Frank Bogun

University of Michigan, Ann Arbor, Michigan, United States

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Publications (216)1402.57 Total impact


  • No preview · Article · Dec 2015 · Journal of the American College of Cardiology
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    ABSTRACT: Background: Adenosine can reveal dormant pulmonary vein (PV) conduction after PV isolation (PVI) in patients with paroxysmal atrial fibrillation (AF). However the impact of elimination of adenosine-provoked dormant PV conduction after PVI has not been formally evaluated. Objective: The goal of the study is to determine whether ablation of PV reconnections unmasked by adenosine improves outcomes. Methods: Patients (n=129) with paroxysmal AF were randomized to receive either adenosine (n=61) or no adenosine (n=68) after PV isolation. Dormant conduction revealed by adenosine after PVI was ablated until all adenosine-mediated reconnections were eliminated. Thereafter, both groups received isoproterenol. Results: Acute reconnection was seen in 23 patients (37%) in the adenosine group. There was a significant difference between the number of PVs reconnected if adenosine was given >60 minutes compared to those receiving adenosine <60 minutes after initial PV isolation [3/32 (9.4%) vs. 24/32 (75%), p<0.0001]. Patients who did not receive adenosine had more PV reconnections after isoproterenol infusion as compared to the adenosine group [17/68 (25.0%) vs. 5/61 (8.2%), p=0.018). There was no difference in the rate of AF recurrence in patients who received adenosine (24/61; 39%) as compared to control patients (23/68, 34%; log-rank p=0.83). Conclusion: Adenosine can reveal dormant conduction in a more than one-third of the patients with paroxysmal AF undergoing PVI. However, adenosine administration, and additional ablation of the resultant connections, does not improve long-term outcomes with a protocol that includes isoproterenol infusion.
    No preview · Article · Oct 2015 · Heart rhythm: the official journal of the Heart Rhythm Society
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    ABSTRACT: Background: Ventricular tachycardia (VT) in patients with cardiomyopathy originates in scar tissue. Intramural or epicardial scar may result in ineffective ablation if mapping and ablation are limited to the endocardium. The purpose of this study was to investigate whether preprocedural magnetic resonance imaging (MRI) is beneficial in patients with failed endocardial VT ablations in determining an appropriate ablation strategy. Methods and results: A cardiac MRI was performed in 20 patients with a failed ablation procedure and cardiomyopathy (nonischemic n = 12, ischemic n = 8). A subsequent ablation strategy was determined by a delayed enhanced MRI (DE-MRI) and an epicardial subxyphoid access was planned only in patients with epicardial or intramural free-wall scar. MRIs were performed in all patients with or without an implanted cardioverter defibrillator (ICD). The location of scar tissue in the MRI predicted the origin of VT in all patients. In 9/20 patients an epicardial procedure was performed based on the result of the MRI. An endocardial procedure was performed in the remaining 11 patients who had either endocardial or septal scarring and 1 patient in whom the MRI only showed artifact. Five patients remained inducible post ablation and 4 patients had VT recurrence within a follow-up period of 17±22 months. All of the latter patients had an intramural scar pattern. Conclusions: Imaging with DE-MRI prior to VT ablation in patients with previously failed endocardial ablation procedures is beneficial in identifying an ablation strategy, helps to focus on an area of interest intraprocedurally, and provides valuable outcomes information. This article is protected by copyright. All rights reserved.
    No preview · Article · Oct 2015 · Journal of Cardiovascular Electrophysiology
  • William Froehlich · Frank M Bogun · Thomas C Crawford

    No preview · Article · Sep 2015 · Circulation
  • Frank M. Bogun · Konstantinos C. Siontis

    No preview · Article · Sep 2015 · JACC Clinical Electrophysiology
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    ABSTRACT: Frequent idiopathic premature ventricular complexes (PVCs) can result in a reversible form of cardiomyopathy. The impact of variability in PVC frequency throughout the day on PVC-induced cardiomyopathy was assessed. The subjects of this study were 107 consecutive patients (58 men [54%], mean age 49.7±15.0 years, ejection fraction: 50.4±11.4%) referred for ablation of frequent PVCs. All patients had a 24 hour Holter prior to the ablation procedure. The circadian variation in PVC burden was determined and correlated with the presence or absence of cardiomyopathy. A total of 43 patients (40%) had cardiomyopathy. Patients with cardiomyopathy had an ejection fraction of 38.4±6.9%, a higher PVC burden (28.5±11.5% vs 19.5±10.5%, p=0.0001), less variability in circadian PVC distribution (Coefficient of variation (CoV) hourly: 31.5±21% vs 59.8±32.4%, p=0.0001), more frequent interpolated PVCs (20 patients [47%] vs 15 patients [23%], p=0.022), and were more frequently asymptomatic compared to patients without cardiomyopathy (56% vs 19%, p=0.0001). By multivariate analysis, consistency in PVC burden throughout the day was an independent predictor of PVC-induced cardiomyopathy (OR 16.3, 95% CI 1.115-155.3, p=0.015). In patients with frequent PVCs, consistency in hourly PVC frequency throughout the day is an independent predictor of PVC-induced cardiomyopathy. Copyright © 2015. Published by Elsevier Inc.
    No preview · Article · Aug 2015 · Heart rhythm: the official journal of the Heart Rhythm Society
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    ABSTRACT: Pace-mapping (PM) is used to identify the origin of ventricular arrhythmias (VAs). For intramural VAs the site of origin often cannot be reached and therefore pace-mapping is less accurate. Combining digitized PMs obtained from 2 breakthrough sites in different anatomic structures might help to differentiate intramural from non-intramural VA. In 18 consecutive patients with idiopathic intramural VAs, PM was performed from 2 breakthrough sites at adjacent anatomic structures. Twelve-lead electrocardiograms of the 2 PMs were averaged in MATLAB and compared (correlation coefficient [CC]) to the targeted VA. Dual-site PM was performed in a control group of 18 patients with non-intramural VAs, at the sites of earliest electrical activation and a breakthrough site at an adjacent anatomic location. Dual-site PMs had a higher CC compared to best single-site pace-maps (CC: 0.87±0.1 vs 0.81±0.16, p=0.02) in patients with intramural VAs. At the site of origin, single-site PMs showed a higher CC than dual-site PMs from adjacent anatomic locations (0.93±0.04 vs 0.89±0.05, p=0.0004) in patients with non-intramural VAs. Sensitivity, specificity, positive and negative predictive value of dual-site PMs for identifying an intramural VA was 89%, 82%, 84%, 88%, and 86%, respectively. Furthermore, by receiver operator characteristic curve analysis, a CC cut-off value for single-site pace-maps of ≤0.86 best differentiated intramural from non-intramural VAs. Higher CC with dual-site PMs from breakthrough sites as well as a PM CC ≤0.86 at the site of earliest electrical activity can differentiate intramural from non-intramural VAs. Copyright © 2015. Published by Elsevier Inc.
    No preview · Article · Aug 2015 · Heart rhythm: the official journal of the Heart Rhythm Society
  • Miki Yokokawa · Fred Morady · Frank Bogun
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    ABSTRACT: The failure to identify a successful target site for catheter ablation despite extensive endocardial and epicardial mapping is a common feature for an intramural site of origin of a ventricular arrhythmia. The purpose of this study was to assess whether transient suppression of premature ventricular complexes (PVCs) by injection of cold saline into the distal coronary venous system can identify an intramural focus. Cold saline (room temperature) was injected through an irrigated tip catheter into the distal coronary venous system in a consecutive series of 26 patients with frequent PVCs referred for catheter ablation. PVCs were temporarily suppressed in 11/26 patients during injection of cold saline. Extensive mapping suggested the presence of an intramural site of origin in 9/11 patients with PVC suppression by cold saline but in only 1/15 patients in whom PVCs were not suppressed. The suppression of PVCs by cold saline was associated with the presence of an intramural PVC focus with an accuracy of 88% (p=0.0002; sensitivity: 90%, specificity: 88%, positive predictive value: 82%, negative predictive value: 93%). Temporary suppression of PVCs by cold saline infused into the distal coronary venous system and the perforator veins strongly suggests the presence of an intramural septal focus of the PVCs. Copyright © 2015. Published by Elsevier Inc.
    No preview · Article · Aug 2015 · Heart rhythm: the official journal of the Heart Rhythm Society
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    ABSTRACT: Recurrent atrial fibrillation (AF) after successful cardioversion can be predicted by obstructive sleep apnea (OSA) diagnosed by polysomnography. However, it is not known whether the validated STOP-BANG questionnaire can predict AF recurrence after radiofrequency ablation (RFA). Our objective is to determine the prevalence of unrecognized OSA in patients with AF and its relation to freedom from AF after RFA. Validated surveys were administered to 247 consecutive AF patients following radiofrequency ablation from January to October 2011. OSA status was assessed at baseline RFA. Clinical follow up occurred at 3-6 month intervals. OSA had been previously diagnosed in 94/247 (38%). Among 153 patients without prior diagnosis of OSA, 121 (79%) had high risk STOP-BANG scores for OSA. Probability of maintaining sinus rhythm after RFA was similar among patients with known OSA (66/94, 70%) and high risk OSA scores (95/124, 77%) and higher than among patients with low risk OSA scores (29/32, 91%, P=0.03). Among patients without prior OSA, a high risk STOP-BANG score did predict recurrent AF (OR = 3.7, 95 % CI 1.4-11.4, P = 0.0005). Multivariate analysis showed a higher risk of atrial arrhythmia recurrence for non-paroxysmal AF patients (OR = 3.1, ± 95 % CI 1.4-7.1, P = 0.005). The majority of AF patients undergoing RFA have high risk OSA scores, suggesting that OSA is vastly underdiagnosed in this population. STOP-BANG independently predicted recurrent AF in patients without a prior diagnosis of OSA.
    Full-text · Article · Jun 2015 · Journal of Interventional Cardiac Electrophysiology
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    ABSTRACT: Objectives This study reports multicenter outcomes and complications for catheter ablation of premature ventricular complexes (PVCs) and investigates predictors of procedural success, as well as development of PVC-induced cardiomyopathy. Background Catheter ablation of frequent idiopathic PVCs is used to eliminate symptoms and treat PVC-induced cardiomyopathy. Large-scale multicenter outcomes and complication rates have not been reported. Methods This retrospective cohort study included 1,185 patients (55% female; mean age 52 ± 15 years; mean ejection fraction 55 ± 10%; mean PVC burden 20 ± 13%) who underwent catheter ablation for idiopathic PVCs at 8 centers between 2004 and 2013. The following factors were evaluated: patient demographics, procedural characteristics, complication rates, and clinical outcomes. Results Acute procedural success was achieved in 84% of patients. In centers at which patients were followed up routinely with post-ablation Holter monitoring, continued success at clinical follow-up without use of antiarrhythmic drugs was 71%. Including the use of antiarrhythmic medications, the success rate at a mean of 1.9 years of follow-up was 85%. In a multivariate analysis, the significant predictors of acute success were PVC location and number of distinct PVC configurations (p < 0.03). The only significant predictor of continued success at clinical follow-up was a right ventricular outflow tract PVC location (p < 0.01). In 245 patients (21%) with PVC-induced cardiomyopathy, the mean ejection fraction improved from 38% to 50% (p < 0.01) after ablation. Independent predictors for development of PVC-induced cardiomyopathy were male gender, PVC burden, lack of symptoms, and epicardial PVC origin (p < 0.05). The overall complication rate was 5.2% (2.4% major complications and 2.8% minor complications), and complications were most commonly related to vascular access (2.8%). There was no procedure-related mortality. Conclusions Catheter ablation of frequent PVCs is a low-risk and often effective treatment strategy to eliminate PVCs and associated symptoms. In patients with PVC-induced cardiomyopathy, cardiac function is frequently restored after successful ablation. © 2015 American College of Cardiology Foundation Published By Elsevier Inc.
    No preview · Article · Jun 2015 · JACC Clinical Electrophysiology
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    ABSTRACT: A recent meta-analysis demonstrated a survival benefit in post-infarction patients whose ventricular tachycardia (VT) was rendered noninducible by catheter ablation. Furthermore, patients with noninducible VT had a lower VT recurrence rate than did patients whose VT remained inducible after ablation. The purpose of this multicenter cohort study was to assess whether noninducibility after VT ablation is independently associated with improved survival. Data from 1,064 patients who underwent VT ablation for post-infarction VT at seven international centers were analyzed. The ablation procedure was considered successful if no VT was inducible at the end of the procedure and unsuccessful if VT remained inducible or if programmed stimulation was not performed at the end of the ablation. Median follow-up time was 633 days. Noninducibility was independently associated with lower mortality (adjusted hazard ratio: 0.65; 95% confidence interval: 0.53 to 0.79; p < 0.001). Atrial fibrillation, diabetes, and age were other independent predictors of higher mortality. Ablation of only the clinical VT in patients who also had inducible, nonclinical VTs was not associated with improved survival. Noninducibility after VT ablation in patients with post-infarction VT is independently associated with lower mortality during long-term follow-up. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
    No preview · Article · Apr 2015 · Journal of the American College of Cardiology
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    ABSTRACT: The natural history of premature ventricular complex (PVC)-induced cardiomyopathy is incompletely understood. The purpose of this study was to assess long term follow-up data in patients who underwent successful PVC ablation for PVC-induced cardiomyopathy. The subjects of this study were 60 patients (17 women, mean age: 52.5±16.8 years, ejection fraction:37.3±8.5% [median:40%, interquartile range (IQR):15]) with PVC-induced cardiomyopathy who underwent successful ablation of their predominant PVCs between 2005 and 2012. Patients were followed for a mean of 23.6±17.2 months. The EF improved to 57.2±4.7% [median:55%, IQR 5] (p=0.0001) within 9.6±8.4 months of the ablation procedure. During follow-up 10/60 (16.7%) patients had recurrent frequent PVCs and 50/60 (83.3%) patients did not. Patients underwent repeat assessment of EF and PVC burden. During follow-up of 23.6±17.2 months, 10 patients had recurrent frequent PVCs with an increase of their PVC burden from 1.4±0.9% [median:1.05%, IQR:1.59] after the initial ablation to 27.2±8.8% [median:26.0%, IQR:18.2] (p=0.018). Their EF decreased from 55.7±3.4% [median:55%, IQR:5.8] after the initial ablation to 40.2±5.1% [median:40%, IQR:15] (p=0.005). In the remaining patients with PVC-induced cardiomyopathy, the EF and PVC burden remained unchanged during follow-up. Patients with PVC recurrence had a higher number of pleomorphic PVC morphologies during initial presentation (4.7±2.2 vs 2.5±2.8, p=0.002). Recurrence of frequent PVCs in patients with a history of PVC cardiomyopathy can result in recurrence of cardiomyopathy. Follow-up in patients with PVC-induced cardiomyopathy is important, especially if patients were asymptomatic from the PVCs and have pleomorphic PVCs. Copyright © 2015. Published by Elsevier Inc.
    No preview · Article · Mar 2015 · Heart rhythm: the official journal of the Heart Rhythm Society
  • Rakesh Latchamsetty · Frank Bogun
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    ABSTRACT: Presentation, prognosis, and management of premature ventricular contractions (PVCs) vary significantly among patients and depend on PVC characteristics as well as patient comorbidities. Presentation can range from incidental discovery in an asymptomatic patient to debilitating heart failure. Prognosis is heavily dependent on various PVC characteristics including frequency and the presence or absence of underlying heart disease. Our understanding of the clinical significance of frequent PVCs, particularly as it relates to development of cardiomyopathy has advanced greatly in the past decade. In this chapter, we will explore the mechanisms governing PVC initiation and discuss prevalence and frequency in the general population. We will also explore prognostic implications based on PVC frequency as well as the presence or absence of underlying heart disease. We will then take a focused look at PVC-induced cardiomyopathy and identify predictors for developing cardiomyopathy. Finally, we will discuss clinical evaluation and management of patients presenting with frequent PVCs. Management can include clinical observation, addressing reversible causes, lifestyle modification, pharmacotherapy, or catheter ablation.
    No preview · Article · Mar 2015 · Current Problems in Cardiology
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    ABSTRACT: Cardiac sarcoidosis (CS) patients are at increased risk for sudden death. Isolated CS is rare and can be difficult to diagnose. In this multicenter retrospective review, patients with CS and an implantable cardiac defibrillator (ICD) were identified. Of 235 patients with CS and ICD, 13 (5.5 %) had isolated CS, including 7 (3.0 %) with definite isolated CS (biopsy or necropsy-proven) and 6 (2.6 %) with suspected isolated CS based on a constellation of clinical, ECG, and imaging findings. Among 13 patients with isolated CS, 10 (76.9 %) were male, mean age was 53.8 ± 7.6 years, and mean left ventricular ejection fraction was 38.3 ± 16.5. Diagnosis was made by cardiac magnetic resonance (CMR) (n = 2), biopsy (n = 3), CMR and biopsy (n = 2), CMR and positron emission tomography (PET) (n = 2), PET (n = 1), late enhanced cardiac CT (n = 1), pathology at heart transplant (n = 1), and autopsy (n = 1). Eight of 13 (61.5 %) patients with isolated CS had a secondary prevention indication (VT in 6 and VF in 2) vs. 80 of 222 (36.0 %) with sarcoidosis in other organs (p = 0.04). Over a mean of 4.2 years, 9 of 13 (69.2 %) patients with isolated CS received appropriate ICD therapy, including anti-tachycardia pacing (ATP) and/or shock, compared with 75 of 222 (33.8 %) patients with cardiac and extracardiac sarcoidosis (p = 0.0150). Six of 7 (85.7 %) patients with definite isolated CS received appropriate ICD intervention, compared with 78 of 228 patients (34.2 %) without definite isolated CS (p = 0.0192.) CONCLUSIONS: In this retrospective study, patients with isolated CS had very high rates of appropriate ICD therapy. Prospective, long-term follow-up of consecutive patients with isolated CS is needed to determine the true natural history and rates of ventricular arrhythmias in this rare and difficult-to-diagnose disease.
    No preview · Article · Feb 2015 · Journal of Interventional Cardiac Electrophysiology
  • Mario Njeim · Frank Bogun
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    ABSTRACT: Percutaneous catheter ablation has emerged as an effective treatment modality for the management of ventricular tachycardia. Despite years of progress in this field, the role of epicardial mapping and ablation needs to be further refined. In this review, we discuss the relationship between the type of underlying heart disease and the location of the arrythmogenic substrate as it pertains to a procedural approach. We describe the contribution of preprocedural and intraprocedural diagnostic tools for the localisation of the arrhythmogenic substrate, with a special emphasis on cardiac MRI and electrophysiological mapping. In our opinion, the preferred approach to target ventricular tachycardia should depend on the patient’s underlying heart disease and the location of scar tissue, which can be best visualised using cardiac MRI.
    No preview · Article · Jan 2015
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    ABSTRACT: Frequent idiopathic premature ventricular complexes (PVCs) can result in PVC-induced cardiomyopathy. Frequent PVCs can also aggravate ischemic cardiomyopathy (CMP). The impact of frequent PVCs on nonischemic cardiomyopathy has not been established. This was a consecutive series of 30 patients (age mean 59.1±12.1, 18 men, mean ejection fraction [EF] 38±15%) with structurally abnormal hearts based on the presence of scar in cardiac magnetic resonance imaging and/or a history of cardiomyopathy prior to the presence of frequent PVCs who were referred for ablation of frequent PVCs. Ablation was successful in 18/30 patients (60%), resulting in an increase of the mean EF from 33.9±14.5% to 45.7±17% (p-value <0.0001) during a mean follow-up of 30±28 months. The PVC burden in these patients was reduced from 23.1±8.8% to 1.0±0.9% (p-value <0.0001). The mean EF did not change in patients with a failed ablation procedure (44.4±16 vs 43.5±21, p-value=0.85). The PVC site of origin was in scar tissue in 14/18 patients with a successful ablation procedure. The mean NYHA functional class improved from 2.3±0.6 to 1.1±0.2 (p-value <0.0001) in patients with a successful outcome and remained unchanged in patients with an unsuccessful outcome (1.9±0.9 vs 1.9±0.7; p-value=1). In patients with frequent PVCs and nonischemic cardiomyopathy, the EF and functional class can be improved but not always normalized by successful PVC ablation. In most patients with an effective ablation, the arrhythmogenic substrate was located in scar tissue. Copyright © 2014. Published by Elsevier Inc.
    No preview · Article · Dec 2014 · Heart rhythm: the official journal of the Heart Rhythm Society
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    ABSTRACT: Background: The purpose of this study was to assess whether delayed enhancement (DE) on MRI is associated with ventricular tachycardia (VT)/ventricular fibrillation or death in patients with cardiac sarcoidosis and left ventricular ejection fraction >35%. Methods and results: Fifty-one patients with cardiac sarcoidosis and left ventricular ejection fraction >35% underwent DE-MRI. DE was assessed by visual scoring and quantified with the full-width at half-maximum method. The patients were followed for 48.0 ± 20.2 months. Twenty-two of 51 patients (63%) had DE. Forty patients had no prior history of VT (primary prevention cohort). Among those, 3 patients developed VT and 2 patients died. DE was associated with risk of VT/ventricular fibrillation or death (P=0.0032 for any DE and P<0.0001 for right ventricular DE). The positive predictive values of the presence of any DE, multifocal DE, and right ventricular DE for death or VT/ventricular fibrillation at mean follow-up of 48 months were 22%, 48%, and 100%, respectively. Among the 11 patients with a history of VT before the MRI, 10 patients had subsequent VTs, 1 of whom died. Conclusions: RV DE in patients with cardiac sarcoidosis is associated with a risk of adverse events in patients with cardiac sarcoidosis and preserved ejection fraction in the absence of a prior history of VT. Patients with DE and a prior history of VT have a high VT recurrence rate. Patients without DE on MRI have a low risk of VT.
    Full-text · Article · Sep 2014 · Circulation Arrhythmia and Electrophysiology
  • Rakesh Latchamsetty · Frank Bogun
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    ABSTRACT: Fascicular tachycardia is a reentrant ventricular tachycardia using the left fascicular conduction system with distinct ECG characteristics and clinical manifestations. Patients commonly present with exercise-induced palpitations and are often treated acutely with calcium channel blockers. Chronic management can be achieved either pharmacologically or by catheter ablation. The arrhythmia is usually found in patients without structural heart disease and has a favorable long-term prognosis.
    No preview · Article · Sep 2014 · Cardiac electrophysiology clinics
  • Thomas Crawford · Mario Njeim · Frank Bogun

    No preview · Article · Aug 2014 · Journal of the American College of Cardiology
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    ABSTRACT: Background: Epicardial left ventricular (LV) idiopathic ventricular arrhythmias (VAs) can be approached via the pericardial space, the coronary venous system (CVS), or other surrounding structures. The anatomic relationships between epicardial sites of origin (SOO) of VAs and surrounding anatomic structures have not been systematically described. Methods and results: In 17 patients with idiopathic epicardial VAs, the relationships between the SOO and the CVS and other neighboring anatomic structures were assessed by computed tomographic angiography. Ablation was successful in 12/17 patients (71%). In 10/17 patients, the SOO was at a distance of ≤4 mm from a coronary artery. The SOO was closer to the CVS (2.1 ± 1.5 mm) than to the pericardial space (9.7 ± 3.7 mm) or the LV endocardium (7.7 ± 2.7 mm). Successful ablations were carried out from the CVS (n = 3), the CVS and LV endocardium (n = 5), the CVS and the aortic cusp (n = 1), the CVS, the LV endocardium, and the aortic cusp (n = 1), the LV endocardium (n = 1), and the CVS and the pericardial space (n = 1). In the remaining 5 patients, a subxyphoid pericardial ablation procedure was attempted and failed in all 5 patients. Conclusion: The CVS is closer to the SOO of epicardial idiopathic VAs than the pericardial space, the ventricular endocardium, and the aortic cusps. Given the proximity to coronary arteries at the SOO, radiofrequency energy often cannot be safely delivered to eliminate a VA and ablation may also need to be performed from adjacent structures. A subxyphoid pericardial ablation procedure has a low probability of success in patients with idiopathic epicardial VAs.
    No preview · Article · Jul 2014 · Journal of Cardiovascular Electrophysiology

Publication Stats

8k Citations
1,402.57 Total Impact Points

Institutions

  • 1996-2015
    • University of Michigan
      • • Division of Cardiovascular Medicine
      • • Division of Pediatric Cardiology
      Ann Arbor, Michigan, United States
  • 1995-2015
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States
  • 2006
    • FACC Aerostructures Engines & Nacelles Interiors
      Neuhofen, Lower Austria, Austria
  • 2002-2004
    • Henry Ford Hospital
      Detroit, Michigan, United States
  • 1997-2002
    • Goethe-Universität Frankfurt am Main
      • • Center for Internal Medicine
      • • Medizinische Klinik III: Kardiologie, Angiologie/Hämostaseologie, Nephrologie
      Frankfurt, Hesse, Germany