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

      1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 2 , 12 , 23 , 24 , 25 , 26 , 27 , 12 , 28 , 29 , 30 , 31 , 32 , 33 , 13 , 34 , , , , , , , , , , , , , , , , , , , ESC Scientific Document Group

      EP Europace

      Oxford University Press (OUP)

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          Abstract

          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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          Most cited references 936

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          Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of-principle cohort study.

          Renal sympathetic hyperactivity is associated with hypertension and its progression, chronic kidney disease, and heart failure. We did a proof-of-principle trial of therapeutic renal sympathetic denervation in patients with resistant hypertension (ie, systolic blood pressure >/=160 mm Hg on three or more antihypertensive medications, including a diuretic) to assess safety and blood-pressure reduction effectiveness. We enrolled 50 patients at five Australian and European centres; 5 patients were excluded for anatomical reasons (mainly on the basis of dual renal artery systems). Patients received percutaneous radiofrequency catheter-based treatment between June, 2007, and November, 2008, with subsequent follow-up to 1 year. We assessed the effectiveness of renal sympathetic denervation with renal noradrenaline spillover in a subgroup of patients. Primary endpoints were office blood pressure and safety data before and at 1, 3, 6, 9, and 12 months after procedure. Renal angiography was done before, immediately after, and 14-30 days after procedure, and magnetic resonance angiogram 6 months after procedure. We assessed blood-pressure lowering effectiveness by repeated measures ANOVA. This study is registered in Australia and Europe with ClinicalTrials.gov, numbers NCT 00483808 and NCT 00664638. In treated patients, baseline mean office blood pressure was 177/101 mm Hg (SD 20/15), (mean 4.7 antihypertensive medications); estimated glomerular filtration rate was 81 mL/min/1.73m(2) (SD 23); and mean reduction in renal noradrenaline spillover was 47% (95% CI 28-65%). Office blood pressures after procedure were reduced by -14/-10, -21/-10, -22/-11, -24/-11, and -27/-17 mm Hg at 1, 3, 6, 9, and 12 months, respectively. In the five non-treated patients, mean rise in office blood pressure was +3/-2, +2/+3, +14/+9, and +26/+17 mm Hg at 1, 3, 6, and 9 months, respectively. One intraprocedural renal artery dissection occurred before radiofrequency energy delivery, without further sequelae. There were no other renovascular complications. Catheter-based renal denervation causes substantial and sustained blood-pressure reduction, without serious adverse events, in patients with resistant hypertension. Prospective randomised clinical trials are needed to investigate the usefulness of this procedure in the management of this condition.
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            Practice guidelines for sedation and analgesia by non-anesthesiologists.

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              Association of fibrosis with mortality and sudden cardiac death in patients with nonischemic dilated cardiomyopathy.

              Risk stratification of patients with nonischemic dilated cardiomyopathy is primarily based on left ventricular ejection fraction (LVEF). Superior prognostic factors may improve patient selection for implantable cardioverter-defibrillators (ICDs) and other management decisions. To determine whether myocardial fibrosis (detected by late gadolinium enhancement cardiovascular magnetic resonance [LGE-CMR] imaging) is an independent and incremental predictor of mortality and sudden cardiac death (SCD) in dilated cardiomyopathy. Prospective, longitudinal study of 472 patients with dilated cardiomyopathy referred to a UK center for CMR imaging between November 2000 and December 2008 after presence and extent of midwall replacement fibrosis were determined. Patients were followed up through December 2011. Primary end point was all-cause mortality. Secondary end points included cardiovascular mortality or cardiac transplantation; an arrhythmic composite of SCD or aborted SCD (appropriate ICD shock, nonfatal ventricular fibrillation, or sustained ventricular tachycardia); and a composite of HF death, HF hospitalization, or cardiac transplantation. Among the 142 patients with midwall fibrosis, there were 38 deaths (26.8%) vs 35 deaths (10.6%) among the 330 patients without fibrosis (hazard ratio [HR], 2.96 [95% CI, 1.87-4.69]; absolute risk difference, 16.2% [95% CI, 8.2%-24.2%]; P < .001) during a median follow-up of 5.3 years (2557 patient-years of follow-up). The arrhythmic composite was reached by 42 patients with fibrosis (29.6%) and 23 patients without fibrosis (7.0%) (HR, 5.24 [95% CI, 3.15-8.72]; absolute risk difference, 22.6% [95% CI, 14.6%-30.6%]; P < .001). After adjustment for LVEF and other conventional prognostic factors, both the presence of fibrosis (HR, 2.43 [95% CI, 1.50-3.92]; P < .001) and the extent (HR, 1.11 [95% CI, 1.06-1.16]; P < .001) were independently and incrementally associated with all-cause mortality. Fibrosis was also independently associated with cardiovascular mortality or cardiac transplantation (by fibrosis presence: HR, 3.22 [95% CI, 1.95-5.31], P < .001; and by fibrosis extent: HR, 1.15 [95% CI, 1.10-1.20], P < .001), SCD or aborted SCD (by fibrosis presence: HR, 4.61 [95% CI, 2.75-7.74], P < .001; and by fibrosis extent: HR, 1.10 [95% CI, 1.05-1.16], P < .001), and the HF composite (by fibrosis presence: HR, 1.62 [95% CI, 1.00-2.61], P = .049; and by fibrosis extent: HR, 1.08 [95% CI, 1.04-1.13], P < .001). Addition of fibrosis to LVEF significantly improved risk reclassification for all-cause mortality and the SCD composite (net reclassification improvement: 0.26 [95% CI, 0.11-0.41]; P = .001 and 0.29 [95% CI, 0.11-0.48]; P = .002, respectively). Assessment of midwall fibrosis with LGE-CMR imaging provided independent prognostic information beyond LVEF in patients with nonischemic dilated cardiomyopathy. The role of LGE-CMR in the risk stratification of dilated cardiomyopathy requires further investigation.
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                Author and article information

                Journal
                EP Europace
                Oxford University Press (OUP)
                1099-5129
                1532-2092
                May 10 2019
                May 10 2019
                Affiliations
                [1 ]Hartford Hospital, Hartford, Connecticut
                [2 ]University of Michigan, Ann Arbor, Michigan
                [3 ]University Hospital Rangueil, Toulouse, France
                [4 ]Institute for Clinical and Experimental Medicine, Prague, Czech Republic
                [5 ]Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
                [6 ]Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
                [7 ]Centro Privado de Cardiología, Tucuman, Argentina
                [8 ]Instituto Brasília de Arritmia, Brasília, Brazil
                [9 ]Duke University Medical Center, Durham, North Carolina
                [10 ]Beth Israel Deaconess Medical Center, Boston, Massachusetts
                [11 ]Heart Institute, Teknon Medical Center, Barcelona, Spain
                [12 ]University of Pennsylvania, Philadelphia, Pennsylvania
                [13 ]Cleveland Clinic, Cleveland, Ohio
                [14 ]Washington University School of Medicine, St. Louis, Missouri
                [15 ]Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
                [16 ]Northwestern University Feinberg School of Medicine, Chicago, Illinois
                [17 ]Ospedale San Raffaele, Milan, Italy
                [18 ]Herz- und Gefäß-Klinik, Bad Neustadt, Germany
                [19 ]University of Maryland, Baltimore, Maryland
                [20 ]Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
                [21 ]University of Queensland, The Prince Charles Hospital, Chermside, Australia
                [22 ]University of Alabama at Birmingham, Birmingham, Alabama
                [23 ]Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
                [24 ]University of Tsukuba, Ibaraki, Japan
                [25 ]University of California San Francisco Benioff Children’s Hospital, San Francisco, California
                [26 ]Australian National University, Canberra Hospital, Canberra, Australia
                [27 ]CardioInfantil Foundation, Cardiac Institute, Bogota, Columbia
                [28 ]Queen Elizabeth II Health Sciences Centre, Halifax, Canada
                [29 ]University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
                [30 ]Kyorin University School of Medicine, Tokyo, Japan
                [31 ]Vanderbilt University Heart and Vascular Center, Nashville, Tennessee
                [32 ]Brigham and Women’s Hospital, Boston, Massachusetts
                [33 ]University of Colorado Denver, Aurora, Colorado
                [34 ]Leiden University Medical Center, Leiden, the Netherlands
                Article
                10.1093/europace/euz132
                © 2019

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