Hands On
LAA ligation using the LARIAT suture delivery device: Tips and tricks for a successful procedure
Chronic oral anticoagulation (OAC) has traditionally been considered as the most effective prophylaxis against thromboembolic events in patients with atrial fibrillation (AF). However, as many as 20% of the patients with AF are not candidates for OAC.1,2 Reasons for ineligibility range from intracranial bleeding (the most serious complication) to increased propensity for mechanical injury (the least serious complication). The resumption of OAC in patients who have suffered a life-threatening complication due to OAC is associated with a much higher risk of such events in the future.Safety and feasibility of transseptal puncture for atrial fibrillation ablation in patients with atrial septal defect closure devices
AF is often found in association with an ASD.1–4 There are an increasing number of patients undergoing transcatheter closure of an ASD who subsequently develop AF in clinical practice.2–4 Catheter ablation has emerged as an effective treatment strategy for drug-refractory symptomatic AF.5 While transseptal access to the left atrium (LA) is a prerequisite for AF ablation, it may prove difficult in the presence of an ASD closure device.6,7 Anticipating technical difficulties and potential complications may discourage operators from considering catheter ablation of AF in this particular patient population.Two-incision technique for implantation of the subcutaneous implantable cardioverter-defibrillator
Three incisions in the chest are necessary for implantation of the entirely subcutaneous implantable cardioverter-defibrillator (S-ICD). The superior parasternal incision is a possible risk for infection and a potential source of discomfort. A less invasive alternative technique of implanting the S-ICD electrode—the two-incision technique—avoids the superior parasternal incision.How to perform ventricular tachycardia ablation with a percutaneous left ventricular assist device
A majority of patients with structural heart disease and scar-related ventricular tachycardia (VT) have fast, hemodynamically unstable VT.1 In fact, up to one-fifth of the patients have only unstable VT, which precludes detailed activation and entrainment mapping.2 In addition, even in those with well-tolerated VT, procedural success can be complicated by acute heart failure as a consequence of prolonged episodes of induced VT and intravascular volume expansion; and one consequence of this acute decompensated heart failure is a significant increase in the short-term morbidity and mortality of the procedure.How to perform antral pulmonary venous isolation using the cryoballoon
This article describes our current practice, clinical outcomes, and future directions for the use of balloon cryoablation for the treatment of atrial fibrillation.Management of hemopericardium related to percutaneous epicardial access, mapping, and ablation
Percutaneous epicardial access (Figs. 1A and 1B) has gained wide acceptance as an interventional technique to access the pericardial space. Since its initial description1 in targeting epicardial circuits of ventricular tachycardia (VT) in patients with Chagasic cardiomyopathy, percutaneous epicardial access and ablation has come to play an important role in interventional electrophysiology. This technique has been recognized as a vital addition to catheter ablation of certain cardiac arrhythmias and for the delivery of newer investigational devices such as epicardial suture ligation of the left atrial appendage.Recording and interpreting unipolar electrograms to guide catheter ablation
Electrophysiology laboratories commonly use closely spaced bipolar recordings for mapping. However, unipolar recordings have some useful features that can provide additional complimentary information, provided the limitations of these recordings and the particular recording techniques are recognized.Implantable cardioverter-defibrillators in congenital heart disease: 10 programming tips
Advances in cardiac care of the young have given rise to a growing and aging population of patients with congenital heart disease. Despite remarkable improvements in overall survival, sudden cardiac death remains the most common cause of late mortality. As a result, implantable cardioverter-defibrillators (ICDs) are increasingly used in this heterogeneous patient population. Tetralogy of Fallot and transposition of the great arteries are the most prevalent subtypes of congenital heart disease in ICD recipients.Left cardiac sympathetic denervation for the prevention of life-threatening arrhythmias: The surgical supraclavicular approach to cervicothoracic sympathectomy
The progressive understanding of the diseases associated with significant risk for sudden cardiac death has fostered the development of early diagnosis and risk stratification. Thus, instead of starting from either a sudden death victim or a survivor of a cardiac arrest, it has become relatively common for cardiologists to identify individuals at high risk for sudden death, often after an arrhythmic nonlethal cardiac event such as syncope. Besides ischemic heart disease, it has also been recognized that children and young adults can be affected by arrhythmogenic disorders of genetic origin with a high propensity for lethal arrhythmias.How to troubleshoot the electroanatomic map
An electroanatomical mapping system is a useful tool for complex arrhythmia ablation. The system reconstructs the precise 3-dimensional chamber of interest with electrical and anatomical information. There are several technical aspects that physicians should be aware of to maximize its efficacy. This review provides relevant information on troubleshooting of the mapping system.How to perform and interpret rotational angiography in the electrophysiology laboratory
Sophisticated imaging methods have been growing in popularity since the introduction of curative ablation procedures for atrial fibrillation (AF). This trend is predicated on the need for a precise anatomic guidance within the complex left atrial (LA) anatomy and less reliance on electrocardiographic characteristics of the substrate. Traditional two-dimensional imaging methods such as fluoroscopy would not satisfy the needs of a complex catheter navigation inside three-dimensional (3D) anatomic structures that may not be confined to the radiographic cardiac silhouette (e.g., pulmonary veins [PVs]).How to implant a defibrillation coil in the azygous vein
Implantable cardioverter-defibrillator (ICD) defibrillation testing may reveal failure to achieve a satisfactory safety margin (conventionally, ≥10 J below the maximum energy of the generator) for defibrillation. Options for modification of the defibrillation threshold include repositioning of the ventricular lead, use (or removal) of a defibrillation coil in the superior vena cava (SVC), reversal of shock polarity, and modifying the shock waveform (not available in all devices). Additional defibrillator coils can be added to the subcutaneous space, the subclavian vein, or the coronary sinus.How to diagnose and treat cardiac tamponade in the electrophysiology laboratory
As certain as death and taxes occur, complications will occur when invasive procedures are performed. Pericardial effusion, with or without tamponade, is a well-documented complication even in the most experienced centers.1,2 As a result, electrophysiologists should know how to recognize and manage this complication over the course of their careers. In most situations, the outcome is excellent if the complication is recognized and managed expeditiously; however, delay in diagnosis and treatment can lead to catastrophic results.CRT delivery systems based on guide support for LV lead placement
Despite improvements in LV pacing leads, their placement continues to be limited by the coronary venous anatomy. Frequently, the angioplasty wire does not provide adequate support to advance the LV lead into the vein. However, a guiding catheter preshaped to fit into the ostium of the target can easily provide the required support.1,2 Many implanting physicians are reluctant to adopt preshaped guides for direct LV lead delivery because of lack of familiarity with the approach to open lumen catheter manipulation and contrast injection.How to use balloons as anchors to facilitate cannulation of the coronary sinus left ventricular lead placement and to regain lost coronary sinus or target vein access
Coronary venous anatomy can make successful implantation of a cardiac resynchronization therapy device difficult or impossible. Venogram and coronary balloons can be used as anchors to facilitate initial coronary sinus (CS) cannulation and left ventricular lead placement and to recover lost CS and target vein access.Catheter ablation in tetralogy of Fallot
Tetralogy of Fallot is the most common form of cyanotic heart disease, accounting for approximately 10% of congenital heart defects. Corrective surgery involves atrial and/or ventricular incisions and patches that, when combined with altered hemodynamics, predispose to the late onset of arrhythmias.1,2 In a multicenter cohort followed up for 35 years after corrective surgery, sustained atrial and ventricular tachyarrhythmias occurred in 10% and 12% of patients, respectively.1 Macroreentrant right atrial tachycardia is the most common atrial arrhythmia.Catheter ablation in transposition of the great arteries with Mustard or Senning baffles
Complete transposition of the great arteries (D-TGA) accounts for 5% to 7% of congenital heart defects. Although the arterial switch procedure has now replaced atrial redirection as the surgical procedure of choice, most adults today with D-TGA have had Mustard or Senning baffles. These surgeries involve extensive atrial reconstruction and predispose to sinus node dysfunction and atrial tachyarrhythmias.1,2 By 20 years after surgery, the prevalence of atrial tachyarrhythmias is approximately 25%, continues to increase with time, and is similar among patients with Mustard or Senning baffles.How to perform magnetic resonance imaging on patients with implantable cardiac arrhythmia devices
Magnetic resonance imaging (MRI) offers unrivaled soft tissue resolution and multiplanar imaging capabilities. Cardiac MRI is capable of accurate characterization of cardiac function and is uniquely capable of identifying scar fibrosis and fat deposition, thus making it an ideal imaging modality for the evaluation of patients presenting with arrhythmia. In addition, the absence of x-ray radiation makes MRI suitable for follow-up of chronic disease and for imaging in young patients and women of childbearing age.How to identify the location of an accessory pathway by the 12-lead ECG
Radiofrequency catheter ablation has become the treatment of choice for patients with symptomatic Wolff-Parkinson-White syndrome (WPW). The QRS complex morphology present on the 12-lead electrocardiogram (ECG) in WPW patients depends on the location of the accessory pathway(s) (AP) and the degree of fusion over the normal atrioventricular (AV) conduction. Accordingly, it is determined by the site of ventricular insertion of the accessory pathway, AV node conduction time, and atrial conduction.Ablation above the semilunar valves: When, why, and how? Part I
In this two-part series, we discuss the anatomical basis for arrhythmias arising above the semilunar valves. In this part (part I), we describe the relevant anatomy and technique for mapping and ablation of ventricular arrhythmias arising above either the pulmonic or the aortic valve. After an initial discussion of the underlying anatomy and characteristics of the substrate targeted for ablation above the semilunar valve, an approach for safe and effective ablation of supravalvar ventricular arrhythmias is presented.Ablation above the semilunar valves: When, why, and how? Part II
In this two-part series on arrhythmias occurring above the semilunar valve, we discuss the relevant underlying anatomy and the technique for mapping and ablation above the aortic and pulmonic valve. In part I, we focused on ventricular arrhythmias, and in this paper (part II), we discuss the anatomy and present knowledge of the substrate mapped and ablated above the aortic valve for atrial tachycardia in certain unusual accessory pathways. The background anatomy of the aortic valve has been discussed in part I of this series, to which the reader is referred.How to prevent, recognize, and manage complications of lead extraction. Part III: Procedural factors
The major risks of percutaneous lead extraction include cardiac perforation (1%–4%), emergency cardiac surgery (1%–2%), and death (0.4%–0.8%). However, risk to an individual varies in accordance with a number of factors (Table 1), and informed consent must be tailored to the specific patient. Indicators of very high risk (Table 2) define relative contraindications to the procedure; patients without other options should be referred to experienced centers capable of managing these special cases. Surgical backup should be secured prior to every extraction.How to avoid inappropriate shocks
Implantable cardioverter-defibrillator (ICD) usage has increased dramatically over the past decade. In part this is due to improved patient survival after myocardial infarction, but principally this is due to the increased number of implants for primary prevention. While the salutary effects of ICD therapy in this population of patients are generally accepted, complications from ICD implantation have become a common and pressing issue. First among these complications, both in terms of frequency and impact on quality of life, is inappropriate ICD therapy.Ablation using irrigated radiofrequency: A hands-on guide
The advent of irrigated radiofrequency (RF) catheters has led to the common misconception that irrigation somehow makes ablation both safer and more effective. In fact, this is not true. Irrigation (or any other means of cooling the catheter tip) results in the ability to deliver greater energy and as such can lead to steam pops, collateral damage, and thrombus formation. It is important to recognize that irrigation allows greater energy delivery; it does not mandate it. The operator must determine the appropriate power settings, irrigant flow rates, and lesion duration for each ablation site.Novel ablative approach for atrial fibrillation to decrease risk of esophageal injury
Percutaneous atrial fibrillation (AF) ablation using catheter-delivered radiofrequency energy continues to improve in safety and effectiveness. Nonetheless, the potential risk of esophageal injury often limits the ability to fully ablate the posterior portion of the left atrium to achieve optimal procedural success without complications. We present a comprehensive approach that addresses this challenge. Our ablative strategies include (1) identifying the esophagus to minimize ablative energy, when possible, in the proximity of the esophagus, (2) maximize the ability of the esophagus to remove heat and to heal from potential thermal injury, and (3) optimizing energy delivery to avoid deep tissue injury while maintaining procedural efficacy.How to prevent, recognize, and manage complications of lead extraction. Part II: Avoiding lead extraction—Noninfectious issues
The first part of this review examined the infectious indications for lead extraction. This part discusses noninfectious indications for lead extraction and strategies for reducing the incidence of such indications.How to prevent, recognize, and manage complications of lead extraction. Part I: Avoiding lead extraction—Infectious issues
As the number of implanted devices continues to grow, so does the need for extraction of chronic endocardial leads. Extraction carries with it considerable risk of morbidity and mortality (both intraprocedure and postprocedure), even in experienced hands. Although the evolution of technology directed at this approach has facilitated the successful removal of leads, no evidence indicates that this technology has lessened the incidence or nature of adverse events. Risks associated with lead extraction include vascular and cardiac perforation, tricuspid valve injury, various arrhythmias, sepsis, pulmonary embolism, bleeding, stroke, and myocardial infarction.Percutaneous extraction of coronary sinus vein and branch leads
Extraction of cardiac leads and electrodes will continue to be a statistical necessity as electrode implant numbers and durations increase. Improved implant success and expanded indications in heart failure patients for left ventricular (LV) pacing electrodes via the coronary sinus (CS) and its branches have resulted in unique interactions among the leads, venous system, and epicardial heart that are not typically seen with traditional endocardial right heart cardiac electrodes. LV lead placement, as well as the myocardium’s response to it, requires continual evaluation to better understand the limitations that may be encountered during extraction of LV leads, especially as the mean duration of implant reaches beyond 1 year.European perspective on lead extraction: Part II
If manual extraction is not successful, a locking stylet is used after the inner lumen is reamed using another stylet to remove debris. Use of a locking stylet with a very flexible tip is essential so that a tortuous lead can be negotiated. Equally important is locking the stylet as close as possible to the lead tip and not allowing the stylet to slip during the procedure. The risk of severing the sometimes fragile interpolar section of encapsulated bipolar leads is high if a positive lock close to the lead tip cannot be achieved.A European perspective on lead extraction: Part I
The need for lead extraction has increased exponentially in the last decade due to greatly increased “total lead exposure time.” The increased total lead exposure time is the result of new indications for device treatment, device therapy involving more leads per patient, and longer average patient life. Improved general lead reliability noted over recent years may have decreased slightly the need for extraction; however, this effect is more than countered by recent advisories, recalls, and increased complication rates, probably related to many new centers offering device treatment.How to treat and identify device infections
The incidence of device-related infections depends directly on the definition employed. The lack of precision is also compounded by the latency between the initiation and manifestation of the infection. It is not rare for there to be some erythema at the incision site during the first week of healing, and it is not clear that this represents infection. Less frequent, but still common, there can be a small, superficial stitch abscess, which will respond to local measures. When the diagnosis of device system infection is made, it should be made on the basis of pocket cellulitis, erosion, abscess, persistent bacteremia, or endocarditis with or without vegetation on the lead.Lead extraction
Lead extraction has grown from a “niche” procedure practiced by a select few individuals to a fairly widely disseminated technique. With the apparent increase in device infections, occluded veins and the need for device “upgrades,” more physicians are attempting to extract chronically implanted pacing and implantable cardioverter-defibrillator (ICD) leads. Unfortunately, obtaining training for this procedure is difficult outside of a training program at a center with a physician experienced in lead extraction.Lead extraction using the femoral vein
Lead extraction using the femoral vein is an alternate approach for lead removal. It has often been dubbed “the inferior approach.” This is because today it is often reserved for use only after a failed primary approach via the implant vein. In reality it is the most versatile approach for lead removal. Prior to the advent of powered sheaths, it was frequently used as a primary approach. It is also the only approach, and the procedure of choice, for removal of broken or cut leads with free ends.How to select patients for lead extraction
The techniques and tools for percutaneous removal of transvenous leads have undergone substantial development over the past several decades. Although the use of locking stylets and powered sheaths to free leads from encapsulated scar tissue has improved the success rate, the procedure still carries a significant risk of morbidity and mortality even in the hands of experienced operators. The threshold for lead extraction continues to evolve. The initial use of the procedure was limited to patients with life-threatening infections because of limited tools, lower success rates and high complication rates.How to perform linear lesions
Atrial fibrillation (AF) is a particularly complex arrhythmia because the mechanisms leading to fibrillation are not fully understood. Accordingly, ablation strategies have evolved largely on an empirical basis. The creation of linear lesions is a fundamental strategy that is indispensable to an electrophysiology laboratory performing ablation for treatment of this arrhythmia.Pacing maneuvers for nonpulmonary vein sources: Part II
Superior vena caval (SVC) potentials are similar to pulmonary vein (PV) potentials. The concepts of multiple far-field electrograms and the use of perivenous pacing and specific site and simultaneous pacing described above are equally applicable to understanding the complex electrograms found within the SVC (Figure 1). Specific sites that require pacing to determine the components of a complex electrogram found in the SVC include the right atrium (RA), azygos vein, anomalous PVs draining into the SVC, and right upper PV; in some cases, an anomalous superior branch of the right inferior PV may be required.Pulmonary vein–related maneuvers: Part I
With the rapid evolution of atrial fibrillation ablation procedures, electrophysiologists have necessarily strived for simple and anatomic-based approaches. In all except the most straightforward procedures, however, questions regarding the significance of various potentials recorded on mapping and ablation catheters arise.1,2 Other articles in this series have described in detail the various approaches to atrial fibrillation ablation. In this article, the anatomic and electrophysiologic bases for pacing maneuvers used with a variety of ablation approaches are reviewed.How to determine and assess endpoints for left atrial ablation
Studies have demonstrated that myocardium surrounding pulmonary vein (PV) ostia plays an important role in the initiation and perpetuation of atrial fibrillation (AF).1,2 This important finding has led to the development of segmental PV ostial isolation, circumferential ablation, and isolation around the PVs using circular linear lesions guided by three-dimensional (3D) electroanatomic mapping. Substrate modification using limited linear ablation also has been demonstrated to improve the clinical outcome after PV isolation in patients with AF inducibility.How to recognize, manage, and prevent complications during atrial fibrillation ablation
Seminal observations by Haissaguerre et al1 demonstrating initiation of atrial fibrillation (AF) by pulmonary vein (PV) depolarizations led to the development of percutaneous catheter-based endocardial AF ablation procedure. Since its original description, the AF ablation procedure has evolved considerably. Currently, the most accepted ablation strategy involves creating circumferential radiofrequency (RF) ablation lesions around PV ostia (either individually or encircling wide areas around the left-sided and right-sided veins) with or without additional atrial lesions.How to use intracardiac echocardiography for atrial fibrillation ablation procedures
Intracardiac echocardiography (ICE) has been an important tool in the development of advanced catheter ablation procedures. ICE technology now allows complete echocardiographic interrogation of all four heart chambers from the right atrium. A list of the uses for ICE in ablation procedures is given in Table 1.How and when to ablate the ligament of Marshall
The ligament of Marshall is an epicardial vestigial fold that marks the location of the embryologic left superior vena cava. It contains the nerve, vein (vein of Marshall), and muscle tracts.1,2 The proximal portions of the muscle tracts connect directly to the coronary sinus myocardial sleeves. The distal portions of the muscle tracts extend upward into the pulmonary vein region. Figure 1 shows a postmortem human heart with the ligament of Marshall located between the left atrial (LA) appendage and left pulmonary vein.How to perform electrogram-guided atrial fibrillation ablation
Over the past decade, several mapping studies of human atrial fibrillation (AF) have made the following important observations: (1) Atrial electrograms during sustained atrial fibrillation have three distinct patterns: single potential, double potential, and complex fractionated potential(s) (CFAEs).1–3 (2) The distribution of these atrial electrograms during AF localizes to specific atrial sites, and these electrograms exhibit remarkable temporal and spatial stability.1,2 (3) The CFAE areas represent AF substrate sites and are important targets for AF ablation.How to perform encircling ablation of the left atrium
The purpose of this article is to describe the technique and results of circumferential pulmonary vein ablation (CPVA) in patients with atrial fibrillation (AF) as currently performed in Milan.1–14 Since a significant learning curve still exists with the standard procedure, we have recently developed a new system, called remote magnetic navigation and ablation, which can be performed by less experienced operators while at the same time still reducing complications.13 The results of our standard technique with manually deflectable catheters are based on about 10,000 patients with paroxysmal, persistent, or permanent AF, many of whom have structural heart disease.How to access the axillary vein
The axillary vein has become a desirable structure for venous access for implantation of defibrillator and pacemaker leads because the vein is large, easily accessed, and can accommodate multiple leads. Furthermore, axillary vein access is not associated with problems accompanying subclavian vein access, including pneumothorax and subclavian crush syndrome.1,2How to interpret electroanatomic maps
Electroanatomic mapping refers to the acquisition and display of electrical information combined with spatial localization. Technologies presently available include both contact and noncontact electroanatomic mapping. This review focuses on the creation and proper interpretation of contact electroanatomic maps, which involves the sequential recording of unipolar or bipolar electrograms with a catheter in contact with the endocardium or epicardium and display of this information on a three-dimensional navigation system.How to analyze T-wave alternans
Noninvasive detection of patients prone to ventricular tachyarrhythmias and sudden cardiac death using measurements of ventricular repolarization derived from the 12-lead surface ECG has received enormous interest. Among the methods introduced for this purpose are assessment of QT dispersion, determination of QT dynamics assessed from long-term ECG recordings, and morphologic assessment of T-wave patterns. Analysis of microvolt T-wave alternans has emerged as the most promising. Considerable experimental evidence links microvolt T-wave alternans to the genesis of life-threatening ventricular tachyarrhythmias.How to ablate left atrial flutter
Typical atrial flutter ablation has become an increasingly common indication for catheter ablation, with success rates routinely exceeding 90% in most laboratories. In contrast, catheter ablation of left atrial flutter is technically challenging, and high success rates are uncommon.How to ablate atrioventricular nodal reentry using cryoenergy
Most electrophysiologists are well acquainted with the technique of radiofrequency (RF) ablation of AV nodal reentrant supraventricular tachycardia (AVNRT). This familiarity has, in turn, translated into a high degree of efficacy and safety with this method of ablation. On the other hand, catheter cryoablation is a relatively new approach for treating patients with AVNRT.1,2 Although the two ablation methods have certain similarities, understanding the unique features of cryoablation is important so that the method can be optimally used.Atrial lead implantation in the Bachmann bundle
The search for alternative atrial pacing sites has been driven by the observation that atrial activation patterns can influence the incidence of atrial fibrillation (AF).1,2 One goal of atrial pacing is to prevent nonphysiologic delay between right and left atrial activation. Pacing from atrial sites that decrease dispersion of atrial refractoriness may decrease the incidence of AF.Using the twelve-lead electrocardiogram to localize the site of origin of ventricular tachycardia
The basis of this review is the underlying hypothesis that the QRS morphology on 12-lead ECG is, to a great extent, determined by the site from which a focal ventricular tachycardia (VT) arises or from which a reentrant circuit exits the central isthmus to activate the “normal” myocardium. The ability to localize or, at the very least, regionalize “the sites of origin” of VTs enables the electrophysiologist to concentrate mapping to a specific region. Several factors limit the ability of the QRS patterns to localize VT origin, including (1) presence and size of infarction, (2) degree of intramyocardial fibrosis, (3) shape of the heart (e.g., aneurysm) and its position within the chest cavity, (4) site and mechanism of VT within an infarct or scarred area, (5) influence of nonuniform anisotropy in affecting propagation from the site of the tachycardia, (6) effects of acute ischemia, antiarrhythmic drugs, or metabolic abnormalities on conduction, (7) integrity of the His-Purkinje system, (8) presence of increased myocardial mass, and (9) presence of structural abnormalities unrelated to tachycardia origin or mechanisms.
