Debate: Do all patients with heart failure require implantable defibrillators to prevent sudden death?

Sudden death is a major cause of mortality in patients with ventricular dysfunction. The highest risk occurs among patients with less severe functional impairment. Current methods of risk stratification are inadequate, and a rational therapy for prevention of sudden death is not available. The implantable cardioverter-defibrillator (ICD) has proven to be more effective than drugs in reducing sudden-death risk in some subsets of patients. Empiric ICD therapy, targeting the general population with mild to moderate heart failure, will maximize the impact of such a strategy to prevent sudden death and improve long-term survival

2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: executive summary.

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2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: executive summary.

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Driving Restrictions Advised by Midwestern Cardiologists Implanting Cardioverter Defibrillators: Present Practices, Criteria Utilized, and Compatibility with Existing State Laws

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73175/1/j.1540-8159.1992.tb03115.x.pd

Isolated Potentials and Pace-Mapping as Guides for Ablation of Ventricular Tachycardia in Various Types of Nonischemic Cardiomyopathy

Nonischemic Cardiomyopathy and Ventricular Tachycardia.    Background : In patients with prior infarction, isolated potentials (IPs) during sinus rhythm reflect fixed scar and often indicate sites critical for ventricular tachycardia (VT). The purpose of this study was to determine the value of IPs in conjunction with pace-mapping to guide VT ablation in patients with various types of nonischemic cardiomyopathy. Methods : Mapping and ablation of VT were performed in 35 consecutive patients (26 men, age 55 ± 13 years, ejection fraction 0.31 ± 0.14) with VT and various etiologies of nonischemic cardiomyopathy. Pace-mapping was performed at sites with low voltage. Radiofrequency energy was delivered at sites with concealed entrainment or matching pace-maps. Results : One hundred ninety-five VTs (mean cycle length 363 ± 88 ms) were induced. Sites with prespecified ablation criteria displaying IPs during sinus rhythm were recorded in 21 of 35 patients (60%, IP-positive). In these patients, a total of 216 sites meeting prespecified ablation criteria were identified and 146 of 216 sites (68%) displayed IPs. Fifteen of 21 IP-positive patients (71%) no longer had inducible VT after ablation. In 14 of 35 patients, no sites with IPs where prespecified ablation criteria were met were identified (IP-negative) despite combined endocardial and epicardial mapping in 7 of 14 patients. Only 1 of 14 IP-negative patients (7%) no longer had inducible VT at the end of the ablation procedure. During a mean follow-up of 18 ± 13 months, 14 of 21 IP-positive patients (67%) remained arrhythmia-free, compared to 1 of 14 IP-negative patients (7%; P < 0.01). Half of the IP-negative patients had major adverse events due to recurrent arrhythmias, compared to none in IP-positive patients. Conclusion : IPs in conjunction with pace-mapping are helpful for identifying critical isthmus areas for ablation of VT in patients with various types of nonischemic cardiomyopathy. Patients with nonischemic cardiomyopathy in whom the arrhythmogenic substrate is characterized by IPs have a more favorable outcome than patients in whom IPs are absent. J Cardiovasc Electrophysiol, Vol. 21, pp. 1017-1023, September 2010)Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79253/1/j.1540-8167.2010.01756.x.pd

Thromboembolic prophylaxis protocol with warfarin after radiofrequency catheter ablation of infarct‐related ventricular tachycardia

IntroductionAblation in the left ventricle (LV) is associated with a risk of thromboembolism. There are limited data on the use of specific thromboembolic prophylaxis strategies postablation. We aimed to evaluate a thromboembolic prophylaxis protocol after ventricular tachycardia (VT) ablation.Methods and resultsThe index procedures of 217 patients undergoing ablation for infarct‐related VT with open irrigated‐tip catheters were included. Patients with large LV endocardial ablation area (>3 cm between ablation lesions) were started on low‐dose, slowly escalating unfractionated heparin (UFH) infusion 8 hours after access hemostasis, followed by 3 months of anticoagulation. Patients with less extensive ablation were treated only with antiplatelet agents postablation. Postablation bridging anticoagulation was used in 181 (83%) patients. Of them, 11 (6%) patients experienced bleeding events (1 required endovascular intervention) and 1 (0.6%) experienced lower extremity arterial embolism requiring vascular surgery. Systemic anticoagulation was prescribed in 190 (89%) of 214 patients discharged from the hospital (warfarin in 98%), while the rest received single‐ or dual‐antiplatelet therapy alone. Patients treated with an anticoagulant had significantly longer radiofrequency time compared to patients treated with antiplatelet agents only. One (0.5%) of the patients treated with oral anticoagulation experienced major bleeding 2 weeks postablation. No thromboembolic events were documented in either the anticoagulation or the “antiplatelet only” group postdischarge.ConclusionA slowly escalating bridging regimen of UFH, followed by 3 months of oral anticoagulation, is associated with low thromboembolic and bleeding risks after infarct‐related VT ablation. In the absence of extensive ablation, antiplatelet therapy alone is reasonable.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/143666/1/jce13418.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/143666/2/jce13418_am.pd

Effect of Interelectrode Distance on the Bipolar Strength‐Interval Relationship and Ventricular Effective Refractory Period in Humans

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106840/1/j.1540-8167.1990.tb01052.x.pd