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Mujović N, Marinković M, Lenarczyk R, Tilz R, Potpara TS. Catheter Ablation of Atrial Fibrillation: An Overview for Clinicians. Adv Ther 2017; 34:1897-1917. [PMID: 28733782 PMCID: PMC5565661 DOI: 10.1007/s12325-017-0590-z] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Indexed: 12/12/2022]
Abstract
Catheter ablation (CA) of atrial fibrillation (AF) is currently one of the most commonly performed electrophysiology procedures. Ablation of paroxysmal AF is based on the elimination of triggers by pulmonary vein isolation (PVI), while different strategies for additional AF substrate modification on top of PVI have been proposed for ablation of persistent AF. Nowadays, various technologies for AF ablation are available. The radiofrequency point-by-point ablation navigated by electro-anatomical mapping system and cryo-balloon technology are comparable in terms of the efficacy and safety of the PVI procedure. Long-term success of AF ablation including multiple procedures varies from 50 to 80%. Arrhythmia recurrences commonly occur, mostly due to PV reconnection. The recurrences are particularly common in patients with non-paroxysmal AF, dilated left atrium and the "early recurrence" of AF within the first 2-3 post-procedural months. In addition, this complex procedure can be accompanied by serious complications, such as cardiac tamponade, stroke, atrio-esophageal fistula and PV stenosis. Therefore, CA represents a second-line treatment option after a trial of antiarrhythmic drug(s). Good candidates for the procedure are relatively younger patients with symptomatic and frequent episodes of AF, with no significant structural heart disease and no significant left atrial enlargement. Randomized trials demonstrated the superiority of ablation compared to antiarrhythmic drugs in terms of improving the quality of life and symptoms in AF patients. However, nonrandomized studies reported additional clinical benefits from ablation over drug therapy in selected AF patients, such as the reduction of the mortality and stroke rates and the recovery of tachyarrhythmia-induced cardiomyopathy. Future research should enable the creation of more durable ablative lesions and the selection of the optimal lesion set in each patient according to the degree of atrial remodeling. This could provide better long-term CA success and expand indications for the procedure, especially among the patients with non-paroxysmal AF.
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Affiliation(s)
- Nebojša Mujović
- Cardiology Clinic, Clinical Center of Serbia, Višegradska 26, Belgrade, Serbia.
- School of Medicine, University of Belgrade, Dr Subotića 8, Belgrade, Serbia.
| | - Milan Marinković
- Cardiology Clinic, Clinical Center of Serbia, Višegradska 26, Belgrade, Serbia
| | - Radoslaw Lenarczyk
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Centre for Heart Diseases, Silesian Medical University, Zabrze, Poland
| | - Roland Tilz
- Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, University Heart Center Lübeck, Zabrze, Poland
| | - Tatjana S Potpara
- Cardiology Clinic, Clinical Center of Serbia, Višegradska 26, Belgrade, Serbia.
- School of Medicine, University of Belgrade, Dr Subotića 8, Belgrade, Serbia.
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Hussein A, Das M, Chaturvedi V, Asfour IK, Daryanani N, Morgan M, Ronayne C, Shaw M, Snowdon R, Gupta D. Prospective use of Ablation Index targets improves clinical outcomes following ablation for atrial fibrillation. J Cardiovasc Electrophysiol 2017. [PMID: 28639728 DOI: 10.1111/jce.13281] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIMS Late recovery of ablated tissue leading to reconnection of pulmonary veins remains common following radiofrequency catheter ablation for AF. Ablation Index (AI), a novel ablation quality marker, incorporates contact force (CF), time, and power in a weighted formula. We hypothesized that prospective use of our previously published derived AI targets would result in better outcomes when compared to CF-guided ablation. METHODS Eighty-nine consecutive drug-refractory AF patients (49% paroxysmal) underwent AI-guided ablation (AI-group). AI targets were 550 for anterior/roof and 400 for posterior/inferior left atrial segments. Procedural and clinical outcomes of these patients were compared to 89 propensity-matched controls who underwent CF-guided ablation (CF-group). All 178 procedures were otherwise similar, and both groups were followed-up for 12 months. The last 25 patients from each group underwent analysis of all VisiTags™ for ablation duration, CF, Force-Time Integral, and impedance drop. RESULTS First-pass pulmonary vein isolation (PVI) was more frequent in AI-group than in CF-group (173 [97%] vs. 149 [84%] circles, P < 0.001), and acute PV reconnection was lower (11 [6%] vs. 24 [13%] circles, P = 0.02). Mean PVI ablation time was similar (AI-group: 42 ± 9 vs. CF-group: 45 ± 14 minutes, P = 0.14). Median impedance drop for AI-group was significantly higher than in CF-group (13.7 [9-19] Ω vs. 8.8 [5.2-13] Ω, P < 0.001). Two major complications occurred in CF-group and none in AI-group. Atrial tachyarrhythmia recurrence was significantly lower in AI-group (15 of 89 [17%]) than in CF-group (33 of 89 [37%], P = 0.002). CONCLUSION AI-guided ablation is associated with significant improvements in the incidence of acute PV reconnection and atrial tachyarrhythmia recurrence rate compared to CF-guided ablation, potentially due to creation of better quality lesions as suggested by greater impedance drop.
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Affiliation(s)
- Ahmed Hussein
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Moloy Das
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Vivek Chaturvedi
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Issa Khalil Asfour
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Niji Daryanani
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Maureen Morgan
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Christina Ronayne
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Matthew Shaw
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Richard Snowdon
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Dhiraj Gupta
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
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Willems S, Khairy P, Andrade JG, Hoffmann BA, Levesque S, Verma A, Weerasooriya R, Novak P, Arentz T, Deisenhofer I, Rostock T, Steven D, Rivard L, Guerra PG, Dyrda K, Mondesert B, Dubuc M, Thibault B, Talajic M, Roy D, Nattel S, Macle L. Redefining the Blanking Period After Catheter Ablation for Paroxysmal Atrial Fibrillation: Insights From the ADVICE (Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination) Trial. Circ Arrhythm Electrophysiol 2017; 9:CIRCEP.115.003909. [PMID: 27516462 DOI: 10.1161/circep.115.003909] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 07/18/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Early recurrences (ERs) of atrial tachyarrhythmia are common after catheter ablation of atrial fibrillation. A 3-month blanking period is recommended by current guidelines. This study sought to investigate the significance of ER during the first 3 months post ablation in predicting late recurrences and determine whether it varies according to timing. METHODS AND RESULTS A total of 401 patients with paroxysmal atrial fibrillation undergoing pulmonary vein isolation were followed for 12 months with transtelephonic monitoring in the ADVICE (Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination) trial. Patients with atrial tachyarrhythmia ≥30 s within the 3-month blanking period were stratified according to the timing of ER. A total of 179 patients (44.6%) experienced their last episode of ER during the first (n=53), second (n=44), or third (n=82) month of the 3-month blanking period. One-year freedom from symptomatic atrial tachyarrhythmia was 77.2% in patients without ER compared with 62.6%, 36.4%, and 7.8% in patients with ER 1, 2, and 3 months post ablation, respectively (P<0.0001). Receiver operating curve analyses revealed a strong correlation between the timing of ER and late recurrence (area under the curve 0.82, P<0.0001). Corresponding hazard ratios for ER during the first, second, and third months were 1.84, 4.45, and 9.64, respectively. CONCLUSIONS This study validates the use of a blanking period after catheter ablation for paroxysmal atrial fibrillation but calls into question the 90-day cut-off value. In particular, >90% of patients with ER during the third month post ablation experience late recurrence by 1 year. However, pending further study, repeat ablation before 90 days cannot be routinely advocated. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01058980.
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Affiliation(s)
| | - Paul Khairy
- For the author affiliations, please see the Appendix
| | | | | | | | - Atul Verma
- For the author affiliations, please see the Appendix
| | | | - Paul Novak
- For the author affiliations, please see the Appendix
| | - Thomas Arentz
- For the author affiliations, please see the Appendix
| | | | | | - Daniel Steven
- For the author affiliations, please see the Appendix
| | - Lena Rivard
- For the author affiliations, please see the Appendix
| | | | - Katia Dyrda
- For the author affiliations, please see the Appendix
| | | | - Marc Dubuc
- For the author affiliations, please see the Appendix
| | | | - Mario Talajic
- For the author affiliations, please see the Appendix
| | - Denis Roy
- For the author affiliations, please see the Appendix
| | | | - Laurent Macle
- For the author affiliations, please see the Appendix.
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54
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Alipour P, Azizi Z, Pirbaglou M, Ritvo P, Pantano A, Verma A, Khaykin Y. Defining Blanking Period Post-Pulmonary Vein Antrum Isolation. JACC Clin Electrophysiol 2017; 3:568-576. [DOI: 10.1016/j.jacep.2017.01.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 12/07/2016] [Accepted: 01/11/2017] [Indexed: 12/25/2022]
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Themistoclakis S, China P. Early Recurrences of Atrial Tachyarrhythmias After Ablation of Atrial Fibrillation. JACC Clin Electrophysiol 2017; 3:577-579. [DOI: 10.1016/j.jacep.2017.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 03/31/2017] [Indexed: 10/19/2022]
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Verma N, Knight BP. What happens during the blanking period does not stay in the blanking period. J Cardiovasc Electrophysiol 2017; 28:634-635. [PMID: 28387480 DOI: 10.1111/jce.13209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 03/08/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Nishant Verma
- Division of Cardiology, Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Bradley P Knight
- Division of Cardiology, Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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Das M, Wynn GJ, Saeed Y, Gomes S, Morgan M, Ronayne C, Bonnett LJ, Waktare JEP, Todd DM, Hall MCS, Snowdon RL, Modi S, Gupta D. Pulmonary Vein Re-Isolation as a Routine Strategy Regardless of Symptoms: The PRESSURE Randomized Controlled Trial. JACC Clin Electrophysiol 2017; 3:602-611. [PMID: 29759434 DOI: 10.1016/j.jacep.2017.01.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/17/2017] [Accepted: 01/19/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVES The goal of this study was to determine whether a strategy of early re-isolation of pulmonary vein (PV) reconnection in all patients, regardless of symptoms, would reduce the recurrence of atrial fibrillation (AF) and improve quality of life. BACKGROUND Lasting pulmonary vein isolation (PVI) remains elusive. PV reconnection is strongly linked to the recurrence of arrhythmia. METHODS A total of 80 patients with paroxysmal AF were randomized 1:1 after contact force-guided PVI to receive either standard care or undergo a repeat electrophysiology study after 2 months regardless of symptoms (repeat study). At the initial procedure, PVI was demonstrated by entrance/exit block and adenosine administration after a minimum 20-min wait. At the repeat study, all sites of PV reconnection were re-ablated. Patients recorded electrocardiograms daily and whenever symptomatic for 12 months using a handheld monitor. Recurrence was defined as ≥30 s of atrial tachyarrhythmia (AT) after a 3-month blanking period. The Atrial Fibrillation Effect on Quality-of-Life Questionnaire was completed at baseline and at 6 and 12 months. RESULTS All 40 patients randomized to repeat study attended for this after 62 ± 6 days, of whom 25 (62.5%) had reconnection of 41 (26%) PVs. There were no complications related to these procedures. Subjects recorded a total of 32,203 electrocardiograms (380 [335 to 447] per patient) during 12.6 (12.2 to 13.2) months of follow-up. AT recurrence was significantly lower for the repeat study group (17.5% vs. 42.5%; p = 0.03), as was AT burden (p = 0.03). Scores on the Atrial Fibrillation Effect on Quality-of-Life Questionnaire were higher in the repeat study group at 6 months (p < 0.001) and 12 months (p = 0.02). CONCLUSIONS A strategy of routine repeat assessment with re-isolation of PV reconnection improved freedom from AT recurrence, AT burden, and quality of life compared with current standard care. (The Effect of Early Repeat Atrial Fibrillation [AF] on AF Recurrence [PRESSURE]; NCT01942408).
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Affiliation(s)
- Moloy Das
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Department of Cardiology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Gareth J Wynn
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; The Royal Melbourne Hospital, Melbourne, Australia
| | - Yawer Saeed
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Sean Gomes
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; The Prince of Wales Hospital, Sydney, Australia
| | - Maureen Morgan
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Christina Ronayne
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Laura J Bonnett
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - Johan E P Waktare
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Derick M Todd
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Mark C S Hall
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Richard L Snowdon
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Simon Modi
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Dhiraj Gupta
- Institute of Cardiovascular Medicine and Science, Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
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Liang JJ, Dixit S, Santangeli P. Mechanisms and clinical significance of early recurrences of atrial arrhythmias after catheter ablation for atrial fibrillation. World J Cardiol 2016; 8:638-646. [PMID: 27957250 PMCID: PMC5124722 DOI: 10.4330/wjc.v8.i11.638] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 09/06/2016] [Accepted: 09/18/2016] [Indexed: 02/06/2023] Open
Abstract
Early recurrence of atrial arrhythmias (ERAA) after ablation is common and strongly predicts late recurrences and ablation failure. However, since arrhythmia may eventually resolve in up to half of patients with ERAA, guidelines do not recommend immediate reintervention for ERAA episodes occurring during a 3-mo post-ablation blanking period. Certain clinical demographic, electrophysiologic, procedural, and ERAA-related characteristics may predict a higher likelihood of long-term ablation failure. In this review, we aim to discuss potential mechanisms of ERAA, and to summarize the clinical significance, prognostic implications, and treatment options for ERAA.
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Efficacy of Short-Term Antiarrhythmic Drugs Use after Catheter Ablation of Atrial Fibrillation-A Systematic Review with Meta-Analyses and Trial Sequential Analyses of Randomized Controlled Trials. PLoS One 2016; 11:e0156121. [PMID: 27224469 PMCID: PMC4880320 DOI: 10.1371/journal.pone.0156121] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 05/10/2016] [Indexed: 12/28/2022] Open
Abstract
Background The efficacy of short-term antiarrhythmic drugs (AADs) use compared with no-AADs prescription after catheter ablation of atrial fibrillation (AF) in preventing atrial arrhythmia recurrence is uncertain. Methods We searched PubMed, Embase, and the Cochrane Library through December 2015 to identify randomized controlled trials (RCTs) which evaluated the efficacy of short-term AADs use compared with no-AADs prescription after AF ablation in preventing atrial arrhythmia recurrence. The primary outcome was labeled as early atrial arrhythmia recurrence within 3 months after ablation. Secondary outcome was defined as late recurrence after 3 months of ablation. Random-effects model or fixed-effects model was used to estimate relative risks (RRs) with 95% confidence intervals (CIs). Results Six RCTs with 2,667 patients were included into this meta-analysis. Compared with no-AADs administration after AF ablation, short-term AADs use was associated with significant reduction of early atrial arrhythmia recurrence (RR, 0.68; 95% CI, 0.52–0.87; p = 0.003). Trial sequential analysis (TSA) showed that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit, establishing sufficient and conclusive evidence. However, compared with no-AADs prescription, short-term AADs use after AF ablation didn’t significantly reduce the risk of late atrial arrhythmia recurrence (RR, 0.92; 95% CI, 0.83–1.03; p = 0.15). TSA supported this result; meanwhile the estimated required information size (1,486 patients) was also met. Conclusion Short-term use of AADs after AF ablation can significantly decrease the risk of early atrial arrhythmia recurrence but not lead to corresponding reduction in risk of late atrial arrhythmia recurrence.
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DAS MOLOY, WYNN GARETHJ, MORGAN MAUREEN, RONAYNE CHRISTINA, WAKTARE JOHANE, TODD DERICKM, HALL MARKC, SNOWDON RICHARDL, MODI SIMON, GUPTA DHIRAJ. Reablated Sites of Acute Reconnection After Pulmonary Vein Isolation Do Not Predict Sites of Late Reconnection at Repeat Electrophysiology Study. J Cardiovasc Electrophysiol 2016; 27:381-9. [DOI: 10.1111/jce.12933] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 12/02/2015] [Accepted: 12/22/2015] [Indexed: 11/28/2022]
Affiliation(s)
- MOLOY DAS
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - GARETH J. WYNN
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - MAUREEN MORGAN
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - CHRISTINA RONAYNE
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - JOHAN E.P. WAKTARE
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - DERICK M. TODD
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - MARK C.S. HALL
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - RICHARD L. SNOWDON
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - SIMON MODI
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - DHIRAJ GUPTA
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
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Sauer WH, Callans DJ. The Tribulations of Atrial Fibrillation Ablation Trialists. Circ Arrhythm Electrophysiol 2016; 9:e003738. [DOI: 10.1161/circep.115.003738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- William H. Sauer
- From the Division of Cardiology, Section of Cardiac Electrophysiology, University of Colorado, Aurora (W.H.S.); Division of Cardiology, Section of Cardiac Electrophysiology, University of Pennsylvania, Philadelphia (D.J.C.)
| | - David J. Callans
- From the Division of Cardiology, Section of Cardiac Electrophysiology, University of Colorado, Aurora (W.H.S.); Division of Cardiology, Section of Cardiac Electrophysiology, University of Pennsylvania, Philadelphia (D.J.C.)
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