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Ciconte G, Conti M, Vicedomini G, Santinelli V, Brugada J, Pappone C. Intermittent alternance of Brugada ECG patterns: Insights from a unique electrophysiological phenomenon. J Cardiovasc Electrophysiol 2017; 28:1482-1484. [PMID: 28833819 DOI: 10.1111/jce.13317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 08/09/2017] [Accepted: 08/14/2017] [Indexed: 11/28/2022]
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Ciconte G, Saviano M, Giannelli L, Calovic Z, Baldi M, Ciaccio C, Cuko A, Vitale R, Giacopelli D, Conti M, Lipartiti F, Giordano F, Maresca F, Moscatiello M, Vicedomini G, Santinelli V, Pappone C. Atrial fibrillation detection using a novel three-vector cardiac implantable monitor: the atrial fibrillation detect study. Europace 2017; 19:1101-1108. [DOI: 10.1093/europace/euw181] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Pappone C, Brugada J, Vicedomini G, Ciconte G, Manguso F, Saviano M, Vitale R, Cuko A, Giannelli L, Calovic Z, Conti M, Pozzi P, Natalizia A, Crisà S, Borrelli V, Brugada R, Sarquella-Brugada G, Guazzi M, Frigiola A, Menicanti L, Santinelli V. Electrical Substrate Elimination in 135 Consecutive Patients With Brugada Syndrome. Circ Arrhythm Electrophysiol 2017; 10:e005053. [DOI: 10.1161/circep.117.005053] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 04/13/2017] [Indexed: 11/16/2022]
Abstract
Background—
There is emerging evidence that localization and elimination of abnormal electric activity in the epicardial right ventricular outflow tract may be beneficial in patients with Brugada syndrome.
Methods and Results—
A total of 135 symptomatic Brugada syndrome patients having implantable cardiac defibrillator were enrolled: 63 (group 1) having documented ventricular tachycardia (VT)/ventricular fibrillation (VF) and Brugada syndrome–related symptoms, and 72 (group 2) having inducible VT/VF without ECG documentation at the time of symptoms. About 27 patients of group 1 experienced multiple implantable cardiac defibrillator shocks for recurrent VT/VF episodes. Three-dimensional maps before and after ajmaline determined the arrhythmogenic electrophysiological substrate (AES) as characterized by prolonged fragmented ventricular potentials. Primary end point was identification and elimination of AES leading to ECG pattern normalization and VT/VF noninducibility. Extensive areas of AES were found in the right ventricle epicardium, which were wider in group 1 (
P
=0.007). AES increased after ajmaline in both groups (
P
<0.001) and was larger in men (
P
=0.008). The increase of type-1 ST-segment elevation correlated with AES expansion (
r
=0.682,
P
<0.001). Radiofrequency ablation eliminated AES leading to ECG normalization and VT/VF noninducibility in all patients. During a median follow-up of 10 months, the ECG remained normal even after ajmaline in all except 2 patients who underwent a repeated effective procedure for recurrent VF.
Conclusions—
In Brugada syndrome, AES is commonly located in the right ventricle epicardium and ajmaline exposes its extent and distribution, which is correlated with the degree of coved ST-elevation. AES elimination by radiofrequency ablation results in ECG normalization and VT/VF noninducibility. Substrate-based ablation is effective in potentially eliminating the arrhythmic consequences of this genetic disease.
Clinical Trial Registration—
URL:
https://clinicaltrials.gov
. Unique identifier: NCT02641431.
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Pappone C, Santinelli V. Implantable cardioverter defibrillator and catheter ablation in Brugada syndrome. J Cardiovasc Med (Hagerstown) 2017; 18 Suppl 1:e35-e39. [DOI: 10.2459/jcm.0000000000000449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Pappone C, Brugada J, Vicedomini G, Ciconte G, Giannelli L, Saviano M, Santinelli V. 22-01: Epicardial ablation in Brugada syndrome. Insights from a prospective Registry study of 50 consecutive patients. Europace 2016. [DOI: 10.1093/europace/18.suppl_1.i25b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Pappone C, Ciconte G, Saviano M, Li W, Afonso V, Mangual J, Romano E, Cuko A, Giannelli L, Conti M, Vitale R, Baldi M, Vicedomini G, Santinelli V. 209-04: Characteristics and Anatomical Distribution of Electrophysiological Drivers in Patients with Paroxysmal and Persistent Atrial Fibrillation. Europace 2016. [DOI: 10.1093/europace/18.suppl_1.i140c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Pappone C, Ciconte G, Saviano M, Li W, Afonso V, Mangual J, Romanelli E, Crisa S, Cuko A, Giannelli L, Vitale R, Conti M, Baldi M, Vicedomini G, Santinelli V. 136-22: Fast and Regular Activities outside the Pulmonary Veins following Circumferential Pulmonary Vein Ablation in AF Patients. Europace 2016. [DOI: 10.1093/europace/18.suppl_1.i95b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Pappone C, Calovic Z, Cuko A, Vicedomini G, Mcspadden L, Ryu K, Caporaso I, Baldi M, Saviano M, Giannelli L, Moscatiello M, Vitale R, Santinelli V. 139-02: Comparison of the long-term efficacy of two different programming strategies for multipoint left ventricular pacing. Europace 2016. [DOI: 10.1093/europace/18.suppl_1.i180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Anselmino M, Matta M, D'ascenzo F, Pappone C, Santinelli V, Bunch TJ, Neumann T, Schilling RJ, Hunter RJ, Noelker G, Fiala M, Frontera A, Thomas G, Katritsis D, Jais P, Weerasooriya R, Kalman JM, Gaita F. Catheter ablation of atrial fibrillation in patients with diabetes mellitus: a systematic review and meta-analysis. Europace 2015; 17:1518-25. [DOI: 10.1093/europace/euv214] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Pappone C, Santinelli V. Electrophysiology testing and catheter ablation are helpful when evaluating asymptomatic patients with Wolff-Parkinson-White pattern: the pro perspective. Card Electrophysiol Clin 2015; 7:371-6. [PMID: 26304515 DOI: 10.1016/j.ccep.2015.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Important advances in the natural history and diagnosis of, and therapy for, asymptomatic Wolff-Parkinson-White (WPW) syndrome have been made in the last decade by our group. These data have necessitated revisiting current practice guidelines to decide on the optimal management of the asymptomatic WPW population. There has also been an emphasis on identifying initially asymptomatic individuals who are at risk by nationwide screening programs using the electrocardiogram for prophylactic catheter ablation to prevent the lifetime risk of sudden cardiac death, particularly in young asymptomatic people, because only a subgroup of them is at high risk, requiring early catheter ablation.
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Brugada J, Pappone C, Berruezo A, Vicedomini G, Manguso F, Ciconte G, Giannelli L, Santinelli V. Brugada Syndrome Phenotype Elimination by Epicardial Substrate Ablation. Circ Arrhythm Electrophysiol 2015; 8:1373-81. [PMID: 26291334 DOI: 10.1161/circep.115.003220] [Citation(s) in RCA: 164] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 07/30/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Whether Brugada syndrome (BrS) depends on functional epicardial substrates, which may be definitively eliminated by radiofrequency ablation, remains unknown. METHODS AND RESULTS Patients with BrS underwent epicardial mapping to identify areas of abnormal electrograms as target for radiofrequency ablation. Substrate identification consisted in mapping right ventricle epicardial surface before and after flecainide (2 mg/kg per 10 minutes). After radiofrequency ablation, flecainide and remap confirmed elimination of abnormal substrate, BrS ECG pattern, and ventricular tachycardia/ventricular fibrillation inducibility. Flecainide testing was performed at each follow-up visits ≤6 months. Fourteen patients with BrS, median age 39 years (30.3-42.3) with implantable cardioverter-defibrillator were enrolled. Low-voltage areas (<1.5 mV) were commonly identified on the anterior right free wall and right ventricular outflow tract, which increased after flecainide from 17.6 cm(2) (12.1-24.2) to 28.5 cm(2) (21.6-30.2; P=0.001). Similarly, areas with abnormal electrograms increased after flecainide from 19.0 (17.5-23.6) to 27.3 cm(2) (24.0-31.2; P=0.001). After 23.8 minutes (18.1-28.5) of radiofrequency ablation, abnormal electrograms disappeared, whereas low-voltage areas were replaced by scar areas (<0.5 mV) of 25.9 cm(2) (19.6-31.0). Substrate elimination resulted in BrS ECG pattern disappearance and no ventricular tachycardia/ventricular fibrillation inducibility without complications. After a median follow-up of 5 months (3.8-5.3), ECG remained normal despite flecainide. CONCLUSIONS In patients with BrS, there is a relationship between abnormal ECG pattern, the extent of abnormal epicardial substrate, and ventricular tachycardia/ventricular fibrillation inducibility. Ablation of the substrate identified in the presence of flecainide can eliminate the BrS phenotype and warrants further study.
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Pappone C, Vicedomini G, Petretta A, Giannelli L, Cuko A, Santinelli V. Ventricular fibrillation in lone atrial fibrillation as clinical manifestation of latent Brugada syndrome: Usefulness of flecainide testing. HeartRhythm Case Rep 2015; 1:285-289. [PMID: 28491569 PMCID: PMC5419534 DOI: 10.1016/j.hrcr.2015.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Pappone C, Vicedomini G, Manguso F, Saviano M, Baldi M, Pappone A, Ciaccio C, Giannelli L, Ionescu B, Petretta A, Vitale R, Cuko A, Calovic Z, Fundaliotis A, Moscatiello M, Tavazzi L, Santinelli V. Response to letter regarding article, "Wolff-Parkinson-White syndrome in the era of catheter ablation: insights from a registry study of 2169 patients". Circulation 2015; 131:e499. [PMID: 25986452 DOI: 10.1161/circulationaha.114.014534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Pappone C, Vicedomini G, Manguso F, Baldi M, Petretta A, Giannelli L, Saviano M, Pappone A, Ionescu B, Ciaccio C, Vitale R, Cuko A, Calovic Z, Fundaliotis A, Moscatiello M, Catalano C, Santinelli V. The natural history of WPW syndrome. Eur Heart J Suppl 2015. [DOI: 10.1093/eurheartj/suv004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Pappone C, alovi A, Cuko A, McSpadden LC, Ryu K, Jordan CD, Saviano M, Baldi M, Pappone A, Dozza L, Giannelli L, Fragakis N, Vicedomini G, Santinelli V. Multipoint left ventricular pacing provides additional echocardiographic benefit to responders and non-responders to conventional cardiac resynchronization therapy. Eur Heart J Suppl 2015. [DOI: 10.1093/eurheartj/suv005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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41
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Pappone C, Vicedomini G, Manguso F, Saviano M, Baldi M, Pappone A, Ciaccio C, Giannelli L, Ionescu B, Petretta A, Vitale R, Cuko A, Calovic Z, Fundaliotis A, Moscatiello M, Tavazzi L, Santinelli V. Wolff-Parkinson-White syndrome in the era of catheter ablation: insights from a registry study of 2169 patients. Circulation 2014; 130:811-9. [PMID: 25052405 DOI: 10.1161/circulationaha.114.011154] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The management of Wolff-Parkinson-White is based on the distinction between asymptomatic and symptomatic presentations, but evidence is limited in the asymptomatic population. METHODS AND RESULTS The Wolff-Parkinson-White registry was an 8-year prospective study of either symptomatic or asymptomatic Wolff-Parkinson-White patients referred to our Arrhythmology Department for evaluation or ablation. Inclusion criteria were a baseline electrophysiological testing with or without radiofrequency catheter ablation (RFA). Primary end points were the percentage of patients who experienced ventricular fibrillation (VF) or potentially malignant arrhythmias and risk factors. Among 2169 enrolled patients, 1001 (550 asymptomatic) did not undergo RFA (no-RFA group) and 1168 (206 asymptomatic) underwent ablation (RFA group). There were no differences in clinical and electrophysiological characteristics between the 2 groups except for symptoms. In the no-RFA group, VF occurred in 1.5% of patients, virtually exclusively (13 of 15) in children (median age, 11 years), and was associated with a short accessory pathway antegrade refractory period (P<0.001) and atrioventricular reentrant tachycardia initiating atrial fibrillation (P<0.001) but not symptoms. In the RFA group, ablation was successful in 98.5%, and after RFA, no patients developed malignant arrhythmias or VF over the 8-year follow-up. Untreated patients were more likely to experience malignant arrhythmias and VF (log-rank P<0.001). Time-dependent receiver-operating characteristic curves for predicting VF identified an optimal anterograde effective refractory period of the accessory pathway cutoff of 240 milliseconds. CONCLUSIONS The prognosis of the Wolff-Parkinson-White syndrome essentially depends on intrinsic electrophysiological properties of AP rather than on symptoms. RFA performed during the same procedure after electrophysiological testing is of benefit in improving the long-term outcomes.
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Pappone C, Berto MB, Santinelli V. The Unique MediGuide Technology For CRT Lead Placement And Catheter Ablation. J Atr Fibrillation 2014; 7:1072. [PMID: 27957083 PMCID: PMC5135152 DOI: 10.4022/jafib.1072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 06/10/2014] [Accepted: 06/09/2014] [Indexed: 11/10/2022]
Abstract
Electrophysiologic procedures such as catheter ablation and/or cardiac resynchronization therapy (CRT) are usually performed under fluoroscopic guidance alone. Currently, we are witnessing the birth of a new era in which many patients can be safely and effectively treated without the use of fluoroscopy. Using MediGuide technology continuous fluoroscopy is no longer required to ascertain the position of the device/catheter, which minimizes the radiation exposure for both the physician and patient, with a further benefit by minimal need for contrast agent. This novel system provides real time tracking of devices projected into live fluoroscopy or pre-recorded cine-angiography. MediGuide technology is an important step forward facilitating complex ablation procedures such as AF ablation and CRT implantation.
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Pappone C, Calovic Z, Cuko A, Mcspadden LC, Ryu K, Romano E, Baldi M, Pappone A, Vicedomini G, Santinelli V. PT077 Multipoint left ventricular pacing gives greater benefit in patients with lower baseline ejection fraction. Glob Heart 2014. [DOI: 10.1016/j.gheart.2014.03.1870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Pappone C, Calovic Z, Cuko A, Mcspadden LC, Ryu K, Romano E, Saviano M, Vitale R, Vicedomini G, Santinelli V. O157 Multipoint left ventricular pacing provides similar acute hemodynamic improvement regardless of QRS duration or lead location in cardiac resynchronization therapy patients. Glob Heart 2014. [DOI: 10.1016/j.gheart.2014.03.1364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Pappone C, Ćalović Ž, Vicedomini G, Cuko A, McSpadden LC, Ryu K, Romano E, Saviano M, Baldi M, Pappone A, Ciaccio C, Giannelli L, Ionescu B, Petretta A, Vitale R, Fundaliotis A, Tavazzi L, Santinelli V. Multipoint left ventricular pacing improves acute hemodynamic response assessed with pressure-volume loops in cardiac resynchronization therapy patients. Heart Rhythm 2014; 11:394-401. [DOI: 10.1016/j.hrthm.2013.11.023] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Indexed: 11/29/2022]
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Pappone C, Augello G, Gugliotta F, Santinelli V. Robotic and magnetic navigation for atrial fibrillation ablation. How and why? Expert Rev Med Devices 2014; 4:885-94. [DOI: 10.1586/17434440.4.6.885] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Pappone C, Vicedomini G, Santinelli V. Atrio-Esophageal Fistula After AF Ablation: Pathophysiology, Prevention &Treatment. J Atr Fibrillation 2013; 6:860. [PMID: 28496888 DOI: 10.4022/jafib.860] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 07/23/2013] [Accepted: 07/23/2013] [Indexed: 11/10/2022]
Abstract
Atrioesophageal fistula is an extremely rare but often fatal late complication of atrial fibrillation ablation procedures resulting from massive thermal injury to the esophagus and surrounding structures. Causes of death include cerebral air embolism, massive gastrointestinal bleeding, and septic shock. Because of its exceptionally low rate of occurrence, no predictors of lesion development have been found and there has not been an uniform approach to either early diagnosis or corrective therapy. Currently, preventive strategies include empirically reducing power titration during PVI and/or while ablating the posterior left atrial wall, limiting energy delivery time and number, avoiding overlapping ablation lines as well as monitoring intraluminal esophageal temperature. In addition, it has been suggested to use conscious sedation rather than general anesthesia for better pain perception, monitoring intraprocedural esophageal position in relation to the posterior left atrium and extensive patient education regarding signs and symptoms of esophageal injury. Early diagnosis is essential to enable an aggressive treatment including stenting and/or surgical intervention to minimize the excessive morbidity and mortality associated with this condition. Unfortunately, despite application of such preventive measures, cases of complete atrial-esophageal fistula have still been reported.
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Pappone C, Calovic Z, Cuko A, McSpadden LC, Ryu K, Baldi M, Pappone A, Saviano M, Giannelli L, Ciaccio C, Petretta A, Moscatiello M, Fundaliotis A, Vitale R, Ionescu B, Vicedomini G, Santinelli V. Multisite Left Ventricular Pacing in a Single Coronary Sinus Branch Improves 3-Month Echocardiographic and Clinical Response to Cardiac Resynchronization Therapy. J Card Fail 2013. [DOI: 10.1016/j.cardfail.2013.06.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Pappone C, Santinelli V. Asymptomatic Wolff-Parkinson-White Syndrome Should be Ablated. Card Electrophysiol Clin 2012; 4:281-285. [PMID: 26939947 DOI: 10.1016/j.ccep.2012.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Wolff-Parkinson-White syndrome (WPW) is associated with a small but lifetime risk of cardiac arrest and/or sudden cardiac death (SCD). However, the exact risk is not well defined, particularly in asymptomatic persons. Over recent years the authors have collected and reported new follow-up data among a large number of asymptomatic WPW patients, particularly children, intensively followed. These data have significantly contributed to the knowledge and definition of the natural history of WPW from childhood to adulthood. The risk of SCD is higher in asymptomatic children than in adults, and early ablation can be offered only to selected subjects after electrophysiologic testing.
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Pappone C, Santinelli V. Post Ablation Left Atrial Tachycardia: Understanding Mechanism, Prevention and Treatment. J Atr Fibrillation 2012; 5:525. [PMID: 28496760 PMCID: PMC5153123 DOI: 10.4022/jafib.525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Revised: 03/14/2012] [Accepted: 03/16/2012] [Indexed: 06/07/2023]
Abstract
Currently, post-ablation Atrial Tachycardias (ATs) represent a growing clinical problem particularly in patients with persistent AF undergoing a more extensive substrate ablation. Understanding mechanisms and location of potentially widely located arrhythmogenic substrates in the left atrium is crucial for successful ablation. Mapping and ablation are challenging since complex and multiple ATs may frequently develop during the index procedure and before conversion to sinus rhythm. Use of irrigated ablation guided by detailed 3-D electroanatomic activation maps combined with entrainment pacing is effective with excellent acute and long-term success rates, rarely requiring multiple procedures.
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