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.

Measuring quality in electrophysiology.

The evolving healthcare environment demands optimally measured quality of care. Performance measures are increasingly being used for quality improvement, public reporting, and reimbursement determinations. The National Quality Forum has created rigorous criteria for the evaluation of potential performance measures across medical fields. The Heart Rhythm Society has championed the development of four separate electrophysiology (EP)-specific performance measures: implantable cardioverter defibrillator complication rate, cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation, infection within 180 days of a cardiac implantable electronic device implantation, replacement, or revision, and in-person evaluation following a cardiac implantable electronic device implantation. National registries serve a key role in developing performance measures and facilitating quality improvement, particularly as they provide improved granularity and accuracy of data compared with administrative claims data. All performance measures demand continued reassessment as technology and performance gaps change and as unintended consequences may arise.

Risk stratification for arrhythmic events in patients with asymptomatic pre-excitation: A systematic review for the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.

OBJECTIVE: To review the literature systematically to determine whether noninvasive or invasive risk stratification, such as with an electrophysiological study of patients with asymptomatic pre-excitation, reduces the risk of arrhythmic events and improves patient outcomes. METHODS: PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (all January 1, 1970, through August 31, 2014) were searched for randomized controlled trials and cohort studies examining noninvasive or invasive risk stratification in patients with asymptomatic pre-excitation. Studies were rejected for low-quality design or the lack of an outcome, population, intervention, or comparator of interest or if they were written in a language other than English. RESULTS: Of 778 citations found, 9 studies met all the eligibility criteria and were included in this paper. Of the 9 studies, 1 had a dual design-a randomized controlled trial of ablation versus no ablation in 76 patients and an uncontrolled prospective cohort of 148 additional patients-and 8 were uncontrolled prospective cohort studies (n=1,594). In studies reporting a mean age, the range was 32 to 50 years, and in studies reporting a median age, the range was 19 to 36 years. The majority of patients were male (range, 50% to 74%), and <10% had structural heart disease. In the randomized controlled trial component of the dual-design study, the 5-year Kaplan-Meier estimates of the incidence of arrhythmic events were 7% among patients who underwent ablation and 77% among patients who did not undergo ablation (relative risk reduction: 0.08; 95% confidence interval: 0.02 to 0.33; p<0.001). In the observational cohorts of asymptomatic patients who did not undergo catheter ablation (n=883, with follow-up ranging from 8 to 96 months), regular supraventricular tachycardia or benign atrial fibrillation (shortest RR interval >250 ms) developed in 0% to 16%, malignant atrial fibrillation (shortest RR interval ≤250 ms) in 0% to 9%, and ventricular fibrillation in 0% to 2%, most of whom were children in the last case. CONCLUSIONS: The existing evidence suggests risk stratification with an electrophysiological study of patients with asymptomatic pre-excitation may be beneficial, along with consideration of accessory-pathway ablation in those deemed to be at high risk of future arrhythmias. Given the limitations of the existing data, well-designed and well-conducted studies are needed.

New directions in clinical outcomes assessment : VIth International Symposium on Interventional Electrophysiology in the Management of Cardiac Arrhythmias.

In recent years, electrophysiology clinical research has made tremendous progress. Not only have the standards for conducting research and assessing clinical outcomes improved substantially, but the power of well-conducted and designed randomized clinical trials has been realized. This has led to the emergence of a plethora of randomized clinical trials in electrophysiology. Despite these improvements, there is an immense need to explore and develop better approaches for assessing clinical outcomes. In this article, I review the strengths, challenges, and limitations of randomized clinical trials, especially as they relate to the field of electrophysiology. To address some of these challenges, I propose potential solutions that involve enhancing clinical trials and complementing them with large registries and databases of electronic medical records. If prudently developed and executed, these new directions in assessing clinical outcomes have great potential to inform, and thereby improve the care of patients receiving electrophysiologic interventions.