Publications by authors named "Wendy S Tzou"

102 Publications

Systemic Diseases and Heart Block.

Card Electrophysiol Clin 2021 12;13(4):721-740

Cardiac Electrophysiology, University of Colorado Anschutz Medical Campus, 12401 E 17th Avenue, MS B-136, Aurora, CO 80045, USA. Electronic address:

Systemic diseases can cause heart block owing to the involvement of the myocardium and thereby the conduction system. Younger patients (<60) with heart block should be evaluated for an underlying systemic disease. These disorders are classified into infiltrative, rheumatologic, endocrine, and hereditary neuromuscular degenerative diseases. Cardiac amyloidosis owing to amyloid fibrils and cardiac sarcoidosis owing to noncaseating granulomas can infiltrate the conduction system leading to heart block. Accelerated atherosclerosis, vasculitis, myocarditis, and interstitial inflammation contribute to heart block in rheumatologic disorders. Myotonic, Becker, and Duchenne muscular dystrophies are neuromuscular diseases involving the myocardium skeletal muscles and can cause heart block.
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http://dx.doi.org/10.1016/j.ccep.2021.06.011DOI Listing
December 2021

Procedural and short-term results of electroanatomic-mapping-guided ganglionated plexus ablation by first-time operators: A multicenter study.

J Cardiovasc Electrophysiol 2022 Jan 25;33(1):117-122. Epub 2021 Oct 25.

Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, USA.

Introduction: Single-center observational studies have shown promising results with fragmented electrogram (FE)-guided ganglionated plexus (GP) ablation in patients with vagally mediated bradyarrhythmia (VMB). We aimed to compare the acute procedural characteristics during FE-guided GP ablation in patients with VMB performed by first-time operators and those of a single high-volume operator.

Methods And Results: This international multicenter cohort study included data collected over 2 years from 16 cardiac hospitals. The primary operators were classified according to their prior GP ablation experience: a single high-volume operator who had performed > 50 GP ablation procedures (Group 1), and operators performing their first GP ablation cases (Group 2). Acute procedural characteristics and syncope recurrence were compared between groups. Forty-seven consecutive patients with VMB who underwent FE-guided GP ablation were enrolled, n = 31 in Group 1 and n = 16 in Group 2. The mean number of ablation points in each GP was comparable between groups. The ratio of positive vagal response during ablation on the left superior GP was higher in Group 1 (90.3% vs. 62.5%, p = .022). Ablation of the right superior GP increased heart rate acutely without any vagal response in 45 (95.7%) cases. The procedure time was longer in group 2 (83.4 ± 21 vs. 118.0 ± 21 min, respectively, p < .001). Over a mean follow-up duration of 8.0 ± 3 months (range 2-24 months), none of the patients suffered from syncope.

Conclusion: This multi-center pilot study shows for the first time the feasibility of FE-guided GP ablation across a large group of procedure-naïve operators.
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http://dx.doi.org/10.1111/jce.15278DOI Listing
January 2022

Increased incidence of cavotricuspid isthmus atrial flutter following slow pathway ablation.

J Interv Card Electrophysiol 2021 Sep 17. Epub 2021 Sep 17.

Section of Electrophysiology, Cardiology Division, University of Colorado, Aurora, CO, 80045, USA.

Purpose: The incidence of atrial flutter following radiofrequency ablation of supraventricular tachycardias is poorly understood. Ablation of atrioventricular nodal reentry tachycardia may place patients at risk of flutter because ablation of the slow pathway is in close proximity to the cavotricuspid isthmus. This study aims to evaluate the risk of atrial flutter following ablation of atrioventricular nodal reentry tachycardia relative to ablation of other supraventricular tachycardias.

Methods: A single-center retrospective analysis was completed for all supraventricular tachycardia ablations performed between July 2006 and July 2016. Patient and procedural details were collected for 544 patients who underwent atrioventricular nodal reentry tachycardia ablation (n = 342), atrioventricular reentry tachycardia ablation (n = 125), or atrial tachycardia ablation (n = 60). Follow-up for flutter after ablation of their incident arrhythmia was assessed.

Results: Patients who underwent atrioventricular nodal reentry tachycardia ablation were more likely to develop CTI-dependent flutter than patients who underwent ablation of other supraventricular tachycardias (4.97% vs. 0%; p = 0.002). Compared with patients who did not develop flutter, patients who developed flutter after atrioventricular nodal reentry tachycardia ablation were more likely to have undergone ablation of atypical atrioventricular nodal reentry tachycardia (11.8% vs. 2.15%; p = 0.016).

Conclusions: We identified an association between atrioventricular nodal reentry tachycardia ablation and development of CTI-dependent atrial flutter. This finding may have implications for the management and follow-up after atrioventricular nodal reentry tachycardia ablation.
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http://dx.doi.org/10.1007/s10840-021-01065-0DOI Listing
September 2021

Open surgical ablation of ventricular tachycardia: Utility and feasibility of contemporary mapping and ablation tools.

Heart Rhythm O2 2021 Jun 11;2(3):271-279. Epub 2021 May 11.

University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado.

Background: Ventricular tachycardia (VT) catheter ablation success may be limited when transcutaneous epicardial access is contraindicated. Surgical ablation (SurgAbl) is an option, but ablation guidance is limited without simultaneously acquired electrophysiological data.

Objective: We describe our SurgAbl experience utilizing contemporary electroanatomic mapping (EAM) among patients with refractory VT storm.

Methods: Consecutive patients with recurrent VT despite antiarrhythmic drugs (AADs) and prior ablation, for whom percutaneous epicardial access was contraindicated, underwent open SurgAbl using intraoperative EAM guidance.

Results: Eight patients were included, among whom mean age was 63 ± 5 years, all were male, mean left ventricular ejection fraction was 39% ± 12%, and 2 (25%) had ischemic cardiomyopathy. Reasons for surgical epicardial access included dense adhesions owing to prior cardiac surgery, hemopericardium, or pericarditis (n = 6); or planned left ventricular assist device (LVAD) implantation at time of SurgAbl (n = 2). Cryoablation guided by real-time EAM was performed in all. Goals of clinical VT noninducibility or core isolation were achieved in 100%. VT burden was significantly reduced, from median 15 to 0 events in the month pre- and post-SurgAbl ( = .01). One patient underwent orthotopic heart transplantation for recurrent VT storm 2 weeks post-SurgAbl. Over mean follow-up of 3.4 ± 1.7 years, VT storm-free survival was achieved in 6 (75%); all continued AADs, although at lower dose.

Conclusion: Surgical mapping and ablation of refractory VT with use of contemporary EAM is feasible and effective, particularly among patients with contraindication to percutaneous epicardial access or with another indication for cardiac surgery.
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http://dx.doi.org/10.1016/j.hroo.2021.05.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8322924PMC
June 2021

A novel approach to electrocardiography in the prone patient.

Heart Rhythm O2 2021 Feb 2;2(1):107-109. Epub 2020 Nov 2.

Section of Cardiac Electrophysiology, Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado.

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http://dx.doi.org/10.1016/j.hroo.2020.10.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183863PMC
February 2021

Utility of Intracardiac Echocardiography for Guiding Ablation of Ventricular Tachycardia in Nonischemic Cardiomyopathy.

Card Electrophysiol Clin 2021 06;13(2):337-343

Division of Cardiology, Section of Cardiac Electrophysiology, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA. Electronic address:

Intracardiac echocardiography (ICE) is a valuable tool in cardiac ablation procedures, especially in ablation of ventricular arrhythmias. The article details how ICE can aid in ablation of ventricular arrhythmias in nonischemic cardiomyopathy.
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http://dx.doi.org/10.1016/j.ccep.2021.03.008DOI Listing
June 2021

A Disruptive Technology: Determining Need for Permanent Pacing After TAVR.

Curr Cardiol Rep 2021 04 16;23(5):53. Epub 2021 Apr 16.

Division of Cardiology, Cardiac Electrophysiology Section, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, 80045, USA.

Purpose Of Review: Transcatheter aortic valve replacement (TAVR) has changed the paradigm for management of severe aortic stenosis. Despite evolution of TAVR over the past 2 decades, conduction system disturbances remain a concern post-TAVR. In this review, we describe (1) permanent pacemaker (PP) implant rates associated with TAVR, (2) risk factors predicting need for PP therapy post-TAVR, (3) management of perioperative conduction abnormalities, and (4) novel areas of research.

Recent Findings: Conduction disturbances remain a common issue post-TAVR, in particular, left bundle branch block (LBBB). Though newer data describes resolution of a significant fraction of these disturbances over time, rates of pacemaker therapy remain high despite improvements in valve technology and procedural technique. Recent consensus statements and guideline documents are important first steps in standardizing an approach to post-TAVR conduction disturbances. New areas of research show promise in both prediction and treatment of conduction disturbances post-TAVR.
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http://dx.doi.org/10.1007/s11886-021-01481-8DOI Listing
April 2021

Amiodarone during ventricular tachycardia ablation: A total eclipse of the heart?

Heart Rhythm 2021 06 19;18(6):894-895. Epub 2021 Mar 19.

Cardiac Electrophysiology Section, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado. Electronic address:

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http://dx.doi.org/10.1016/j.hrthm.2021.03.026DOI Listing
June 2021

Fasciculoventricular and atrioventricular accessory pathways in patients with Danon disease and preexcitation: A multicenter experience.

Heart Rhythm 2021 07 16;18(7):1194-1202. Epub 2021 Mar 16.

Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California.

Background: Studies have suggested that a fasciculoventricular pathway (FVP) may be the cause of preexcitation in patients with Danon disease, a rare X-linked dominant genetic disorder of hypertrophic cardiomyopathy.

Objective: The purpose of this study was to describe the prevalence of ventricular preexcitation on resting 12-lead electrocardiogram (ECG) in patients with Danon disease and the electrophysiological study (EPS) results of those with preexcitation.

Methods: Patients with confirmed Danon disease diagnosed with preexcitation (PR ≤120 ms, delta wave, QRS >110 ms) on ECG were included from a multicenter registry. The incidence of arrhythmias, implantable cardioverter-defibrillator (ICD) procedures, ICD shocks, and EPS results were collected.

Results: Thirteen of 40 patients (32.5%) with Danon disease were found to have preexcitation (mean age 17.3 years; 38% women). EPS performed in 9 of 13 patients (69%) demonstrated FVP only in 2 (22.2%), extranodal pathway without exclusion of FVP in 2 (22.2%), and both FVP and extranodal pathway in 5 (55.6%). Two patients had malignant accessory pathway (AP) properties. Over median follow-up of 842 days (interquartile range 138-1678), 11 patients (85%) had ICD placement, and 6 (46.1%) underwent heart transplantation. No patients required therapy for ventricular tachycardia, and 2 patients (15%) had paroxysmal atrial fibrillation.

Conclusion: In a large multicenter cohort of patients with Danon disease, there was a high prevalence of FVP and extranodal pathways diagnosed on EPS in those with preexcitation. These findings suggest patients with preexcitation and Danon disease should undergo EPS to assess for FVP and potentially malignant extranodal AP.
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http://dx.doi.org/10.1016/j.hrthm.2021.03.024DOI Listing
July 2021

The Evolution of Ventricular Scar Substrate Assessment by Using High-Resolution Mapping Platforms: Ongoing Quest for "Ground Truth".

JACC Clin Electrophysiol 2021 02;7(2):206-209

Cardiac Electrophysiology Section, Division of Cardiovascular Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.

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http://dx.doi.org/10.1016/j.jacep.2020.11.018DOI Listing
February 2021

Open-irrigation for radiofrequency ablation for atrial fibrillation: Worth its salt?

J Cardiovasc Electrophysiol 2021 04 15;32(4):982-983. Epub 2021 Feb 15.

Cardiac Electrophysiology Section, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA.

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http://dx.doi.org/10.1111/jce.14931DOI Listing
April 2021

Catheter ablation of ventricular tachycardia in patients with prior cardiac surgery: An analysis from the International VT Ablation Center Collaborative Group.

J Cardiovasc Electrophysiol 2021 02 24;32(2):409-416. Epub 2021 Jan 24.

Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Introduction: Patients with prior cardiac surgery may represent a subgroup of patients with ventricular tachycardia (VT) that may be more difficult to control with catheter ablation.

Methods: We evaluated 1901 patients with ischemic and nonischemic cardiomyopathy who underwent VT ablation at 12 centers. Clinical characteristics and VT radiofrequency ablation procedural outcomes were assessed and compared between those with and without prior cardiac surgery. Kaplan-Meier analysis was used to estimate freedom from recurrent VT and survival.

Results: There were 578 subjects (30.4%) with prior cardiac surgery identified in the cohort. Those with prior cardiac surgery were older (66.4 ± 11.0 years vs. 60.5 ± 13.9 years, p < .01), with lower left ventricular ejection fraction (30.2 ± 11.5% vs. 34.8 ± 13.6%, p < .01) and more ischemic heart disease (82.5% vs. 39.3%, p < .01) but less likely to undergo epicardial mapping or ablation (9.0% vs. 38.1%, p<.01) compared to those without prior surgery. When epicardial mapping was performed, a significantly greater proportion required surgical intervention for access (19/52 [36.5%] vs. 14/504 [2.8%]; p < .01). Procedural complications, including epicardial access-related complications, were lower (5.7% vs. 7.0%, p < .01) in patients with versus without prior cardiac surgery. VT-free survival (75.1% vs. 74.1%, p = .805) and survival (86.5% vs. 87.9%, p = .397) were not different between those with and without prior heart surgery, regardless of etiology of cardiomyopathy. VT recurrence was associated with increased mortality in patients with and without prior cardiac surgery.

Conclusion: Despite different clinical characteristics and fewer epicardial procedures, the safety and efficacy of VT ablation in patients with prior cardiac surgery is similar to others in this cohort. The incremental yield of epicardial mapping in predominant ischemic cardiomyopathy population prior heart surgery may be low but appears safe in experienced centers.
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http://dx.doi.org/10.1111/jce.14849DOI Listing
February 2021

Uncovering a unique path: Antidromic AVRT utilizing a left anteroseptal Mahaim-like accessory pathway.

Pacing Clin Electrophysiol 2021 01 25;44(1):185-188. Epub 2020 Aug 25.

Section of Electrophysiology, Brigham and Women's Hospital, Boston, Massachusetts.

A 40-year-old man presented to our emergency department 2 hours after onset of shortness of breath, palpitations, and presyncope secondary to an adenosine-responsive wide complex tachycardia. Electrophysiology study was diagnostic for antidromic atrioventricular (AV) reentrant tachycardia utilizing a muscular connection from the anterior interventricular vein to the left ventricle with Mahaim-like properties, successfully treated with ablation in the distal coronary sinus (CS) system. This case highlights accessory pathways (a) with unique features (i.e., Mahaim-like characteristics) and (b) involving musculature from the distal CS system, thereby limiting the value of endocardial ablation for durable treatment. Importantly, the coronary venous system is an accessible vascular network for evaluation and catheter ablation of such arrhythmias.
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http://dx.doi.org/10.1111/pace.14024DOI Listing
January 2021

Epicardial Ablation Biophysics and Novel Radiofrequency Energy Delivery Techniques.

Card Electrophysiol Clin 2020 09;12(3):401-408

Cardiac Electrophysiology, University of Colorado School of Medicine, 12401 East 17th Avenue, MS B-136, Aurora, CO 80045, USA. Electronic address:

Important physiologic and anatomic differences exist between the epicardium and endocardium, particularly of the ventricles, and these differences affect ablation biophysics. Absence of passive convective effects conferred by circulating blood as well as the presence of epicardial fat and vessels and absence of intracavitary ridges and structures affect ablation lesion size when performing epicardial catheter-based ablation, whether using radiofrequency or cryothermal energy. Understanding differential effects in each environment is important in informing strategies to increase ablation lesion depth. When using actively cooled radiofrequency ablation, local impedance can be altered to selectively augment energy delivery.
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http://dx.doi.org/10.1016/j.ccep.2020.05.006DOI Listing
September 2020

A multicenter trial of a shared DECision Support Intervention for Patients offered implantable Cardioverter-DEfibrillators: DECIDE-ICD rationale, design, Medicare changes, and pilot data.

Am Heart J 2020 08 20;226:161-173. Epub 2020 Apr 20.

Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, CO; VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO; Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO.

Shared decision making (SDM) facilitates delivery of medical therapies that are in alignment with patients' goals and values. Medicare national coverage decision for several interventions now includes SDM mandates, but few have been evaluated in nationwide studies. Based upon a detailed needs assessment with diverse stakeholders, we developed pamphlet and video patient decision aids (PtDAs) for implantable cardioverter/defibrillator (ICD) implantation, ICD replacement, and cardiac resynchronization therapy with defibrillation to help patients contemplate, forecast, and deliberate their options. These PtDAs are the foundation of the Multicenter Trial of a Shared Decision Support Intervention for Patients Offered Implantable Cardioverter-Defibrillators (DECIDE-ICD), a multicenter, randomized trial sponsored by the National Heart, Lung, and Blood Institute aimed at understanding the effectiveness and implementation of an SDM support intervention for patients considering ICDs. Finalization of a Medicare coverage decision mandating the inclusion of SDM for new ICD implantation occurred shortly after trial initiation, raising novel practical and statistical considerations for evaluating study end points. METHODS/DESIGN: A stepped-wedge randomized controlled trial was designed, guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) planning and evaluation framework using an effectiveness-implementation hybrid type II design. Six electrophysiology programs from across the United States will participate. The primary effectiveness outcome is decision quality (defined by knowledge and values-treatment concordance). Patients with heart failure who are clinically eligible for an ICD are eligible for the study. Target enrollment is 900 participants. DISCUSSION: Study findings will provide a foundation for implementing decision support interventions, including PtDAs, with patients who have chronic progressive illness and are facing decisions involving invasive, preference-sensitive therapy options.
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http://dx.doi.org/10.1016/j.ahj.2020.04.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442619PMC
August 2020

Radiofrequency Catheter Ablation of Atrial Fibrillation: May the Force (and Stability) Be With You, Always.

JACC Clin Electrophysiol 2020 02;6(2):153-156

Division of Cardiology, Brigham and Women's Hospital Cardiac Arrhythmia Service, Harvard Medical School, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1016/j.jacep.2019.12.006DOI Listing
February 2020

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

J Arrhythm 2020 Feb 3;36(1):1-58. Epub 2020 Jan 3.

University of Pennsylvania Philadelphia PA USA.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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http://dx.doi.org/10.1002/joa3.12264DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7011820PMC
February 2020

Impact of epicardial adipose tissue and catheter ablation strategy on biophysical parameters and ablation lesion characteristics.

J Cardiovasc Electrophysiol 2020 05 18;31(5):1114-1124. Epub 2020 Feb 18.

Section of Cardiac Electrophysiology, Division of Cardiology, Stanford University, Palo Alto, California.

Background: Epicardial adipose (EA) tissue may limit effective radiofrequency ablation (RFA).

Objectives: We sought to evaluate the lesion formation of different ablation strategies on ventricular myocardium with overlying EA.

Methods: Bovine myocardium with EA was placed in a circulating saline bath in an ex vivo model. Open-irrigated (OI) RFA was performed, parallel to the myocardium, over fat at 50 W for variable RF durations, variable contact force, catheter configurations (unipolar RF vs bipolar RF), and catheter irrigants (normal saline vs half-normal saline). Ablation was also performed with a needle-tipped ablation catheter (NTAC), perpendicular to the myocardium.

Results: Increasingly thick EA attenuated lesion size regardless of ablation strategy. RF applied with longer durations and increasing CF produced larger lesion volumes and deeper lesions with ablation over EA more than 3 mm but was unable to produce measurable lesions when EA less than 3 mm. Similarly, ablation with half normal saline irrigant created slightly deeper lesions than bipolar RF and unipolar RF with normal saline as EA thickness increased, but was unable to produce measurable lesions when EA more than 3 mm. Of all ablation strategies, only NTAC produced effective lesion volumes when ablating over thick (>3 mm) EA.

Conclusions: While EA attenuates lesion depth and size, relatively larger, and deeper lesions can be achieved with longer RFA duration, higher CF, half normal saline irrigant, and, to a greater extent, by utilizing bipolar RF or NTAC, but only over thin adipose (<3 mm). Of those catheters/strategies tested, only NTAC was able to effectively deliver RF over thick (>3 mm) EA with this model.
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http://dx.doi.org/10.1111/jce.14383DOI Listing
May 2020

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

Europace 2020 03;22(3):450-495

University of Pennsylvania, Philadelphia, Pennsylvania.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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http://dx.doi.org/10.1093/europace/euz332DOI Listing
March 2020

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

J Interv Card Electrophysiol 2020 Oct;59(1):145-298

University of Pennsylvania, Philadelphia, PA, USA.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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http://dx.doi.org/10.1007/s10840-019-00663-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223859PMC
October 2020

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

J Interv Card Electrophysiol 2020 Oct;59(1):81-133

University of Pennsylvania, Philadelphia, PA, USA.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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http://dx.doi.org/10.1007/s10840-019-00664-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508755PMC
October 2020

Follow-Up After Catheter Ablation of Papillary Muscles and Valve Cusps.

JACC Clin Electrophysiol 2019 10 28;5(10):1185-1196. Epub 2019 Aug 28.

University of Colorado, Section of Cardiac Electrophysiology, Division of Cardiology, Aurora, Colorado. Electronic address:

Objectives: The goal of this study was to determine the impact of catheter ablation in the region of papillary muscles (PMs) and valvular cusps (VC) on mitral, tricuspid, or aortic valve function.

Background: Ventricular arrhythmias arising from PMs and VCs often require extensive catheter ablation. Little is known regarding the risk of valve dysfunction after radiofrequency catheter ablation of such arrhythmias.

Methods: A retrospective analysis was completed for 149 PM and VC VT/premature ventricular contraction (PVC) ablations from 2008 to 2018 at our institution. Patient and procedural details were collected for VT and PVC ablation cases involving PMs and VCs with available echocardiographic data pre-ablation and post-ablation (within 6 months). Degree of valvular regurgitation (VR) was graded from 0 (none) to 4 (severe), and significant valvular dysfunction was defined as a 2+ change in VR.

Results: Of 149 radiofrequency catheter ablation cases, there were 84 (56%) aortic valve cusp ablations, 60 (40%) left ventricular PM ablations, and 5 (3%) right ventricular PM ablations. There were no statistically significant differences between pre-ablation and post-ablation VR severity (p = 0.33). No patients had a 2+ grade change in VR severity when pre-ablation and post-ablation echocardiograms were compared. There were no significant sequelae requiring intervention in the post-ablation period. On follow-up of 36 ± 9 months, for those with a change in VR, the severity had improved to baseline or remained stable.

Conclusions: Despite often-times extensive ablation on and around valvular networks, risk of longstanding or permanent valvular dysfunction after VT/PVC ablation is rare.
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http://dx.doi.org/10.1016/j.jacep.2019.07.004DOI Listing
October 2019

Looking Near and Far: Utility of Multielectrode Mapping in Redefining Voltage Standards.

JACC Clin Electrophysiol 2019 10;5(10):1141-1143

Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1016/j.jacep.2019.07.005DOI Listing
October 2019

Bipolar radiofrequency ablation creates different lesion characteristics compared to simultaneous unipolar ablation.

J Cardiovasc Electrophysiol 2019 12 13;30(12):2960-2967. Epub 2019 Oct 13.

Section of Cardiac Electrophysiology, Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts.

Introduction: Both bipolar and simultaneous radiofrequency ablation (bRFA, simRFA) have been used to treat thick midmyocardial substrate as well as during circular, multipolar ablation between shorter distances.

Objectives: We sought to evaluate the biophysical parameters of simRFA, sequential unipolar RFA (seqRFA), and bRFA.

Methods: Bovine myocardium was placed in a circulating saline bath. To simulate thick substrate conditions, two open irrigated ablation catheters were oriented across from each other, with myocardium in between. Thermocouples were placed in the center, ±2 mm, of the myocardium. Unipolar ablations were performed sequentially or simultaneously at 50 W for 60 seconds and compared to bRFA using the same settings. In addition, to simulate multipolar ablation, two open irrigated ablation catheters were oriented on the same side and perpendicular to myocardium at 1, 2, and 4 mm spacing. SimRFA were performed at 15 and 25 W for 60 seconds and compared to bRFA.

Results: For thicker tissue, simRFA produced similar lesion volume and depth compared to bRFA but with a lesion geometry similar to seqRFA. Unlike seqRFA and simRFA, bRFA had a necrotic core spanning the myocardium. Core depths, volumes, and temperatures were significantly greater for bRFA lesions compared to simRFA or seqRFA (Figure, P < .001). Similar results were consistent for bRFA and simRFA at shorter spacings.

Conclusions: BRFA has greater core lesion temperatures, corresponding to a denser and larger necrotic core, than either simRFA or seqRFA. This may have implications for considering the optimal strategy for deep midmyocardial substrates or during multipolar ablation.
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http://dx.doi.org/10.1111/jce.14213DOI Listing
December 2019

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

J Arrhythm 2019 Jun 10;35(3):323-484. Epub 2019 May 10.

University of Pennsylvania Philadelphia Pennsylvania.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 . An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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http://dx.doi.org/10.1002/joa3.12185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6595359PMC
June 2019

Electrophysiologic testing for diagnostic evaluation and risk stratification in patients with suspected cardiac sarcoidosis with preserved left and right ventricular systolic function.

J Cardiovasc Electrophysiol 2019 10 23;30(10):1939-1948. Epub 2019 Jul 23.

Division of Cardiology, Section of Cardiac Electrophysiology, University of Colorado, Aurora, Colorado.

Introduction: While cardiac sarcoidosis (CS) carries a risk of ventricular arrhythmias (VAs) and sudden cardiac death (SCD), risk stratification of patients with CS and preserved left ventricular/right ventricular (LV/RV) systolic function remains challenging. We sought to evaluate the role of electrophysiologic testing and programmed electrical stimulation of the ventricle (EPS) in patients with suspected CS with preserved ventricular function.

Methods: One hundred twenty consecutive patients with biopsy-proven extracardiac sarcoidosis and preserved LV/RV systolic function underwent EPS. All patients had either probable CS defined by an abnormal cardiac positron emission tomography or cardiac magnetic resonance imaging, or possible CS with normal advanced imaging but abnormal echocardiogram (ECG), SAECG, Holter, or clinical factors. Patients were followed for 4.5 ± 2.6 years for SCD and VAs.

Results: Seven of 120 patients (6%) had inducible ventricular tachycardia (VT) with EPS and received an implantable cardioverter defibrillator (ICD). Three patients (43%) with positive EPS later had ICD therapies for VAs. Kaplan-Meier analysis stratified by EPS demonstrated a significant difference in freedom from VAs and SCD (P = 0.009), though this finding was driven entirely by patients within the cohort with probable CS (P = 0.018, n = 69). One patient with possible CS and negative EPS had unrecognized progression of the disease and unexplained death with evidence of CS at autopsy.

Conclusions: EPS is useful in the risk stratification of patients with probable CS with preserved LV and RV function. A positive EPS was associated with VAs. While a negative EPS appeared to confer low risk, close follow-up is needed as EPS cannot predict fatal VAs related to new cardiac involvement or disease progression.
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http://dx.doi.org/10.1111/jce.14058DOI Listing
October 2019

With Great Power Comes Great Responsibility: Defining the Safety of High-Power Short-Duration Atrial Ablation.

Circ Arrhythm Electrophysiol 2019 06 5;12(6):e007456. Epub 2019 Jun 5.

Division of Cardiovascular Medicine, Brigham and Women's Hospital Cardiac Arrhythmia Service and Harvard Medical School, Boston, MA (W.H.S.). Division of Cardiology, Section of Cardiac Electrophysiology, University of Colorado School of Medicine, Aurora (W.S.T.).

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http://dx.doi.org/10.1161/CIRCEP.119.007456DOI Listing
June 2019
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