study by obtaining records of 138 consecutive ECVs. Two cardiologists independently analysed the pre-ECV ECG and classified fine (fFw) or coarse (cFw) F-waves in leads II and V1 using callipers. Follow up was by analysing the 4-week post ECV ECG to assess rhythm. Demographics, drug treatments and echocardiography parameters were analysed as well. <h3>Results</h3> From the 138 consecutive ECVs, 8 were excluded due to incomplete datasets, 15 due to atrial flutter being the starting rhythm and 3 due to non-concurrent classification of the Fw by the two cardiologists. Out of the 112 pre-ECV ECGs, 32% (36/112) had cFw in V1, lead II or both. After ECV, SR was immediately achieved in 95% (106/112) of patients. Overall, of those that were successful, 46% (49/106) were back in AF at the 4-week clinic visit. All patients with cFw had successful initial ECV. At follow-up, 75% (27/36) of patients with cFw on pre-ECV remained in SR compared with 43% (30/70) of patients with fFw who had a successful initial ECV (p = 0.001, Fisher’s exact test). The cFw and fFw groups were of the similar mean age (70.5 vs. 71.2, p = 0.72). Amiodarone use was similar between groups (8% vs. 17%, p = 0.26) as was left atrial size (4.2 vs. 4.4 cm, p = 0.3); left atrial volume (59 vs. 54 mls, p = 0.5) and indexed left atrial volume (41.8 vs. 39.0 mls/m², p = 0.34) (Table 1). <h3>Conclusion</h3> The presence of coarse Fw in V1, lead II or both resulted in a significantly higher ECV success rate at 4 weeks than fine Fw in both leads. This appeared to be independent of traditional factors thought to affect success. The presence of cFw may be a simple ECG based measure to refine the role of ECV in the treatment of patients with AF. <h3>References</h3> Lundström T, Rydén L. Chronic atrial fibrillation. Long-term results of direct current conversion. ActaMedScand.1988;223(1):53–59 Xi Q, Swiryn S. Atrial fibrillatory wave characteristics on surface electrogram. J Cardiovasc Electrophysiol. 2004;15(8):911–917 Schricker AA, Narayan SM. Human Atrial Fibrillation Initiates via Organized Rather Than Disorganized Mechanisms. Circ Arrhythm Electrophysiol. 2014;7(5):816–824

HRS Expert Consensus Statement on remote interrogation and monitoring for cardiovascular implantable electronic devices.

DavidSlotwiner,MD, FHRS, FACC(Chair),Niraj Varma,MD,PhD, FRCP(Co-chair), JosephG.Akar,MD,PhD, George Annas, JD, MPH, Marianne Beardsall, MN/NP, CCDS, FHRS, Richard I. Fogel, MD, FHRS, Nestor O. Galizio, MD, Taya V. Glotzer, MD, FHRS, FACC, Robin A. Leahy, RN, BSN, CCDS, FHRS, Charles J. Love, MD, CCDS, FHRS, FACC, FAHA, Rhondalyn C. McLean, MD, Suneet Mittal, MD, FHRS, Loredana Morichelli, RN, MSN, Kristen K. Patton, MD, Merritt H. Raitt, MD, FHRS, Renato Pietro Ricci, MD, John Rickard, MD, MPH, Mark H. Schoenfeld, MD, CCDS, FHRS, FACC, FAHA, Gerald A. Serwer, MD, FHRS, FACC, Julie Shea, MS, RNCS, FHRS, CCDS, Paul Varosy, MD, FHRS, FACC, FAHA, Atul Verma, MD, FHRS, FRCPC, Cheuk-Man Yu, MD, FACC, FRCP, FRACP From the Hofstra School of Medicine, North Shore Long Island Jewish Health System, New Hyde Park, New York, Cleveland Clinic, Cleveland, Ohio, Yale University School of Medicine, New Haven, Connecticut, Boston University School of Public Health, Boston, Massachusetts, Southlake Regional Health Centre, Newmarket, Ontario, Canada, St. Vincent Medical Group, Indianapolis, Indiana, Favaloro Foundation University Hospital, Buenos Aires, Argentina, Hackensack University Medical Center, Hackensack, New Jersey, Sanger Heart & Vascular Institute, Carolinas HealthCare System, Charlotte, North Carolina, New York University Langone Medical Center, New York City, New York, University of Pennsylvania Health System, Philadelphia, Pennsylvania, The Arrhythmia Institute at Valley Hospital, New York, New York, Department of Cardiovascular Diseases, San Filippo Neri Hospital, Rome, Italy, University of Washington, Seattle, Washington, VA Portland Health Care System, Oregon Health & Science University, Knight Cardiovascular Institute, Portland, Oregon, Johns Hopkins University, Baltimore, Maryland, Yale University School of Medicine, Yale-New Haven Hospital Saint Raphael Campus, New Haven, Connecticut, University of Michigan Congenital Heart Center, University of Michigan Health Center, Ann Arbor, Michigan, Brigham and Women’s Hospital, Boston, Massachusetts, Veterans Affairs Eastern Colorado Health Care System, University of Colorado, Denver, Colorado, and Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China.

Safety and prevention of complications during percutaneous epicardial access for the ablation of cardiac arrhythmias.

Since its introduction, percutaneous epicardial access is increasingly being performed to facilitate catheter ablation of ventricular tachycardias (VTs) with epicardial circuits, difficult cases of idiopathic VTs, focal atrial tachycardia, and accessory pathways that cannot be successfully targeted endocardially. 1 Sosa E. Scanavacca M. d’Avila A. Pilleggi F. A new technique to perform epicardial mapping in the electrophysiology laboratory. J Cardiovasc Electrophysiol. 1996; 7: 531-536 Crossref PubMed Scopus (656) Google Scholar A thorough understanding of the clinical anatomy and potential complications is vital in order to perform a safe procedure. 2 Sacher F. Roberts-Thomson K. Maury P. et al. Epicardial ventricular tachycardia ablation a multicenter safety study. J Am Coll Cardiol. 2010; 55: 2366-2372 Abstract Full Text Full Text PDF PubMed Scopus (334) Google Scholar In this article, we present the clinical anatomy related to epicardial access, the technique of performing a subxiphoid epicardial puncture, and various measures to prevent complications.

Electrocardiographic criteria and outcome in patients with arrhythmgenic right ventricular cardiomyopathy. Re: Electrocardiographic predictors of electroanatomic scar size in arrhythmogenic right ventricular cardiomyopathy: Implications for arrhythmic risk stratification

Current literature in arrhythmogenic right ventricular cardiomyopathy supposes that the amount of T wave inversions of electroanatomic scar size predicts arrhythmic risk [ [1] Zorzi A. Migliore F. Elmaghawry M. et al. Electrocardiographic predictors of electroanatomic scar size in arrhythmogenic right ventricular cardiomyopathy: implications for arrhythmic risk stratification. J Cardiovasc Electrophysiol. 2013; 24: 1321-1327 Crossref PubMed Scopus (55) Google Scholar ]. In this study 47 patients were included.