Publications by authors named "Jeffrey Arkles"

56 Publications

Percutaneous Removal of a Pulmonary Artery Catheter Inadvertently Sutured to the Heart During Valve Surgery.

JACC Case Rep 2020 Dec 25;2(15):2323-2326. Epub 2020 Nov 25.

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

A 74-year old woman underwent "mini-mitral" valve surgery via a right thoracotomy. The pulmonary artery catheter could not be removed thereafter and was found to be pierced by the atriotomy suture. Removal was performed by percutaneously lacerating the catheter above and below the suture, leaving behind a small segment. ().
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http://dx.doi.org/10.1016/j.jaccas.2020.07.065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8304588PMC
December 2020

Diagnostic Approach to Wide Complex Tachycardia.

JAMA Intern Med 2021 Jul 19. Epub 2021 Jul 19.

Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.

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http://dx.doi.org/10.1001/jamainternmed.2021.3189DOI Listing
July 2021

Subserratus implantation of the subcutaneous implantable cardioverter-defibrillator.

Heart Rhythm 2021 Jun 11. Epub 2021 Jun 11.

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

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http://dx.doi.org/10.1016/j.hrthm.2021.06.1169DOI Listing
June 2021

Esophageal luminal temperature rise during atrial fibrillation ablation is associated with lower radiofrequency electrode distance and baseline impedance.

J Cardiovasc Electrophysiol 2021 Jul 28;32(7):1857-1864. Epub 2021 May 28.

Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.

Introduction: Esophageal injury during atrial fibrillation (AF) ablation is a life-threatening complication. We sought to measure the association of esophageal temperature attenuation with radiofrequency (RF) electrode impedance, contact force, and distance from the esophagus.

Methods: The retrospective study cohort included 35 patients with mean age 64 ± 10 years, of whom 74.3% were male, and 40% had persistent AF. All patients had undergone preprocedural cardiac magnetic resonance (CMR) followed by AF ablation with luminal esophageal temperature monitoring. Lesion locations were co-registered with CMR image segmentations of left atrial and esophageal anatomy. Luminal esophageal temperature, time matched RF lesion data, and ablation distance from the nearest esophageal location were collected as panel data.

Results: Luminal esophageal temperature changes corresponding to 3667 distinct lesions, delivered with mean power 27.9 ± 5.5 W over a mean duration of 22.2 ± 10.5 s were analyzed. In multivariable analyses, clustered per patient, examining posterior wall lesions only, and adjusted for lesion power and duration as set by the operator, lesion distance from the esophagus (-0.003°C/mm, p < .001), and baseline impedance (-0.015°C/Ω, p < .001) were associated with changes in luminal esophageal temperature.

Conclusion: Esophageal luminal temperature rises are associated with shorter lesion distance from esophagus and lower baseline impedance during RF lesion delivery. When procedural strategy requires RF delivery near the esophagus, selection of sites with higher baseline impedance may improve safety.
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http://dx.doi.org/10.1111/jce.15097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8256679PMC
July 2021

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

Stroke, Timing of Atrial Fibrillation Diagnosis, and Risk of Death.

Neurology 2021 03 3;96(12):e1655-e1662. Epub 2021 Feb 3.

From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN.

Objective: To evaluate the prognosis of patients with ischemic stroke according to the timing of an atrial fibrillation (AF) diagnosis, we created an inception cohort of incident stroke events and compared the risk of death between patients with stroke with (1) sinus rhythm, (2) known AF (KAF), and (3) AF diagnosed after stroke (AFDAS).

Methods: We used the Penn AF Free study to create an inception cohort of patients with incident stroke. Mortality events were identified after linkage with the National Death Index through June 30, 2017. We also evaluated initiation of anticoagulants and antiplatelets across the study duration. Cox proportional hazards models evaluated associations between stroke subtypes and death.

Results: We identified 1,489 individuals who developed an incident ischemic stroke event: 985 did not develop AF at any point during the study period, 215 had KAF before stroke, 160 had AF detected ≤6 months after stroke, and 129 had AF detected >6 months after stroke. After a median follow-up of 4.9 years (interquartile range 1.9-6.8), 686 deaths occurred. The annualized mortality rate was 8.8% in the stroke, no AF group; 12.2% in the KAF group; 15.8% in the AFDAS ≤6 months group; and 12.7% in the AFDAS >6 months group. Patients in the AFDAS ≤6 months group had the highest independent risk of all-cause mortality even after multivariable adjustment for demographics, clinical risk factors, and the use of antithrombotic therapies (hazard ratio 1.62 [1.22-2.14]). Compared to the stroke, no AF group, those with KAF had a higher mortality risk that was rendered nonsignificant after adjustment.

Conclusions: The AFDAS group had the highest risk of death, which was not explained by comorbidities or use of antithrombotic therapies.
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http://dx.doi.org/10.1212/WNL.0000000000011633DOI Listing
March 2021

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

JACC Clin Electrophysiol 2021 Jul 27;7(7):831-840. Epub 2021 Jan 27.

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

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.

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.

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 cm [8 to 29 cm]) and unipolar LVA in all patients (median extent 48 cm [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 months (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
July 2021

Impact of Left Atrial Bipolar Electrogram Voltage on First Pass Pulmonary Vein Isolation During Radiofrequency Catheter Ablation.

Front Physiol 2020 15;11:594654. Epub 2020 Dec 15.

Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States.

Background: First pass pulmonary vein isolation (PVI) is associated with durable isolation and reduced recurrence of atrial fibrillation (AF).

Objective: We sought to investigate the relationship between left atrial electrogram voltage using multielectrode fast automated mapping (ME-FAM) and first pass isolation with radiofrequency ablation.

Methods: We included consecutive patients (pts) undergoing first time ablation for paroxysmal AF (pAF), and compared the voltage characteristics between patients with and without first pass isolation. Left atrium (LA) adjacent to PVs was divided into 6 regions, and mean voltages obtained with ME-FAM (Pentaray, Biosense Webster) in each region and compared. LA electrograms with marked low voltage (<0.5 mV) were identified and the voltage characteristics at the site of difficult isolation was compared to the voltage in adjacent region.

Results: Twenty consecutive patients (10 with first pass and 10 without) with a mean age of 63.3 ± 6.2 years, 65% males, were studied. Difficult isolation occurred on the right PVs in eight pts and left PVs in three pts. The mean voltage in pts without first pass isolation was lower in all 6 regions; posterior wall (1.93 ± 1.46 versus 2.99 ± 2.19; < 0.001), roof (1.83 ± 2.29 versus 2.47 ± 1.99; < 0.001), LA-LPV posterior (1.85 ± 3.09 versus 2.99 ± 2.19, < 0.001), LA-LPV ridge (1.42 ± 1.04 versus 1.91 ± 1.61; < 0.001), LA-RPV posterior (1.51 ± 1.11 versus 2.30 ± 1.77, < 0.001) and LA-RPV septum (1.55 ± 1.23 versus 2.31 ± 1.40, < 0.001). Patients without first pass isolation also had a larger percentage of signal with an amplitude of <0.5 mV for each of the six regions (12.8% versus 7.5%). In addition, the mean voltage at the site of difficult isolation was lower at 8 out of 11 sites compared to mean voltage for remaining electrograms in that region.

Conclusion: In patients undergoing PVI for paroxysmal AF, failure in first pass isolation was associated with lower global LA voltage, more marked low amplitude signal (<0.5 mV) and lower local signal voltage at the site with difficult isolation. The results suggest that a greater degree of global and segmental fibrosis may play a role in ease of PV isolation with radiofrequency energy.
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http://dx.doi.org/10.3389/fphys.2020.594654DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7769759PMC
December 2020

PRECAF Randomized Controlled Trial.

Circ Arrhythm Electrophysiol 2021 01 10;14(1):e008993. Epub 2020 Dec 10.

Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (L.K., D.S.F., A.L., J.A., M.H., P.S., F.E.M., S.N.).

Background: We have previously shown that the presence of dual muscular coronary sinus (CS) to left atrial (LA) connections, coupled with rate-dependent unidirectional block in one limb, is associated with atrial fibrillation (AF) induction. This study sought to examine whether ablation of distal CS to LA connections at a first AF ablation reduces arrhythmia recurrence during follow-up.

Methods: In this single-center, randomized, controlled trial, 35 consecutive patients with drug-refractory AF undergoing first-time ablation between August 2018 and August 2019, were randomly assigned to (1) standard ablation (pulmonary vein isolation and nonpulmonary vein trigger ablation) versus (2) standard ablation plus elimination of distal CS to LA connections targeting the earliest LA activation during distal CS pacing with a deca-polar catheter placed with its proximal electrode at the ostium. Change of the local CS atrial electrogram and LA activation sequence to early activation of the LA septum or roof during distal CS pacing were the end point for CS-LA connection elimination.

Results: Thirty patients completed 6 months study follow-up (15 patients in each group). Demographic characteristics including age and AF persistence were similar in both groups. After a mean follow-up of 170±22 days, there were 7 atrial arrhythmia recurrences in the standard group and 1 recurrence in the CS-LA connection elimination group (46.7% versus 6.7%, hazard ratio, 0.12, =0.047).

Conclusions: Elimination of distal CS to LA connections reduced atrial arrhythmia recurrences compared with standard pulmonary vein isolation and nonpulmonary vein trigger ablation in patients undergoing a first AF ablation procedure in a small randomized study. This strategy warrants further evaluation in a multicenter randomized trial. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03646643.
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http://dx.doi.org/10.1161/CIRCEP.120.008993DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8054782PMC
January 2021

Catheter ablation of atrial arrhythmias following lung transplant: Electrophysiological findings and outcomes.

J Cardiovasc Electrophysiol 2021 01 25;32(1):49-57. Epub 2020 Nov 25.

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

Introduction: Data on the mechanisms of atrial arrhythmias (AAs) and outcomes of catheter ablation (CA) in lung transplantation (LT) patients are insufficient. We evaluated the electrophysiologic features and outcomes of CA of AAs in LT patients. METHODS AND RESULTS: We conducted a retrospective study of all the LT patients who underwent CA for AAs at our institution between 2004 and 2019. A total of 15 patients (43% males, age: 61 ± 10 years) with a history of LT (60% bilateral and 40% unilateral) were identified. All patients had documented organized AA on surface electrocardiogram and seven patients also had atrial fibrillation (AF; 47% with >1 clinical arrhythmia). At electrophysiological study, 19 organized AAs were documented (48% focal and 52% macro-re-entrant). Focal atrial tachycardias/flutters were targeted along the pulmonary vein (PV) anastomotic site at the left inferior PV (n = 2), ridge and carina of the left superior PV (n = 2), left atrium (LA) posterior wall (n = 3), LA roof (n = 1), and tricuspid annulus (n = 1). Macro-re-entrant AAs included cavotricuspid isthmus-dependent flutter (n = 2), incisional LA flutter (n = 4), LA roof-dependent flutter (n = 1), and mitral annular flutter (n = 3). In patients with LA mapping (n = 13), PV reconnection on the side of the LT was found in six patients (40%, all with clinically documented AF), with a mean of 2.1 ± 0.9 PVs reconnected per patient. Patients with AF underwent successful PV isolation. After a median follow-up of 19 months (range: 6-86 months), 75% of patients remained free from recurrent AAs. No procedural major complications occurred.

Conclusion: In patients with prior LT, recurrent AAs are typically associated with substrate surrounding the surgical anastomotic lines and/or chronically reconnected PVs. CA of AAs in this population is safe and effective to achieve long-term arrhythmia control.
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http://dx.doi.org/10.1111/jce.14816DOI Listing
January 2021

Strategies for Catheter Ablation of Left Ventricular Papillary Muscle Arrhythmias: An Institutional Experience.

JACC Clin Electrophysiol 2020 10 16;6(11):1381-1392. Epub 2020 Sep 16.

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

Objectives: This study sought to address whether technological innovations such as contact force sensing (CFS) can improve acute and long-term ablation outcomes of left ventricular papillary muscle (LV PAP) ventricular arrhythmias (VAs).

Background: Catheter ablation of LV PAP VAs has been less efficacious than another focal VAs. It remains unclear whether technological innovations such as CFS can improve acute and long-term ablation outcomes of LV PAP VA.

Methods: From January 2015 to December 2019, a total of 137 patients underwent LV PAP VA ablation. VA site of origin (SOO) was identified using activation and pace-mapping guided by intracardiac echocardiography. Radiofrequency energy (20 to 50 W for 60 to 90 s) was delivered by irrigated catheter with or without CFS. We defined acute success as complete suppression of targeted VA ≥30 min post ablation and clinical success as ≥80% VA burden reduction at outpatient follow-up.

Results: VA manifested as premature ventricular complexes in 98 (71%), nonsustained ventricular tachycardia in 18 (13%), sustained ventricular tachycardia in 12 (9%) and premature ventricular complexes induced ventricular fibrillation in 9 (7%). VA SOO was anterolateral PAP in 51 (37%), posteromedial PAP in 73 (53%), and both PAPs in 13 (10%). VAs were targeted using CFS in 97 (71%) and non-CFS in 40 (29%). After a single procedure, acute success was achieved in 130 (95%) and clinical success was achieved in 112 (82%); neither was impacted by VA SOO and/or CFS. Complications occurred in 5 patients (3.6%).

Conclusion: Independent of CFS technology, intracardiac echocardiography-guided catheter ablation is highly efficacious and may be considered as first-line therapy in the management of LV PAP VA.
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http://dx.doi.org/10.1016/j.jacep.2020.06.026DOI Listing
October 2020

Ablation of Ventricular Arrhythmias From the Left Ventricular Apex in Patients Without Ischemic Heart Disease.

JACC Clin Electrophysiol 2020 09 27;6(9):1089-1102. Epub 2020 May 27.

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

Objectives: This study aimed to characterize the incidence, clinical characteristics, and electrocardiographic and electrophysiologic features of LVA VA in the absence of CAD and to describe the experience with catheter ablation (CA) in this group.

Background: The left ventricular apex (LVA) is a well-described source of ventricular arrhythmias (VAs) in patients with coronary artery disease (CAD) and history of apical infarction but is a rare source of VA in the absence of CAD.

Methods: Patients referred for CA of VA at our institution were retrospectively reviewed, and those with LVA VA in the absence of CAD were identified.

Results: Of 3,710 consecutive patients undergoing VA ablation, CA of LVA VA was performed in 24 patients (20 with monomorphic ventricular tachycardia, 4 with premature ventricular contractions or nonsustained ventricular tachycardia; 18 men; mean age: 54 ± 15 years). These cases comprised 10 of 35 (29%) hypertrophic cardiomyopathy, 9 of 789 (1.2%) nonischemic cardiomyopathy, and 5 of 1,432 (0.4%) idiopathic VA ablation procedures. VA QRS morphology was predominantly right bundle with slurred upstroke and right superior frontal plane axis with precordial transition ≤V3. Epicardial ablation was performed in 14 of 24 (58%). After a median of 1 procedure (range 1 to 4) at this institution and median follow-up of 47 months (range 0-176), VA recurred in 1 patient (4%).

Conclusions: LVA VA in the absence of CAD is unusual and may occur in patients with hypertrophic cardiomyopathy or nonischemic cardiomyopathy or, rarely, in the absence of structural heart disease. It can be recognized by characteristic ECG features. CA of LVA VA is challenging; multiple procedures, including epicardial approaches, may be required to achieve VA control over long-term follow-up.
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http://dx.doi.org/10.1016/j.jacep.2020.04.021DOI Listing
September 2020

Massive myocardial edema and inflow cannula obstruction due to epicardial surgical ventricular tachycardia cryoablation at time of left ventricular assist device implantation.

HeartRhythm Case Rep 2020 Aug 28;6(8):523-527. Epub 2020 May 28.

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

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http://dx.doi.org/10.1016/j.hrcr.2020.05.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7424293PMC
August 2020

COVID-19 and cardiac arrhythmias.

Heart Rhythm 2020 Sep 22;17(9):1439-1444. Epub 2020 Jun 22.

Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Background: Early studies suggest that coronavirus disease 2019 (COVID-19) is associated with a high incidence of cardiac arrhythmias. Severe acute respiratory syndrome coronavirus 2 infection may cause injury to cardiac myocytes and increase arrhythmia risk.

Objectives: The purpose of this study was to evaluate the risk of cardiac arrest and arrhythmias including incident atrial fibrillation (AF), bradyarrhythmias, and nonsustained ventricular tachycardia (NSVT) in a large urban population hospitalized for COVID-19. We also evaluated correlations between the presence of these arrhythmias and mortality.

Methods: We reviewed the characteristics of all patients with COVID-19 admitted to our center over a 9-week period. Throughout hospitalization, we evaluated the incidence of cardiac arrests, arrhythmias, and inpatient mortality. We also used logistic regression to evaluate age, sex, race, body mass index, prevalent cardiovascular disease, diabetes, hypertension, chronic kidney disease, and intensive care unit (ICU) status as potential risk factors for each arrhythmia.

Results: Among 700 patients (mean age 50 ± 18 years; 45% men; 71% African American; 11% received ICU care), there were 9 cardiac arrests, 25 incident AF events, 9 clinically significant bradyarrhythmias, and 10 NSVTs. All cardiac arrests occurred in patients admitted to the ICU. In addition, admission to the ICU was associated with incident AF (odds ratio [OR] 4.68; 95% confidence interval [CI] 1.66-13.18) and NSVT (OR 8.92; 95% CI 1.73-46.06) after multivariable adjustment. Also, age and incident AF (OR 1.05; 95% CI 1.02-1.09) and prevalent heart failure and bradyarrhythmias (OR 9.75; 95% CI 1.95-48.65) were independently associated. Only cardiac arrests were associated with acute in-hospital mortality.

Conclusion: Cardiac arrests and arrhythmias are likely the consequence of systemic illness and not solely the direct effects of COVID-19 infection.
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http://dx.doi.org/10.1016/j.hrthm.2020.06.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7307518PMC
September 2020

Evaluation of Radiofrequency Ablation Irrigation Type: In Vivo Comparison of Normal Versus Half-Normal Saline Lesion Characteristics.

JACC Clin Electrophysiol 2020 06 27;6(6):684-692. Epub 2020 May 27.

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

Objectives: This study investigated the impact of the type of catheter irrigant used during delivery of radiofrequency ablation.

Background: The use of half-normal saline (HNS) as an irrigant has been suggested as a method for increasing ablation lesion size but has not been rigorously studied in the beating heart or the use of a low-flow irrigation catheter.

Methods: Sixteen swine underwent left ventricular mapping and ablation using either normal saline (NS) (group 1: n = 9) or half-normal saline (HNS) (group 2: n = 7). All lesions were delivered using identical parameters (40 W with 10-second ramp, 30-second duration, 15 ml/min flow, and 8- to14-g target contact force). An occurrence of steam pop, catheter char, or thrombus was assessed using intracardiac echocardiography and catheter inspection following each application. Lesion depth, width, and area were measured using electronic calibers.

Results: A total of 109 lesions were delivered in group 1 and 77 in group 2. There were significantly more steam pops in group 2 (32 of 77 [42%] vs. 24 of 109 [22%], respectively). The frequencies of catheter tip char were similar (group 1: 9 of 109 [8%] vs. group 2: 10 of 77 [13%]; p = 0.29). Lesion depths, widths, and areas also were similar in both groups.

Conclusions: The use of an HNS irrigant using a low-flow open irrigated ablation catheter platform results in more tissue heating due to higher radiofrequency current delivery directed to tissue, but this can lead to higher rate of steam pops. In this in vivo porcine beating-heart model, the use of HNS does not appear to significantly increase lesion size in normal myocardium despite evidence of increased radiofrequency heating.
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http://dx.doi.org/10.1016/j.jacep.2020.02.013DOI Listing
June 2020

QRS morphology in lead V for the rapid localization of idiopathic ventricular arrhythmias originating from the left ventricular papillary muscles: A novel electrocardiographic criterion.

Heart Rhythm 2020 10 23;17(10):1711-1718. Epub 2020 May 23.

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

Background: Twelve-lead electrocardiogram (ECG) criteria have been developed to identify idiopathic ventricular arrhythmias (VAs) from the left ventricular (LV) papillary muscles (PAPs), but accurate localization remains a challenge.

Objective: The purpose of this study was to develop ECG criteria for accurate localization of LV PAP VAs using lead V exclusively.

Methods: Consecutive patients undergoing mapping and ablation of VAs from the LV PAPs guided by intracardiac echocardiography from 2007 to 2018 were reviewed (study group). The QRS morphology in lead V was compared to patients with VAs with a "right bundle branch block" morphology from other LV locations (reference group). Patients with structural heart disease were excluded.

Results: One hundred eleven patients with LV PAP VAs (mean age 54 ± 16 years; 65% men) were identified, including 64 (55%) from the posteromedial PAP and 47 (42%) from the anterolateral PAP. The reference group included patients with VAs from the following LV locations: fascicles (n = 21), outflow tract (n = 36), ostium (n = 37), inferobasal segment (n = 12), and apex (5). PAP VAs showed 3 distinct QRS morphologies in lead V 93% of the time: Rr (53%), R with a slurred downslope (29%), and RR (11%). Sensitivity, specificity, positive predictive value, and negative predictive value for the 3 morphologies combined are 93%, 98%, 98%, and 93%, respectively. The intrinsicoid deflection of PAP VAs in lead V was shorter than that of the reference group (63 ± 13 ms vs 79 ± 24 ms; P < .001). An intrinsicoid deflection time of <74 ms best differentiated the 2 groups (sensitivity 79%; specificity 87%).

Conclusion: VAs originating from the LV PAPs manifest unique QRS morphologies in lead V, which can aid in rapid and accurate localization.
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http://dx.doi.org/10.1016/j.hrthm.2020.05.021DOI Listing
October 2020

Durability of posterior wall isolation after catheter ablation among patients with recurrent atrial fibrillation.

Heart Rhythm 2020 10 7;17(10):1740-1744. Epub 2020 May 7.

Department of Medicine, Division of Cardiology, Section for Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Background: Electrical posterior wall isolation (PWI) is increasingly being used for the treatment of patients with atrial fibrillation (AF). Few data exist on the durability of PWI using current technology.

Objective: The purpose of this study was to characterize the frequency and location of posterior wall reconnection at the time of repeat catheter ablation for AF.

Methods: We performed a single-center retrospective cohort study of 50 patients undergoing repeat AF ablation after previous PWI. Durability of PWI was assessed at the time of repeat ablation based on posterior wall entrance and exit block. Sites of posterior wall reconnection were characterized based on review of recorded electrical signals and electroanatomic maps.

Results: At the time of repeat ablation, mean age was 67 ± 10 years, 31 of 50 patients had persistent AF, and mean CHADS-VASc score was 3.0 ± 1.8. Of the 50 patients, 30 had durable PWI at repeat ablation, 1.4 ± 1.6 years after the index procedure. Patients with posterior wall reconnection required repeat ablation earlier (0.9 ± 0.6 years vs1.8 ± 1.9 years from index PWI; P = .048) and were more likely to have atypical atrial flutter (55% vs 27%; P = .043). Among patients with posterior wall reconnection, the roof was the most common site of reconnection (14/20), and 12 patients had multiple regions of reconnection noted.

Conclusion: Posterior wall reconnection is noted in 40% of patients undergoing repeat ablation after an index PWI. The roof of the left atrium is the most common site of posterior wall reconnection.
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http://dx.doi.org/10.1016/j.hrthm.2020.05.005DOI Listing
October 2020

Wire countertraction for sheath placement through stenotic and tortuous veins: The "body flossing" technique.

Heart Rhythm O2 2020 Apr 27;1(1):21-26. Epub 2020 Apr 27.

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

Background: Innominate vein stenosis and venous tortuosity are common findings during cardiac implantable electronic device upgrades or replacements and present a challenge to the implanting physician. Various techniques have been described to facilitate lead placement, including serial dilation, balloon venoplasty, and percutaneous access medial to the stenosis, each with its own benefits and risks.

Objective: The purpose of this study was to assess the feasibility, safety, and efficacy of the wire countertraction ("body flossing") technique to facilitate sheath placement through tortuous and stenotic vessels.

Methods: Patients undergoing cardiac implantable electronic device procedures requiring the body flossing technique due to inability to place vascular sheaths over the wire through stenoses or tortuosity were retrospectively analyzed. Clinical characteristics, procedural equipment, and outcomes were analyzed.

Results: Simultaneous countertraction was successful in all attempted cases, including 8 patients with stenoses and 2 with tortuosity. In 2 of the stenosis cases, venoplasty had previously failed. No complications occurred.

Conclusion: Simultaneous countertraction (body flossing) is an effective tool to overcome venous stenosis and tortuosity that are amenable to wire advancement but not to vascular sheaths. It seems to be a safe and effective alternative to other techniques used in these scenarios.
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http://dx.doi.org/10.1016/j.hroo.2020.01.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183965PMC
April 2020

Collateral injury of the conduction system during catheter ablation of septal substrate in nonischemic cardiomyopathy.

J Cardiovasc Electrophysiol 2020 07 5;31(7):1726-1739. Epub 2020 May 5.

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

Introduction: In patients with nonischemic cardiomyopathy (NICM) little is known about the clinical impact of catheter ablation (CA) of septal ventricular tachycardia (VT) resulting in the collateral injury of the conduction system (CICS).

Methods And Results: Ninety-five consecutive patients with NICM underwent CA of septal VT. Outcomes in patients with no baseline conduction abnormalities who developed CICS (group 1, n = 28 [29%]) were compared to patients with no CICS (group 2, n = 17 [18%]) and to patients with preexisting conduction abnormalities or biventricular pacing (group 3, n = 50 [53%]). Group-1 patients were younger, had a higher left ventricular ejection fraction and a lower prevalence of New York Heart Association III/IV class compared to group 3 while no significant differences were observed with group 2. After a median follow-up of 15 months, VT recurred in 14% of patients in group 1, 12% in group 2 (P = .94) and 32% in group 3 (P = .08) while death/transplant occurred in 14% of patients in group 1, 18% in group 2 (P = .69) and 28% in group 3 (P = .15). A worsening of left ventricular ejection fraction (LVEF) (median LVEF variation, -5%) was observed in group 1 compared to group 2 (median LVEF variation, 0%; P < .01) but not group-3 patients (median LVEF variation, -4%; P = .08) with a consequent higher need for new biventricular pacing in group 1 (43%) compared to group 2 (12%; P = .03) and group 3 (16%; P < .01).

Conclusions: In patients with NICM and septal substrate, sparing the abnormal substrate harboring the conduction system provides acceptable VT control while preventing a worsening of the systolic function.
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http://dx.doi.org/10.1111/jce.14498DOI Listing
July 2020

Non-Scar-Related and Purkinje-Related Ventricular Tachycardia in Patients With Structural Heart Disease: Prevalence, Mapping Features, and Clinical Outcomes.

JACC Clin Electrophysiol 2020 02 18;6(2):231-240. Epub 2019 Dec 18.

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

Objectives: This study sought to evaluate the prevalence, mapping features, and ablation outcomes of non-scar-related ventricular tachycardia (NonScar-VT) and Purkinje-related VT (Purkinje-VT) in patients with structural heart disease.

Background: VT in structural heart disease is typically associated with scar-related myocardial re-entry. NonScar-VTs arising from areas of normal myocardium or Purkinje-VTs originating from the conduction system are less common.

Methods: We retrospectively analyzed 690 patients with structural heart disease who underwent VT ablation between 2013 and 2017.

Results: A total of 37 (5.4%) patients (16 [43%] with ischemic cardiomyopathy, 16 [43%] with nonischemic dilated cardiomyopathy, and 5 [14%] others) demonstrated NonScar/Purkinje-VTs, which represented the clinical VT in 76% of cases. Among the 37 VTs, 31 (84%) were Purkinje-VTs (28 bundle branch re-entrant VT). The remaining 6 (16%) VTs were NonScar-VTs and included 4 idiopathic outflow tract VTs. A total of 16 patients had prior history of VT ablations: empirical scar substrate modification was performed in 6 (38%) patients and residual inducibility of VT had not been assessed in 7 (44%). In all 37 patients, the NonScar/Purkinje-VT was successfully ablated. After a median follow-up of 18 months, the targeted NonScar/Purkinje-VT did not recur in any patients, and 28 (76%) of patients were free from any recurrent VT episodes.

Conclusions: NonScar/Purkinje-VTs can be identified in 5.4% of patients undergoing VT ablation in the setting of structural heart disease. Careful effort to induce, characterize, and map these VTs is important because substrate-based ablation strategies would fail to eliminate these types of VT.
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http://dx.doi.org/10.1016/j.jacep.2019.09.014DOI Listing
February 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

Association of Left Atrial High-Resolution Late Gadolinium Enhancement on Cardiac Magnetic Resonance With Electrogram Abnormalities Beyond Voltage in Patients With Atrial Fibrillation.

Circ Arrhythm Electrophysiol 2020 02 15;13(2):e007586. Epub 2020 Jan 15.

Cardiovascular Imaging Section, Department of Radiology (B.D), Perelman School of Medicine at the University of Pennsylvania, Philadelphia.

Background: Conflicting data have been reported on the association of left atrial (LA) late gadolinium enhancement (LGE) with atrial voltage in patients with atrial fibrillation. The association of LGE with electrogram fractionation and delay remains to be examined. We sought to examine the association between LA LGE on cardiac magnetic resonance and electrogram abnormalities in patients with atrial fibrillation.

Methods: High-resolution LGE cardiac magnetic resonance was performed before electrogram mapping and ablation in atrial fibrillation patients. Cardiac magnetic resonance features were quantified using LA myocardial signal intensity score (SI-Z), a continuous normalized variable, as well as a dichotomous LGE variable based on previously validated methodology. Electrogram mapping was performed pre-ablation during sinus rhythm or LA pacing, and electrogram locations were coregistered with cardiac magnetic resonance images. Analyses were performed using multilevel patient-clustered mixed-effects regression models.

Results: In the 40 patients with atrial fibrillation (age, 63.2±9.2 years; 1312.3±767.3 electrogram points per patient), lower bipolar voltage was associated with higher SI-Z in patients who had undergone previous ablation (coefficient, -0.049; <0.001) but not in ablation-naive patients (coefficient, -0.004; =0.7). LA electrogram activation delay was associated with SI-Z in patients with previous ablation (SI-Z: coefficient, 0.004; <0.001 and LGE: coefficient, 0.04; <0.001) but not in ablation-naive patients. In contrast, increased LA electrogram fractionation was associated with SI-Z (coefficient, 0.012; =0.03) and LGE (coefficient, 0.035; <0.001) only in ablation-naive patients.

Conclusions: The association of LA LGE with voltage is modified by ablation. Importantly, in ablation-naive patients, atrial LGE is associated with electrogram fractionation even in the absence of voltage abnormalities.
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http://dx.doi.org/10.1161/CIRCEP.119.007586DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7031051PMC
February 2020

Impact of a nurse-led limited risk factor modification program on arrhythmia outcomes in patients with atrial fibrillation undergoing catheter ablation.

J Cardiovasc Electrophysiol 2020 02 15;31(2):423-431. Epub 2020 Jan 15.

Cardiovascular Division, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania.

Background: We have previously demonstrated the feasibility of a nurse-led risk factor modification (RFM) program for improving weight loss and obstructive sleep apnea (OSA) care among patients with atrial fibrillation (AF).

Objective: We now report its impact on arrhythmia outcomes in a subgroup of patients undergoing catheter ablation.

Methods: Participating patients with obesity and/or need for OSA management (high risk per Berlin Questionnaire or untreated OSA) underwent in-person consultation and monthly telephone calls with the nurse for up to 1 year. Arrhythmias were assessed by office ECGs and ≥2 wearable monitors. Outcomes, defined as Arrhythmia control (0-6 self-terminating recurrences, with ≤1 cardioversion for nonparoxysmal AF) and Freedom from arrhythmias (no recurrences on or off antiarrhythmic drugs), were compared at 1 year between patients undergoing catheter ablation who enrolled and declined RFM.

Results: Between 1 November 2016 and 1 April 2018, 195 patients enrolled and 196 declined RFM (body mass index, 35.1 ± 6.7 vs 34.3 ± 6.3 kg/m ; 50% vs 50% paroxysmal AF; P = NS). At 1 year, enrolled patients demonstrated significant weight loss (4.7% ± 5.3% vs 0.3% ± 4.4% in declined patients; P < .0001) and improved OSA care (78% [n = 43] of patients diagnosed with OSA began treatment). However, outcomes were similar between enrolled and declined patients undergoing ablation (arrhythmia control in 80% [n = 48] vs 79% [n = 38]; freedom from arrhythmia in 58% [n = 35] vs 71% [n = 34]; P = NS).

Conclusion: Despite improving weight loss and OSA care, our nurse-led RFM program did not impact 1-year arrhythmia outcomes in patients with AF undergoing catheter ablation.
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http://dx.doi.org/10.1111/jce.14336DOI Listing
February 2020

Septal Versus Lateral Mitral Isthmus Ablation for Treatment of Mitral Annular Flutter.

JACC Clin Electrophysiol 2019 11 30;5(11):1292-1299. Epub 2019 Oct 30.

Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Objectives: This study sought to compare efficacy and safety of the septal mitral isthmus line (SMIL) with that of the lateral mitral isthmus line (LMIL) for treatment of mitral annular flutter (MAF).

Background: MAF is the most common left atrial macro-re-entrant organized atrial tachycardia (OAT) occurring after catheter ablation of atrial fibrillation. The 2 most common lesion sets for treating MAF include linear ablation from the anteroseptal mitral annulus to the right superior pulmonary vein (SMIL) and from the lateral mitral annulus to left inferior pulmonary vein (LMIL).

Methods: The study included all mitral isthmus ablations performed at the Hospital of the University of Pennsylvania in 2016 and 2017. Acute procedural results and long-term arrhythmia-free survival were compared between groups.

Results: Of 114 total MILs, conduction block was achieved across 73 (93.6%) SMILs compared with 29 (80.6%) LMILs (p = 0.05). Although the length of the SMIL was longer (48.9 ± 12.8 cm vs. 38.7 ± 12.8 cm; p = 0.001), time required to achieve block was shorter (25.2 ± 15.9 min vs. 36.6 ± 21.3 min; p = 0.03). Coronary sinus ablation was required in 58.3% of LMILs due to inability to achieve conduction block with left atrial ablation alone. In multivariate analysis, only failure to achieve acute MIL block remained significantly associated with subsequent OAT recurrence (hazard ratio: 6.39; 95% confidence interval: 1.37 to 29.9; p = 0.02).

Conclusions: The SMIL requires less time to complete and more frequently results in acute MIL block than the LMIL. Additionally, ablation is rarely required outside the left atrium. Failure to achieve acute MIL block is strongly associated with subsequent OAT recurrence.
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http://dx.doi.org/10.1016/j.jacep.2019.08.014DOI Listing
November 2019

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

Electrocardiographic and Electrophysiologic Characteristics of Idiopathic Ventricular Arrhythmias Originating From the Basal Inferoseptal Left Ventricle.

JACC Clin Electrophysiol 2019 07 8;5(7):833-842. Epub 2019 May 8.

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

Objectives: This study sought to characterize ventricular arrhythmia (VA) ablated from the basal inferoseptal left ventricular endocardium (BIS-LVe) and identify electrocardiographic characteristics to differentiate from inferobasal crux (IBC) VA.

Background: The inferior basal septum is an uncommon source of idiopathic VAs, which can arise from its endocardial or epicardial (crux) aspect. Because the latter are often targeted from the coronary venous system or epicardium, distinguishing between the 2 is important for successful ablation.

Methods: Consecutive patients undergoing ablation of idiopathic VA from the BIS-LVe or IBC from 2009 to 2018 were identified and clinical characteristics and electrocardiographs of VA were compared.

Results: Of 931 patients undergoing idiopathic VA ablation, Virginia was eliminated from the BIS-LVe in 19 patients (2%) (17 male, age 63.7 ± 9.2 years, LV ejection fraction: 45.0 ± 9.3%). QRS complexes typically manifested right bundle branch block morphology with "reverse V pattern break" and left superior axis (more negative in lead III than II). VA elimination was achieved after median of 2 lesions (interquartile range [IQR]: 1-6; range 1 to 20) (radiofrequency ablation time: 123 s [IQR: 75-311]). Compared with 7 patients with IBC VA (3 male, age 51.9 ± 20.1 years, LV ejection fraction: 51.4 ± 17.7%), BIS-LVe VA less frequently had initial negative forces (QS pattern) in leads II, III, and/or aVF (p < 0.001), R-S ratio <1 in lead V (p = 0.005), and notching in lead II (p = 0.006) were narrower (QRS duration: 178.2 ± 22.4 vs. 221.1 ± 41.9 ms; p = 0.04) and more frequently had maximum deflection index of <0.55 (p < 0.001).

Conclusions: The BIS-LVe region is an uncommon source of idiopathic VA. Distinguishing these from IBC VA is important for procedural planning and ablation success.
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http://dx.doi.org/10.1016/j.jacep.2019.04.002DOI Listing
July 2019

Comparison of the Ventricular Tachycardia Circuit Between Patients With Ischemic and Nonischemic Cardiomyopathies: Detailed Characterization by Entrainment.

Circ Arrhythm Electrophysiol 2019 07 12;12(7):e007249. Epub 2019 Jul 12.

Electrophysiology Section, Division of Cardiovascular Medicine, Perlman School of Medicine at the University of Pennsylvania, Philadelphia.

Background: There has been increasing awareness of the 3-dimensional nature of ventricular tachycardia (VT) circuits. VT circuits in patients with ischemic cardiomyopathies (ICM) and non-ICM (NICM) may differ in this regard.

Methods: Among patients with structural heart disease and at least 1 hemodynamically tolerated VT undergoing ablation, we retrospectively analyzed responses to all entrainment maneuvers.

Results: Of 445 patients (ICM 228, NICM 217) undergoing VT ablation, detailed entrainment mapping of at least 1 tolerated VT was performed in 111 patients (ICM 71, NICM 40). Of 89 ICM VTs, the isthmus could be identified by endocardial entrainment in 55 (62%), compared with only 8 of 47 (17%) NICM VTs ( P<0.01). With combined endocardial and epicardial mapping, the isthmus could be identified in 56 (63%) ICM VTs and 12 (26%) NICM VTs ( P<0.01), whereas any critical component (defined as entrance, isthmus or exit) could be identified in 76 (85%) ICM VTs and 37 (79%) NICM VTs ( P=0.3). Complete success (no inducible VT at the end of ablation, 82% versus 65%, P=0.04) and 1-year, single-procedure VT-free survival (82% versus 55%, P<0.01) were both higher among patients with ICM.

Conclusions: Among mappable ICM VTs, critical circuit components can usually be identified on the endocardium. In contrast, among mappable NICM VTs, although some critical component can typically be identified with the addition of epicardial mapping, the isthmus is less commonly identified, possibly due to midmyocardial location.
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July 2019

Noninvasive Programmed Ventricular Stimulation-Guided Management Following Ventricular Tachycardia Ablation.

JACC Clin Electrophysiol 2019 06 1;5(6):719-727. Epub 2019 May 1.

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

Objectives: This study sought to determine the impact of repeat catheter ablation (CA) prior to hospital discharge based on inducibility of clinical ventricular tachycardia (VT) during noninvasive programmed ventricular stimulation (NIPS).

Background: Inducibility of clinical VT during NIPS performed several days after CA identifies patients at high risk of recurrence. The impact of NIPS-guided repeat CA has not been reported.

Methods: Consecutive patients with structural heart disease undergoing CA of VT followed by NIPS were studied. Clinical VT was defined by comparison with 12-lead electrocardiograms and stored implantable cardioverter-defibrillator electrograms from spontaneous VT episodes. Among those with inducible clinical VT at NIPS, VT-free survival was compared between those in whom ablation was repeated (group 1) versus those in whom ablation was not repeated (group 2) prior to hospital discharge.

Results: Among 469 patients (64 ± 12 years of age; 85% males; 60% ischemic), 216 patients (46%) underwent NIPS 3 days (interquartile range: 2 to 4 days) after CA. Clinical VT was induced in 45 patients (21%). Among those 45, CA was repeated in 11 patients (24%). There were no significant differences in baseline clinical or index CA characteristics between groups 1 and 2. Over a median 36-month follow-up, only 1 patient (9%) in group 1 experienced VT recurrence compared to 24 patients (71%) in group 2 (p < 0.01). In univariate Cox regression, repeat CA guided by NIPS (hazard ratio: 0.07; 95% confidence interval: 0.01 to 0.58; p = 0.01) was the only predictor of VT-free survival.

Conclusions: In patients with inducible clinical VT during post-ablation NIPS, repeat CA was associated with significantly lower risk of subsequent recurrence.
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http://dx.doi.org/10.1016/j.jacep.2019.03.007DOI Listing
June 2019

Ischemic ventricular tachycardia from below the posteromedial papillary muscle, a particular entity: Substrate characterization and challenges for catheter ablation.

Heart Rhythm 2019 08 11;16(8):1174-1181. Epub 2019 May 11.

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

Background: In patients with ischemic ventricular tachycardia (VT), substrate may be "protected" by the posteromedial papillary muscle (PMPM), explaining failure of endocardial-only ablation.

Objective: We sought to characterize the arrhythmogenic substrate and ablation approach in patients with ischemic VT mapped to the inferior left ventricle in which endocardial ablation failed because of inaccessible substrate underlying the PMPM.

Methods: We included 10 patients with recurrent ischemic VT, evidence of inferior scar, and failed endocardial ablation. In all patients, epicardial mapping was performed via a percutaneous (n = 9) or surgical (n = 1) approach, and VT elimination was achieved by ablation opposite to the PMPM. Clinical characteristics, electrocardiographic characteristics, and procedural data were analyzed.

Results: In all patients, intracardiac echocardiography showed hyperechoic scar below the PMPM, and 5 exhibited a pattern characterized by subendocardial basal scar that became intramural and epicardial at distal segments. In 4 patients, VT remained inducible despite endocardial scar isolation, manifested by the absence of electrograms, dissociated potentials, and/or exit block. Eleven inducible VTs were mapped to the epicardium underlying the PMPM: 8 had a right bundle branch block configuration with variable transition, while 3 exhibited left bundle branch block with negative concordance. An inferior QS pattern was present in 10 of 11 VTs. Noninducibility was achieved in 8 patients, and 7 patients remained arrhythmia-free after a mean follow-up of 27 ± 23 months.

Conclusion: In patients with inferior ischemic scar, VT may arise from the area underneath the PMPM, limiting endocardial ablation. Intracardiac echocardiography accurately defines the substrate distribution, and an epicardial approach may eliminate VT. A pattern of "basal-endocardial/apical-epicardial" ischemic involvement is described.
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http://dx.doi.org/10.1016/j.hrthm.2019.02.016DOI Listing
August 2019
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