Background-Reducing sympathetic output to the heart from the neuraxis can protect against ventricular arrhythmias. The purpose of this study was to assess the value of thoracic epidural anesthesia (TEA) and left cardiac sympathetic denervation (LCSD) in the management of ventricular arrhythmias in patients with structural heart disease. Methods and Results-Clinical data of 14 patients (25 to 75 years old, meanϮSD of 54.2Ϯ16.6 years; 13 men) who underwent TEA, LCSD, or both to control ventricular tachycardia (VT) refractory to medical therapy and catheter ablation were reviewed. Twelve patients were in VT storm, and 2 experienced recurrent VT despite maximal medical therapy and catheter ablation procedures. The total number of therapies per patient before either procedure ranged from 5 to 202 (median of 24; 25th and 75th percentile, 5 and 56). Eight patients underwent TEA, and 9 underwent LCSD (3 patients had both procedures). No major procedural complications occurred. After initiation of TEA, 6 patients had a large (Ն80%) decrease in VT burden. After LCSD, 3 patients had no further VT, 2 had recurrent VT that either resolved within 24 hours or responded to catheter ablation, and 4 continued to have recurrent VT. Nine of 14 patients survived to hospital discharge (2 TEA alone, 3 TEA/LCSD combined, and 4 LCSD alone), 1 of the TEA alone patients underwent an urgent cardiac transplantation. Conclusions-Initiation of TEA and LCSD in patients with refractory VT was associated with a subsequent decrease in arrhythmia burden in 6 (75%) of 8 patients (68% confidence interval 51% to 91%) and 5 (56%) of 9 patients (68% confidence interval 34% to 75%), respectively. These data suggest that TEA and LCSD may be effective additions to the management of refractory ventricular arrhythmias in structural heart disease when other treatment modalities have failed or may serve as a bridge to more definitive therapy. (Circulation. 2010;121:2255-2262.)

Background Data comparing outcomes in heart failure ( HF ) across Asia are limited. We examined regional variation in mortality among patients with HF enrolled in the ASIAN ‐HF (Asian Sudden Cardiac Death in Heart Failure) registry with separate analyses for those with reduced ejection fraction ( EF ; <40%) versus preserved EF (≥50%). Methods and Results The ASIAN ‐ HF registry is a prospective longitudinal study. Participants with symptomatic HF were recruited from 46 secondary care centers in 3 Asian regions: South Asia (India), Southeast Asia (Thailand, Malaysia, Philippines, Indonesia, Singapore), and Northeast Asia (South Korea, Japan, Taiwan, Hong Kong, China). Overall, 6480 patients aged >18 years with symptomatic HF were recruited (mean age: 61.6±13.3 years; 27% women; 81% with HF and reduced r EF ). The primary outcome was 1‐year all‐cause mortality. Striking regional variations in baseline characteristics and outcomes were observed. Regardless of HF type, Southeast Asians had the highest burden of comorbidities, particularly diabetes mellitus and chronic kidney disease, despite being younger than Northeast Asian participants. One‐year, crude, all‐cause mortality for the whole population was 9.6%, higher in patients with HF and reduced EF (10.6%) than in those with HF and preserved EF (5.4%). One‐year, all‐cause mortality was significantly higher in Southeast Asian patients (13.0%), compared with South Asian (7.5%) and Northeast Asian patients (7.4%; P <0.001). Well‐known predictors of death accounted for only 44.2% of the variation in risk of mortality. Conclusions This first multinational prospective study shows that the outcomes in Asian patients with both HF and reduced or preserved EF are poor overall and worst in Southeast Asian patients. Region‐specific risk factors and gaps in guideline‐directed therapy should be addressed to potentially improve outcomes. Clinical Trial Registration URL : https://www.clinicaltrials.gov/ . Unique identifier: NCT 01633398.

Introduction: The increasing implementation of transcatheter aortic valve implantation (TAVI) in various Australian centres warrants real-world data on the prevalence and outcomes of these patients. Methods: From the Centre-of-Health-Record-Linkage registry, all New South Wales residents who underwent TAVI in public and private facilities between 5-June,2013 and 30-June,2018 were identified. Public centres with an average TAVI caseload ,20 per-annum were classified as low-volume facilities. Private centres did not have individual facility identifier available and were classified as one category. Allcause mortality was tracked from the statewide death registry. Results: The study cohort comprised 1098 persons (mean [6SD] age: 83.367.7yrs; 58.8% males). 37.1% (407/1098 cases) were performed in public centres, and 53.3% (217/407 cases) of these were performed in low-volume centres. 62.9% (691/1098 cases) were performed in private centres. Proportion of cases performed in the public sector reduced from 83.3% in 2013 to 33.1% by 2017. In-hospital, 30-days and 180days all-cause mortality rates were 1.28%, 2.0% and 4.92% respectively. TAVI performed in low-volume compared to private or high-volume public centres was an independent predictor for all-cause mortality at 180-days (adjusted hazard ratio 3.49, 95% confidence interval 1.39-8.78, p=0.01). Conclusion: TAVI procedures are increasing, with a greater proportion of cases now performed in private centres. High-volume caseload may be an important determinant of patient outcomes.

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