Cardiac Electrophysiology Clinics

Inherited cardiomyopathy and arrhythmia syndromes are associated with significant morbidity and mortality, particularly in young people. Medical management of these conditions has primarily been limited to agents previously developed for more common forms of heart disease and not tailored to their distinct pathophysiology. As our understanding of their underlying genetics and disease mechanisms has improved, an era of targeted therapies for these rare conditions has begun to emerge. In recent years, several novel agents have been developed and tested in preclinical models and, in some cases, have advanced to both the clinical trial and clinical approval stages with exciting results...

Diagnosis and risk stratification of rare genetic heart diseases remains clinically challenging. In many cases, there are few data and insufficient numbers to support randomized controlled trials. While implantable cardioverter defibrillator (ICD) use is vital to protect higher-risk individuals from life-threatening ventricular arrhythmias, low-risk individuals also require protection from unnecessary ICDs and their associated complications. Once an ICD has been implanted, appropriate device programming is essential to ensure maximal protection while balancing the risks of inappropriate therapy...

Genetic testing has increasingly been shown to provide critical information regarding the treatment and management of patients with hereditary cardiomyopathies and arrhythmias and is available for a wide variety of conditions. It can provide information regarding arrhythmia risk, lifestyle recommendations, such as exercise avoidance, pharmaceutical therapies, and prognosis. Beyond the proband, genetic testing can be a valuable tool for cascade screening in the family. Genetic testing should be accompanied with genetic counseling, as genetic tests should be accompanied by expert interpretation, support in cascade family evaluation, and psychosocial considerations...

Cardiac genetic counseling is the process of helping individuals adapt to a personal diagnosis or family history of an inherited heart condition. The process is shown to benefit patients and includes specialized skills, such as counseling children and interpreting complex genetic results. Emerging areas include: evolving service delivery models for caring for patients and communicating risk to relatives, new areas of need including postmortem molecular autopsy, and new populations of individuals found to carry a likely pathogenic/pathogenic cardiac variant identified through genomic screening...

No abstract text is available yet for this article.

No abstract text is available yet for this article.

Early experience with percutaneous LAA closure documented complication rates of ∼10%, with failure to implant devices in ∼10% of patients. These numbers are unrecognizable in contemporary practice due to the iterative changes made largely in the last 10 years. Here we look forward to ask what might change, and when, to bring percutaneous LAA closure out of the niche early adopter centers into routine use. We consider the opportunity to incorporate different technologies into LAAc devices in the context of managing patient with atrial fibrillation...

Left atrial appendage (LAA) epicardial exclusion has been associated with addressing 2 potential deleterious consequences attributed to the LAA, namely, thrombus formation and an arrhythmogenic contributor in advanced forms of atrial fibrillation. With more than 60 years of history, the surgical exclusion of the LAA has been firmly established. Numerous approaches have been used for surgical LAA exclusion including surgical resections, suture ligation, cutting and non-cutting staples, and surgical clips. Additionally, a percutaneous epicardial LAA ligation approach has been developed...

Left atrial appendage closure aims to eliminate the stasis component of Virchow triad by eliminating a cul-de-sac that favors thrombosis, particularly when atrial contractility becomes inefficient, such as in atrial fibrillation. Left atrial appendage closure devices have a common objective of sealing the appendage completely, with device stability and avoidance of device thrombosis. Two main device designs have been used to perform left atrial appendage closure: those that use a pacifier design (lobe + disk) and those that use a plug (single lobe) design...

Endocardial left atrial appendage (LAA) occluders with a covering disc encompass a wide range of devices that share the common feature of a distal anchoring "body" and proximal covering "disc" design. This unique design feature has potential advantages in certain complex LAA anatomies and challenging clinical scenarios. The current review article summarizes the different features of established and novel devices, preprocedural imaging updates, intraprocedural technical considerations, and postprocedural follow-up issues specific to this category of LAA occluders...

This review summarizes the evidence for left atrial appendage closure (LAAC) as an alternative to oral anticoagulation (OAC) for stroke prevention in atrial fibrillation. LAAC reduces hemorrhagic stroke and mortality versus warfarin, but is inferior for ischemic stroke reduction based on randomized data. Whilst a feasible treatment in OAC-ineligible patients, questions remain over procedural safety, and the improvement in complications observed in nonrandomized registries is uncorroborated by contemporary randomized trials...

Routine postprocedural imaging with transesophageal echocardiography or cardiac computed tomography angiography is the most commonly used imaging modality for follow-up surveillance usually performed 1 to 6 months after the procedure. Imaging enables recognition of well-suited and sealed devices in the left atrial appendage as well as of potential harmful complications such as peri-device leaks, device-related thrombus, and device embolization, which may lead to further surveillance observation with recurrent imaging, reinitiation of oral anticoagulants, or additional interventional procedures...

Left atrial appendage closure (LAAC) has become a commonly used alternative to anticoagulation for stroke prevention in patients with atrial fibrillation. There is a growing interest in adopting a minimally invasive procedural approach using intracardiac echocardiography (ICE) and moderate sedation. In this article, we review the rational for and the data supporting ICE-guided LAAC and discuss the pros and cons of this approach.

In the wake of rapid advancement in cardiovascular procedural technologies, physician-led preprocedural planning utilizing multi-modality imaging training is increasingly recognized as invaluable for procedural accuracy. Left atrial appendage occlusion (LAAO) is one such procedure in which complications such as device leak, cardiac injury, and device embolization can be decreased substantially with incorporation of physician driven imaging and digital tools. We discuss the benefits of cardiac CT and 3D printing in preprocedural planning for the Heart Team, as well as novel applications by physicians of intraprocedural 3D angiography and dynamic fusion imaging...

Left atrial appendage (LAA) occlusion is emerging as a viable alternative to oral anticoagulation in high-risk patients with atrial fibrillation. However, there remains limited evidence for this approach, especially in certain subgroups, and therefore patient selection is an important aspect of treatment. Here, the authors present arguments for LAA occlusion as either a last resort versus patient choice by evaluating contemporary studies on this topic and discuss practical steps in the approach of patients who may be suitable for LAA occlusion...

Although the left atrial appendage (LAA) seems useless, it has several critical functions that are not fully known yet, such as the causes for being the main origin of cardioembolic stroke. Difficulties arise due to the extreme range of LAA morphologic variability, making the definition of normality challenging and hampering the stratification of thrombotic risk. Furthermore, obtaining quantitative metrics of its anatomy and function from patient data is not straightforward. A multimodality imaging approach, using advanced computational tools for their analysis, allows a complete characterization of the LAA to individualize medical decisions related to left atrial thrombosis patients...

A comprehensive evaluation is necessary to identify the etiologic factors in order to select optimal stroke-prevention measures. Atrial fibrillation is one of the most important stroke causes. Although anticoagulant therapy is the treatment of choice for patients with nonvalvular atrial fibrillation, it should not be considered uniformly to treat all patients given the high mortality associated with anticoagulant-related hemorrhages. The authors propose a risk-stratified individualized approach for stroke prevention in patients with nonvalvular atrial fibrillation by considering nonpharmacologic approaches for patients at high hemorrhage risk or otherwise unsuitable for lifelong anticoagulation...

No abstract text is available yet for this article.

No abstract text is available yet for this article.

The left ventricular summit is a site of origin for idiopathic ventricular arrhythmias. With advancements in mapping and ablation techniques, sites previously considered inaccessible can now be approached. Anatomical knowledge of the 3-dimensional landmarks of this space is important, as critical structures reside within its boundaries and are potentially liable to collateral injury during ablation. This article reviews reported complications from ablation of ventricular arrhythmias arising from the left ventricular summit and its vicinity and discusses the pros and cons of different ablation technique and the role of an individualized anatomical approach to reduce procedural related complications and improve outcomes...