Publications by authors named "Erica S Zado"

99 Publications

Interatrial septal tachycardias following atrial fibrillation ablation or cardiac surgery: Electrophysiological features and ablation outcomes.

Heart Rhythm 2021 May 11. Epub 2021 May 11.

Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Background: Interatrial septal tachycardias (IAS-ATs) following atrial fibrillation (AF) ablation or cardiac surgery are rare, and their management is challenging.

Objective: The purpose of this study was to investigate the electrophysiological features and outcomes associated with catheter ablation of IAS-AT.

Methods: We screened 338 patients undergoing catheter ablation of ATs following AF ablation or cardiac surgery. Diagnosis of IAS-AT was based on activation mapping and analysis of response to atrial overdrive pacing.

Results: Twenty-nine patients (9%) had IAS-AT (cycle length [CL] 311 ± 104 ms); 16 (55%) had prior AF ablation procedures (median 3; range 1-5), 3 (10%) had prior surgical maze, and 12 (41%) had prior cardiac surgery (including atrial septal defect surgical repair in 5 and left atrial myxoma resection in 1). IAS substrate abnormalities were documented in all patients. Activation mapping always demonstrated a diffuse early IAS breakout with centrifugal biatrial activation, and atrial overdrive pacing showed a good postpacing interval (equal or within 25 ms of the AT CL) only at 1 or 2 anatomically opposite IAS sites in all cases. Ablation was acutely successful in 27 patients (93%) (from only the right IAS in 2, only the left IAS in 9, both IAS sides with sequential ablation in 13, and both IAS sides with bipolar ablation in 3). After median follow-up of 15 (6-52) months, 17 patients (59%) remained free from recurrent arrhythmias.

Conclusion: IAS-ATs are rare and typically occur in patients with evidence of IAS substrate abnormalities and prior cardiac surgery. Catheter ablation can be challenging and may require sequential unipolar ablation or bipolar ablation.
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http://dx.doi.org/10.1016/j.hrthm.2021.04.036DOI Listing
May 2021

Periprocedural Acute Kidney Injury in Patients With Structural Heart Disease Undergoing Catheter Ablation of VT.

JACC Clin Electrophysiol 2021 02 28;7(2):174-186. Epub 2020 Oct 28.

Electrophysiology Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address:

Objectives: This study sought to examine the impact of periprocedural acute kidney injury (AKI) in scar-related ventricular tachycardia (VT) patients undergoing radiofrequency catheter ablation (RFCA) on short- and long-term outcomes.

Background: The clinical significance of periprocedural AKI in patients with scar-related VT undergoing RFCA has not been previously investigated.

Methods: This study included 317 consecutive patients with scar-related VT undergoing RFCA (age: 64 ± 13 years, mean left ventricular ejection fraction: 33 ± 13%, 55% ischemic cardiomyopathy). Periprocedural AKI was defined as an absolute increase in creatinine of ≥0.3 mg/dl over 48 h or an increase of >1.5× the baseline values within 1 week post-procedure.

Results: Periprocedural AKI occurred in 31 patients (10%). Independent predictors of AKI included chronic kidney disease (odds ratio [OR]: 3.43; 95% confidence interval [CI]: 1.48 to 7.96; p = 0.004), atrial fibrillation (OR: 2.42; 95% CI: 1.01 to 5.78; p = 0.047), and peri-procedural acute hemodynamic decompensation (OR: 3.98; 95% CI: 1.17 to 13.52; p = 0.003). After a median follow-up of 39 months (interquartile range: 6 to 65 months), 95 patients (30%) died. Periprocedural AKI was associated with increased risk of early mortality (within 30 days; hazard ratio [HR]: 9.91; 95% CI: 2.87 to 34.22; p < 0.001) and late mortality (within 1 year) (HR: 4.57; 95% CI: 2.08 to 10.05; p < 0.001). After multivariable adjustment, AKI remained independently associated with increased risk of early and late mortality (HR: 4.49; 95% CI: 1.1 to 18.36; p = 0.04, and HR: 3.28; 95% CI: 1.43 to 7.49; p = 0.005, respectively).

Conclusions: Periprocedural AKI occurs in 10% of patients undergoing RFCA of scar-related VT and is strongly associated with increased risk of early and late post-procedural mortality.
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http://dx.doi.org/10.1016/j.jacep.2020.08.018DOI Listing
February 2021

Myocardial Substrate Characterization by CMR T Mapping in Patients With NICM and No LGE Undergoing Catheter Ablation of VT.

JACC Clin Electrophysiol 2021 Jan 20. Epub 2021 Jan 20.

Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address:

Background: A substantial proportion of patients with nonischemic dilated cardiomyopathy (NICM) and ventricular tachycardia (VT) do not have scar detectable by cardiac magnetic resonance late gadolinium enhancement (LGE) imaging. In these patients, the significance of diffuse fibrosis (DF) detected with T mapping has not been previously investigated.

Objectives: The goal of this study was to characterize the relationship between DF, the electroanatomic mapping (EAM) substrate, and outcomes of catheter ablation of VT in NICM.

Methods: This study included 51 patients with NICM and VT undergoing catheter ablation (median age 55 years; 77% male subjects) who had no evidence of LGE on pre-procedural cardiac magnetic resonance. Post-contrast T relaxation time determined on the septum was assessed as a surrogate of DF burden. The extent of endocardial low-voltage areas (LVAs) at EAM was correlated with T mapping data.

Results: Bipolar LVAs were present in 22 (43%) patients (median extent 15 [8 to 29] cm) and unipolar LVA in all patients (median extent 48 [26 to 120] cm). A significant inverse correlation was found between T values and both unipolar-LVA (R = 0.64; β = -0.85; p < 0.01) and bipolar-LVA (R = 0.16; β = -1.63; p < 0.01). After a median follow-up of 45 (22 to 57) months, 2 (4%) patients died, 3 (6%) underwent heart transplantation, and 8 (16%) experienced VT recurrence. Shorter post-contrast T time was associated with an increased risk of VT recurrence (hazard ratio: 1.16; 95% confidence interval: 1.03 to 1.33 per 10 ms decrease; p = 0.02).

Conclusions: In patients with NICM and no evidence of LGE undergoing catheter ablation of VT, DF estimated by using post-contrast T mapping correlates with the voltage abnormality at EAM and seems to affect post-ablation outcomes.
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http://dx.doi.org/10.1016/j.jacep.2020.10.002DOI Listing
January 2021

Association of septal late gadolinium enhancement on cardiac magnetic resonance with ventricular tachycardia ablation targets in nonischemic cardiomyopathy.

J Cardiovasc Electrophysiol 2020 12 27;31(12):3262-3276. Epub 2020 Oct 27.

Department of Medicine, Cardiovascular Division, Cardiology and Electrophysiology Section, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Background: Ablation of septal substrate-associated ventricular tachycardia (VT) in patients with nonischemic cardiomyopathy (NICM) is challenging. We sought to standardize the characterization of septal substrates on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) and to examine the association of that substrate with VT exit and isthmus sites on invasive mapping.

Methods: LGE-CMR was performed before electroanatomic mapping and ablation for VT in 20 NICM patients. LGE extent and distribution were quantified using myocardial signal-intensity Z scores (SI-Z). The SI-Z thresholds correlating to previously validated voltage thresholds, for abnormal tissue and dense scar were defined.

Results: Bipolar and unipolar (electrogram) voltage amplitude measurements from the LV and RV were negatively associated with SI-Z from LGE-CMR imaging (p < .05). SI-Z thresholds for appropriate CMR identification of septal substrates were determined to be greater than -.15 for border zone and greater than .03 for a dense scar. Among all patients, 34 critical VT sites were identified with SI-Z distribution in the range of -.97 to .06. Thirty (88.2%) critical sites were located in the dense LGE, 1 (2.9%) in the border zone, and 3 (8.9%) in healthy tissue but within 7 mm of LGE. Of note, critical VT sites were all located at the basal septum close to valves (distance to aortic valve: 17.5 ± 31.2 mm, mitral valve: 21.2 ± 8.7 mm) in nonsarcoidosis cases.

Conclusions: Critical sites of septal VT in NICM patients are predominantly in the CMR defined dense scar when using standardized signal-intensity thresholds.
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http://dx.doi.org/10.1111/jce.14777DOI Listing
December 2020

Right bundle branch block ventricular tachycardia in arrhythmogenic right ventricular cardiomyopathy more commonly originates from the right ventricle: Criteria for identifying chamber of origin.

Heart Rhythm 2021 Feb 1;18(2):163-171. Epub 2020 Sep 1.

Cardiac Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Background: Right bundle branch block (RBBB) ventricular tachycardia (VT) morphology is a criterion for left ventricular (LV) involvement in arrhythmogenic right ventricular cardiomyopathy (ARVC).

Objective: The purpose of this study was to determine the frequency and chamber of origin of RBBB VT in patients with ARVC and VT.

Methods: We studied 110 consecutive patients with VT who met the diagnostic International Task Force criteria for ARVC and underwent VT mapping/ablation. Patients with ≥1 RBBB VT were identified. Right ventricular (RV) origin of the RBBB VT was determined based on standard mapping criteria and elimination with ablation.

Results: Nineteen patients (17%) had 26 RBBB VTs. Eleven of these 19 patients (58%) had 16 RBBB VTs from the RV, and 9 patients (47%) had 10 RBBB VTs originating from the LV, with 1 patient demonstrating both. RBBB VT from RV most commonly (13/16 RBBB VTs) had an early precordial QRS transition (V or V), with superiorly and typically leftward directed frontal plane axis, consistent with exit from dilated RV adjacent to inferior LV septum, whereas all 10 VTs from LV had RBBB morphology with positive R waves to V or V and rightward axis in 6 VTs characteristic of basal lateral origin.

Conclusion: In patients with ARVC and VT presenting for VT ablation, RBBB VT occurs in 17% of cases, with most RBBB VTs (62%) originating from the RV and not indicative of LV origin. Precordial R-wave transition and frontal plane axis can be used to identify the anticipated chamber of origin of RBBB VT.
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http://dx.doi.org/10.1016/j.hrthm.2020.08.016DOI Listing
February 2021

Direct Thrombin Inhibitors as an Alternative to Heparin During Catheter Ablation: A Multicenter Experience.

JACC Clin Electrophysiol 2020 05 26;6(5):484-490. Epub 2020 Feb 26.

Division of Cardiology, University of California San Francisco, San Francisco, California, USA. Electronic address:

Objectives: The goal of this study was to report a multicenter series of left-sided catheter ablations performed by using intravenous direct thrombin inhibitors (DTIs) as an alternative to heparin.

Background: Amidst a looming worldwide shortage of heparin, there are insufficient data to guide nonheparin-based peri-procedural anticoagulation in patients undergoing catheter ablation.

Methods: This study reviewed all catheter ablations at 6 institutions between 2006 and 2019 to assess the safety and efficacy of DTIs for left-sided radiofrequency catheter ablation of atrial fibrillation and ventricular tachycardia.

Results: In total, 53 patients (age 63.0 ± 9.3 years, 68% male, CHA₂DS₂-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65 to 74 years, sex category] score 2.8 ± 1.6, left ventricular ejection fraction 46 ± 15%) underwent ablation with DTIs (75% bivalirudin, 25% argatroban) due to heparin contraindication(s) (72% heparin-induced thrombocytopenia, 21% heparin allergy, 4% protamine reaction, and 4% religious reasons). The patient's usual oral anticoagulant was continued without interruption in 69%. Procedures were performed for atrial fibrillation (64%) or ventricular tachycardia/premature ventricular contractions (36%). Transseptal puncture was undertaken in 81%, and a contact force-sensing catheter was used in 70%. Vascular ultrasound was used in 71%, and femoral arterial access was gained in 36%. A bolus followed by infusion was used in all but 4 cases, and activated clotting time was monitored peri-procedurally in 72%, with 32% receiving additional boluses. Procedure duration was 216 ± 116 min, and ablation time was 51 ± 22 min. No major bleeding or embolic complications were observed. Four patients had minor self-limiting bleeding complications, including a small pericardial effusion (<1 cm), a small groin hematoma, and hematuria.

Conclusions: In this multicenter series, intravenous DTIs were safely used as an alternative to heparin for left-sided catheter ablation.
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http://dx.doi.org/10.1016/j.jacep.2019.12.003DOI Listing
May 2020

Trends in Successful Ablation Sites and Outcomes of Ablation for Idiopathic Outflow Tract Ventricular Arrhythmias.

JACC Clin Electrophysiol 2020 02 27;6(2):221-230. Epub 2019 Nov 27.

Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address:

Objectives: This study sought to examine clinical characteristics of procedural and long-term outcomes in patients undergoing catheter ablation (CA) of outflow tract ventricular arrhythmias (OT-VAs) over 16 years.

Background: CA is an effective treatment strategy for OT-VAs.

Methods: Patients undergoing CA for OT-VAs from 1999 to 2015 were divided into 3 periods: 1999 to 2004 (early), 2005 to 2010 (middle), and 2011 to 2015 (recent). Successful ablation site (right ventricular OT, aortic cusps/left ventricular OT, or coronary venous system/epicardium), VA morphology (right bundle branch block or left bundle branch block), and acute and clinical success rates were assessed.

Results: Six hundred eighty-two patients (336 female) were included (early: n = 97; middle: n = 204; recent: n = 381). Over time there was increase in use of irrigated ablation catheters and electroanatomic mapping, and more VAs were ablated from the aortic cusp/left ventricular OT or coronary venous system/epicardium (14% vs. 45% vs. 56%; p < 0.0001). Acute procedural success was achieved in 585 patients (86%) and was similar between groups (82% vs. 84% vs. 88%; p = 0.27). Clinical success was also similar between groups (86% vs. 87% vs. 88%; p = 0.94), but more patients in earlier periods required repeat ablation (18% vs. 17% vs. 9%; p = 0.02). Overall complication rate was 2% (similar between groups).

Conclusions: Over a 16-year period there was an increase in patients undergoing CA for OT-VTs, with more ablations performed at non-right ventricular outflow tract locations using electroanatomic mapping and irrigated-tip catheters. Over time, single procedure success has improved and complications have remained limited.
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http://dx.doi.org/10.1016/j.jacep.2019.10.004DOI Listing
February 2020

Incidence of Left Atrial Appendage Triggers in Patients With Atrial Fibrillation Undergoing Catheter Ablation.

JACC Clin Electrophysiol 2020 01 30;6(1):21-30. Epub 2019 Oct 30.

Electrophysiology Section, Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address:

Objective: This study sought to investigate incidence of left atrial appendage (LAA) triggers of atrial fibrillation (AF) and/or organized atrial tachycardias (OAT) in patients undergoing AF ablation and to evaluate outcomes after ablation.

Background: Although LAA isolation is being increasingly performed during AF ablation, the true incidence of LAA triggers for AF remains unclear.

Methods: All patients with LAA triggers of AF and/or OAT during AF ablation from 2001 to 2017 were included. LAA triggers were defined as atrial premature depolarizations from the LAA, which initiated sustained AF and/or OAT.

Results: Out of 7,129 patients undergoing AF ablation over 16 years, LAA triggers were observed in 21 (0.3%) subjects (age 60 ± 9 years; 57% males; 52% persistent AF). Twenty (95%) patients were undergoing repeat ablation. The LAA was the only nonpulmonary vein trigger in 3 patients; the remaining 18 patients had both LAA and other nonpulmonary vein triggers. LAA triggers were eliminated in all patients (focal ablation in 19 patients; LAA isolation in 2 patients). Twelve months after ablation, 47.6% remained free from recurrent arrhythmia. After overall follow-up of 5.0 ± 3.6 years (median: 3.7 years; interquartile range: 1.4 to 8.9 years), 38.1% were arrhythmia-free. All 3 patients with triggers limited to the LAA remained free of AF recurrence. One patient undergoing LAA isolation developed LAA thrombus during follow-up.

Conclusions: The incidence of true LAA triggers is very low (0.3%). Most patients with LAA triggers have additional nonpulmonary vein triggers, and despite elimination of LAA triggers, long-term arrhythmia recurrence rates remain high. Potential risks of empiric LAA isolation during AF ablation (especially first-time AF ablation) may outweigh benefits.
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http://dx.doi.org/10.1016/j.jacep.2019.08.012DOI Listing
January 2020

Analysis of local ventricular repolarization using unipolar recordings in patients with arrhythmogenic right ventricular cardiomyopathy.

J Interv Card Electrophysiol 2020 Mar 23;57(2):261-270. Epub 2019 Aug 23.

Cardiac Electrophysiology Program, Cardiovascular Division Hospital of the University of Pennsylvania, 9 Founders Pavilion - Cardiology, 3400 Spruce St., Philadelphia, PA, 19104, USA.

Purpose: In arrhythmogenic right ventricular cardiomyopathy (ARVC), abnormal electroanatomic mapping (EAM) areas are proportional to extent of T-wave inversion on 12-lead ECG. We aimed to evaluate local repolarization changes and their relationship to EAM substrate in ARVC.

Methods: Using unipolar recordings, we analyzed the proportion of negative T waves ≥ 1 mV in depth (NegT), NegT area, Q-Tpeak (QTP), Tpeak-Tend (TPE) intervals and their relationship to bipolar (< 1.5 mV ENDO, < 1.0 mV EPI) and unipolar (< 5.5 mV) endocardial (ENDO) and epicardial (EPI) low-voltage area (LVA) in 21 pts. (15 men, mean age 39 ± 14) with ARVC. Control group included 5 pts. with normal hearts and idiopathic PVCs.

Results: On ENDO, the % of NegT (7 ± 5% vs 30 ± 20%, p = 0.004) and the NegT area (12.9 ± 9.7 c m vs 61.4 ± 30.0 cm, p = 0.001) were smaller in ARVC compared to controls. On EPI, the % of NegT was similar (5 ± 7% vs 3 ± 4%, p = 0.323) and the NegT area, larger (11.0 ± 8.4 cm vs 2.7 ± 0.9 cm, p = 0.027) in ARVC group. In ARVC group, the % of NegT area inside LVA was larger on EPI compared to ENDO for both bipolar (81 ± 27% vs 31 ± 33%, p < 0.001) and unipolar (90 ± 19% vs 73 ± 28%, p = 0.036) recordings. Compared to normal voltage regions, QTP inside ENDO abnormal LVA was on average 58 ± 26 ms shorter and TPE, 25 ± 56 ms longer (97 ± 26 ms and 56 ± 86 ms on EPI, respectively).

Conclusions: In ARVC, NegT areas are more closely associated with abnormal depolarization LVA on the EPI and QTP is shorter and TPE longer inside ENDO and EPI abnormal LVA compared to normal voltage regions. The results add to our understanding of ARVC arrhythmia substrate.
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http://dx.doi.org/10.1007/s10840-019-00594-zDOI Listing
March 2020

Usefulness of ICD electrograms analysis to distinguish endocardial vs epicardial ventricular tachycardia in arrhythmogenic right ventricular cardiomyopathy.

J Cardiovasc Electrophysiol 2019 09 8;30(9):1526-1534. Epub 2019 Jul 8.

Department of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Introduction: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is characterized by an epicardial (EPI) to endocardial (ENDO) fibrofatty infiltration of the RV predisposing to both EPI and ENDO ventricular tachycardia (VT). The relative timing between the VT QRS onset on the far-field ventricular electrogram (VEGM) to the local activation time recorded at the RV apex on the near-field VEGM from stored implantable cardioverter-defibrillator (ICD) events of VT can be helpful to discriminate ENDO from EPI VT in ARVC.

Methods And Results: We analyzed consecutive ARVC patients undergoing catheter ablation between 2006 and 2018. Only patients with retrievable ICD VEGMs of clinical VTs which could be matched with VTs induced at the time of ablation were included. A total of 26 VT events (16 ENDO, 10 EPI) from 19 ARVC patients were examined, yielding a mean far-field to near-field interval of 33 ± 15 ms for ENDO VTs and 52 ± 20 ms for EPI VTs (P = .020). At receiver-operating characteristic analysis, a far-field to a near-field interval of 60 ms or more ruled out ENDO VTs in 16 (100%) cases and identified EPI VTs with a positive predictive value (PPV) of 100% and a negative predictive value (NPV) of 73%. An interval of less than or equal to 30 ms ruled out EPI VTs in eight (80%) cases and diagnosed ENDO VTs with a PPV of 80% and an NPV of 50%.

Conclusion: Far-field to near-field ICD VEGM timing may be used to predict ENDO vs EPI VT in ARVC before ablation, indicating an ENDO origin if the timing is less than or equal to 30 ms and an EPI origin if greater than or equal to 60 ms.
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http://dx.doi.org/10.1111/jce.14014DOI Listing
September 2019

P-wave morphology and multipolar intracardiac atrial activation to facilitate nonpulmonary vein trigger localization.

J Cardiovasc Electrophysiol 2019 06 12;30(6):865-876. Epub 2019 Mar 12.

Cardiac Electrophysiology Program, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Introduction: Nonpulmonary vein (non-PV) triggers of atrial fibrillation (AF) are targets for ablation but their localization remains challenging. The aim of this study was to describe P-wave (PW) morphologic characteristics and intra-atrial activation patterns and timing from multipolar coronary sinus (CS) and crista terminalis (CT) catheters that localize non-PV triggers.

Methods And Results: Selective pacing from six right and nine left atrial common non-PV trigger sites was performed in 30 consecutive patients. We analyzed 12 lead ECG features based on PW duration, amplitude and morphology, and patterns and timing of multipolar activation for all 15 sites. Regionalization and then precise localization required criteria present in at least 70% of assessments at each pacing site. The algorithm was then prospectively evaluated by four blinded observers in a validation cohort of 18 consecutive patients undergoing the same pacing protocol and 60 consecutive patients who underwent successful non-PV trigger ablation. The algorithm for site regionalization included 1) negative PW in V1, ≥30 µV change in PW amplitude across the leads V1-V3, and PW duration ≤100 milliseconds in lead 2 and 2) unique intra-atrial activation patterns and timing noted in the multipolar catheters. Specific ECG and intra-atrial activation timing characteristics included in the algorithm allowed for more precise site localization after regionalization. In the prospective evaluation, the algorithm identified the site of origin for 72% of paced and 70% of spontaneous non-PV trigger sites.

Conclusion: An algorithm based on PW morphology and intra-atrial multipolar activation pattern and timing can help identify non-PV trigger sites of origin.
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http://dx.doi.org/10.1111/jce.13899DOI Listing
June 2019

"As Needed" nonvitamin K antagonist oral anticoagulants for infrequent atrial fibrillation episodes following atrial fibrillation ablation guided by diligent pulse monitoring: A feasibility study.

J Cardiovasc Electrophysiol 2019 05 4;30(5):631-638. Epub 2019 Feb 4.

Department of Medicine, Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Introduction: After atrial fibrillation (AF) ablation, oral anticoagulation (OAC) is recommended if stroke risk as assessed by CHA DS -VASc score is high. However, patients without AF are often reluctant to take daily OAC. We describe outcome using as needed nonvitamin K antagonist (NOACs) guided by pulse monitoring to detect AF following successful ablation.

Methods And Results: We identified 99 patients (84% male, age 64 ± 8 years), CHA DS -VASc score greater than or equal to 1 in men and greater than or equal to 2 in women (median 2, range 1-6), capable of pulse assessment twice daily and no AF on extended monitoring after AF ablation. All patients were instructed to start NOAC if AF >1 hour or recurrent shorter episodes. Duration of NOAC use after restart was typically 2 to 4 weeks. After 30 ± 14 months (total 244 patient-years), 22 patients (22%) transitioned to daily NOAC because of noncompliance with pulse assessment or patient preference (six patients) or because of suspected or documented AF episode(s) in 16 (16%) patients. Of the remaining 77 (78%), 14 (14%) used NOACs but did not transition back to daily use, most (10 patients) with single use (seven patients) or non-AF rhythm (three patients) documented. There was only one thromboembolic event (0.4%/yr of follow-up) in patient without AF and one mild bleeding event (epistaxis).

Conclusion: The use of as needed NOACs when AF is suspected with pulse monitoring is effective and safe to maintain low risk of stroke and bleeding after successful ablation. Transition back to daily NOAC use should be anticipated in about one quarter of patients.
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http://dx.doi.org/10.1111/jce.13859DOI Listing
May 2019

Outcomes of Catheter Ablation in Arrhythmogenic Right Ventricular Cardiomyopathy Without Background Implantable Cardioverter Defibrillator Therapy: A Multicenter International Ventricular Tachycardia Registry.

JACC Clin Electrophysiol 2019 01 28;5(1):55-65. Epub 2018 Nov 28.

Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas. Electronic address:

Objectives: This study sought to determine the long-term outcomes of catheter ablation (CA) of ventricular tachycardia (VT) in a series of patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) without background implantable cardioverter-defibrillator (ICD) therapy.

Background: Endo-epicardial CA of VT has been demonstrated to be highly effective in reducing recurrent VT in patients with ARVC.

Methods: Thirty-two patients (age 45 ± 13 years, 72% male) with ARVC and VT underwent CA in the absence of ICD therapy. ICD was recommended in all cases, but implantation was not performed due to patient refusal (63%) or financial hardship (37%). CA was guided by activation/entrainment mapping for mappable VT and pace mapping/targeting of abnormal substrate in cases of unmappable VT.

Results: Symptoms associated with clinical VT included palpitations (78%), chest pain and shortness of breath (22%), pre-syncope (16%), and syncope (13%). Prior to ablation, 22 patients (69%) failed a mean of 1.3 ± 0.5 antiarrhythmic drugs. Epicardial mapping and ablation was performed as first-line strategy (20 [63%]) or in case of recurrent VT or persistent inducibility after endocardial-only ablation (3 [9%]-surgical epicardial cryoablation in 1 patient). After a mean of 1.6 (range 1 to 3) procedures, all patients demonstrated noninducibility of sustained VT from at least 2 RV sites; 75% also had stimulation on isoproterenol with no inducible VT. At a median follow-up of 46 months (range 26 to 65 months) following the last ablation, no deaths were observed and freedom from recurrent VT was 81%.

Conclusions: In this multicenter international registry of patients with ARVC and VT, CA performed in the absence of background ICD was associated with a low rate of symptomatic VT recurrence (19%) without mortality during 46-month median follow-up. These data suggest that further prospective studies may refine selection of patients with structural heart disease at low risk for SCD, possibly obviating the benefit of ICD therapy.
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http://dx.doi.org/10.1016/j.jacep.2018.09.019DOI Listing
January 2019

Electrophysiologic Substrate, Safety, Procedural Approaches, and Outcomes of Catheter Ablation for Ventricular Tachycardia in Patients After Aortic Valve Replacement.

JACC Clin Electrophysiol 2019 01 26;5(1):28-38. Epub 2018 Sep 26.

Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Objectives: This study sought to investigate the substrate, procedural strategies, safety, and outcomes of catheter ablation (CA) for ventricular tachycardia (VT) in patients with aortic valve replacement (AVR).

Background: VT ablation in patients with AVR is challenging, particularly when mapping and ablation in the periaortic region are necessary.

Methods: We identified consecutive patients with mechanical, bioprosthetic, and transcatheter AVR who underwent CA for VT refractory to antiarrhythmic drugs and analyzed VT substrate, approach to LV access, complications, and long-term outcomes.

Results: Overall, 29 patients (87% men, mean age 67.9 ± 9.8 years, left ventricular ejection fraction 39 ± 10%) with prior AVR (13 mechanical, 15 bioprosthetic, 1 transcatheter AVR) underwent 40 ablations from 2004 to 2016. Left-sided mapping/CA was performed in 27 patients (36 procedures). Access was retrograde aortic in 11 procedures (all bioprosthetic), transseptal in 24 (13 mechanical; 10 bioprosthetic; 1 transcatheter AVR), or transventricular septal in 1. Periaortic bipolar or unipolar scar was detected in all 24 patients in whom detailed periaortic mapping was performed. Clinical VT circuit(s) involved the periaortic region in 10 patients (34%), 2 (7%) had bundle branch re-entry VT, and 17 (59%) had substrate unrelated to AVR. There were 2 major complications (both related to vascular access). Only 2 patients (9.1%) had VT recurrence. Over median follow-up of 12.8 months, 11 patients died (none as a result of recurrent VT).

Conclusions: Whereas most patients undergoing CA for VT after AVR had VT from substrate unrelated to AVR, periaortic scar is universally present and bundle branch re-entry can be the VT mechanism. CA can be safely performed with excellent long-term VT elimination.
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http://dx.doi.org/10.1016/j.jacep.2018.08.008DOI Listing
January 2019

Feasibility of complex transfemoral electrophysiology procedures in patients with inferior vena cava filters.

Heart Rhythm 2019 06 24;16(6):873-878. Epub 2018 Dec 24.

Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Background: The presence of inferior vena cava filters (IVCFs) has been considered a relative contraindication to electrophysiology (EP) procedures that require transfemoral venous placement of multiple catheters and/or long sheaths. There are inadequate data related to complex EP procedures in this population.

Objective: The purpose of this study was to describe the experience of a single high-volume center with respect to complex EP procedures in patients with IVCFs.

Methods: Patients with IVCFs undergoing complex EP procedures between 2004 and 2018 were identified. Clinical characteristics, IVCF type, procedural findings, and complications were analyzed.

Results: Fifty complex ablation procedures were performed in 40 patients (mean age 63.8 ± 10.9 years; 68% men). The mean IVCF dwell time was 69.1 ± 19.1 months, and 48 patients (96%) were on chronic oral anticoagulation. Procedures included ablation of atrial fibrillation (n = 21), ventricular tachycardia (n = 20), supraventricular tachycardia (n = 3), cavotricuspid isthmus flutter (n = 3), supraventricular tachycardia and cavotricuspid isthmus flutter (n = 1), and transvenous lead extraction (n = 3). Twenty procedures included quadripolar catheters (mean 1.4 ± 0.75), and 33 procedures involved deflectable decapolar catheters (mean 1.7 ± 0.47). Long sheaths were used in 35 cases (mean 1.63 ± 0.49) and intracardiac echocardiography in 38. In 4 cases (involving 3 patients), the IVCF was occluded and could not be crossed. There were no procedural complications related to the IVCF.

Conclusion: The substantial majority of IVCFs in patients presenting for complex EP procedures were patent and easily crossed under fluoroscopic guidance. The presence of an IVCF should not discourage operators from performing procedures that require transfemoral deployment of multiple catheters and/or sheaths.
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http://dx.doi.org/10.1016/j.hrthm.2018.12.022DOI Listing
June 2019

Anatomical proximity dictates successful ablation from adjacent sites for outflow tract ventricular arrhythmias linked to the coronary venous system.

Europace 2019 Mar;21(3):484-491

Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of University of Pennsylvania, 9 Founders Pavilion - Cardiology, 3400 Spruce St. Philadelphia, PA, USA.

Aims: Catheter ablation of outflow tract ventricular arrhythmias (OTVAs) with the earliest activation within the coronary venous system (CVS) can be challenging. When ablation from the CVS is not feasible or ineffective, an approach from anatomically adjacent site(s) can be considered. We report the outcomes of an anatomical approach for OTVAs linked to the CVS.

Methods And Results: We retrospectively analysed 665 OTVA patients. Of these, 65 (9.8%) had the earliest activation within the CVS. In 53 (82%) cases, an anatomical approach was attempted. The targeted adjacent anatomical structure was the endocardial left ventricular outflow tract (LVOT) in 24 (45%), the left coronary cusp or the left/right cusp junction in 17 (32%) patients, and the right ventricular outflow tract (RVOT) in 12 (23%). The anatomical approach was successful in 26 (49%) patients (27% from the coronary cusps, 65% from the LVOT, and 8% from the RVOT). The difference in activation times between the earliest activation site within the CVS and the targeted site was not significantly different between the successful and unsuccessful groups (14.2 ± 11.2 ms vs. 13.2 ± 9.3 ms; P = 0.89). The anatomical distance from the earliest activation site to the targeted site was shorter for the successful group (9.7 ± 2.4 mm vs. 13.1 ± 6.5 mm; P < 0.05). In particular, when the anatomical distance was >12.8 mm, anatomical approach was successful in only 1/13 (8%).

Conclusion: In patients with OTVAs linked to the CVS, an anatomical approach targeting an adjacent site can be effective, particularly when the distance between the sites is <12.8 mm.
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http://dx.doi.org/10.1093/europace/euy255DOI Listing
March 2019

Variant of ventricular outflow tract ventricular arrhythmias requiring ablation from multiple sites: Intramural origin.

Heart Rhythm 2019 05 30;16(5):724-732. Epub 2018 Nov 30.

Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas. Electronic address:

Background: The optimal site of ablation of idiopathic left ventricular outflow tract (LVOT) ventricular arrhythmias (VAs) is challenging as activation mapping can reveal similar activation times in different anatomical sites, suggesting an intramural origin.

Objective: We sought to assess whether in patients with intramural VAs and with multiple early activation sites (EASs), sequential ablation of all the early EASs could improve acute and long-term clinical outcomes.

Methods: A total of 116 patients undergoing catheter ablation for symptomatic LVOT VAs were enrolled in this study. Thirty-nine patients (34%) were referred for a redo procedure, whereas the remaining presented for a first procedure. Mapping was performed manually in 86 cases (74%) and with a magnetic robotic system (Niobe, Stereotaxis, St. Louis, MO) in the remainder of the cases.

Results: Of the 116 patients, 15 (13%) were found to have multiple sites of equally early activation. In patients with multiple EASs, the mean pre-QRS activation time was significantly less than in patients with a single EASs (-26 ± 3 ms vs -38 ± 6 ms; P < .005). Sequential ablation of all the EASs was possible in 14 patients (93%), resulting in complete arrhythmia suppression. After a mean follow-up of 21 ± 5 months, all patients with successful ablation of all multiple early EASs remained free from clinical VAs.

Conclusion: Intramural LVOT VAs manifesting with multiple EASs require ablation at all sites to achieve acute and long-term success, particularly if none of the EASs is > -30ms pre-QRS activation time.
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http://dx.doi.org/10.1016/j.hrthm.2018.11.028DOI Listing
May 2019

Importance of the Interventricular Septum as Part of the Ventricular Tachycardia Substrate in Nonischemic Cardiomyopathy.

JACC Clin Electrophysiol 2018 09 27;4(9):1155-1162. Epub 2018 Jun 27.

Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Objectives: This study sought to characterize septal substrate in patients with nonischemic left ventricular cardiomyopathy (NILVCM) undergoing ventricular tachycardia (VT) ablation.

Background: The interventricular septum is an important site of VT substrate in NILVCM.

Methods: The authors studied 95 patients with NILVCM and VT. Electroanatomic mapping using standard bipolar (<1.5 mV) and unipolar (<8.3 mV) low-voltage criteria identified septal scar location and size. Analysis of unipolar voltage was performed and scars quantified using graded unipolar cutoffs from 4 to 8.3 mV were correlated with delayed gadolinium-enhanced cardiac magnetic resonance (DE-CMR), performed in 57 patients.

Results: Detailed LV endocardial mapping (mean 262 ± 138 points) showed septal bipolar and unipolar voltage abnormalities (VAs) in 44 (46%) and 79 (83%) patients, most commonly with basal anteroseptal involvement. Of the 59 patients in whom the septum was targeted, bipolar and unipolar septal VAs were seen in 36 (61%) and 54 (92%). Of the 35 with CMR-defined septal scar, bipolar and unipolar septal VAs were seen in 18 (51%) and 31 (89%). In 12 patients without CMR septal scar, 6 (50%) had isolated unipolar septal VAs on electroanatomic mapping, a subset of whom the septum was targeted for ablation (44%). In the graded unipolar analysis, the optimal cutoff associated with magnetic resonance imaging septal scar was 4.8 mV (sensitivity 75%, specificity 70%; area under the curve: 0.75; 95% confidence interval: 0.60 to 0.90).

Conclusions: Septal substrate by unipolar or bipolar voltage mapping in patients with NILVCM and VT is common. A unipolar voltage cutoff of 4.8 mV provides the best correlation with DE-CMR. A subset of patients with septal VT had normal DE-CMR or endocardial bipolar voltage with abnormal unipolar voltage.
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http://dx.doi.org/10.1016/j.jacep.2018.04.016DOI Listing
September 2018

Epicardial ventricular tachycardia in ischemic cardiomyopathy: Prevalence, electrophysiological characteristics, and long-term ablation outcomes.

J Cardiovasc Electrophysiol 2018 11 8;29(11):1530-1539. Epub 2018 Oct 8.

Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Introduction: The characteristics of the epicardial (EPI) substrate responsible for ventricular tachycardia (VT) in ischemic cardiomyopathy (ICM) are undefined, and data on the long-term outcomes of EPI catheter ablation limited. We evaluated the prevalence, electrophysiologic features, and outcomes of catheter ablation of EPI VT in ICM.

Methods And Results: From December 2010 to June 2013, a total of 13 of 93 (14%) patients with ICM underwent catheter ablation at our institution and had conclusive evidence of critical EPI substrate demonstrated to participate in VT with activation, entrainment and/or pace mapping during sinus rhythm (two other patients underwent EPI mapping but had no optimal ablation targets). The electrophysiologic substrate characteristics and activation/entrainment mapping data were compared with a reference group of ICM patients without evidence of critical EPI substrate (N = 44), defined as a complete procedural success (noninducibility of any VT at programmed stimulation) after endocardial (ENDO)-only ablation. Patients with failed EPI access (N = 2) or history of cardiac surgery (N = 92) were excluded from the study. All 13 patients had evidence of abnormal EPI substrate with fractionated/late/split electrograms and low-bipolar voltage areas. The critical VT ablation sites were all located within the EPI bipolar "dense" scar (<1.0 mV) opposite the ENDO bipolar scar in 77% of cases and extending beyond the ENDO bipolar scar (within the ENDO unipolar low-voltage area) in the remaining patients. Compared with the reference ENDO-only group, patients with EPI VT had a smaller ENDO bipolar scar area, 54.0 (37.1-84) vs 86.7 (55.6-112) cm ; P = 0.0159, with a similar extent of ENDO unipolar low voltage. No other substrate characteristics or location differed between the two groups. After 35.2 ± 24.2 months of follow-up, VT-free survival was 73% in patients with EPI VT compared with 66% in the ENDO-only group (log-rank P = 0.56).

Conclusions: The presence of the critical EPI substrate responsible for VT can be demonstrated in at least 14% of patients with ICM. The majority of EPI critical ablation sites are distributed opposite the ENDO bipolar scar area and catheter ablation is effective in achieving long-term arrhythmia control.
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http://dx.doi.org/10.1111/jce.13739DOI Listing
November 2018

Lead I R-wave amplitude to differentiate idiopathic ventricular arrhythmias with left bundle branch block right inferior axis originating from the left versus right ventricular outflow tract.

J Cardiovasc Electrophysiol 2018 11 8;29(11):1515-1522. Epub 2018 Oct 8.

Cardiac Electrophysiology Program, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Introduction: Differentiation of right versus left ventricular outflow tract (RVOT vs. LVOT) arrhythmia origin with left bundle branch block right inferior axis (LBRI) morphology is relevant to ablation planning and risk discussion. Our aim was to determine if lead I R-wave amplitude is useful for differentiation of RVOT from LVOT arrhythmias with LBRI morphology.

Methods: The R-wave amplitude in lead I was measured in a retrospective cohort of 75 consecutive patients with LBRI pattern ventricular arrhythmias (VAs) successfully ablated from the RVOT (n = 54), LVOT (n = 16), or the anterior interventricular vein (AIV; n = 5). The optimal R-wave threshold was identified and diagnostic indices were compared with the previously reported transitional zone (TZ) index and V2S/V3R index.

Results: An R-wave amplitude greater than or equal to 0.1 mV predicted LVOT origin with 75% sensitivity and 98.2% specificity. In comparison, the TZ and V2S/V3R indices had 50% and 68.8% sensitivity, and 75.9% and 88.9% specificity, respectively, for predicting LVOT origin. The area under the curve (AUC) was 0.85 for lead I R-wave amplitude, 0.87 for V2S/V3R, and 0.72 for the TZ index. Of 36 cases with QS in lead I, 30 (83.3%) were from the anterior RVOT, three (8.3%) from the LVOT, and three (8.3%) from the AIV.

Conclusion: The presence of R-wave amplitude in lead I (≥0.1 mV) is a simple and useful criterion to identify LVOT cusp or endocardium focus in LBRI arrhythmias. A QS pattern in lead I suggests an origin in the anterior RVOT, or less commonly the adjacent LV summit.
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http://dx.doi.org/10.1111/jce.13747DOI Listing
November 2018

QRS morphology shift following catheter ablation of idiopathic outflow tract ventricular arrhythmias: Prevalence, mapping features, and ablation outcomes.

J Cardiovasc Electrophysiol 2018 12 5;29(12):1664-1671. Epub 2018 Oct 5.

Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Introduction: In patients with monomorphic idiopathic outflow tract ventricular arrhythmias (OT-VAs), catheter ablation (CA) at the earliest activation site can result in a shift in QRS morphology indicating a change in the activation patterns. This study aimed to investigate the prevalence, mapping features, and ablation outcomes of OT-VAs displaying a QRS morphology shift following CA.

Methods And Results: We retrospectively analyzed 446 patients with monomorphic OT-VAs. A QRS morphology shift following CA was observed in 17 (4%) patients. Initially, the earliest activation site was within the right ventricular outflow tract (RVOT) in one (6%) patient, the left ventricular outflow tract (LVOT) in 10 (59%) patients (left coronary cusp/right coronary cusp junction in seven patients and LVOT endocardium in three patients), and within the distal coronary venous system in six (35%) patients. The VA was suppressed in all 17 patients, but VA recurrence with a different QRS morphology was observed after a waiting period. The recurrent VA was remapped in all patients and was eliminated targeting the new earliest site in 15 (88%) cases. In 11 of 15 successful cases, the ablation site for the recurrent VA shifted to an anatomical structure distinct from but adjacent to the initial site. In the remaining four patients, the recurrent VA was eliminated within the same anatomical structure.

Conclusions: In patients with idiopathic OT-VAs, a QRS morphology shift following CA can be observed in 4% of the cases. In these cases, detailed remapping is necessary since the successful ablation site for the VAs with altered QRS morphology shifts to different anatomical structures in most patients.
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http://dx.doi.org/10.1111/jce.13728DOI Listing
December 2018

Percutaneous cryoablation for papillary muscle ventricular arrhythmias after failed radiofrequency catheter ablation.

J Cardiovasc Electrophysiol 2018 12 5;29(12):1654-1663. Epub 2018 Oct 5.

Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Background: Catheter ablation of ventricular arrhythmias (VA) from the papillary muscles (PM) is challenging due to limited catheter stability and contact on the PMs with their anatomic complexity and mobility.

Objective: This study aimed to evaluate the effectiveness of cryoablation as an adjunctive therapy for PM VAs when radiofrequency (RF) ablation has failed.

Methods: We evaluated a retrospective series of patients who underwent cryoablation for PM VAs when RF ablation had failed. The decision to switch to cryoablation was at the operator's discretion when intracardiac echocardiography (ICE) suggested that cryoablation might be more effective in achieving catheter stability and energy delivery.

Results: Sixteen patients underwent cryoablation of PM VAs between 2014 and 2016 after RF ablation was unsuccessful. VAs originated from the anterolateral left ventricle (LV) PM (six patients), posterolateral LV PM (six patients), and right ventricle PM (four patients). VAs were predominantly frequent premature ventricular complexes (PVCs); however, patients with sustained ventricular tachycardia and PVC-triggered VF were also represented. Fifteen of the 16 patients were treated with cryoablation; in one patient, a procedural complication with retrograde aortic access precluded treatment. In all patients treated with cryoablation, contact and stability was confirmed with ICE to be superior to the RF catheter, and there was acute and long-term elimination of VAs.

Conclusion: Cryoablation is a useful adjunctive therapy in ablation of PM VAs, providing excellent procedural outcomes even when RF ablation has failed. Cryoablation catheters are less maneuverable than RF ablation catheters and care is required to avoid complications.
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http://dx.doi.org/10.1111/jce.13716DOI Listing
December 2018

Long-Term Outcome of Catheter Ablation for Treatment of Bundle Branch Re-Entrant Tachycardia.

JACC Clin Electrophysiol 2018 03 19;4(3):331-338. Epub 2018 Mar 19.

Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Objectives: This study reports the long-term outcome of patients with bundle branch re-entrant tachycardia (BBRT) who underwent catheter ablation for ventricular tachycardia (VT).

Background: BBRT is an uncommon mechanism of VT. Data on long-term outcomes of patients with BBRT treated with catheter ablation are insufficient.

Methods: Between 2005 and 2016, 32 patients had a sustained VT due to a bundle branch re-entrant mechanism. Diagnosis of BBRT was established per standard published criteria.

Results: The mode of presentation was syncope in 17 patients (53%) and palpitations in 15 (47%). BBRT was inducible in all subjects, and successful ablation of the right bundle branch in 19 patients (59%) or the left bundle branch in 13 patients (41%) was performed. During follow-up of 95 ± 36 months, 6 patients (19%) died, 3 of progressive heart failure and 3 of noncardiac causes. Recurrent VT due to BBRT did not occur in any patient. At baseline, 25 patients (78%) had a prolonged HV interval (>55 ms) and 7 (22%) had a normal HV interval (≤55 ms). In patients with a normal HV interval, there was only 1 death (due to malignancy), and no one developed heart block during 90 ± 36 months of follow-up. Ten patients (31%) had normal left ventricular (LV) function (LV ejection fraction ≥50%), and 22 (69%) had depressed LV function (LV ejection fraction <50%). No deaths were recorded in patients with normal LV function (5 with no implantable cardioverter-defibrillator) compared with 6 deaths among patients with depressed LV function (n = 22; p = 0.07).

Conclusions: Radiofrequency ablation of the bundle branch is an effective therapy for treatment of BBRT. Sustained BBRT can be seen in patients with normal LV systolic function and HV interval with excellent long-term outcomes after ablation.
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http://dx.doi.org/10.1016/j.jacep.2017.11.021DOI Listing
March 2018

Characterization of the Electroanatomic Substrate in Cardiac Sarcoidosis: Correlation With Imaging Findings of Scar and Inflammation.

JACC Clin Electrophysiol 2018 03 29;4(3):291-303. Epub 2017 Nov 29.

Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Objectives: This study sought to characterize the electroanatomic (EAM) substrate in patients with cardiac sarcoidosis (CS) and ventricular tachycardia and its relationship to imaging findings of inflammation and fibrosis.

Background: CS is characterized by coexistence of active inflammation and replacement fibrosis.

Methods: A total of 42 patients with CS based on established criteria and ventricular tachycardia underwent high-density EAM mapping. Abnormal electrograms (EGM) were collected and independently classified as multicomponent fractionated, isolated, late, and split according to standard criteria and regardless of the peak-to-peak bipolar/unipolar voltage. A total of 29 patients (69%) underwent pre-procedural cardiac magnetic resonance (CMR) and positron emission tomography (PET)/computed tomography (CT). The distribution of EAM substrate was correlated with regions of late gadolinium enhancement (LGE) on CMR and increased 18F-fluorodeoxyglucose uptake on PET/CT.

Results: Of 21,451 bipolar and unipolar EGM, 4,073 (19%) were classified as abnormal with a predominant distribution in the basal perivalvular segments and interventricular septum. Using the standard bipolar (<1.5 mV) and unipolar (<8.3 mV for left ventricle <5.5 mV for the right) voltage cutoff values, 40% and 22% of the abnormal EGM were located outside the EAM low-voltage areas, respectively. LGE was present in 26 of 29 patients (90%), whereas abnormal 18F-fluorodeoxyglucose uptake in 14 of 29 patients (48%) with imaging. Segments with abnormal EGM had more LGE-evident scar transmurality [median: 24% (interquartile range [IQR]: 4% to 40%) vs. median: 5% (IQR: 0% to 15%); p < 0.001] and lower metabolic activity (median: 20 g glucose [IQR: 14 g to 30 g] vs. median: 29 g glucose [IQR: 18 g to 39 g]; p < 0.001). Overall, the agreement between the presence of abnormal EGM was higher with the presence of LGE (κ = 0.51; p < 0.001) than with the presence of active inflammation (κ = -0.12; p = 0.003).

Conclusions: In patients with CS and ventricular tachycardia, pre-procedural imaging with CMR and PET/CT can be useful in detecting EAM abnormalities that are potential targets for substrate ablation. Abnormal EGM were more likely located in segments with more scar transmurality (LGE) at CMR and a lower degree of inflammation on PET.
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http://dx.doi.org/10.1016/j.jacep.2017.09.175DOI Listing
March 2018

Coronary Sinus Activation and ECG Characteristics of Roof-Dependent Left Atrial Flutter After Pulmonary Vein Isolation.

Circ Arrhythm Electrophysiol 2018 06;11(6):e005948

Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of Pennsylvania Health System, Philadelphia (R.C.A., S.M., M.K., P.S., F.C.G., T.H., E.S.Z., F.E.M.).

Background: The electrocardiographic and intracardiac activation features of left atrial roof-dependent macroreentrant flutter have been incompletely characterized.

Methods: Patients post-pulmonary vein (PV) isolation with roof-dependent atrial flutter based on activation and entrainment mapping were included. ECG and coronary sinus activation were compared with mitral annular (MA) flutter.

Results: The roof-dependent left atrial flutter circled the right PVs in 32 of 33 cases. Two forms of roof flutters were identified, posteroanterior, ascendant on posterior wall and descendant on anterior wall (n=24); and anteroposterior, ascendant on the anterior wall and descendent on the posterior wall (n=9). Both forms had positive large amplitude P waves in V through V with decreasing amplitude in V through V. Posteroanterior roof flutters had positive P wave in the inferior and negative P wave in leads I and aVL similar to counterclockwise MA flutter, but coronary sinus activation was simultaneous for roof and proximal to distal for counterclockwise. Anteroposterior roof flutters were similar to clockwise MA flutter with negative P in inferior leads and transition to flat or negative P in V through V. Coronary sinus activation time ≤39 ms identified roof versus MA flutter (sensitivity: 100% and specificity: 97%).

Conclusions: Roof-dependent flutter around right PVs is more common than around left PVs. The ECG pattern for roof-dependent flutter around right PVs is similar to MA flutter with frontal plane axis dictated by septal activation. Roof-dependent flutter can be distinguished from MA flutter by more simultaneous rather than sequential coronary sinus activation.
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http://dx.doi.org/10.1161/CIRCEP.117.005948DOI Listing
June 2018

Long-Term Outcomes of Catheter Ablation of Electrical Storm in Nonischemic Dilated Cardiomyopathy Compared With Ischemic Cardiomyopathy.

JACC Clin Electrophysiol 2017 07 26;3(7):767-778. Epub 2017 Apr 26.

Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Objectives: The goal of this study was to determine the long-term outcomes of catheter ablation (CA) of electrical storm in patients with nonischemic dilated cardiomyopathy (NIDCM) compared with patients with ischemic cardiomyopathy (ICM).

Background: CA of ventricular tachycardia (VT) electrical storm has been shown to improve VT-free survival in patients with ICM. Data on the outcomes of CA of electrical storm in patients with NIDCM are insufficient.

Methods: The study included 267 consecutive patients with NIDCM (n = 71; ejection fraction 32 ± 14%) and ICM (n = 196; ejection fraction 28 ± 12%). Endo-epicardial CA was performed in 59 (22%) patients. CA was guided by activation and entrainment mapping for tolerated VT and pacemapping/targeting of abnormal substrate for unmappable VT.

Results: After a median follow-up of 45 (25th to 75th percentile: 9 to 71) months and 1 (25th to 75th percentile: 1 to 8) procedures, 76 (29%) patients died, 25 (9%) underwent heart transplantation, 87 (33%) experienced VT recurrence, and 13 (5%) had recurrence of electrical storm. Overall VT-free survival was 54% at 60 months (48% in NIDCM and 54% in ICM; p = 0.128). Patients with VT recurrence experienced a median of 2 (1 to 10) VT episodes in the 5 (1 to 14) months after the procedure. Death/transplantation-free survival was 62% at 60 months (53% in NIDCM and 64% in ICM; p = 0.067). Persistent inducibility of any VT with cycle length ≥250 ms at programmed stimulation at the end of the procedure was the only independent predictor of VT recurrence. Low ejection fraction, New York Heart Association functional class, and VT recurrence over follow-up independently predicted death/transplantation.

Conclusions: CA of electrical storm was similarly effective in patients with NIDCM compared with patients with ICM, with elimination of electrical storm in 95% of cases and achievement of complete VT control at long-term follow-up in most patients.
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http://dx.doi.org/10.1016/j.jacep.2017.01.020DOI Listing
July 2017

12-Lead Electrocardiogram to Localize Region of Abnormal Electroanatomic Substrate in Arrhythmogenic Right Ventricular Cardiomyopathy.

JACC Clin Electrophysiol 2017 07 26;3(7):654-665. Epub 2017 Apr 26.

Cardiac Electrophysiology Program, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Objectives: The purpose of this study was to evaluate the relationship between electrocardiogram (ECG) QRS fragmentation (fQRS) and right ventricular (RV) endocardial (ENDO) and epicardial (EPI) electroanatomic substrate abnormalities in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC).

Background: fQRS is frequently observed in patients with ARVC and reflects delayed conduction due to RV fibrosis.

Methods: A total of 30 consecutive patients met the task force criteria for ARVC (19 men, mean age 41.1 ± 14.3 years) presenting for ventricular tachycardia ablation with detailed RV ENDO and EPI electroanatomic maps were included. Of these, 25 patients had depolarization abnormalities (fragmentation during and/or immediately after the QRS complex [fQRS]) in ≥2 contiguous ECG leads. Inferior (II, III, aVF) fQRS was identified in 23 patients, anterior (V to V) in 15 patients, and basal superior (I/aVR) in 11 patients. The surface area and anatomic distribution of ENDO and EPI bipolar low-voltage regions (ENDO ≤1.5 mV, <0.5 mV "dense scar"/EPI ≤1.0 mV) and degree of isolated late potential activity consistent with a marked substrate abnormality were compared to the location of region-specific fQRS.

Results: In fQRS patients, ENDO very low bipolar voltage area (27.4 ± 24.9 cm [median 19 cm] vs. 5.8 ± 5.4 cm [median 5 cm]; p = 0.02) and EPI late potential percentage (22.6 ± 9.6% [median 24%] vs. 6.8 ± 3.9% [median 8%]; p = 0.002) were significantly larger than in patients without fQRS. Overall, ENDO and EPI bipolar low voltage area and late potential density increased as the number of fQRS ECG regions (0 to 3) increased. Inferior fQRS most frequently identified EPI inferior substrate (82% sensitivity, 100% specificity), anterior fQRS identified RV EPI mid-free wall substrate (55% sensitivity, 100% specificity), and basal superior fQRS identified ENDO (45.8% sensitivity, 100% specificity) and EPI (52% sensitivity, 100% specificity) RV outflow tract substrate abnormalities.

Conclusions: The extent and distribution of RV voltage substrate abnormalities can be predicted by region-specific ECG depolarization changes in patients with ARVC and ventricular tachycardia.
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http://dx.doi.org/10.1016/j.jacep.2017.01.009DOI Listing
July 2017

Outcomes with prophylactic use of percutaneous left ventricular assist devices in high-risk patients undergoing catheter ablation of scar-related ventricular tachycardia: A propensity-score matched analysis.

Heart Rhythm 2018 10 10;15(10):1500-1506. Epub 2018 May 10.

Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Background: The PAINESD score predicts the risk of periprocedural acute hemodynamic decompensation (AHD) and postprocedural mortality in patients undergoing catheter ablation (CA) of scar-related ventricular tachycardia (VT). The role of prophylactic placement of percutaneous left ventricular assist devices (pLVADs) in high-risk patients is unknown.

Objective: The purpose of this study was to evaluate the outcomes of prophylactic use of pLVAD in high-risk patients undergoing CA of scar-related VT.

Methods: We included 75 patients undergoing CA of scar-related VT in whom a prophylactic pLVAD was implanted because of perceived high risk. The control population was a propensity-matched group of 75 patients who did not undergo prophylactic pLVAD placement. The PAINESD score was used for propensity matching.

Results: The median PAINESD score was 13 (41% with score ≥15) in the prophylactic pLVAD group and 12 (40% with score ≥15) in the control group. Periprocedural AHD occurred in 5 patients (7%) in the prophylactic pLVAD group and in 17 patients (23%) in the control group (P < .01). The 12-month cumulative incidence of VT was 40% in the prophylactic pLVAD group vs 41% in the control group (P = .97), while the 12-month incidence of death/transplant was 33% vs 66%, respectively (P < .01). In multivariable analysis, left ventricular ejection fraction (HR 0.97, 95% CI 0.95-0.99, P = .03), chronic kidney disease (HR 2.24, 95% CI 1.35-3.72, P < .01), VT recurrence (HR 2.33, 95% CI 1.31-4.14, P < .01), and prophylactic pLVAD (HR 0.28, 95% CI 0.16-0.49, P < .01) were all independently associated with death/transplant.

Conclusion: Prophylactic pLVAD placement in high-risk patients undergoing CA of scar-related VT is associated with a reduced risk of AHD and death/transplant during follow-up without affecting VT-free survival.
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http://dx.doi.org/10.1016/j.hrthm.2018.04.028DOI Listing
October 2018

Frameshifts in Code and in Care: The Importance of Timely Genetic Evaluation.

Circ Genom Precis Med 2018 05;11(5):e002215

Center for Inherited Cardiovascular Disease, Division of Cardiovascular Medicine (N.R., J.L.C., S.L.M., A.M., A.T.O.)

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http://dx.doi.org/10.1161/CIRCGEN.118.002215DOI Listing
May 2018