RF-Energized Intracoronary Guidewire to Enhance Bipolar Ablation of the Interventricular Septum: In-silico Feasibility Study

"This is an Accepted Manuscript of an article published by Taylor & Francis in International Journal of Hyperthermiaon [date of publication], available online: https://doi.org/10.1080/02656736.2018.1425487"[EN] Purpose: Although bipolar radiofrequency (RF) ablation (RFA) is broadly used to eliminate ventricular tachycardias in the interventricular septum wall, it can fail to create transmural lesions in thick ventricular walls. To solve this problem, we explored whether an RF-energised guidewire inserted into the ventricular wall would enhance bipolar RFA in the creation of transmural lesions through the ventricular wall.Methods: We built three-dimensional computational models including two irrigated electrodes placed on opposing sides of the interventricular septum and a metal guidewire inserted into the septum. Computer simulations were conducted to compare the temperature distributions obtained with two ablation modes: bipolar mode (RF power delivered between both irrigated electrode) and time-division multiplexing (TDM) technique, which consists of activating the bipolar mode for 90% of the time and applying RF power between the guidewire and both irrigated electrodes during the remaining time.Results: The TDM technique was the most suitable in terms of creating wider lesions through the entire ventricular wall, avoiding the hour-glass shape of thermal lesions associated with the bipolar mode. This was especially apparent in the case of thick walls (15mm). Furthermore, the TDM technique was able to create transmural lesions even when the guidewire was displaced from the midplane of the wall.Conclusions: An RF-energised guidewire could enhance bipolar RFA by allowing transmural lesions to be made through thick ventricular walls. However, the safety of this new approach must be assessed in future pre-clinical studies, especially in terms of the risk of stenosis and its clinical impact.This work was supported by the Spanish Ministerio de Economia, Industria y Competitividad under "Plan Estatal de Investigacion, Desarrollo e Innovacion Orientada a los Retos de la Sociedad" Grant "TEC2014-52383-C3 (TEC2014-52383-C3-1-R)". A. Gonzalez-Suarez has a "Juan de la Cierva-formacion" Postdoctoral Grant (FJCI-2015-27202) supported by the Spanish Ministerio de Economia, Industria y Competitividad, Secretaria de Estado de Investigacion, Desarrollo e Innovacion.Pérez, JJ.; González Suárez, A.; D Avila, A.; Berjano, E. (2018). RF-Energized Intracoronary Guidewire to Enhance Bipolar Ablation of the Interventricular Septum: In-silico Feasibility Study. International Journal of Hyperthermia. 34(8):1202-1212. https://doi.org/10.1080/02656736.2018.1425487S12021212348Baszko, A., Telec, W., Kałmucki, P., Iwachów, P., Kochman, K., Szymański, R., … Siminiak, T. (2016). Bipolar irrigated radiofrequency ablation of resistant ventricular tachycardia with a septal intramural origin: the initial experience and a description of the method. Clinical Case Reports, 4(10), 957-961. doi:10.1002/ccr3.648Gizurarson, S., Spears, D., Sivagangabalan, G., Farid, T., Ha, A. C. T., Masse, S., … Nanthakumar, K. (2014). Bipolar ablation for deep intra-myocardial circuits: human ex vivo development and in vivo experience. Europace, 16(11), 1684-1688. doi:10.1093/europace/euu001Koruth, J. S., Dukkipati, S., Miller, M. A., Neuzil, P., d’ Avila, A., & Reddy, V. Y. (2012). Bipolar irrigated radiofrequency ablation: A therapeutic option for refractory intramural atrial and ventricular tachycardia circuits. Heart Rhythm, 9(12), 1932-1941. doi:10.1016/j.hrthm.2012.08.001Baldinger, S. H., Kumar, S., Barbhaiya, C. R., Mahida, S., Epstein, L. M., Michaud, G. F., … Stevenson, W. G. (2015). Epicardial Radiofrequency Ablation Failure During Ablation Procedures for Ventricular Arrhythmias. Circulation: Arrhythmia and Electrophysiology, 8(6), 1422-1432. doi:10.1161/circep.115.003202Santangeli, P., Shaw, G. C., & Marchlinski, F. E. (2017). Radiofrequency Wire Facilitated Interventricular Septal Access for Catheter Ablation of Ventricular Tachycardia in a Patient With Aortic and Mitral Mechanical Valves. Circulation: Arrhythmia and Electrophysiology, 10(1). doi:10.1161/circep.116.004771Berjano, E. J., Hornero, F., Atienza, F., & Montero, A. (2003). Long electrodes for radio frequency ablation: comparative study of surface versus intramural application. Medical Engineering & Physics, 25(10), 869-877. doi:10.1016/s1350-4533(03)00125-5McLELLAN, A. J. A., ELLIMS, A. H., PRABHU, S., VOSKOBOINIK, A., ILES, L. M., HARE, J. L., … KISTLER, P. M. (2016). Diffuse Ventricular Fibrosis on Cardiac Magnetic Resonance Imaging Associates With Ventricular Tachycardia in Patients With Hypertrophic Cardiomyopathy. Journal of Cardiovascular Electrophysiology, 27(5), 571-580. doi:10.1111/jce.12948Berjano, E. J. (2006). Theoretical modeling for radiofrequency ablation: state-of-the-art and challenges for the future. BioMedical Engineering OnLine, 5(1). doi:10.1186/1475-925x-5-24Pérez, J. J., González-Suárez, A., & Berjano, E. (2017). Numerical analysis of thermal impact of intramyocardial capillary blood flow during radiofrequency cardiac ablation. International Journal of Hyperthermia, 34(3), 243-249. doi:10.1080/02656736.2017.1336258Labonte, S. (1994). Numerical model for radio-frequency ablation of the endocardium and its experimental validation. IEEE Transactions on Biomedical Engineering, 41(2), 108-115. doi:10.1109/10.284921Doss, J. D. (1982). Calculation of electric fields in conductive media. Medical Physics, 9(4), 566-573. doi:10.1118/1.595107PÉREZ, J. J., D’AVILA, A., ARYANA, A., & BERJANO, E. (2015). Electrical and Thermal Effects of Esophageal Temperature Probes on Radiofrequency Catheter Ablation of Atrial Fibrillation: Results from a Computational Modeling Study. Journal of Cardiovascular Electrophysiology, 26(5), 556-564. doi:10.1111/jce.12630Jo, B., & Aksan, A. (2010). Prediction of the extent of thermal damage in the cornea during conductive keratoplasty. Journal of Thermal Biology, 35(4), 167-174. doi:10.1016/j.jtherbio.2010.02.004Gonzalez-Suarez, A., & Berjano, E. (2016). Comparative Analysis of Different Methods of Modeling the Thermal Effect of Circulating Blood Flow During RF Cardiac Ablation. IEEE Transactions on Biomedical Engineering, 63(2), 250-259. doi:10.1109/tbme.2015.2451178WINTERFIELD, J. R., JENSEN, J., GILBERT, T., MARCHLINSKI, F., NATALE, A., PACKER, D., … WILBER, D. J. (2015). Lesion Size and Safety Comparison Between the Novel Flex Tip on the FlexAbility Ablation Catheter and the Solid Tips on the ThermoCool and ThermoCool SF Ablation Catheters. Journal of Cardiovascular Electrophysiology, 27(1), 102-109. doi:10.1111/jce.12835PÉREZ, J. J., D’AVILA, A., ARYANA, A., TRUJILLO, M., & BERJANO, E. (2016). Can Fat Deposition After Myocardial Infarction Alter the Performance of RF Catheter Ablation of Scar-Related Ventricular Tachycardia?: Results from a Computer Modeling Study. Journal of Cardiovascular Electrophysiology, 27(8), 947-952. doi:10.1111/jce.13006Haines, D. E. (2011). Letter by Haines Regarding Article, «Direct Measurement of the Lethal Isotherm for Radiofrequency Ablation of Myocardial Tissue». Circulation: Arrhythmia and Electrophysiology, 4(5). doi:10.1161/circep.111.965459González-Suárez, A., Trujillo, M., Koruth, J., d’ Avila, A., & Berjano, E. (2014). Radiofrequency cardiac ablation with catheters placed on opposing sides of the ventricular wall: Computer modelling comparing bipolar and unipolar modes. International Journal of Hyperthermia, 30(6), 372-384. doi:10.3109/02656736.2014.949878Gianni, C., Mohanty, S., Trivedi, C., Di Biase, L., Al-Ahmad, A., Natale, A., & David Burkhardt, J. (2017). Alternative Approaches for Ablation of Resistant Ventricular Tachycardia. Cardiac Electrophysiology Clinics, 9(1), 93-98. doi:10.1016/j.ccep.2016.10.006Boll, D. T., Lewin, J. S., Duerk, J. L., & Merkle, E. M. (2003). Do Surgical Clips Interfere with Radiofrequency Thermal Ablation? American Journal of Roentgenology, 180(6), 1557-1560. doi:10.2214/ajr.180.6.1801557Eung Je Woo, Tungjitkusolmun, S., Hong Cao, Jang-Zem Tsai, Webster, J. G., Vorperian, V. R., & Will, J. A. (2000). A new catheter design using needle electrode for subendocardial RF ablation of ventricular muscles: finite element analysis and in vitro experiments. IEEE Transactions on Biomedical Engineering, 47(1), 23-31. doi:10.1109/10.817616BLOUIN, L. T., & MARCUS, F. I. (1989). The Effect of Electrode Design on the Efficiency of Delivery of Radiofrequency Energy to Cardiac Tissue In Vitro. Pacing and Clinical Electrophysiology, 12(1), 136-143. doi:10.1111/j.1540-8159.1989.tb02640.xTao, W., Jian-ping, G., Xu, H., Wen-sheng, L., Liang, C., Guo-ping, C., … Jin-hua, S. (2013). The effects of endovenous radiofrequency ablation on coagulation and the vein wall in an experimental canine model. Vascular, 21(4), 215-219. doi:10.1177/1708538113478762Badham, G. E., Strong, S. M., & Whiteley, M. S. (2014). An in vitro study to optimise treatment of varicose veins with radiofrequency-induced thermo therapy. Phlebology: The Journal of Venous Disease, 30(1), 17-23. doi:10.1177/0268355514552005Kreidieh, B., Rodríguez-Mañero, M., A. Schurmann, P., Ibarra-Cortez, S. H., Dave, A. S., & Valderrábano, M. (2016). Retrograde Coronary Venous Ethanol Infusion for Ablation of Refractory Ventricular Tachycardia. Circulation: Arrhythmia and Electrophysiology, 9(7). doi:10.1161/circep.116.00435

Procedural Adaptations to Avoid Haemodynamic Instability During Catheter Ablation of Scar-related Ventricular Tachycardia

Classically, catheter ablation for scar-related ventricular tachycardia (VT) relied upon activation and entrainment mapping of induced VT. Advances in post-MI therapies have led to VTs that are faster and haemodynamically less stable, because of more heterogeneous myocardial fibrosis patterns. The PAINESD score is one means of identifying patients at highest risk for haemodynamic decompensation during attempted VT induction, who may, therefore, benefit from alternative ablation strategies. One strategy is to use temporary mechanical circulatory support, although this warrants formal assessment of cost-effectiveness. A second strategy is to minimise or avoid VT induction altogether by employing a family of ‘substrate’-based approaches aimed at identifying VT isthmuses during sinus or paced rhythm. Substrate mapping techniques are diverse, and focus on the timing, morphology and amplitude of local ventricular electrograms – sometimes aided by advanced non-invasive cardiac imaging modalities. In this review, the evolution of VT ablation over time is discussed, with an emphasis on procedural adaptations to the challenge of haemodynamic instability

Radiofrequency cardiac ablation with catheters placed on opposing sides of the ventricular wall: Computer modelling comparing bipolar and unipolar modes

Purpose: The aim of this study was to compare the efficacy of bipolar (BM) vs. unipolar (UM) mode of radiofrequency ablation (RFA) in terms of creating transmural lesions across the interventricular septum (IVS) and ventricular free wall (VFW). Materials and methods: We built computational models to study the temperature distributions and lesion dimensions created by BM and UM on IVS and VFW during RFA. Two different UM types were considered: sequential (SeUM) and simultaneous (SiUM). The effect of ventricular wall thickness, catheter misalignment, epicardial fat, and presence of air in the epicardial space were also studied. Results: Regarding IVS ablation, BM created transmural and symmetrical lesions for wall thicknesses up to 15 mm. SeUM and SiUM were not able to create transmural lesions with IVS thicknesses >= 12.5 and 15 mm, respectively. Lesions were asymmetrical only with SeUM. For VFW ablation, BM also created transmural lesions for wall thicknesses up to 15 mm. However, with SeUM and SiUM transmurality was obtained for VFW thicknesses <= 7.5 and 12.5 mm, respectively. With the three modes, VFW lesions were always asymmetrical. In the scenario with air or a fat tissue layer on the epicardial side, only SiUM was capable of creating transmural lesions. Overall, BM was superior to UM in IVS and VFW ablation when the catheters were not aligned. Conclusions: Our findings suggest that BM is more effective than UM in achieving transmurality across both ventricular sites, except in the situation of the epicardial catheter tip surrounded by air or placed over a fat tissue layer.This work received financial support from the Spanish 'Plan Nacional de I+D+I del Ministerio de Ciencia e Innovacion' (TEC2011-27133-C02-01), and from the Universitat Politecnica de Valencia (PAID-06-11 Ref. 1988). A. Gonzalez-Suarez is the recipient of a Grant VaLi+D (ACIF/2011/194) from the Generalitat Valenciana, Spain. The authors alone are responsible for the content and writing of the paper.González Suárez, A.; Trujillo Guillen, M.; Koruth, J.; D'avila, A.; Berjano, E. (2014). Radiofrequency cardiac ablation with catheters placed on opposing sides of the ventricular wall: Computer modelling comparing bipolar and unipolar modes. International Journal of Hyperthermia. 30(6):372-384. https://doi.org/10.3109/02656736.2014.949878S372384306SIVAGANGABALAN, G., BARRY, M. A., HUANG, K., LU, J., POULIOPOULOS, J., THOMAS, S. P., … KOVOOR, P. (2010). Bipolar Ablation of the Interventricular Septum is More Efficient at Creating a Transmural Line than Sequential Unipolar Ablation. Pacing and Clinical Electrophysiology, 33(1), 16-26. doi:10.1111/j.1540-8159.2009.02602.xNagashima, K., Watanabe, I., Okumura, Y., Ohkubo, K., Kofune, M., Ohya, T., … Hirayama, A. (2011). Lesion Formation by Ventricular Septal Ablation With Irrigated Electrodes. Circulation Journal, 75(3), 565-570. doi:10.1253/circj.cj-10-0870D’ Avila, A., Houghtaling, C., Gutierrez, P., Vragovic, O., Ruskin, J. N., Josephson, M. E., & Reddy, V. Y. (2004). Catheter Ablation of Ventricular Epicardial Tissue. Circulation, 109(19), 2363-2369. doi:10.1161/01.cir.0000128039.87485.0bDukkipati, S. R., d’ Avila, A., Soejima, K., Bala, R., Inada, K., Singh, S., … Reddy, V. Y. (2011). Long-Term Outcomes of Combined Epicardial and Endocardial Ablation of Monomorphic Ventricular Tachycardia Related to Hypertrophic Cardiomyopathy. Circulation: Arrhythmia and Electrophysiology, 4(2), 185-194. doi:10.1161/circep.110.957290Sosa, E., Scanavacca, M., d’ Avila, A., Oliveira, F., & Ramires, J. A. F. (2000). Nonsurgical transthoracic epicardial catheter ablation to treat recurrent ventricular tachycardia occurring late after myocardial infarction. Journal of the American College of Cardiology, 35(6), 1442-1449. doi:10.1016/s0735-1097(00)00606-9Nagashima, K., Watanabe, I., Okumura, Y., Sonoda, K., Kofune, M., Mano, H., … Hirayama, A. (2012). Epicardial Ablation With Irrigated Electrodes. Circulation Journal, 76(2), 322-327. doi:10.1253/circj.cj-11-0984Berjano, E. J. (2006). BioMedical Engineering OnLine, 5(1), 24. doi:10.1186/1475-925x-5-24Abraham, J. P., & Sparrow, E. M. (2007). A thermal-ablation bioheat model including liquid-to-vapor phase change, pressure- and necrosis-dependent perfusion, and moisture-dependent properties. International Journal of Heat and Mass Transfer, 50(13-14), 2537-2544. doi:10.1016/j.ijheatmasstransfer.2006.11.045Jo, B., & Aksan, A. (2010). Prediction of the extent of thermal damage in the cornea during conductive keratoplasty. Journal of Thermal Biology, 35(4), 167-174. doi:10.1016/j.jtherbio.2010.02.004HAINES, D. E., & WATSON, D. D. (1989). Tissue Heating During Radiofrequency Catheter Ablation: A Thermodynamic Model and Observations in Isolated Perfused and Superfused Canine Right Ventricular Free Wall. Pacing and Clinical Electrophysiology, 12(6), 962-976. doi:10.1111/j.1540-8159.1989.tb05034.xZhao, G., Zhang, H.-F., Guo, X.-J., Luo, D.-W., & Gao, D.-Y. (2007). Effect of blood flow and metabolism on multidimensional heat transfer during cryosurgery. Medical Engineering & Physics, 29(2), 205-215. doi:10.1016/j.medengphy.2006.03.005Chang, I. A., & Nguyen, U. D. (2004). BioMedical Engineering OnLine, 3(1), 27. doi:10.1186/1475-925x-3-27Whitney, J., Carswell, W., & Rylander, N. (2013). Arrhenius parameter determination as a function of heating method and cellular microenvironment based on spatial cell viability analysis. International Journal of Hyperthermia, 29(4), 281-295. doi:10.3109/02656736.2013.802375Pearce, J. A. (2013). Comparative analysis of mathematical models of cell death and thermal damage processes. International Journal of Hyperthermia, 29(4), 262-280. doi:10.3109/02656736.2013.786140Doss, J. D. (1982). Calculation of electric fields in conductive media. Medical Physics, 9(4), 566-573. doi:10.1118/1.595107Watanabe, I., Nuo, M., Okumura, Y., Ohkubo, K., Ashino, S., Kofune, M., … Hirayama, A. (2010). Temperature-Controlled Cooled-Tip Radiofrequency Ablation in Left Ventricular Myocardium. International Heart Journal, 51(3), 193-198. doi:10.1536/ihj.51.193Yokoyama, K., Nakagawa, H., Wittkampf, F. H. M., Pitha, J. V., Lazzara, R., & Jackman, W. M. (2006). Comparison of Electrode Cooling Between Internal and Open Irrigation in Radiofrequency Ablation Lesion Depth and Incidence of Thrombus and Steam Pop. Circulation, 113(1), 11-19. doi:10.1161/circulationaha.105.540062Kumar, P., Mounsey, J. P., Gehi, A. K., Schwartz, J. D., & Chung, E. H. (2013). Use of a closed loop irrigated catheter in epicardial ablation of ventricular tachycardia. Journal of Interventional Cardiac Electrophysiology, 38(1), 35-42. doi:10.1007/s10840-013-9799-1Schutt, D., Berjano, E. J., & Haemmerich, D. (2009). Effect of electrode thermal conductivity in cardiac radiofrequency catheter ablation: A computational modeling study. International Journal of Hyperthermia, 25(2), 99-107. doi:10.1080/02656730802563051Gopalakrishnan, J. (2002). A Mathematical Model for Irrigated Epicardial Radiofrequency Ablation. Annals of Biomedical Engineering, 30(7), 884-893. doi:10.1114/1.1507845Suárez, A. G., Hornero, F., & Berjano, E. J. (2010). Mathematical Modeling of Epicardial RF Ablation of Atrial Tissue with Overlying Epicardial Fat. The Open Biomedical Engineering Journal, 4(1), 47-55. doi:10.2174/1874120701004020047Haemmerich, D., Chachati, L., Wright, A. S., Mahvi, D. M., Lee, F. T., & Webster, J. G. (2003). Hepatic radiofrequency ablation with internally cooled probes: effect of coolant temperature on lesion size. IEEE Transactions on Biomedical Engineering, 50(4), 493-500. doi:10.1109/tbme.2003.809488Koruth, J. S., Dukkipati, S., Miller, M. A., Neuzil, P., d’ Avila, A., & Reddy, V. Y. (2012). Bipolar irrigated radiofrequency ablation: A therapeutic option for refractory intramural atrial and ventricular tachycardia circuits. Heart Rhythm, 9(12), 1932-1941. doi:10.1016/j.hrthm.2012.08.001González-Suárez, A., Trujillo, M., Burdío, F., Andaluz, A., & Berjano, E. (2012). Feasibility study of an internally cooled bipolar applicator for RF coagulation of hepatic tissue: Experimental and computational study. International Journal of Hyperthermia, 28(7), 663-673. doi:10.3109/02656736.2012.716900Agah, R., Gandjbakhche, A. H., Motamedi, M., Nossal, R., & Bonner, R. F. (1996). Dynamics of temperature dependent optical properties of tissue: dependence on thermally induced alteration. IEEE Transactions on Biomedical Engineering, 43(8), 839-846. doi:10.1109/10.508546Haines, D. E. (2011). 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Segurança na mudança direta de natalizumabe para fingolimode em um grupo de pacientes com esclerose múltipla e positivos para JCV

To assess safety of the switch between natalizumab and fingolimod without a washout period. Methods Prospective data on 25 JCV positive patients who underwent this medication switch were collected and analyzed. Results After a median period of nine months from the medication switch, there were no safety issues to report. The patients had good disease control and no adverse events were reported. Conclusion Washout may not be necessary in daily practice when switching from natalizumab to fingolimod. Expertise on multiple sclerosis management, however, is essential for drug switching748650652Avaliar a segurança na mudança entre natalizumabe e fingolimode sem período de washout. Métodos Dados prospectivos de 25 pacientes positivos para vírus JC que tiveram sua medicação modificada foram coletados e analisados. Resultados Após uma mediana de nove meses da troca de medicação, não havia aspectos de segurança a relatar. Os pacientes estavam com bom controle da doença e não foram relatados eventos adversos. Conclusão Washout pode não ser necessário na prática diária para a mudança entre natalizumabe e fingolimode. No entanto, expertise no manejo de esclerose múltipla é essencial para esta troca entre medicaçõe

Correlation between the modified oxford scale and perineometry measurements in incontinent patients

Introdução: Diversas técnicas foram propostas para avaliação da musculatura do assoalho pélvico, porém, nenhum método mostrou-se capaz de medir as duas funções desses músculos: elevação e força de compressão. Na rotina de avaliação clínica é comumente empregada a palpação vaginal e, especialmente, o escore de Oxford modificado; entretanto, alguns trabalhos questionam a sensibilidade da escala de Oxford e sua correlação com medidas objetivas de força de contração muscular. Objetivo: Neste estudo, propõe-se correlacionar as variáveis medidas na perineometria com o escore de Oxford modificado. Métodos: Foram incluídas no estudo 45 pacientes com incontinência urinária que procuraram o ambulatório de Uroginecologia do Hospital de Clínicas de Porto Alegre. As pacientes foram submetidas à palpação vaginal, realizada por uma fisioterapeuta treinada na escala de Oxford, e a medição da força de compressão da musculatura pélvica por meio de balonete conectado a transdutor de pressão. As duas avaliações foram realizadas no mesmo dia. Resultados: Encontrou-se correlação significativa (P <0,001) entre o escore de Oxford e as variáveis pressão máxima de contração e tempo de ativação muscular com coeficientes de Pearson de 0,69 e -0,532, respectivamente. Contudo, observa- se uma superposição entre as medidas perineométricas e do escore de Oxford entre categorias adjacentes. Conclusões: Os resultados mostram que apesar de estar incorporada a rotina clínica de avaliação, deve haver restrições quanto ao uso do escala de Oxford com propósitos científicos.Background: Several techniques have been proposed for the assessment of pelvic floor muscles; however, none of them were able to measure the two main functions of these muscles: lifting and compressive force. Vaginal palpation and especially the Modified Oxford Scale (MOS) are frequently used during routine clinical evaluation, but some studies have questioned the sensitivity of the MOS and its correlation with objective measurements of muscle contraction force. Aim: The objective of this study is to correlate perineometry measurements with the MOS. Methods: Forty-five patients with urinary incontinence treated at the Urogynecology Outpatient Clinic of Hospital de Clínicas de Porto Alegre were included. The patients were submitted to vaginal palpation performed by a physical therapist trained in the MOS. The compression force of their pelvic muscles was measured by means of an air-filled ballonet connected to a pressure transducer. Both tests were carried out on the same day. Results: We found significant correlation (P <0.001) between the MOS and the variables maximum contraction pressure and muscular activation time with Pearson's coefficients of 0.69 and -0.532, respectively. However, we found overlapping results between the perineomtry measurements and the MOS scores in neighboring categories. Conclusions: These findings show that, although incorporated into routine clinical evaluation, there should be restrictions to the use of the MOS for scientific purposes

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

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