2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: executive summary.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Acute Hemodynamic Effects of Biventricular Pacing After Left Ventricular Assist Device.

BACKGROUND: Despite cardiac resynchronization therapy (CRT), some patients with heart failure progress and undergo left ventricular assist device (LVAD) implantation. Management of CRT after LVAD implantation has not been well studied. The purpose of this study was to determine whether RV pacing or biventricular pacing measurably affects acute hemodynamics in patients with an LVAD and a CRT device. METHODS AND RESULTS: Seven patients with CRT and LVAD underwent right heart catheterization. Pressures and oximetry were measured and LVAD parameters were recorded during 3 different conditions: RV pacing alone, biventricular pacing, and intrinsic atrioventricular conduction. Paired t tests were used to evaluate changes within subjects. There were no significant changes in right atrial pressure, pulmonary arterial pressures, pulmonary capillary wedge pressure, cardiac index, or any LVAD parameter (P > .05). CONCLUSIONS: Our data suggest that CRT probably has no acute hemodynamic effect in patients with LVADs, but further study is needed.

A novel electrocardiographic criterion for differentiating a left from right ventricular outflow tract tachycardia origin: the V2S/V3R index.

INTRODUCTION: Although several ECG criteria have been proposed for differentiating between left and right origins of idiopathic ventricular arrhythmias (VA) originating from the outflow tract (OT-VA), their accuracy and usefulness remain limited. This study was undertaken to develop a more accurate and useful ECG criterion for differentiating between left and right OT-VA origins. METHODS AND RESULTS: We studied OT-VAs with a left bundle branch block pattern and inferior axis QRS morphology in 207 patients who underwent successful catheter ablation in the right (RVOT; n = 154) or left ventricular outflow tract (LVOT; n = 53). The surface ECGs during the OT-VAs and during sinus beats were analyzed with an electronic caliper. The V2S/V3R index was defined as the S-wave amplitude in lead V2 divided by the R-wave amplitude in lead V3 during the OT-VA. The V2S/V3R index was significantly smaller for LVOT origins than RVOT origins (P < 0.001). The area under the curve (AUC) for the V2S/V3R index by a receiver operating characteristic analysis was 0.964, with a cut-off value of ≤1.5 predicting an LVOT origin with an 89% sensitivity and 94% specificity. In the AUC and accuracy, the V2S/V3R index was superior to any previously proposed ECG criteria in an analysis of all OT-VAs. This advantage of the V2S/V3R index over the V2 transition ratio and other indices also held true for a subanalysis of 77 OT-VAs with a lead V3 precordial transition. CONCLUSION: The V2S/V3R index outperformed other ECG criteria to differentiate left from right OT-VA origins independent of the site of the precordial transition.

Atrial flutter following pulmonary vein isolation: what is the mechanism?

A 70-year-old man with atrial flutter (AFL) following pulmonary vein (PV) isolation (PVI) underwent electrophysiologic testing. The AFL exhibited positive P waves in the inferior leads and lead V1. Left atrial activation mapping revealed 2 remote sites with early activation that were located at the antrum of the left superior PV roof and the left inferior PV bottom. A single irrigated radiofrequency ablation targeting the earliest PV activation at the left PV carina eliminated the AFL. This case demonstrated that PV carina tachycardia with multiple conduction gaps and inter-PV conduction after PVI might mimic double focal atrial tachycardias.