Download Case-Based Curriculum in Clinical Electrophysiology

Case-Based Curriculum in Clinical Electrophysiology
Fundamental Concepts in Electrophysiology
in Cases and Reviews
William G. Stevenson, MD; and Samuel Asirvatham, MD
A
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ssimilating the increasing body of knowledge required
for the treatment of patients with cardiac arrhythmias
is a substantial task. The trainee is bombarded with chapters
and reviews that are important for providing the frame work
from which to develop a detailed and nuanced knowledge
acquired from clinical experience and ongoing education.
Images and Case Reports provide succinct observations of
not only a novel or unusual finding, but often of the fundamentals that must be appreciated to place novel findings in context. The Teaching Points series in Circulation
Arrhythmia and Electrophysiology provides a more indepth synthesis of case-based learning building on common
and uncommon clinical findings. The purpose of this Casebased Curriculum in Clinical Electrophysiology is to provide the clinician and trainee with an easily accessible body
of current reviews, cases and Teaching Points that cover a
broad range of the field. Links to the individual articles are
provided to facilitate using this article as a spring board
for review.
Teaching points with 3-dimensional mapping of cardiac arrhythmia: Mechanism of arrhythmia and accounting for the
cycle length. Del Carpio Munoz F, et al.5
Accurate activation sequence mapping of cardiac arrhythmias is a fundamental skill in cardiac electrophysiology. For complex arrhythmias
an electroanatomic mapping system, which allows the mapping data to
be displayed on a representation of the anatomy is often employed, as
discussed in a series of articles Del Carpio Munoz and colleagues.3–6
Accurate mapping requires selecting an appropriate reference point and
mapping window and identification of the electrogram that indicates
local activation. In applying a mapping strategy it is important to recognize features of macroreentrant, as compared to focal arrhythmias,
and to recognize that seemingly small errors in assigning activation
times, reference electrograms, or mapping windows, can render a map
uninterpretable or meaningless. These issues are discussed in detail.
Teaching points with 3-dimensional mapping of cardiac arrhythmia: How to overcome potential pitfalls during substrate mapping? Del Carpio Munoz F, et al.6
Endocardial unipolar voltage mapping to detect epicardial
ventricular tachycardia substrate in patients with nonischemic left ventricular cardiomyopathy. Hutchinson MD, et al.7
Substrate mapping is a term that refers to localization of the likely
arrhythmia substrate, during sinus or paced rhythm rather than during VT, and is often based on concept that areas with low amplitude
electrograms are often regions of scar, that contain reentry circuits for
scar-related arrhythmias. Del Carpio Munoz and colleagues review
substrate mapping and potential pitfalls.6 Hutchinson and colleagues
describe the use of unipolar voltage maps, exploiting the “wider field
of view” of unipolar as opposed to bipolar recordings, to detect areas
of epicardial scar that can overly relatively normal appearing endocardial regions in nonischemic cardiomyopathy.7
Fundamentals of Electrophysiology, Mapping,
Ablation, and Electrocardiography
Emergence of complex behavior: An interactive model of
cardiac excitation provides a powerful tool for understanding electric propagation. Spector PS, et al.1
To facilitate an understanding of the relations between electrophysiologic properties and geometry that govern conduction, block and
reentry, Spector and colleagues have developed an interactive model
that allows the student to study the effects of varying parameters on
conduction, block, reentry and even entrainment (http://circep.ahajournals.org/cgi/content/full/CIRCEP.110.961524/DC1).1
Signals and signal processing for the electrophysiologist:
Part i: Electrogram acquisition. Venkatachalam KL, et al.8
Signals and signal processing for the electrophysiologist: Part
ii: Signal processing and artifact. Venkatachalam KL, et al.9
The pathophysiologic basis of fractionated and complex
electrograms and the impact of recording techniques on
their detection and interpretation. de Bakker JM et al.10
Arrhythmogenic implications of fibroblast-myocyte interactions. Rohr S.2
Myocardial fibrosis has major roles in creating the substrate for atrial
and ventricular arrhythmias and is reviewed by Rohr.2
Recording and interpreting electrograms is fundamental to electrophysiologic studies and mapping. An understanding of how recording
techniques influence electrograms, including discussion of artifacts
is provided by Venkatachalam and coworkers.8,9 Multicomponent,
fractionated electrograms are markers of abnormal conduction and
often considered for ablation targets for both ventricular and atrial
arrhythmias. De Bakker and Wittkampf discuss the genesis of these
signals, how they are influenced by recording techniques, and potential pitfalls related to their use for guiding ablation.10
Teaching points with 3-dimensional mapping of cardiac arrhythmias: Taking points: Activation mapping. Del Carpio
Munoz F et al.3
Teaching points with 3-dimensional mapping of cardiac arrhythmias: Teaching point 3: When early is not early. Del
Carpio Munoz F, et al.4
From The Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (W.G.S.); and Division of Cardiology, Mayo
Clinic, Rochester, MN (S.J.A.).
All articles referenced have been made free to the reader and accessible from links in the reference list.
Correspondence to William G. Stevenson, MD, Editor, Circulation: Arrhythmia and Electrophysiology Editorial Office, 560 Harrison Ave, Suite 502,
Boston, MA 02118. E-mail [email protected]
(Circ Arrhythm Electrophysiol. 2013;6:e95-e100.)
© 2013 American Heart Association, Inc.
Circ Arrhythm Electrophysiol is available at http://circep.ahajournals.org
e95
DOI: 10.1161/CIRCEP.113.001044
e96 Circ Arrhythm Electrophysiol December 2013
Catheter cryoablation: Biology and clinical uses. Andrade
JG, et al.11
Andrade et al review the mechanism of tissue injury, advantages, and
limitations of cryoablation.
Pseudo-heart block and pseudo-brugada morphology from
signal-averaging artifact during exercise stress testing.
Mendenhall GS, et al.12
Signal processing tools are applied not only to electrograms recorded
in the electrophysiology laboratory, but also to surface electrocardiograms recorded during ambulatory monitoring and exercise testing.
Recognition of the potential for artifacts is important with all recording technologies. Mendenhall et al show how a signal averaging algorithm applied during exercise testing produced artifacts mimicking
AV block and Brugda syndrome.12
Atrial Fibrillation and Flutter
Left atrial anatomy revisited. Ho SY, et al.13
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Mapping and ablation in the left atrium requires a detailed understanding of left atrial anatomy, which is provided by Ho and colleagues in
this review, which also includes discussion of adjacent structures at
risk for ablation injury, including the esophagus and phrenic nerves.13
Simultaneous, but dissociated left atrial fibrillation (AF) and
pulmonary vein tachycardia: A case of occult pulmonary
vein isolation. Miller MA, et al.
Pulmonary vein isolation is a cornerstone of catheter ablation for AF.
The correct interpretation of pulmonary vein electrograms and confirming isolation of the vein are important for procedural success.
Miller et al show that atrial tachycardia from within a pulmonary
vein can make it difficult to recognize isolation when ablation is performed during AF.14
How to approach reentrant atrial tachycardia after atrial
fibrillation ablation. Miyazaki S et al.15
Multiple atrial tachycardias after atrial fibrillation ablation: The importance of careful mapping and observation.
Miyazaki S et al.16
Restoration of sinus rhythm by incarceration, not elimination, of focal atrial tachycardia in left atrial substrate post
atrial fibrillation ablation. Shah AJ et al.17
Interatrial electrical dissociation after catheter-based ablation for atrial fibrillation and flutter. Gautam S, John RM.18
Organized atrial tachycardias are common after catheter or surgical
ablation procedures for atrial fibrillation. Their origin can be focal
or macroreentrant, and identification and ablation can be difficult. In
their teaching rounds paper Miyazaki et al show a case of macroreentrant tachycardia and demonstrate a systematic approach to defining
the circuit and site for ablation using a combination of activation and
entrainment mapping.15 In a case report Miyazaki et al show that
multiple tachycardias and tachycardia mechanisms can exist in a
single patient and again demonstrate the use of careful activation and
entrainment mapping to sequentially ablate these arrhythmias.16 Shah
et al show a case of a focal reentrant tachycardia after prior extensive
left atrial ablation, such that ablation of the tachycardia isolated the
left atrial appendage.17 Gautam and John show a case in which extensive ablation for AF electrically separated the left and right atria.18
Entrainment with long postpacing intervals from within the
flutter circuit: what is the mechanism? Wong KC, et al.19
This case demonstrates how decremental conduction properties in an
atrial reentry circuit can increase the post-pacing interval (PPI) following entrainment, producing a misleadingly long “false negative
PPIs at sites in the reentry circuit. Other causes of misleading PPIs
are also discussed.
Epicardial-only block during endocardial mitral isthmus ablation facilitated by coronary sinus occlusion. Shah AJ, et al.20
Recurrent perimitral tachycardia using epicardial coronary
sinus connection to bypass endocardial conduction block at
the mitral isthmus. Miyazaki S et al.21
Ablation lines between the mitral annulus and left pulmonary veins
are commonly placed to interrupt perimitral atrial flutter, but achieving block and confirming block is often difficult. The cases presented
in these articles illustrate methods for assessing conduction block and
show pitfalls that can occur and how to recognize them.20 Shah and
Miyazaki and their coworkers show cases in which the separation of
epicardial musculature around the coronary sinus from the left atrial
musculature creates the possibility for conduction block in only the
epicardial or endocardial component of the “mitral isthmus,” falsely
suggesting complete block.20,21
Catheter ablation of atrial fibrillation in transposition of the
great arteries treated with mustard atrial baffle. Frankel DS,
et al.22
As the number of adults with repaired congenital heart disease
increases, AF will be increasing encountered in this population of
patients who have complex atrial anatomy. Frankel et al show that
catheter ablation for AF is feasible for some of these patients and
illustrates the anatomic challenges that can be encountered.22
Congenital sick sinus syndrome with atrial inexcitability and
coronary sinus flutter. Varma N, et al.23
Sinus node dysfunction, atrial flutter and fibrillation are rare in children in the absence of structural heart disease. Varma et al present
a teaching rounds case of congenital atrial disease with sinus node
dysfunction, areas of atrial tachycardia and atrial electrical inexcitability, consistent with extensive fibrosis illustrating the coexistence
of multiple brady and tachyarrhythmias in this rare congenital atrial
disease.23
Cavotricuspid isthmus ablation guided by real-time magnetic resonance imaging. Piorkowski C, et al.24
Achieving conduction block in the common cavotricuspid isthmus
is difficult in some patients due to anatomic constraints, as can also
be encountered in other areas of the heart. Piorkowski et al show the
first human case of catheter ablation guided by real time magnetic
resonance imaging (MRI), which has the promise of facilitating ablation through better understanding of anatomic – catheter relationships during ablation, as well as future potential assessment of tissue
injury.24
Remaining ice cap on second-generation cryoballoon after
deflation. Bordignon S, et al.25
Cryoballoon ablation is effective for pulmonary vein isolation. Bordignon show a case of ice formation on the balloon, observable with
angiography illustrating the relevant anatomy and discuss the potential risk.25
Acute liver failure associated with dronedarone. Joghetaei
N, et al.26
Consideration and recognition of toxicities is critically important
in selecting therapies for AF. Although rare, dronedarone can cause
severe liver toxicity, and monitoring is warranted.26
Pacemakers and Defibrillators
Minimizing inappropriate or “unnecessary” implantable
cardioverter-defibrillator shocks: Appropriate programming. Koneru JN, et al.27
Posttraumatic stress and the implantable cardioverterdefibrillator patient: What the electrophysiologist needs to
know. Sears SF, et al.28
Stevenson and Asirvatham Cases and Reviews e97
Basic science of cardiac resynchronization therapy: Molecular
and electrophysiological mechanisms. Cho H, et al.29
Although patients with ICDs have effective protection from arrhythmic
death, recurrent symptomatic arrhythmias can have significant consequences for quality of life and psychological functioning. Optimizing
ICD programming, as reviewed by Koneru and colleagues27 is important. The recognition of the impact of arrhythmias on patients and the
need psychologic support is reviewed by Sears and coworkers.28
Biventricular pacing can improve ventricular function and extend survival in selected patients, and the beneficial effects stemming from
the change in ventricular activation extends beyond the immediate
mechanical effects as reviewed by Cho and colleagues.29
Autopsy analysis of the implantation site of a permanent
selective direct his bundle pacing lead. Correa de Sa DD,
et al.30
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Arrhythmia management devices have not only improved outcomes
for patients with arrhythmias, but also provided substantial insights
into pathophysiology. Correa de Sa et al describe an anatomic study
of a patient who had effective, chronic His bundle pacing for 2 years
and at autopsy the lead position could be directly examined and
related to the anatomy of the conduction system.30
Shock lead impedance alert: Replace or reconsider?
Hilgendorf I, et al.31
Charge circuit timeout: A sequence of events leading to failure of an implantable cardioverter-defibrillator to deliver
therapy. Catanzaro JN, et al.32
Trouble shooting arrhythmia management devices is an important
aspect of cardiac electrophysiology. Hilgendorf describe a case
of a fall in ICD lead impedance and discuss causes.31 Catanzaro et
al report a case of an unusual ICD software error and discuss the
sequence of events in capacitor charging.32
Seventh try’s a charm: Ventricular fibrillation terminated by
the seventh shock. Li J, et al.33
Transvenous implantable defibrillators are highly effective in terminating ventricular tachycardia and fibrillation. Li et al describe a
patient who required multiple shocks and review features associated
with increased energy requirements for defibrillation.33
Right coronary artery fistula as a result of delayed right atrial perforation by a passive fixation lead. Khoueiry G, et al.34
Cardiac perforation is an important risk of transvenous lead placement, that usually occurs acutely and often requires only lead repositioning, although tamponade and pericarditis can occur. Khoueiry
et al report an unusual case of chronic perforation of an atrial lead
ultimately leading to a right atrial right coronary artery fistula, and
review factors associated with lead perforation.34
Paroxysmal Supraventricular Tachycardias
Wenckebach during supraventricular tachycardia. Nguyen
DT, et al.35
Premature beats and unexpected heart block: An unusual
mechanism confirmed by ablation. Morris KE, et al.36
AV nodal reentry tachycardia is the most common paroxysmal supraventricular tachycardia encountered in adults and ablation of the slow
AV nodal pathway is usually straight forward. The AV node and its
connections to the atrium are variable, however, and can be complex.
Nguyen show that lower common pathway block can falsely suggest
atrial tachycardia, and that some patients require ablation of the leftward extension of the AV node.35
Morris et al present a case with complex interaction between an AV
nodal slow pathway and fast pathway producing a dual ventricular response in sinus rhythm and interesting episodes of AV block,
providing an opportunity to review the physiology of concealed
conduction and the distinction of junctional automatic beats from
simultaneous dual conduction through the AV node.36
Two cases of supraventricular tachycardia after accessory
pathway ablation. Wright JM, et al.37 Editors’ Perspective:
Con-founding Eccentricity
Approach to the difficult septal atrioventricular accessory
pathway: The importance of regional anatomy. Liu E, et al.38
Editors’ Perspective: Atrioventricular Accessory Pathways
and the Atrio-Ventricular Septum
Catheter ablation of an unusual decremental accessory pathway in the left coronary cusp of the aortic valve mimicking
outflow tract ventricular tachycardia. Wilsmore BR, et al.39
Editors’ Perspective: Teaching Points for
Decremental Pathways
“Classical” response in a pre-excited tachycardia: What
are the pathways involved? Thajudeen A, et al.40 Editors’
Perspective: Since We Cannot Directly Measure…We Must
Deduce…
Struck by lightning: A case of nature-induced pre-excited
atrial fibrillation. Leiria TL, et al.41
Rare forms of preexcitation: A case study and brief overview of familial forms of preexcitation. Koneru JN, et al.42
Editors’ Perspective: Difficult Accessory Pathways and
Ventricular Diseases
It is important to have a systematic approach to mapping and ablation of accessory pathways causing tachycardias. Most are straight
forward, but when difficult and confusing data are observed there are
several considerations including: multiple accessory pathways, multiple tachycardia mechanisms, unusually accessory pathway locations,
complex septal anatomy and prior ablation altering the atrial activation
sequence during orthodromic tachycardia. Mapping the atrial insertion
of accessory pathways can be difficult due to the potential for insertion of the pathway into musculature around the coronary sinus, rather
than the left atrium, and interpretation of activation may be made more
difficult in the presence of prior ablation lesions. These issues are well
shown in cases described by Wright37 and Liu38 and coworkers.
Antidromic tachycardias use an accessory pathway in the atrial to
ventricular direction and can mimic ventricular tachycardias. A systematic approach to exclude ventricular tachycardia and other types
of supraventricular tachycardia with aberrancy is needed. Wilsmore
and coworkers illustrate the approach to an antidromic tachycardia
in a patient with an unusual accessory pathway that mimicked RV
outflow tract VT due to its unusual location.39 In their Teaching Points
presentation Thajudeen and coworkers demonstrate these principles
in a patient with multiple accessory pathways with antidromic AV
reentry and orthodromic tachycardias as well as atrial tachycardia.40
Leiria and colleagues provide an unusual case illustrating the dangerously rapid ventricular response that can occur during atrial fibrillation in the presence of a rapidly conducting accessory pathway.41
Although accessory pathways are most commonly encountered in
patients without other forms of heart disease, they are associated with
a number of genetic disorders, which are important to consider, as
reviewed by Koneru and colleagues.42
Atrial tachycardia originating from the junction of the right
atrium and a diverticulum of the inferior vena cava. Yamada
T, et al.43
Deglutition-induced atrial tachycardia: Direct visualization
by intracardiac echocardiography. Ip JE, et al.44
Focal atrial tachycardias often originate from defined atrial structures.
The approach to mapping focal atrial tachycardia is nicely shown in
the case report from Yamada et al.43 Ip and colleagues describe a case
of atrial tachycardia precipitated by deglutition that originated from
a pulmonary vein.44
e98 Circ Arrhythm Electrophysiol December 2013
Sudden Death: Diseases and Syndromes
Long-qt syndrome: From genetics to management.
Circulation. Arrhythmia and electrophysiology. Schwartz
PJ, et al.45
Short qt syndrome: From bench to bedside. Patel C, et al.46
Sudden cardiac death in hypertrophic cardiomyopathy.
O’Mahony C, et al.47
Arrhythmogenic right ventricular cardiomyopathy. Basso C,
et al.48
Brugada syndrome. Mizusawa Y, Wilde AA.49
Catecholaminergic polymorphic ventricular tachycardia.
Leenhardt A, et al.50
Dilated cardiomyopathy. Lakdawala NK, et al.51
How to perform and interpret provocative testing for the
diagnosis of brugada syndrome, long-qt syndrome, and
catecholaminergic polymorphic ventricular tachycardia.
Obeyesekere MN, et al.52
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Reviews of genetic syndromes causing sudden death and their diagnosis are provided by Schwartz,45 Patel,46 O’Mahony,47 Mizusawa,49
Leenhardt,50 Basso,48 Lakdawala,51 and Obeyesekere.52
Left-dominant arrhythmogenic cardiomyopathy. Smaldone
C, et al.53
Smaldone and colleagues present a case of cardiomyopathy with
myocardial fibrosis and fat infiltration commonly associated with
arrhythmogenic RV cardiomyopathy, but in this case prominently
involving the LV, and discuss the difficult diagnosis.53
Does a Brugada pattern ecg precipitated by excessive-dose
flecainide provide a diagnosis of a Brugada syndrome patient and/or contraindicate its use? A case study. Reiffel JA.54
Management of an asymptomatic patient with a Brugada type electrocardiogram remains a challenging problem, as the risk of arrhythmic
events is low, but an unquantifiable possibility of sudden death often
remains. Reiffle present a case that illustrates the conundrum and
reviews possible approaches.54
Anomalous right coronary artery and sudden cardiac death.
Greet B, et al.55
Congenital coronary anomalies are a potential cause of sudden death,
but documentation of the mechanism is rare. Greet and colleagues
present a patient who was resuscitated from ventricular fibrillation
and found to have anomalous origin of the right coronary artery from
the left coronary cusp, and review the relation of coronary anomalies
to sudden death.55
Successful catheter ablation of bidirectional ventricular
premature contractions triggering ventricular fibrillation
in catecholaminergic polymorphic ventricular tachycardia
with ryr2 mutation. Kaneshiro T, et al.56
Repetitive episodes of polymorphic VT or ventricular fibrillation
(VF) initiated by identifiable PVC foci can be ablated to control the
arrhythmia. This situation is most commonly encountered in patients
with idiopathic VF, but has also been seen in long QT syndrome, Brugada syndrome, post myocardial infarction, and in cardiomyopathies.
Kaneshiro and coworkers report ablation in a patient with catecholaminergic polymorphic VT, showing the features of this rare disease,
as well as the approach to focal ablation of PVC triggers.56
Pantoprazole (proton pump inhibitor) contributing to torsades de pointes storm. Bibawy JN, et al.57
A large number of agents can cause QT prolongation and the polymorphic VT torsade de pointes. Bibawy and colleagues report a case
linked to a proton pump inhibitor in a patient with other predisposing
factors and review issues surrounding evaluation and management of
acquired torsade de pointes.57
Ventricular Arrhythmias
For reviews of mapping relevant to ventricular arrhythmias also see
the Teaching Points articles by Del Carpio3–6 noted above.
Examination of explanted heart after radiofrequency ablation
for intractable ventricular arrhythmia. Kelesidis I, et al.58
Left ventricular perforation during cooled-tip radiofrequency ablation for ischemic ventricular tachycardia. Jimenez A,
et al.59
Sustained monomorphic VT in patients with structural heart disease is usually due to scar-related reentry. Kelesidis and coworkers
compare voltage maps and ablation sites in electroanatomic maps
to direct observation of the anatomy after the heart was explanted
at transplantation from a patient with nonischemic cardiomyopathy,
showing the appears of RF lesions, and anatomic obstacles, including
papillary muscles and the thick ventricular wall that can make ablation challenging.58 Irrigated RF ablation often allows creation of deep
RF lesions that facilitates ablation, but as shown in the case described
by Jimenez, creation of transmural lesions through the myocardium
can result in perforation.59
Ablation of ventricular tachycardia in chronic chagasic cardiomyopathy with giant basal aneurysm: Carto sound, ct,
and mri merge. Valdigem BP, et al.60
Unusual complications of percutaneous epicardial access
and epicardial mapping and ablation of cardiac arrhythmias. Koruth JS, et al.61
Pleuropericardial fistula formation after prior epicardial
catheter ablation for ventricular tachycardia. Mathuria N,
et al.62
Percutaneous access to the pericardial space for epicardial mapping
is required for subepicardial VTs, particularly in patients with nonischemic cardiomyopathies and arrhythmogenic right ventricular
cardiomyopathy.63,64 Valdigem and coworkers show a case of endocardial and epicardial mapping for VT due to Chagas disease, with
preprocedure imaging that further illustrates the anatomic relations.60
Epicardial mapping and ablation procedure are likely associated
with a greater risk of complications than endocardial ablation.65 In
a case series Koruth and coworkers describe potential complications
related to obtaining epicardial access, mapping and ablation, including pericardial bleeding, subdiaphragmatic bleeding, right ventricular
to abdominal fistula, and coronary spasm.61 Mathuria and coworkers
report a case of a pleuropericardial fistula related to epicardial mapping and ablation and review the relevant anatomy.62
The left ventricular ostium: An anatomic concept relevant to
idiopathic ventricular arrhythmias. Yamada T, et al.66
Supravalvular arrhythmia: Identifying and ablating the substrate. Tabatabaei N, Asirvatham SJ.67
A novel, minimally-invasive surgical approach for ablation
of ventricular tachycardia originating near the proximal left
anterior descending coronary artery. Mulpuru SK, et al.68
Bipolar ablation of ventricular tachycardia in a patient after
atrial switch operation for dextro-transposition of the great
arteries. Piers SR, et al.69
VT originating from the outflow tract and supravalvular regions of
the heart are encountered in patients with and without structural
heart disease. Understanding the anatomy in this region is critical
to successful ablation and is reviewed by Tabatabaei and Yamada
and colleagues.66,67 Arrhythmias in the protected area anterior to the
aorta, beneath the left coronary artery are not approachable with
catheter ablation. Mulpuru show a surgical approach to ablation of
this region.68 Piers and coworkers present a challenging case of VT
originating from tissue between the aorta and RV in a patients with
repaired congenital heart disease.69 Integrating CT and mapping data
illustrates the anatomic challenges.
Stevenson and Asirvatham Cases and Reviews e99
Disclosures
W.G.S. is coholder of a patent on needle ablation that is consigned to
Brigham and Women’s Hospital. S.J.A. receives no significant honoraria and is a consultant with Abiomed, Atricure, Biotronik, Boston
Scientific, Medtronic, Spectranetics, St Jude, Sanofi-Aventis, Wolters
Kluwer, and Elsevier.
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Fundamental Concepts in Electrophysiology in Cases and Reviews
William G. Stevenson and Samuel Asirvatham
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Circ Arrhythm Electrophysiol. 2013;6:e95-e100
doi: 10.1161/CIRCEP.113.001044
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