Hands On
Mitral isthmus ablation: A hierarchical approach guided by electroanatomic correlation
Mitral isthmus ablation is an established technique used to treat perimitral atrial flutter. The classic approach involves creating an ablation line connecting the left inferior pulmonary vein (LIPV) to the lateral mitral annulus.1 Its feasibility was first prospectively studied by Jais et al,1 who reported a high rate of bidirectional block. However, subsequent studies by the same group, as well as others, have been less promising.2 This is important because failure to achieve bidirectional block with ablation has been shown to be proarrhythmic.Implantation of the subcutaneous implantable cardioverter–defibrillator with truncal plane blocks
Operative anesthetic requirements and perioperative discomfort are barriers to wide adoption of the subcutaneous implantable cardioverter–defibrillator (SICD) system. The SICD implant procedure involves incision and dissection in the richly innervated midaxillary line of the chest wall for placement of the pulse generator and tunneling in subcutaneous tissue for implantation of the defibrillator lead.1 Intraoperative local anesthetic wound infiltration is routine and provides moderate analgesia, but the effects are short-lasting, and complete coverage of the affected areas is difficult.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.
