Hypertension and LAD are independent pre-procedural predictors of AF recurrence after CPVA to treat AF. These data may help in patient selection for AF ablation.

Background-Catheter ablation (CA) and minimally invasive surgical ablation (SA) have become accepted therapy for antiarrhythmic drug-refractory atrial fibrillation. This study describes the first randomized clinical trial comparing their efficacy and safety during a 12-month follow-up. Methods and Results-One hundred twenty-four patients with antiarrhythmic drug-refractory atrial fibrillation with left atrial dilatation and hypertension (42 patients, 33%) or failed prior CA (82 patients, 67%) were randomized to CA (63 patients) or SA (61 patients). CA consisted of linear antral pulmonary vein isolation and optional additional lines. SA consisted of bipolar radiofrequency isolation of the bilateral pulmonary vein, ganglionated plexi ablation, and left atrial appendage excision with optional additional lines. Follow-up at 6 and 12 months was performed by ECG and 7-day Holter recording. The primary end point, freedom from left atrial arrhythmia Ͼ30 seconds without antiarrhythmic drugs after 12 months, was 36.5% for CA and 65.6% for SA (Pϭ0.0022). There was no difference in effect for subgroups, which was consistent at both sites. The primary safety end point of significant adverse events during the 12-month follow-up was significantly higher for SA than for CA (nϭ21 [34.4%] versus nϭ10 [15.9%]; Pϭ0.027), driven mainly by procedural complications such as pneumothorax, major bleeding, and the need for pacemaker. In the CA group, 1 patient died at 1 month of subarachnoid hemorrhage. Conclusion-In atrial fibrillation patients with dilated left atrium and hypertension or failed prior atrial fibrillation CA, SA is superior to CA in achieving freedom from left atrial arrhythmias after 12 months of follow-up, although the procedural adverse event rate is significantly higher for SA than for CA. Clinical Trial Registration-URL: http://clinicaltrials.gov. Unique identifier: NCT00662701.

Accumulated lifetime physical activity, height, and left atrial size are risk factors for LAF in healthy middle-aged individuals.

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.

Background-Some ventricular tachycardias (VTs) originating from the epicardium are not suitable for endocardial radiofrequency ablation and require an epicardial approach. The aim of this study was to define the ECG characteristics that may identify an epicardial origin of VTs. Methods and Results-We analyzed the 12-lead ECG recordings during epicardial and endocardial left ventricular pacing in 9 patients to verify the hypothesis that the epicardial origin of the ventricular activation widens the initial part of the QRS complex. Then, we analyzed the ECG pattern in 14 VTs successfully ablated from the epicardium after a failed endocardial approach (group A), in 27 VTs successfully ablated from the endocardium (group B), and in 28 additional VTs that could not be ablated from the endocardium (group C). Four distinct intervals of ventricular activation were defined and measured: (1) the pseudodelta wave, (2) the intrinsicoid deflection time in V2, (3) the shortest RS complex, and (4) the QRS complex. VTs from groups A and C showed a significantly longer pseudodelta wave, intrinsicoid deflection time, and RS complex duration compared with VTs of group B. There was no difference between groups A and C. A pseudodelta wave of Ն34 ms has a sensitivity of 83% and a specificity of 95%, an intrinsicoid deflection time of Ն85 ms has a sensitivity of 87% and a specificity of 90%, and an RS complex duration of Ն121 ms has a sensitivity of 76% and a specificity of 85% in identifying an epicardial origin of the VTs. Conclusions-ECG suggests VTs originating from the epicardium and those with an unsuccessful radiofrequency ablation from the endocardium.

Left Atrial Sphericity is a new independent predictor of recurrence after AF ablation and may be useful in selecting the best candidates for AF ablation.

Long-term endurance sport practice is associated with a higher risk of symptomatic LAF in men. This risk is associated with a larger left atrial inferosuperior diameter and volume in physically active subjects.

Background-Whether Brugada syndrome (BrS) depends on functional epicardial substrates, which may be definitively eliminated by radiofrequency ablation, remains unknown. Methods and Results-Patients with BrS underwent epicardial mapping to identify areas of abnormal electrograms as target for radiofrequency ablation. Substrate identification consisted in mapping right ventricle epicardial surface before and after flecainide (2 mg/kg per 10 minutes). After radiofrequency ablation, flecainide and remap confirmed elimination of abnormal substrate, BrS ECG pattern, and ventricular tachycardia/ventricular fibrillation inducibility. Flecainide testing was performed at each follow-up visits ≤6 months. Fourteen patients with BrS, median age 39 years (30.3-42.3) with implantable cardioverter-defibrillator were enrolled. Low-voltage areas (<1.5 mV) were commonly identified on the anterior right free wall and right ventricular outflow tract, which increased after flecainide from 17.6 cm 2 (12.1-24.2) to 28.5 cm 2 (21.6-30.2; P=0.001). Similarly, areas with abnormal electrograms increased after flecainide from 19.0 (17.5-23.6) to 27.3 cm 2 (24.0-31.2; P=0.001). After 23.8 minutes (18.1-28.5) of radiofrequency ablation, abnormal electrograms disappeared, whereas low-voltage areas were replaced by scar areas (<0.5 mV) of 25.9 cm 2 (19.6-31.0). Substrate elimination resulted in BrS ECG pattern disappearance and no ventricular tachycardia/ventricular fibrillation inducibility without complications. After a median follow-up of 5 months (3.8-5.3), ECG remained normal despite flecainide. experimental observations suggested that RFA applied to the epicardium may be more effective than applied to the endocardium in eliminating VT in patients with BrS. 7 A more recent report from 9 symptomatic BrS patients with repetitive ICD shocks indicates that the electrophysiological substrate for the BrS is delayed depolarization exclusively over the anterior aspect of the RVOT epicardium and that catheter ablation of this abnormal area may prevent VT/VF. 8 These observations open the possibility that eliminating localized epicardial substrates responsible for the disease phenotype may cure patients with BrS. However, it is not known if there is a relationship between the presence, location and extent of the epicardial substrate abnormalities, and typical BrS ECG pattern. In addition, many other issues such as methodology for substrate identification and elimination and testing of acute and midterm results remain to be clarified. The purpose of this study was to systematically report the methodology, results, and complications of epicardial RFA of consecutive selected patients with BrS. Particular attention was focused on endocardial/epicardial mapping and flecainide testing to characterize and establish the most appropriate target sites for successful RFA and elimination of both ECG BrS pattern and inducibility of VT/VF. Conclusions-In patients with BrS Methods Patient CharacteristicsPatients referred to the Arrhythmology Departments of Maria ...