2003;41:239 44. 304. Epstein AE, Miles WM, Benditt DG, et al. Personal and public safety issues related to arrhythmias that may affect consciousness: implications for regulation and physician recommendations. A medical/scientific statement from the American Heart Association and the North American Society of Pacing and Electrophysiology. Circulation. 1996;94:1147 66. 305. Pelliccia A, Zipes DP, Maron BJ. Bethesda Conference #36 and the European Society of Cardiology Consensus Recommendations revisited a comparison of US and European criteria for eligibility and disqualifica- tion of competitive athletes with cardiovascular abnormalities. J Am Coll Cardiol. 2008;52:1990 6. 306. Klein GJ, Yee R, Sharma AD. Longitudinal electrophysiologic assess- ment of asymptomatic patients with the Wolff-Parkinson-White electro- cardiographic pattern. N Engl J Med. 1989;320:1229 33. 307. Leitch JW, Klein GJ, Yee R, et al. Prognostic value of electrophysiology testing in asymptomatic patients with Wolff-Parkinson-White pattern. Circulation. 1990;82:1718 23. 308. Milstein S, Sharma AD, Klein GJ. Electrophysiologic profile of asymptomatic Wolff-Parkinson-White pattern. Am J Cardiol. 1986;57:1097 100. 309. Satoh M, Aizawa Y, Funazaki T, et al. Electrophysiologic evaluation of asymptomatic patients with the Wolff-Parkinson-White pattern. Pacing Clin Electrophysiol. 1989;12:413 20. 310. Havr nek S, Simek J, St ov ek P, et al. Distribution of mean cycle length in cavo-tricuspid isthmus dependent atrial flutter. Physiol Res. 2012;61:43 51. 311. Waldo AL, Feld GK. Inter-relationships of atrial fibrillation and atri- al flutter mechanisms and clinical implications. J Am Coll Cardiol. 2008;51:779 86. 312. Ellis K, Wazni O, Marrouche N, et al. Incidence of atrial fibrillation post- cavotricuspid isthmus ablation in patients with typical atrial flutter: left- atrial size as an independent predictor of atrial fibrillation recurrence. J Cardiovasc Electrophysiol. 2007;18:799 802. 313. Hsieh M-H, Tai C-T, Chiang C-E, et al. Recurrent atrial flutter and atrial fibrillation after catheter ablation of the cavotricuspid isthmus: a very long-term follow-up of 333 patients.


Recurrent atrial flutter and atrial fibrillation after catheter ablation of the cavotricuspid isthmus: a very long-term follow-up of 333 patients. J Interv Card Electrophysiol. 2002;7:225 31. 314. Tai CT, Chen SA, Chiang CE, et al. Long-term outcome of radiofrequen- cy catheter ablation for typical atrial flutter: risk prediction of recurrent arrhythmias. J Cardiovasc Electrophysiol. 1998;9:115 21. 315. Paydak H, Kall JG, Burke MC, et al. Atrial fibrillation after radiofre- quency ablation of type I atrial flutter: time to onset, determinants, and clinical course. Circulation. 1998;98:315 22. 316. Chinitz JS, Gerstenfeld EP, Marchlinski FE, et al. Atrial fibrillation is common after ablation of isolated atrial flutter during long-term follow- up. Heart Rhythm. 2007;4:1029 33. 317. Reithmann C, Hoffmann E, Spitzlberger G, et al. Catheter ablation of atrial flutter due to amiodarone therapy for paroxysmal atrial fibrillation. Eur Heart J. 2000;21:565 72. 318. Bertaglia E, Bonso A, Zoppo F, et al. Different clinical courses and pre- dictors of atrial fibrillation occurrence after transisthmic ablation in pa- tients with preablation lone atrial flutter, coexistent atrial fibrillation, and drug induced atrial flutter. Pacing Clin Electrophysiol. 2004;27:1507 12. 319. Satomi K, Chun KRJ, Tilz R, et al. Catheter ablation of multiple un- stable macroreentrant tachycardia within the right atrium free wall in patients without previous cardiac surgery. Circ Arrhythm Electrophysiol. 2010;3:24 31. 320. Seiler J, Schmid DK, Irtel TA, et al. Dual-loop circuits in postoperative atrial macro re-entrant tachycardias. Heart. 2007;93:325 30. 321. Roberts-Thomson KC, Kistler PM, Kalman JM. Focal atrial tachycar- dia I: clinical features, diagnosis, mechanisms, and anatomic location. Pacing Clin Electrophysiol. 2006;29:643 52. 322. Barbato G, Carinci V, Tomasi C, et al. Is electrocardiography a reli- able tool for identifying patients with isthmus-dependent atrial flutter? Europace. 2009;11:1071 6. 323. Akar JG, Al-Chekakie MO, Hai A, et al.


2009;11:1071 6. 323. Akar JG, Al-Chekakie MO, Hai A, et al. Surface electrocardiographic patterns and electrophysiologic characteristics of atrial flutter fol- lowing modified radiofrequency MAZE procedures. J Cardiovasc Electrophysiol. 2007;18:349 55. 324. Chugh A, Latchamsetty R, Oral H, et al. Characteristics of cavotricuspid isthmus-dependent atrial flutter after left atrial ablation of atrial fibrilla- tion. Circulation. 2006;113:609 15. 325. Shah D. ECG manifestations of left atrial flutter. Curr Opin Cardiol. 2009;24:35 41. Page et al 2015 ACC/AHA/HRS SVT Guideline e565 326. Nakagawa H, Jackman WM. Use of a 3-dimensional electroanatomi- cal mapping system for catheter ablation of macroreentrant right atrial tachycardia following atriotomy. J Electrocardiol. 1999;32 Suppl:16 21. 327. Delacretaz E, Ganz LI, Soejima K, et al. Multi atrial maco-re-entry cir- cuits in adults with repaired congenital heart disease: entrainment map- ping combined with three-dimensional electroanatomic mapping. J Am Coll Cardiol. 2001;37:1665 76. 328. Magnin-Poull I, De Chillou C, Miljoen H, et al. Mechanisms of right atrial tachycardia occurring late after surgical closure of atrial septal de- fects. J Cardiovasc Electrophysiol. 2005;16:681 7. 329. Kanagasundram AN, Baduashvili A, Liu CF, et al. A novel criterion for conduction block after catheter ablation of right atrial tachycardia after mitral valve surgery. Circ Arrhythm Electrophysiol. 2013;6:39 47. 330. Teh AW, Medi C, Lee G, et al. Long-term outcome following ablation of atrial flutter occurring late after atrial septal defect repair. Pacing Clin Electrophysiol. 2011;34:431 5. 331. McElderry HT, McGiffin DC, Plumb VJ, et al. Proarrhythmic aspects of atrial fibrillation surgery: mechanisms of postoperative macroreentrant tachycardias. Circulation. 2008;117:155 62. 332. Wazni OM, Saliba W, Fahmy T, et al. Atrial arrhythmias after sur- gical maze: findings during catheter ablation. J Am Coll Cardiol. 2006;48:1405 9. 333. Gerstenfeld EP, Callans DJ, Dixit S, et al. Mechanisms of organized left atrial tachycardias occurring after pulmonary vein isolation. Circulation.


Mechanisms of organized left atrial tachycardias occurring after pulmonary vein isolation. Circulation. 2004;110:1351 7. 334. Chugh A, Oral H, Lemola K, et al. Prevalence, mechanisms, and clinical significance of macroreentrant atrial tachycardia during and following left atrial ablation for atrial fibrillation. Heart Rhythm. 2005;2:464 71. 335. Veenhuyzen GD, Knecht S, O Neill MD, et al. Atrial tachycardias en- countered during and after catheter ablation for atrial fibrillation: part I: classification, incidence, management. Pacing Clin Electrophysiol. 2009;32:393 8. 336. Karch MR, Zrenner B, Deisenhofer I, et al. Freedom from atrial tachyarrhythmias after catheter ablation of atrial fibrillation: a random- ized comparison between 2 current ablation strategies. Circulation. 2005;111:2875 80. 337. Sawhney N, Anousheh R, Chen W, et al. Circumferential pulmonary vein ablation with additional linear ablation results in an increased incidence of left atrial flutter compared with segmental pulmonary vein isolation as an initial approach to ablation of paroxysmal atrial fibrillation. Circ Arrhythm Electrophysiol. 2010;3:243 8. 338. Neumann T, Vogt J, Schumacher B, et al. Circumferential pulmonary vein isolation with the cryoballoon technique results from a prospective 3-center study. J Am Coll Cardiol. 2008;52:273 8. 339. Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial de- sign: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and SurgicalAblation ofAtrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Heart Rhythm. 2012;9:632 96.e21. 340.


Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Heart Rhythm. 2012;9:632 96.e21. 340. Ellenbogen KA, Stambler BS, Wood MA, et al. Efficacy of intravenous ibutilide for rapid termination of atrial fibrillation and atrial flutter: a dose-response study. J Am Coll Cardiol. 1996;28:130 6. 341. Suttorp MJ, Kingma JH, Jessurun ER, et al. The value of class IC antiar- rhythmic drugs for acute conversion of paroxysmal atrial fibrillation or flutter to sinus rhythm. J Am Coll Cardiol. 1990;16:1722 7. 342. Stambler BS, Wood MA, Ellenbogen KA, et al. Efficacy and safety of repeated intravenous doses of ibutilide for rapid conversion of atrial flut- ter or fibrillation. Ibutilide Repeat Dose Study Investigators. Circulation. 1996;94:1613 21. 343. Kingma JH, Suttorp MJ. Acute pharmacologic conversion of atrial fibril- lation and flutter: the role of flecainide, propafenone, and verapamil. Am J Cardiol. 1992;70:56A 60A. 344. Vos MA, Golitsyn SR, Stangl K, et al. Superiority of ibutilide (a new class III agent) over DL-sotalol in converting atrial flutter and atrial fibrillation. The Ibutilide/Sotalol Comparator Study Group. Heart. 1998;79:568 75. 345. Volgman AS, Carberry PA, Stambler B, et al. Conversion effica- cy and safety of intravenous ibutilide compared with intravenous procainamide in patients with atrial flutter or fibrillation. J Am Coll Cardiol. 1998;31:1414 9. 346. Singh S, Zoble RG, Yellen L, et al. Efficacy and safety of oral dofetilide in converting to and maintaining sinus rhythm in patients with chronic atrial fibrillation or atrial flutter: the Symptomatic Atrial Fibrillation Investigative Research on Dofetilide (SAFIRE-D) study. Circulation. 2000;102:2385 90. 347.


Efficacy and safety of oral dofetilide in converting to and maintaining sinus rhythm in patients with chronic atrial fibrillation or atrial flutter: the Symptomatic Atrial Fibrillation Investigative Research on Dofetilide (SAFIRE-D) study. Circulation. 2000;102:2385 90. 347. Blackshear JL, Stambler BS, Strauss WE, et al. Control of heart rate dur- ing transition from intravenous to oral diltiazem in atrial fibrillation or flutter. Am J Cardiol. 1996;78:1246 50. 348. Singh BN, Hecht HS, Nademanee K, et al. Electrophysiologic and hemo- dynamic effects of slow-channel blocking drugs. Prog Cardiovasc Dis. 1982;25:103 32. 349. Akhtar M, Tchou P, Jazayeri M. Use of calcium channel entry blockers in the treatment of cardiac arrhythmias. Circulation. 1989;80:IV31 9. 350. Delle Karth G, Geppert A, Neunteufl T, et al. Amiodarone versus diltia- zem for rate control in critically ill patients with atrial tachyarrhythmias. Crit Care Med. 2001;29:1149 53. 351. Ellenbogen KA, Dias VC, Plumb VJ, et al. A placebo-controlled trial of continuous intravenous diltiazem infusion for 24-hour heart rate control during atrial fibrillation and atrial flutter: a multicenter study. J Am Coll Cardiol. 1991;18:891 7. 352. Ellenbogen KA, Dias VC, Cardello FP, et al. Safety and efficacy of in- travenous diltiazem in atrial fibrillation or atrial flutter. Am J Cardiol. 1995;75:45 9. 353. Platia EV, Michelson EL, Porterfield JK, et al. Esmolol versus verapamil in the acute treatment of atrial fibrillation or atrial flutter. Am J Cardiol. 1989;63:925 9. 354. Salerno DM, Dias VC, Kleiger RE, et al. Efficacy and safety of intra- venous diltiazem for treatment of atrial fibrillation and atrial flutter. The Diltiazem-Atrial Fibrillation/Flutter Study Group. Am J Cardiol. 1989;63:1046 51. 355. Basta M, Klein GJ, Yee R, et al. Current role of pharmacologic therapy for patients with paroxysmal supraventricular tachycardia. Cardiol Clin. 1997;15:587 97. 356. Gallagher MM, Guo XH, Poloniecki JD, et al.


1997;15:587 97. 356. Gallagher MM, Guo XH, Poloniecki JD, et al. Initial energy setting, out- come and efficiency in direct current cardioversion of atrial fibrillation and flutter. J Am Coll Cardiol. 2001;38:1498 504. 357. Botkin SB, Dhanekula LS, Olshansky B. Outpatient cardiover- sion of atrial arrhythmias: efficacy, safety, and costs. Am Heart J. 2003;145:233 8. 358. Pizzale S, Lemery R, Green MS, et al. Frequency and predictors of tachy- cardia-induced cardiomyopathy in patients with persistent atrial flutter. Can J Cardiol. 2009;25:469 72. 359. Van Gelder IC, Crijns HJ, Van Gilst WH, et al. Prediction of uneventful cardioversion and maintenance of sinus rhythm from direct-current elec- trical cardioversion of chronic atrial fibrillation and flutter. Am J Cardiol. 1991;68:41 6. 360. Boriani G, Tukkie R, Manolis AS, et al. Atrial antitachycardia pacing and managed ventricular pacing in bradycardia patients with paroxysmal or persistent atrial tachyarrhythmias: the MINERVA randomized multicen- tre international trial. Eur Heart J. 2014;35:2352 62. 361. Mitchell ARJ, Spurrell PAR, Cheatle L, et al. Effect of atrial antitachy- cardia pacing treatments in patients with an atrial defibrillator: ran- domised study comparing subthreshold and nominal pacing outputs. Heart. 2002;87:433 7. 362. Gillis AM, Unterberg-Buchwald C, Schmidinger H, et al. Safety and ef- ficacy of advanced atrial pacing therapies for atrial tachyarrhythmias in patients with a new implantable dual chamber cardioverter-defibrillator. J Am Coll Cardiol. 2002;40:1653 9. 363. Waldo AL, MacLean WA, Cooper TB, et al. Use of temporarily placed epicardial atrial wire electrodes for the diagnosis and treatment of cardi- ac arrhythmias following open-heart surgery. J Thorac Cardiovasc Surg. 1978;76:500 5. 364. Peters RW, Shorofsky SR, Pelini M, et al. Overdrive atrial pacing for conversion of atrial flutter: comparison of postoperative with nonpostop- erative patients. Am Heart J. 1999;137:100 3. 365. Ghali WA, Wasil BI, Brant R, et al.


1999;137:100 3. 365. Ghali WA, Wasil BI, Brant R, et al. Atrial flutter and the risk of throm- boembolism: a systematic review and meta-analysis. Am J Med. 2005;118:101 7. 366. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146:857 67. 367. Gallagher MM, Hennessy BJ, Edvardsson N, et al. Embolic complica- tions of direct current cardioversion of atrial arrhythmias: association with low intensity of anticoagulation at the time of cardioversion. J Am Coll Cardiol. 2002;40:926 33. 368. Schmidt H, von der Recke G, Illien S, et al. Prevalence of left atrial chamber and appendage thrombi in patients with atrial flutter and its clinical significance. J Am Coll Cardiol. 2001;38:778 84. 369. Lanzarotti CJ, Olshansky B. Thromboembolism in chronic atrial flutter: is the risk underestimated? J Am Coll Cardiol. 1997;30:1506 11. 370. Clemo HF, Wood MA, Gilligan DM, et al. Intravenous amiodarone for acute heart rate control in the critically ill patient with atrial tachyar- rhythmias. Am J Cardiol. 1998;81:594 8. 371. Roberts SA, Diaz C, Nolan PE, et al. Effectiveness and costs of digoxin treatment for atrial fibrillation and flutter. Am J Cardiol. 1993;72:567 73. 372. Natale A, Newby KH, Pisan E, et al. Prospective randomized compari- son of antiarrhythmic therapy versus first-line radiofrequency ablation in patients with atrial flutter. J Am Coll Cardiol. 2000;35:1898 904. 373. Bastani H, Drca N, Insulander P, et al. Cryothermal vs. radiofrequency ablation as atrial flutter therapy: a randomized comparison. Europace. 2013;15:420 8. 374. Poty H, Saoudi N, Nair M, et al. Radiofrequency catheter abla- tion of atrial flutter. Further insights into the various types of isth- mus block: application to ablation during sinus rhythm. Circulation. 1996;94:3204 13. 375. Schwartzman D, Callans DJ, Gottlieb CD, et al.


1996;94:3204 13. 375. Schwartzman D, Callans DJ, Gottlieb CD, et al. Conduction block in the inferior vena caval-tricuspid valve isthmus: association with outcome of radiofrequency ablation of type I atrial flutter. J Am Coll Cardiol. 1996;28:1519 31. 376. Da Costa A, Th venin J, Roche F, et al. Results from the Loire-Ard che- Dr me-Is re-Puy-de-D me (LADIP) trial on atrial flutter, a multicentric prospective randomized study comparing amiodarone and radiofrequency ablation after the first episode of symptomatic atrial flutter. Circulation. 2006;114:1676 81. 377. Pedersen OD, Bagger H, Keller N, et al. Efficacy of dofetilide in the treatment of atrial fibrillation-flutter in patients with reduced left ven- tricular function: a Danish Investigations of Arrhythmia and Mortality on Dofetilide (DIAMOND) substudy. Circulation. 2001;104:292 6. 378. Benditt DG, Williams JH, Jin J, et al. Maintenance of sinus rhythm with oral d,l-sotalol therapy in patients with symptomatic atrial fibrillation and/or atrial flutter. d,l-Sotalol Atrial Fibrillation/Flutter Study Group. Am J Cardiol. 1999;84:270 7. 379. Huang DT, Monahan KM, Zimetbaum P, et al. Hybrid pharmacologic and ablative therapy: a novel and effective approach for the management of atrial fibrillation. J Cardiovasc Electrophysiol. 1998;9:462 9. 380. Schumacher B, Jung W, Lewalter T, et al. Radiofrequency ablation of atrial flutter due to administration of class IC antiarrhythmic drugs for atrial fibrillation. Am J Cardiol. 1999;83:710 3. 381. Mohanty S, Mohanty P, Di Biase L, et al. Results from a single-blind, randomized study comparing the impact of different ablation approaches on long-term procedure outcome in coexistent atrial fibrillation and flut- ter (APPROVAL). Circulation. 2013;127:1853 60. 382. Wazni O, Marrouche NF, Martin DO, et al. Randomized study compar- ing combined pulmonary vein-left atrial junction disconnection and ca- votricuspid isthmus ablation versus pulmonary vein-left atrial junction disconnection alone in patients presenting with typical atrial flutter and atrial fibrillation. Circulation.


Randomized study compar- ing combined pulmonary vein-left atrial junction disconnection and ca- votricuspid isthmus ablation versus pulmonary vein-left atrial junction disconnection alone in patients presenting with typical atrial flutter and atrial fibrillation. Circulation. 2003;108:2479 83. 383. Aliot E, Denjoy I. Comparison of the safety and efficacy of flecainide versus propafenone in hospital out-patients with symptomatic paroxys- mal atrial fibrillation/flutter. The Flecainide AF French Study Group. Am J Cardiol. 1996;77:66A 71A. 384. Van Gelder IC, Crijns HJ, Van Gilst WH, et al. Efficacy and safety of flecainide acetate in the maintenance of sinus rhythm after electrical cardioversion of chronic atrial fibrillation or atrial flutter. Am J Cardiol. 1989;64:1317 21. 385. Pietersen AH, Hellemann H. Usefulness of flecainide for prevention of paroxysmal atrial fibrillation and flutter. Danish-Norwegian Flecainide Multicenter Study Group. Am J Cardiol. 1991;67:713 7. 386. Crijns HJ, Van Gelder IC, Kingma JH, et al. Atrial flutter can be termi- nated by a class III antiarrhythmic drug but not by a class IC drug. Eur Heart J. 1994;15:1403 8. 387. Alboni P, Botto GL, Baldi N, et al. Outpatient treatment of recent-onset atrial fibrillation with the pill-in-the-pocket approach. N Engl J Med. 2004;351:2384 91. 388. Ruder MA, Davis JC, Eldar M, et al. Clinical and electrophysiologic char- acterization of automatic junctional tachycardia in adults. Circulation. 1986;73:930 7. 389. Villain E, Vetter VL, Garcia JM, et al. Evolving concepts in the manage- ment of congenital junctional ectopic tachycardia. A multicenter study. Circulation. 1990;81:1544 9. 390. Raja P, Hawker RE, Chaikitpinyo A, et al. Amiodarone management of junctional ectopic tachycardia after cardiac surgery in children. Br Heart J. 1994;72:261 5. 391. Wyndham CR, Dhingra RC, Smith T, et al. Concealed nonparoxysmal junctional tachycardia. Circulation. 1979;60:707 10. 392. Konecke LL, Knoebel SB. Nonparoxysmal junctional tachycardia com- plicating acute myocardial infarction. Circulation. 1972;45:367 74. 393.


Nonparoxysmal junctional tachycardia com- plicating acute myocardial infarction. Circulation. 1972;45:367 74. 393. Fishenfeld J, Desser KB, Benchimol A. Non-paroxysmal A-V junctional tachycardia associated with acute myocardial infarction. Am Heart J. 1973;86:754 8. 394. Breslow MJ, Evers AS, Lebowitz P. Successful treatment of acceler- ated junctional rhythm with propranolol: possible role of sympathetic stimulation in the genesis of this rhythm disturbance. Anesthesiology. 1985;62:180 2. 395. Lee KL, Chun HM, Liem LB, et al. Effect of adenosine and verapamil in catecholamine-induced accelerated atrioventricular junctional rhythm: insights into the underlying mechanism. Pacing Clin Electrophysiol. 1999;22:866 70. 396. Padanilam BJ, Manfredi JA, Steinberg LA, et al. Differentiating junctional tachycardia and atrioventricular node re-entry tachycardia based on re- sponse to atrial extrastimulus pacing. J Am Coll Cardiol. 2008;52:1711 7. 397. Kumagai K,Yamato H,YamanouchiY, et al. Automatic junctional tachy- cardia in an adult. Clin Cardiol. 1990;13:813 6. 398. Cook JR, Steinberg JS. An incessant form of junctional ectopic tachycardia in an adult responsive to a class 1C agent. Am Heart J. 1991;122:1487 9. 399. Kuck KH, Kunze KP, Schl ter M, et al. Encainide versus flecainide for chronic atrial and junctional ectopic tachycardia. Am J Cardiol. 1988;62:37L 44L. 400. Paul T, Reimer A, Janousek J, et al. Efficacy and safety of propafe- none in congenital junctional ectopic tachycardia. J Am Coll Cardiol. 1992;20:911 4. 401. Sarubbi B, Musto B, Ducceschi V, et al. Congenital junctional ectopic tachycardia in children and adolescents: a 20 year experience based study. Heart. 2002;88:188 90. 402. Mamchur SE, Kurilin MY. High-amplitude pace mapping increases safe- ty of radiofrequency catheter ablation of parahisian ectopic foci. Pacing Clin Electrophysiol. 2012;35:1458 63. 403. Scheinman MM, Gonzalez RP, Cooper MW, et al. Clinical and electro- physiologic features and role of catheter ablation techniques in adult patients with automatic atrioventricular junctional tachycardia. Am J Cardiol.


Clinical and electro- physiologic features and role of catheter ablation techniques in adult patients with automatic atrioventricular junctional tachycardia. Am J Cardiol. 1994;74:565 72. 404. Fan R, Tardos JG, Almasry I, et al. Novel use of atrial overdrive pacing to rapidly differentiate junctional tachycardia from atrioventricular nodal reentrant tachycardia. Heart Rhythm. 2011;8:840 4. 405. Srivathsan K, Gami AS, Barrett R, et al. Differentiating atrioventricu- lar nodal reentrant tachycardia from junctional tachycardia: novel application of the delta H-A interval. J Cardiovasc Electrophysiol. 2008;19:1 6. 406. Field ME, Miyazaki H, Epstein LM, et al. Narrow complex tachy- cardia after slow pathway ablation: continue ablating? J Cardiovasc Electrophysiol. 2006;17:557 9. 407. Garson A Jr., Gillette PC. Electrophysiologic studies of supraventricular tachycardia in children. I. Clinical-electrophysiologic correlations. Am Heart J. 1981;102:233 50. 408. Ko JK, Deal BJ, Strasburger JF, et al. Supraventricular tachycardia mech- anisms and their age distribution in pediatric patients. Am J Cardiol. 1992;69:1028 32. 409. Weindling SN, Saul JP, Walsh EP. Efficacy and risks of medical therapy for supraventricular tachycardia in neonates and infants. Am Heart J. 1996;131:66 72. 410. Garson A Jr., Gillette PC, McNamara DG. Supraventricular tachycar- dia in children: clinical features, response to treatment, and long-term follow-up in 217 patients. J Pediatr. 1981;98:875 82. 411. Di Mambro C, Russo MS, Righi D, et al. Ventricular pre-excitation: symptomatic and asymptomatic children have the same potential risk of sudden cardiac death. Europace. 2015:617 21. 412. Pediatric and Congenital Electrophysiology Society (PACES), Heart Rhythm Society (HRS), American College of Cardiology Foundation (ACCF), et al. PACES/HRS expert consensus statement on the man- agement of the asymptomatic young patient with a Wolff-Parkinson- White (WPW, ventricular preexcitation) electrocardiographic pattern. Developed in partnership between the Pediatric and Congenital Page et al 2015 ACC/AHA/HRS SVT Guideline e567 Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS).


Developed in partnership between the Pediatric and Congenital Page et al 2015 ACC/AHA/HRS SVT Guideline e567 Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Heart Rhythm. 2012;9:1006 24. 413. Dixon J, Foster K, Wyllie J, et al. Guidelines and adenosine dosing in supraventricular tachycardia. Arch Dis Child. 2005;90:1190 1. 414. D az-Parra S, S nchez-Ya ez P, Zabala-Arg elles I, et al. Use of adenos- ine in the treatment of supraventricular tachycardia in a pediatric emer- gency department. Pediatr Emerg Care. 2014;30:388 93. 415. Losek JD, Endom E, Dietrich A, et al. Adenosine and pediatric supraven- tricular tachycardia in the emergency department: multicenter study and review. Ann Emerg Med. 1999;33:185 91. 416. Sanatani S, Potts JE, Reed JH, et al. The study of antiarrhythmic medi- cations in infancy (SAMIS): a multicenter, randomized controlled trial comparing the efficacy and safety of digoxin versus propranolol for prophylaxis of supraventricular tachycardia in infants. Circ Arrhythm Electrophysiol. 2012;5:984 91. 417. Deal BJ, Keane JF, Gillette PC, et al. Wolff-Parkinson-White syndrome and supraventricular tachycardia during infancy: management and fol- low-up. J Am Coll Cardiol. 1985;5:130 5. 418. Villain E, Bonnet D, Acar P, et al. [Recommendations for the treat- ment of recurrent supraventricular tachycardia in infants]. Arch Pediatr. 1998;5:133 8. 419. Fish FA, Gillette PC, Benson DW Jr. Proarrhythmia, cardiac arrest and death in young patients receiving encainide and flecainide. The Pediatric Electrophysiology Group. J Am Coll Cardiol. 1991;18:356 65. 420. Lee P-C, Hwang B, Chen S-A, et al. The results of radiofrequency cath- eter ablation of supraventricular tachycardia in children. Pacing Clin Electrophysiol. 2007;30:655 61. 421. Van Hare GF, Javitz H, Carmelli D, et al. Prospective assessment after pediatric cardiac ablation: demographics, medical profiles, and initial outcomes. J Cardiovasc Electrophysiol. 2004;15:759 70. 422. Aiyagari R, Saarel EV, Etheridge SP, et al.


2004;15:759 70. 422. Aiyagari R, Saarel EV, Etheridge SP, et al. Radiofrequency ablation for supraventricular tachycardia in children < or =15 kg is safe and effective. Pediatr Cardiol. 2005;26:622 6. 423. Blaufox AD, Felix GL, Saul JP, et al. Radiofrequency catheter ablation in infants </=18 months old: when is it done and how do they fare?: Short-term data from the Pediatric Ablation Registry. Circulation. 2001;104:2803 8. 424. Blaufox AD, Paul T, Saul JP. Radiofrequency catheter ablation in small children: relationship of complications to application dose. Pacing Clin Electrophysiol. 2004;27:224 9. 425. Kantoch MJ, Gulamhusein SS, Sanatani S. Short- and long-term out- comes in children undergoing radiofrequency catheter ablation before their second birthday. Can J Cardiol. 2011;27:523.e3 9. 426. Schaffer MS, Gow RM, Moak JP, et al. Mortality following radiofre- quency catheter ablation (from the Pediatric Radiofrequency Ablation Registry). Participating members of the Pediatric Electrophysiology Society. Am J Cardiol. 2000;86:639 43. 427. Van Hare GF, Javitz H, Carmelli D, et al. Prospective assessment after pediatric cardiac ablation: recurrence at 1 year after initially successful ablation of supraventricular tachycardia. Heart Rhythm. 2004;1:188 96. 428. Buddhe S, Singh H, Du W, et al. Radiofrequency and cryoablation thera- pies for supraventricular arrhythmias in the young: five-year review of efficacies. Pacing Clin Electrophysiol. 2012;35:711 7. 429. Chiu S-N, Lu C-W, Chang C-W, et al. Radiofrequency catheter abla- tion of supraventricular tachycardia in infants and toddlers. Circ J. 2009;73:1717 21. 430. Batra AS, Chun DS, Johnson TR, et al. A prospective analysis of the incidence and risk factors associated with junctional ectopic tachy- cardia following surgery for congenital heart disease. Pediatr Cardiol. 2006;27:51 5. 431. Andreasen JB, Johnsen SP, Ravn HB. Junctional ectopic tachycardia af- ter surgery for congenital heart disease in children. Intensive Care Med. 2008;34:895 902. 432. Haas NA, Camphausen CK.


Intensive Care Med. 2008;34:895 902. 432. Haas NA, Camphausen CK. Impact of early and standardized treatment with amiodarone on therapeutic success and outcome in pediatric patients with postoperative tachyarrhythmia. J Thorac Cardiovasc Surg. 2008;136:1215 22. 433. Laird WP, Snyder CS, Kertesz NJ, et al. Use of intravenous amiodarone for postoperative junctional ectopic tachycardia in children. Pediatr Cardiol. 2003;24:133 7. 434. Kovacikova L, Hakacova N, Dobos D, et al. Amiodarone as a first-line therapy for postoperative junctional ectopic tachycardia. Ann Thorac Surg. 2009;88:616 22. 435. Walsh EP, Saul JP, Sholler GF, et al. Evaluation of a staged treatment protocol for rapid automatic junctional tachycardia after operation for congenital heart disease. J Am Coll Cardiol. 1997;29:1046 53. 436. van Engelen AD, Weijtens O, Brenner JI, et al. Management out- come and follow-up of fetal tachycardia. J Am Coll Cardiol. 1994;24: 1371 5. 437. Jaeggi ET, Carvalho JS, De Groot E, et al. Comparison of transplacen- tal treatment of fetal supraventricular tachyarrhythmias with digoxin, flecainide, and sotalol: results of a nonrandomized multicenter study. Circulation. 2011;124:1747 54. 438. van der Heijden LB, Oudijk MA, Manten GTR, et al. Sotalol as first- line treatment for fetal tachycardia and neonatal follow-up. Ultrasound Obstet Gynecol. 2013;42:285 93. 439. Strasburger JF, Cuneo BF, Michon MM, et al. Amiodarone therapy for drug-refractory fetal tachycardia. Circulation. 2004;109:375 9. 440. Bouchardy J, Therrien J, Pilote L, et al. Atrial arrhythmias in adults with congenital heart disease. Circulation. 2009;120:1679 86. 441. Bernier M, Marelli AJ, Pilote L, et al. Atrial arrhythmias in adult patients with right- versus left-sided congenital heart disease anomalies. Am J Cardiol. 2010;106:547 51. 442. Engelfriet P, Boersma E, Oechslin E, et al. The spectrum of adult congen- ital heart disease in Europe: morbidity and mortality in a 5 year follow-up period.


The spectrum of adult congen- ital heart disease in Europe: morbidity and mortality in a 5 year follow-up period. The Euro Heart Survey on Adult Congenital Heart Disease. Eur Heart J. 2005;26:2325 33. 443. Trojnarska O, Grajek S, Kramer L, et al. Risk factors of supraven- tricular arrhythmia in adults with congenital heart disease. Cardiol J. 2009;16:218 26. 444. Verheugt CL, Uiterwaal CSPM, van der Velde ET, et al. Gender and out- come in adult congenital heart disease. Circulation. 2008;118:26 32. 445. Collins KK, Love BA, Walsh EP, et al. Location of acutely successful radiofrequency catheter ablation of intraatrial reentrant tachycardia in patients with congenital heart disease. Am J Cardiol. 2000;86:969 74. 446. de Groot NMS, Zeppenfeld K, Wijffels MC, et al. Ablation of focal atrial arrhythmia in patients with congenital heart defects after surgery: role of circumscribed areas with heterogeneous conduction. Heart Rhythm. 2006;3:526 35. 447. Koyak Z, Kroon B, de Groot JR, et al. Efficacy of antiarrhythmic drugs in adults with congenital heart disease and supraventricular tachycardias. Am J Cardiol. 2013;112:1461 7. 448. Mah DY, Alexander ME, Cecchin F, et al. The electroanatomic mecha- nisms of atrial tachycardia in patients with tetralogy of Fallot and double outlet right ventricle. J Cardiovasc Electrophysiol. 2011;22:1013 7. 449. Wasmer K, K be J, Dechering DG, et al. Isthmus-dependent right atrial flutter as the leading cause of atrial tachycardias after surgical atrial sep- tal defect repair. Int J Cardiol. 2013;168:2447 52. 450. Cuypers JAAE, Opi P, Menting ME, et al. The unnatural history of an atrial septal defect: longitudinal 35 year follow up after surgical closure at young age. Heart. 2013;99:1346 52. 451. Khairy P, Aboulhosn J, Gurvitz MZ, et al. Arrhythmia burden in adults with surgically repaired tetralogy of Fallot: a multi-institutional study. Circulation. 2010;122:868 75.


Arrhythmia burden in adults with surgically repaired tetralogy of Fallot: a multi-institutional study. Circulation. 2010;122:868 75. 452. de Groot NMS, Atary JZ, Blom NA, et al. Long-term outcome after ab- lative therapy of postoperative atrial tachyarrhythmia in patients with congenital heart disease and characteristics of atrial tachyarrhythmia recurrences. Circ Arrhythm Electrophysiol. 2010;3:148 54. 453. H rdhammar PA, van Beusekom HM, Emanuelsson HU, et al. Reduction in thrombotic events with heparin-coated Palmaz-Schatz stents in normal porcine coronary arteries. Circulation. 1996;93:423 30. 454. Tanner H, Lukac P, Schwick N, et al. Irrigated-tip catheter ablation of in- traatrial reentrant tachycardia in patients late after surgery of congenital heart disease. Heart Rhythm. 2004;1:268 75. 455. Triedman JK, Saul JP, Weindling SN, et al. Radiofrequency ablation of intra-atrial reentrant tachycardia after surgical palliation of congenital heart disease. Circulation. 1995;91:707 14. 456. DeMazumder D, Lake DE, Cheng A, et al. Dynamic analysis of cardiac rhythms for discriminating atrial fibrillation from lethal ventricular ar- rhythmias. Circ Arrhythm Electrophysiol. 2013;6:555 61. 457. Yap S-C, Harris L, Silversides CK, et al. Outcome of intra-atrial re-en- trant tachycardia catheter ablation in adults with congenital heart disease: negative impact of age and complex atrial surgery. J Am Coll Cardiol. 2010;56:1589 96. 458. Scaglione M, Caponi D, Ebrille E, et al. Very long-term results of electroanatomic-guided radiofrequency ablation of atrial arrhythmias in patients with surgically corrected atrial septal defect. Europace. 2014:1800 7. 459. Feltes TF, Friedman RA. Transesophageal echocardiographic detection of atrial thrombi in patients with nonfibrillation atrial tachyarrhythmias and congenital heart disease. J Am Coll Cardiol. 1994;24:1365 70. 460. Ammash NM, Phillips SD, Hodge DO, et al. Outcome of direct current cardioversion for atrial arrhythmias in adults with congenital heart dis- ease. Int J Cardiol. 2012;154:270 4. 461. Pass RH, Liberman L, Al-Fayaddh M, et al.


2012;154:270 4. 461. Pass RH, Liberman L, Al-Fayaddh M, et al. Continuous intravenous dil- tiazem infusion for short-term ventricular rate control in children. Am J Cardiol. 2000;86:559 562. A9. 462. Garnock-Jones KP. Esmolol: a review of its use in the short-term treat- ment of tachyarrhythmias and the short-term control of tachycardia and hypertension. Drugs. 2012;72:109 32. 463. diMarco JP, Sellers TD, Lerman BB, et al. Diagnostic and therapeutic use of adenosine in patients with supraventricular tachyarrhythmias. J Am Coll Cardiol. 1985;6:417 25. 464. Haines DE, DiMarco JP. Sustained intraatrial reentrant tachycardia: clinical, electrocardiographic and electrophysiologic characteristics and long-term follow-up. J Am Coll Cardiol. 1990;15:1345 54. 465. Kall JG, Kopp D, Olshansky B, et al. Adenosine-sensitive atrial tachycar- dia. Pacing Clin Electrophysiol. 1995;18:300 6. 466. Olshansky B, Okumura K, Hess PG, et al. Use of procainamide with rap- id atrial pacing for successful conversion of atrial flutter to sinus rhythm. J Am Coll Cardiol. 1988;11:359 64. 467. Heisel A, Jung J, Stopp M, et al. Facilitating influence of procain- amide on conversion of atrial flutter by rapid atrial pacing. Eur Heart J. 1997;18:866 9. 468. Hoyer AW, Balaji S. The safety and efficacy of ibutilide in children and in patients with congenital heart disease. Pacing Clin Electrophysiol. 2007;30:1003 8. 469. Crawford W, Plumb VJ, Epstein AE, et al. Prospective evaluation of transesophageal pacing for the interruption of atrial flutter. Am J Med. 1989;86:663 7. 470. Rhodes LA, Walsh EP, Saul JP. Conversion of atrial flutter in pediatric patients by transesophageal atrial pacing: a safe, effective, minimally in- vasive procedure. Am Heart J. 1995;130:323 7. 471. Brockmeier K, Ulmer HE, Hessling G. Termination of atrial reentrant tachycardias by using transesophageal atrial pacing. J Electrocardiol. 2002;35 Suppl:159 63. 472. Stephenson EA, Casavant D, Tuzi J, et al.


2002;35 Suppl:159 63. 472. Stephenson EA, Casavant D, Tuzi J, et al. Efficacy of atrial antitachycar- dia pacing using the Medtronic AT500 pacemaker in patients with con- genital heart disease. Am J Cardiol. 2003;92:871 6. 473. Rao SO, Boramanand NK, Burton DA, et al. Atrial tachycardias in young adults and adolescents with congenital heart disease: conversion using single dose oral sotalol. Int J Cardiol. 2009;136:253 7. 474. Wells R, Khairy P, Harris L, et al. Dofetilide for atrial arrhythmias in congenital heart disease: a multicenter study. Pacing Clin Electrophysiol. 2009;32:1313 8. 475. Murphy JG, Gersh BJ, McGoon MD, et al. Long-term outcome after surgical repair of isolated atrial septal defect. Follow-up at 27 to 32 years. N Engl J Med. 1990;323:1645 50. 476. Konstantinides S, Geibel A, Olschewski M, et al. A comparison of surgi- cal and medical therapy for atrial septal defect in adults. N Engl J Med. 1995;333:469 73. 477. Pfammatter JP, Paul T, Ziemer G, et al. Successful management of junc- tional tachycardia by hypothermia after cardiac operations in infants. Ann Thorac Surg. 1995;60:556 60. 478. Giamberti A, Chessa M, Foresti S, et al. Combined atrial septal defect surgical closure and irrigated radiofrequency ablation in adult patients. Ann Thorac Surg. 2006;82:1327 31. 479. Huang CJ, Chiu IS, Lin FY, et al. Role of electrophysiological stud- ies and arrhythmia intervention in repairing Ebstein s anomaly. Thorac Cardiovasc Surg. 2000;48:347 50. 480. Reich JD, Auld D, Hulse E, et al. The Pediatric Radiofrequency Ablation Registry s experience with Ebstein s anomaly. Pediatric Electrophysiology Society. J Cardiovasc Electrophysiol. 1998;9: 1370 7. 481. Cappato R, Schl ter M, Weiss C, et al. Radiofrequency current catheter ablation of accessory atrioventricular pathways in Ebstein s anomaly. Circulation. 1996;94:376 83. 482. Misaki T, Watanabe G, Iwa T, et al.


1996;94:376 83. 482. Misaki T, Watanabe G, Iwa T, et al. Surgical treatment of patients with Wolff-Parkinson-White syndrome and associated Ebstein s anomaly. J Thorac Cardiovasc Surg. 1995;110:1702 7. 483. Khositseth A, Danielson GK, Dearani JA, et al. Supraventricular tachyar- rhythmias in Ebstein anomaly: management and outcome. J Thorac Cardiovasc Surg. 2004;128:826 33. 484. Bockeria L, Golukhova E, Dadasheva M, et al. Advantages and disadvan- tages of one-stage and two-stage surgery for arrhythmias and Ebstein s anomaly. Eur J Cardiothorac Surg. 2005;28:536 40. 485. Pressley JC, Wharton JM, Tang AS, et al. Effect of Ebstein s anomaly on short- and long-term outcome of surgically treated patients with Wolff- Parkinson-White syndrome. Circulation. 1992;86:1147 55. 486. Khairy P, Harris L, Landzberg MJ, et al. Sudden death and defibrillators in transposition of the great arteries with intra-atrial baffles: a multicenter study. Circ Arrhythm Electrophysiol. 2008;1:250 7. 487. Banchs JE, Baquero GA, Nickolaus MJ, et al. Clinical efficacy of dofeti- lide for the treatment of atrial tachyarrhythmias in adults with congenital heart disease. Congenit Heart Dis. 2014;9:221 7. 488. Tanel RE, Walsh EP, Lulu JA, et al. Sotalol for refractory arrhythmias in pediatric and young adult patients: initial efficacy and long-term out- come. Am Heart J. 1995;130:791 7. 489. Lukac P, PedersenAK, Mortensen PT, et al.Ablation of atrial tachycardia after surgery for congenital and acquired heart disease using an electro- anatomic mapping system: which circuits to expect in which substrate? Heart Rhythm. 2005;2:64 72. 490. Yap S-C, Harris L, Downar E, et al. Evolving electroanatomic sub- strate and intra-atrial reentrant tachycardia late after Fontan surgery. J Cardiovasc Electrophysiol. 2012;23:339 45. 491. Wu J, Deisenhofer I, Ammar S, et al. Acute and long-term outcome af- ter catheter ablation of supraventricular tachycardia in patients after the Mustard or Senning operation for D-transposition of the great arteries.


Acute and long-term outcome af- ter catheter ablation of supraventricular tachycardia in patients after the Mustard or Senning operation for D-transposition of the great arteries. Europace. 2013;15:886 91. 492. Jones DG, Jarman JWE, Lyne JC, et al. The safety and efficacy of trans- baffle puncture to enable catheter ablation of atrial tachycardias fol- lowing the Mustard procedure: a single centre experience and literature review. Int J Cardiol. 2013;168:1115 20. 493. Kalman JM, VanHare GF, Olgin JE, et al. Ablation of incisional re- entrant atrial tachycardia complicating surgery for congenital heart disease. Use of entrainment to define a critical isthmus of conduction. Circulation. 1996;93:502 12. 494. Ueda A, Suman-Horduna I, Mantziari L, et al. Contemporary outcomes of supraventricular tachycardia ablation in congenital heart disease: a single-center experience in 116 patients. Circ Arrhythm Electrophysiol. 2013;6:606 13. 495. de Groot NMS, Lukac P, Blom NA, et al. Long-term outcome of ab- lative therapy of postoperative supraventricular tachycardias in patients with univentricular heart: a European multicenter study. Circ Arrhythm Electrophysiol. 2009;2:242 8. 496. Silversides CK, Salehian O, Oechslin E, et al. Canadian Cardiovascular Society 2009 Consensus Conference on the management of adults with congenital heart disease: complex congenital cardiac lesions. Can J Cardiol. 2010;26:e98 117. 497. GiambertiA, Chessa M,Abella R, et al. Surgical treatment of arrhythmias in adults with congenital heart defects. Int J Cardiol. 2008;129:37 41. 498. Stulak JM, Dearani JA, Puga FJ, et al. Right-sided Maze procedure for atrial tachyarrhythmias in congenital heart disease. Ann Thorac Surg. 2006;81:1780 4. 499. Mavroudis C, Deal BJ, Backer CL, et al. Arrhythmia surgery in pa- tients with and without congenital heart disease. Ann Thorac Surg. 2008;86:857 68. 500. Karamlou T, Silber I, Lao R, et al. Outcomes after late reoperation in patients with repaired tetralogy of Fallot: the impact of arrhythmia and arrhythmia surgery.


Outcomes after late reoperation in patients with repaired tetralogy of Fallot: the impact of arrhythmia and arrhythmia surgery. Ann Thorac Surg. 2006;81:1786 93. 501. Deal BJ, Mavroudis C, Backer CL, et al. Comparison of anatomic isth- mus block with the modified right atrial maze procedure for late atrial tachycardia in Fontan patients. Circulation. 2002;106:575 9. 502. Mavroudis C, Backer CL, Deal BJ, et al. Total cavopulmonary conver- sion and maze procedure for patients with failure of the Fontan operation. J Thorac Cardiovasc Surg. 2001;122:863 71. 503. Mavroudis C, Deal BJ, Backer CL, et al. J. Maxwell Chamberlain Memorial Paper for congenital heart surgery. 111 Fontan conversions with arrhythmia surgery: surgical lessons and outcomes. Ann Thorac Surg. 2007;84:1457 65. 504. Aboulhosn J, Williams R, Shivkumar K, et al. Arrhythmia recurrence in adult patients with single ventricle physiology following surgical Fontan conversion. Congenit Heart Dis. 2010;5:430 4. 505. Said SM, Burkhart HM, Schaff HV, et al. Fontan conversion: identifying the high-risk patient. Ann Thorac Surg. 2014;97:2115 21. 506. Gutierrez SD, Earing MG, Singh AK, et al. Atrial tachyarrhythmias and the Cox-maze procedure in congenital heart disease. Congenit Heart Dis. 2013;8:434 9. 507. Terada T, Sakurai H, Nonaka T, et al. Surgical outcome of Fontan con- version and arrhythmia surgery: need a pacemaker? Asian Cardiovasc Thorac Ann. 2013;22:682 6. Page et al 2015 ACC/AHA/HRS SVT Guideline e569 508. Theodoro DA, Danielson GK, Porter CJ, et al. Right-sided maze proce- dure for right atrial arrhythmias in congenital heart disease. Ann Thorac Surg. 1998;65:149 53. 509. Silka MJ, Manwill JR, Kron J, et al. Bradycardia-mediated tachyarrhyth- mias in congenital heart disease and responses to chronic pacing at physi- ologic rates. Am J Cardiol. 1990;65:488 93. 510. Ragonese P, Drago F, Guccione P, et al.


1990;65:488 93. 510. Ragonese P, Drago F, Guccione P, et al. Permanent overdrive atrial pac- ing in the chronic management of recurrent postoperative atrial reentrant tachycardia in patients with complex congenital heart disease. Pacing Clin Electrophysiol. 1997;20:2917 23. 511. Thorne SA, Barnes I, Cullinan P, et al. Amiodarone-associated thy- roid dysfunction: risk factors in adults with congenital heart disease. Circulation. 1999;100:149 54. 512. Stan MN, Hess EP, Bahn RS, et al. A risk prediction index for amio- darone-induced thyrotoxicosis in adults with congenital heart disease. J Thyroid Res. 2012;2012:210529. 513. Shotan A, Ostrzega E, Mehra A, et al. Incidence of arrhythmias in nor- mal pregnancy and relation to palpitations, dizziness, and syncope. Am J Cardiol. 1997;79:1061 4. 514. Tawam M, Levine J, Mendelson M, et al. Effect of pregnancy on parox- ysmal supraventricular tachycardia. Am J Cardiol. 1993;72:838 40. 515. Silversides CK, Harris L, Haberer K, et al. Recurrence rates of ar- rhythmias during pregnancy in women with previous tachyarrhyth- mia and impact on fetal and neonatal outcomes. Am J Cardiol. 2006;97:1206 12. 516. Ghosh N, Luk A, Derzko C, et al. The acute treatment of maternal su- praventricular tachycardias during pregnancy: a review of the literature. J Obstet Gynaecol Can. 2011;33:17 23. 517. Qasqas SA, McPherson C, Frishman WH, et al. Cardiovascular phar- macotherapeutic considerations during pregnancy and lactation. Cardiol Rev. 2004;12:201 21. 518. Page RL. Treatment of arrhythmias during pregnancy. Am Heart J. 1995;130:871 6. 519. Tromp CHN, Nanne ACM, Pernet PJM, et al. Electrical cardioversion during pregnancy: safe or not? Neth Heart J. 2011;19:134 6. 520. Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12: cardiac ar- rest in special situations: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122:S829 61. 521.


Part 12: cardiac ar- rest in special situations: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122:S829 61. 521. Ersb ll AS, Hedegaard M, S ndergaard L, et al. Treatment with oral beta-blockers during pregnancy complicated by maternal heart disease increases the risk of fetal growth restriction. BJOG. 2014;121:618 26. 522. Allen NM, Page RL. Procainamide administration during pregnancy. Clin Pharm. 1993;12:58 60. 523. Bartalena L, Bogazzi F, Braverman LE, et al. Effects of amiodarone ad- ministration during pregnancy on neonatal thyroid function and subse- quent neurodevelopment. J Endocrinol Invest. 2001;24:116 30. 524. Meidahl Petersen K, Jimenez-Solem E, Andersen JT, et al. -Blocker treatment during pregnancy and adverse pregnancy outcomes: a nation- wide population-based cohort study. BMJ Open. 2012;2. 525. Lydakis C, Lip GY, Beevers M, et al. Atenolol and fetal growth in preg- nancies complicated by hypertension. Am J Hypertens. 1999;12:541 7. 526. Szumowski L, Szufladowicz E, Orczykowski M, et al. Ablation of se- vere drug-resistant tachyarrhythmia during pregnancy. J Cardiovasc Electrophysiol. 2010;21:877 82. 527. Damilakis J, Theocharopoulos N, Perisinakis K, et al. Conceptus radia- tion dose and risk from cardiac catheter ablation procedures. Circulation. 2001;104:893 7. 528. McCollough CH, Schueler BA, Atwell TD, et al. Radiation expo- sure and pregnancy: when should we be concerned? Radiographics. 2007;27:909 17. 529. Colletti PM, Lee KH, Elkayam U. Cardiovascular imaging of the preg- nant patient. AJR Am J Roentgenol. 2013;200:515 21. 530. Chen SA, Lee SH, Wu TJ, et al. Initial onset of accessory pathway-medi- ated and atrioventricular node reentrant tachycardia after age 65: clinical features, electrophysiologic characteristics, and possible facilitating fac- tors. J Am Geriatr Soc. 1995;43:1370 7. 531. Chen SA, Chiang CE, Tai CT, et al.


1995;43:1370 7. 531. Chen SA, Chiang CE, Tai CT, et al. Complications of diagnostic electro- physiologic studies and radiofrequency catheter ablation in patients with tachyarrhythmias: an eight-year survey of 3,966 consecutive procedures in a tertiary referral center. Am J Cardiol. 1996;77:41 6. 532. Zado ES, Callans DJ, Gottlieb CD, et al. Efficacy and safety of catheter ablation in octogenarians. J Am Coll Cardiol. 2000;35:458 62. 533. Rostock T, Risius T, Ventura R, et al. Efficacy and safety of radiofre- quency catheter ablation of atrioventricular nodal reentrant tachycardia in the elderly. J Cardiovasc Electrophysiol. 2005;16:608 10. 534. Kihel J, Da Costa A, Kihel A, et al. Long-term efficacy and safety of radiofrequency ablation in elderly patients with atrioventricular nodal re- entrant tachycardia. Europace. 2006;8:416 20. 535. Dagres N, Piorkowski C, Kottkamp H, et al. Contemporary catheter abla- tion of arrhythmias in geriatric patients: patient characteristics, distribu- tion of arrhythmias, and outcome. Europace. 2007;9:477 80. 536. Pedrinazzi C, Durin O, Agricola P, et al. Efficacy and safety of radio- frequency catheter ablation in the elderly. J Interv Card Electrophysiol. 2007;19:179 85. 537. Hoffmann BA, Brachmann J, Andresen D, et al. Ablation of atrioventric- ular nodal reentrant tachycardia in the elderly: results from the German Ablation Registry. Heart Rhythm. 2011;8:981 7. 538. Yangni N Da O, Brembilla-Perrot B. Clinical characteristics and man- agement of paroxysmal junctional tachycardia in the elderly. Arch Cardiovasc Dis. 2008;101:143 8. 539. Boulos M, Hoch D, Schecter S, et al. Age dependence of complete heart block complicating radiofrequency ablation of the atrioventricular nodal slow pathway. Am J Cardiol. 1998;82:390 1. 540. Goldberg AS, Bathina MN, Mickelsen S, et al. Long-term outcomes on quality-of-life and health care costs in patients with supraventricular tachycardia (radiofrequency catheter ablation versus medical therapy). Am J Cardiol. 2002;89:1120 3. 541.


Long-term outcomes on quality-of-life and health care costs in patients with supraventricular tachycardia (radiofrequency catheter ablation versus medical therapy). Am J Cardiol. 2002;89:1120 3. 541. Bathina MN, Mickelsen S, Brooks C, et al. Radiofrequency catheter ablation versus medical therapy for initial treatment of supraventricular tachycardia and its impact on quality of life and healthcare costs. Am J Cardiol. 1998;82:589 93. 542. Meissner A, Stifoudi I, Weism ller P, et al. Sustained high quality of life in a 5-year long term follow-up after successful ablation for supra- ventricular tachycardia: results from a large retrospective patient cohort. Int J Med Sci. 2009;6:28 36. 543. Wood KA, Stewart AL, Drew BJ, et al. Patient perception of symptoms and quality of life following ablation in patients with supraventricular tachycardia. Heart Lung. 2010;39:12 20. 544. Yildirim O, Yontar OC, Semiz M, et al. The effect of radiofrequency ab- lation treatment on quality of life and anxiety in patients with supraven- tricular tachycardia. Eur Rev Med Pharmacol Sci. 2012;16:2108 12. 545. Farkowski MM, Pytkowski M, Maciag A, et al. Gender-related differ- ences in outcomes and resource utilization in patients undergoing radio- frequency ablation of supraventricular tachycardia: results from Patients Perspective on Radiofrequency Catheter Ablation of AVRT and AVNRT Study. Europace. 2014:1821 7. 546. Larson MS, McDonald K, Young C, et al. Quality of life before and after radiofrequency catheter ablation in patients with drug refractory atrioven- tricular nodal reentrant tachycardia. Am J Cardiol. 1999;84:471 3, A9. 547. Dewland TA, Glidden DV, Marcus GM. Healthcare utilization and clinical outcomes after catheter ablation of atrial flutter. PLoS One. 2014;9:e100509.


Healthcare utilization and clinical outcomes after catheter ablation of atrial flutter. PLoS One. 2014;9:e100509. Key Words: AHA Scientific Statements tachycardia, supraventricular tachycardia, atrioventricular nodal reentry Wolff-Parkinson-White syndrome catheter ablation tachycardia, ectopic atrial tachycardia, ectopic junctional atrial flutter anti-arrhythmia agents accessory atrioventricular bundle Valsalva maneuver tachycardia, reciprocating electric countershock heart defects, congenital death, sudden electrophysiologic techniques, cardiac sinus tachycardia Appendix 1. Author Relationships With Industry and Other Entities (Relevant) 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia (April 2014) Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Voting Recusals by Section* Richard L. Page, Chair University of Wisconsin School of Medicine and Public Health Chair, Department of Medicine None None None None None None None Jos A. Joglar, Vice Chair University of Texas Southwestern Medical Center Professor of Internal Medicine; Program Director, Clinical Cardiac Electrophysiology None None None None None None None Sana M. Al-Khatib Duke Clinical Research Institute Associate Professor of Medicine None None None None None None None Mary A. Caldwell University of California San Francisco Assistant Professor (Retired) None None None None None None None Hugh Calkins Johns Hopkins Hospital Professor of Medicine, Director of Electrophysiology Atricure Boehringer Ingelheim Daiichi-Sankyo None None St. Jude Medical None None All Sections 9.4. Jamie B. Conti University of Florida Professor of Medicine, Chief of Cardiovascular Medicine None None None Medtronic Boston Scientific Medtronic St. Jude Medical None All Sections 9.3.2, and 9.4. Barbara J. Deal Feinberg School of Medicine, Northwestern University Professor of Pediatrics; Ann & Robert H. Lurie Children s Hospital of Chicago Division Head, Cardiology None None None None None None None N.A.


Deal Feinberg School of Medicine, Northwestern University Professor of Pediatrics; Ann & Robert H. Lurie Children s Hospital of Chicago Division Head, Cardiology None None None None None None None N.A. Mark Estes III Tufts University School of Medicine Professor of Medicine Boston Scientific Medtronic St. Jude Medical None None Boston Scientific Boston Scientific Medtronic St. Jude Medical None All Sections 9.4. Michael E. Field University of Wisconsin School of Medicine and Public Health Assistant Professor of Medicine, Director of Cardiac Arrhythmia Service None None None None None None None Zachary D. Goldberger University of Washington School of Medicine Assistant Professor of Medicine None None None None None None None Stephen C. Hammill Mayo Clinic Professor Emeritus of Medicine None None None None None None None Julia H. Indik University of Arizona Associate Professor of Medicine None None None None None None None Bruce D. Lindsay Cleveland Clinic Foundation Professor of Cardiology Biosense Webster Boston Scientific CardioInsight Medtronic None None None Boston Scientific Medtronic St. Jude Medical None All Sections 9.4. Brian Olshansky University of Iowa Hospitals Professor Emeritus of Medicine; Mercy Hospital Mason City Electrophysiologist BioControl Biotronik Boehringer-Ingelheim Boston Scientific-Guidant Daiichi-Sankyo Medtronic Sanofi-aventis None None Amarin (DSMB) Boston Scientific (DSMB) Sanofi-aventis (DSMB) Boston Scientific None All Sections except 2.4 and 9.4. Andrea M. Russo Cooper Medical School of Rowan University Professor of Medicine; Cooper University Hospital Director, Electrophysiology and Arrhythmia Services Biotronik Boston Scientific Medtronic St. Jude Medical None None Medtronic Biotronik Boston Scientific None All Sections 9.4.


Andrea M. Russo Cooper Medical School of Rowan University Professor of Medicine; Cooper University Hospital Director, Electrophysiology and Arrhythmia Services Biotronik Boston Scientific Medtronic St. Jude Medical None None Medtronic Biotronik Boston Scientific None All Sections 9.4. (Continued) Page et al 2015 ACC/AHA/HRS SVT Guideline e571 Win-Kuang Shen Mayo Clinic Arizona Professor of Medicine; Chair, Division of Cardiovascular Diseases None None None None None None None Cynthia M. Tracy George Washington University Professor of Medicine; Associate Director Division of Cardiology, Director of Cardiac Services None None None None None None None This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily re ect relationships with industry at the time of publication. A person is deemed to have a signi cant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $5,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. Relationships that exist with no nancial bene t are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted.


Relationships that exist with no nancial bene t are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) the person or a member of the person s household, has a reasonable potential for nancial, professional or other personal gain or loss as a result of the issues/content addressed in the document. *Writing committee members are required to recuse themselves from voting on sections to which their speci c relationships with industry and other entities may apply. Signi cant relationship. No nancial bene t. ACC indicates American College of Cardiology; AHA, American Heart Association; DSMB, data safety monitoring board; and HRS, Heart Rhythm Society. Appendix 2.


No nancial bene t. ACC indicates American College of Cardiology; AHA, American Heart Association; DSMB, data safety monitoring board; and HRS, Heart Rhythm Society. Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia (March 2015) Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Eugene H. Chung Official Reviewer HRS University of North Carolina School of Medicine Associate Professor of Medicine None None None None Zoll Medical None Timm L. Dickfeld Official Reviewer HRS University of Maryland School of Medicine Associate Professor of Medicine; Baltimore Veterans Affairs Medical Center Director, Electrophysiology Biosense Webster None None Biosense Webster* General Electric* None None Samuel S. Gidding Official Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Nemours Cardiac Center Division Chief of Cardiology; Jefferson Medical College Professor of Pediatrics None None None None None None Richard J. Kovacs Official Reviewer ACC Board of Trustees Krannert Institute of Cardiology Professor of Clinical Medicine Biomedical Systems* None None Siemens AstraZeneca (DSMB) MED Institute* Eli Lilly (DSMB)* Teva Pharmaceuticals None Byron K. Lee Official Reviewer AHA University of California San Francisco Professor of Medicine Biotronik Boston Scientific St. Jude Medical None None Zoll Medical* CarioNet* Defendant, Boehringer Ingelheim, (Continued) Appendix 1.


Reviewer Relationships With Industry and Other Entities (Relevant) 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia (March 2015) Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Eugene H. Chung Official Reviewer HRS University of North Carolina School of Medicine Associate Professor of Medicine None None None None Zoll Medical None Timm L. Dickfeld Official Reviewer HRS University of Maryland School of Medicine Associate Professor of Medicine; Baltimore Veterans Affairs Medical Center Director, Electrophysiology Biosense Webster None None Biosense Webster* General Electric* None None Samuel S. Gidding Official Reviewer ACC/AHA Task Force on Clinical Practice Guidelines Nemours Cardiac Center Division Chief of Cardiology; Jefferson Medical College Professor of Pediatrics None None None None None None Richard J. Kovacs Official Reviewer ACC Board of Trustees Krannert Institute of Cardiology Professor of Clinical Medicine Biomedical Systems* None None Siemens AstraZeneca (DSMB) MED Institute* Eli Lilly (DSMB)* Teva Pharmaceuticals None Byron K. Lee Official Reviewer AHA University of California San Francisco Professor of Medicine Biotronik Boston Scientific St. Jude Medical None None Zoll Medical* CarioNet* Defendant, Boehringer Ingelheim, (Continued) Appendix 1. Continued Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Voting Recusals by Section* (Continued) Gregory F. Michaud Official Reviewer AHA Harvard Medical School Assistant Professor Boston Scientific Medtronic St. Jude Medical None None Biosense Webster* Boston Scientific* St. Jude Medical* None None Simone Musco Official Reviewer ACC Board of Governors The International Heart Institute of Montana Foundation Cardiology Research Investigator None Bristol-Myers Squibb Sanofi-aventis None None None None Mohan N. Viswanathan Official Reviewer AHA University of Washington School of Medicine Assistant Professor of Medicine Biosense Webster Siemens St. Jude Medical None None Medtronic* None None Seshadri Balaji Content Reviewer Oregon Health and Science University Professor of Pediatrics and Pediatric Cardiology, Director of Pacing and Electrophysiology None None None Medtronic* None None Nancy C. Berg Content Reviewer ACC Electrophysiology Section Allina Health System None None None None None None Noel G. Boyle Content Reviewer ACC Electrophysiology Section University of California Los Angeles Clinical Professor of Medicine None None None None None None A. John Camm Content Reviewer St. George s University of London Professor of Clinical Cardiology Bayer* Biotronik Boehringer Ingelheim Boston Scientific ChanRx Daiichi-Sankyo Medtronic Menarini Mitsubishi Novartis Richmond Pharmacology* Sanofi-aventis Servier Pharmaceuticals* St. Jude Medical Takeda Pharmaceuticals Xention Pfizer None None None None Robert M. Campbell Content Reviewer ACC Adult Congenital and Pediatric Cardiology Section Sibley Heart Center Cardiology Director, Chief of Cardiac Services; Emory University School of Medicine Division Director of Pediatric Cardiology, Professor of Pediatrics None None None None None None Susan P. Etheridge Content Reviewer ACC Adult Congenital and Pediatric Cardiology Section University of Utah Training Program Director None None None None None None Paul A. Friedman Content Reviewer Mayo Clinic Professor of Medicine; Cardiovascular Implantable Device Laboratory Director NeoChord None None Biotronik Medtronic St. Jude Medical Preventice Sorin* None Appendix 2.


Continued Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Page et al 2015 ACC/AHA/HRS SVT Guideline e573 Bulent Gorenek Content Reviewer ACC Electrophysiology Section Eskisehir Osmangazi University Professor and Vice Director, Cardiology Department None None None None None None Jonathan L. Halperin Content Reviewer ACC/ AHA Task Force on Clinical Practice Guidelines Mt.


Sinai Medical Professor of Medicine AstraZeneca Bayer Healthcare Biotronik Boehringer Ingelheim Boston Scientific Daiichi-Sankyo Johnson & Johnson Medtronic Pfizer None None None None None Warren M. Jackman Content Reviewer University of Oklahoma Health Sciences Center George Lynn Cross Research Professor Emeritus; Heart Rhythm Institute Senior Scientific Advisor Biosense Webster* Boston Scientific* VytronUS* AtriCure* Biosense Webster* Biotronik* Boston Scientific* None None None None G. Neal Kay Content Reviewer University of Alabama Professor Emeritus None None None None None None George J. Klein Content Reviewer London Health Sciences Center Chief of Cardiology Biotronik Boston Scientific Medtronic None None None None None Bradley P. Knight Content Reviewer Northwestern University Professor of Cardiology Boston Scientific Medtronic Biosense Webster Biotronik Boston Scientific Medtronic None None None None John D. Kugler Content Reviewer University of Nebraska Medical Center Division Chief of Pediatric Cardiology None None None None None None Fred M. Kusumoto Content Reviewer Mayo Clinic Professor of Medicine None None None None None None Glenn N. Levine Content Reviewer ACC/ AHA Task Force on Clinical Practice Guidelines Baylor College of Medicine Professor of Medicine; Director, Cardiac Care Unit None None None None None None Marco A. Mercader Content Reviewer George Washington University Associate Professor of Medicine None None None None None None William M. Miles Content Reviewer University of Florida Professor of Medicine, Silverstein Chair for Cardiovascular Education, Director of the Clinical Cardiac Electrophysiology Fellowship Program None None None None Medtronic (DSMB) None Fred Morady Content Reviewer University of Michigan McKay Professor of Cardiovascular Disease None None None None None None Melvin M. Scheinman Content Reviewer University of California San Francisco Professor of Medicine Amgen Biosense Webster Biotronik* Boston Scientific* Gilead Sciences Janssen Pharmaceuticals Medtronic St. Jude Medical None None None None None (Continued) Appendix 2.


Continued Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Sarah A. Spinler Content Reviewer University of the Sciences, Philadelphia College of Pharmacy Professor of Clinical Pharmacy Portola Pharmaceuticals None None None None None William G. Stevenson Content Reviewer Brigham and Women s Hospital Director, Clinical Cardiac Electrophysiology Program St. Jude Medical None None None None None Albert L. Waldo Content Reviewer University Hospitals Associate Chief of Cardiovascular Medicine for Academic Affairs; Case Western Reserve University School of Medicine Professor of Medicine AtriCure Biosense Webster* CardioInsight ChanRx Daiichi-Sankyo Gilead Sciences Pfizer St. Jude Medical* Bristol-Myers Squibb* Janssen Pharmaceuticals Pfizer* None Gilead Sciences* None None Edward Walsh Content Reviewer Harvard Medical School Professor of Pediatrics; Boston Children s Hospital Chief, Division of Cardiac Electrophysiology Biosense Webster None None None None None Richard C. Wu Content Reviewer University of Texas Southwestern Medical Center Professor of Internal Medicine, Director of Cardiac Electrophysiology Lab None None None Boehringer Ingelheim Janssen Pharmaceutical Medtronic None None This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant to this document. It does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $5000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition.


A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review. According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) the person or a member of the person s household, has a reasonable potential for financial, professional or other personal gain or loss as a result of the issues/content addressed in the document. *Significant relationship. No financial benefit. ACC indicates American College of Cardiology; AHA, American Heart Association; DSMB, data safety monitoring board; and HRS, Heart Rhythm Society. Appendix 3. Abbreviations ACHD adult congenital heart disease AF atrial fibrillation AT atrial tachycardia AV atrioventricular AVNRT atrioventricular nodal reentrant tachycardia AVRT atrioventricular reentrant tachycardia BP blood pressure CTI cavotricuspid isthmus ECG electrocardiogram/electrocardiographic ERC Evidence Review Committee EP electrophysiological Appendix 2. Continued Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness GWC guideline writing committee IST inappropriate sinus tachycardia MAT multifocal atrial tachycardia PJRT permanent form of junctional reciprocating tachycardia PSVT paroxysmal supraventricular tachycardia RCT randomized controlled trial SCD sudden cardiac death SVT supraventricular tachycardia VT ventricular tachycardia WPW Wolff-Parkinson-White Appendix 3. Continued


FOCUSED UPDATE 2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction Endorsed by the Latin American Society of Interventional Cardiology PCI Writing Committee* Glenn N. Levine, MD, FACC, FAHA, Chairy Eric R. Bates, MD, FACC, FAHA, FSCAI, Vice Chair*y James C. Blankenship, MD, FACC, FAHA, FSCAI, Vice Chair*z Steven R. Bailey, MD, FACC, FSCAI*z John A. Bittl, MD, FACCy Bojan Cercek, MD, FACC, FAHAy Charles E. Chambers, MD, FACC, FSCAIz Stephen G. Ellis, MD, FACC*y Robert A. Guyton, MD, FACCx Steven M. Hollenberg, MD, FACC*y Umesh N. Khot, MD, FACC*y Richard A. Lange, MD, FACC, FAHAy Laura Mauri, MD, MSC, FACC, FSCAI*y Roxana Mehran, MD, FACC, FAHA, FSCAI*z Issam D. Moussa, MD, FACC, FAHA, FSCAIz Debabrata Mukherjee, MD, FACC, FAHA, FSCAIy Henry H. Ting, MD, FACC, FAHAy *Writing committee members are required to recuse themselves from voting on sections to which their speci c relationships with industry may apply; see Appendixes 1 and 2 for detailed information. yACC/AHA Representative. zSCAI Representative. xACC/AHA Task Force on Clinical Practice Guidelines Liaison.


zSCAI Representative. xACC/AHA Task Force on Clinical Practice Guidelines Liaison. STEMI Writing Committee* Patrick T. O Gara, MD, FACC, FAHA, Chairy Frederick G. Kushner, MD, FACC, FAHA, FSCAI, Vice Chairy Deborah D. Ascheim, MD, FACCk Ralph G. Brindis, MD, MPH, MACC, FSCAI, FAHAx Donald E. Casey, JR, MD, MPH, MBA, FAHA{ Mina K. Chung, MD, FACC, FAHA*y James A. de Lemos, MD, FACC*y Deborah B. Diercks, MD, MSc# James C. Fang, MD, FACC, FAHA*y Barry A. Franklin, PhD, FAHAy Christopher B. Granger, MD, FACC, FAHA*y Harlan M. Krumholz, MD, SM, FACC, FAHA*y Jane A. Linderbaum, MS, CNP-BCy David A. Morrow, MD, MPH, FACC, FAHA*y L. Kristin Newby, MD, MHS, FACC, FAHA*y Joseph P. Ornato, MD, FACC, FAHA, FACP, FACEP*y Narith Ou, PharmDy Martha J. Radford, MD, FACC, FAHAy Jacqueline E. Tamis-Holland, MD, FACC, FSCAIy Carl L. Tommaso, MD, FACC, FAHA, MSCAIz Cynthia M. Tracy, MD, FACC, FAHAy Y. Joseph Woo, MD, FACC, FAHAy David X. Zhao, MD, FACC*y kDr. Deborah D. Ascheim accepted a position at Capricor Therapeutics in August 2015, after the writing effort was completed. In accordance with ACC/AHA policy, she recused herself from the nal voting process. {ACP Representative. #ACEP Representative. J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y V O L . 6 7 , N O .


J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y V O L . 6 7 , N O . 1 0 , 2 0 1 6 2 0 1 6 B Y T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y F O U N D A T I O N , T H E A M E R I C A N H E A R T A S S O C I A T I O N , I N C . , A N D T H E S O C I E T Y F O R C A R D I O V A S C U L A R A N G I O G R A P H Y A N D I N T E R V E N T I O N S h t t p : / / d x . d o i . o r g / 1 0 . 1 0 1 6 / j . j a c c . 2 0 1 5 . 1 0 .


j a c c . 2 0 1 5 . 1 0 . 0 0 5 P U B L I S H E D B Y E L S E V I E R ACC/AHA Task Force Members Jonathan L. Halperin, MD, FACC, FAHA, Chair Glenn N. Levine, MD, FACC, FAHA, Chair-Elect Jeffrey L. Anderson, MD, FACC, FAHA, Immediate Past Chair** Nancy M. Albert, PhD, RN, FAHA** Sana M. Al-Khatib, MD, MHS, FACC, FAHA Kim K. Birtcher, PharmD, MS, AACC Biykem Bozkurt, MD, PhD, FACC, FAHA Ralph G. Brindis, MD, MPH, MACC Joaquin E. Cigarroa, MD, FACC Lesley H. Curtis, PhD, FAHA Lee A. Fleisher, MD, FACC, FAHA Federico Gentile, MD, FACC Samuel Gidding, MD, FAHA Mark A. Hlatky, MD, FACC John Ikonomidis, MD, PhD, FAHA Jose Joglar, MD, FACC, FAHA Richard J. Kovacs, MD, FACC, FAHA** E. Magnus Ohman, MD, FACC** Susan J. Pressler, PhD, RN, FAHA Frank W. Sellke, MD, FACC, FAHA** Win-Kuang Shen, MD, FACC, FAHA** Duminda N. Wijeysundera, MD, PhD **Former Task Force member; current member during the writing effort. TABLE OF CONTENTS PREAMBLE 1236 1. INTRODUCTION 1237 1.1. Methodology and Evidence Review 1237 1.2. Organization of the GWC 1338 1.3. Review and Approval 1238 2. CULPRIT ARTERY ONLY VERSUS MULTIVESSEL PCI 1239 3.


Organization of the GWC 1338 1.3. Review and Approval 1238 2. CULPRIT ARTERY ONLY VERSUS MULTIVESSEL PCI 1239 3. ASPIRATION THROMBECTOMY 1240 REFERENCES 1241 Author Relationships With Industry and Other Entities (Relevant) 1243 Author Relationships With Industry and Other Entities (Relevant) 1245 Reviewer Relationships With Industry and Other Entities (Relevant) 2015 Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction (Combined Peer Reviewers From 2011 PCI and 2013 STEMI Guidelines) 1247 PREAMBLE To ensure that guidelines re ect current knowledge, available treatment options, and optimum medical care, existing clinical practice guideline recommendations are modi ed and new recommendations are added in response to new data, medications or devices. To keep pace with evolving evidence, the American College This document was approved by the American College of Cardiology Board of Trustees and Executive Committee, the American Heart Association Science Advisory and Coordinating Committee, and the Society of Cardiovascular Angiography and Interventions in September 2015, and by the American Heart Association Executive Committee in October 2015. The American College of Cardiology requests that this document be cited as follows: Levine GN, O Gara PT, Bates ER, Blankenship JC, Kushner FG, Ascheim DD, Bailey SR, Bittl JA, Brindis RG, Casey DE Jr, Cercek B, Chambers CE, Chung MK, de Lemos JA, Diercks DB, Ellis SG, Fang JC, Franklin BA, Granger CB, Guyton RA, Hollenberg SM, Khot UN, Krumholz HM, Lange RA, Linderbaum JA, Mauri L, Mehran R, Morrow DA, Moussa ID, Mukherjee D, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Ting HH, Tommaso CL, Tracy CM, Woo YJ, Zhao DX.


The American College of Cardiology requests that this document be cited as follows: Levine GN, O Gara PT, Bates ER, Blankenship JC, Kushner FG, Ascheim DD, Bailey SR, Bittl JA, Brindis RG, Casey DE Jr, Cercek B, Chambers CE, Chung MK, de Lemos JA, Diercks DB, Ellis SG, Fang JC, Franklin BA, Granger CB, Guyton RA, Hollenberg SM, Khot UN, Krumholz HM, Lange RA, Linderbaum JA, Mauri L, Mehran R, Morrow DA, Moussa ID, Mukherjee D, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Ting HH, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2016;67:1235 50. This article has been copublished in Circulation and Catheterization and Cardiovascular Interventions. Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org), the American Heart Association (my. americanheart.org), and the Society for Cardiovascular Angiography and Interventions (www.scai.org). For copies of this document, please contact Elsevier Re- prints Department via fax (212) 633-3820, or e-mail reprints@elsevier.com. Permissions: Multiple copies, modi cation, alteration, enhancement, and/or distribution of this document is not permitted without the express permission of the American College of Cardiology. Requests may be completed online via the Elsevier site (http://www.elsevier.com/authors/obtainingpermission-to-re-use-elsevier- material). Levine et al. J A C C V O L . 6 7 , N O .


J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Practice Guidelines ( Task Force ) has issued this focused update to revise guideline rec- ommendations on the basis of recently published data. This update is not based on a complete literature review from the date of previous guideline publications, but it has been subject to rigorous, multilevel review and approval, similar to the full guidelines. For speci c focused update criteria and additional methodological details, please see the ACC/AHA guideline methodology manual (1). Modernization In response to published reports from the Institute of Medicine (2,3) and ACC/AHA mandates (4 7), processes have changed leading to adoption of a knowledge byte format. This entails delineation of recommendations addressing speci c clinical questions, followed by concise text, with hyperlinks to supportive evidence. This approach better accommodates time constraints on busy clinicians, facilitates easier access to recommendations via electronic search engines and other evolving tech- nology (e.g., smart phone apps), and supports the evolu- tion of guidelines as living documents that can be dynamically updated as needed. Intended Use Practice guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease. The focus is on medical practice in the United States, but guidelines developed in collaboration with other organiza- tions may have a broader target. Although guidelines may inform regulatory or payer decisions, they are intended to improve quality of care in the interest of patients. Class of Recommendation and Level of Evidence The Class of Recommendation (COR) and Level of Evi- dence (LOE) are derived independently of one another according to established criteria.


Class of Recommendation and Level of Evidence The Class of Recommendation (COR) and Level of Evi- dence (LOE) are derived independently of one another according to established criteria. The COR indicates the strength of recommendation, encompassing the esti- mated magnitude and certainty of bene t of a clinical action in proportion to risk. The LOE rates the quality of scienti c evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1) (1,7,8). Relationships With Industry and Other Entities The ACC and AHA sponsor the guidelines without com- mercial support, and members volunteer their time. The Task Force zealously avoids actual, potential, or perceived con icts of interest that might arise through relationships with industry or other entities (RWI). All Guideline Writing Committee (GWC) members and re- viewers are required to disclose current industry re- lationships or personal interests from 12 months before initiation of the writing effort. Management of RWI in- volves selecting a balanced GWC and assuring that the chair and a majority of committee members have no relevant RWI (Appendixes 1 and 2). Members are restricted with regard to writing or voting on sections to which their RWI apply. For transparency, members comprehensive disclosure information is available online. Comprehensive disclosure information for the Task Force is also available online. The Task Force strives to avoid bias by selecting experts from a broad array of back- grounds representing different geographic regions, sexes, ethnicities, intellectual perspectives/biases, and scopes of clinical practice, and by inviting organizations and pro- fessional societies with related interests and expertise to participate as partners or collaborators.


The Task Force strives to avoid bias by selecting experts from a broad array of back- grounds representing different geographic regions, sexes, ethnicities, intellectual perspectives/biases, and scopes of clinical practice, and by inviting organizations and pro- fessional societies with related interests and expertise to participate as partners or collaborators. Related Issues For additional information pertaining to the methodology for grading evidence, assessment of bene t and harm, shared decision making between the patient and clini- cian, structure of evidence tables and summaries, stan- dardized terminology for articulating recommendations, organizational involvement, peer review, and policies for periodic assessment and updating of guideline docu- ments, we encourage readers to consult the ACC/AHA guideline methodology manual (1). The recommendations in this focused update represent the of cial policy of the ACC and AHA until superseded by published addenda, statements of clari cation, focused up- dates, or revised full-text guidelines. To ensure that guide- lines remain current, new data are reviewed biannually to determine whether recommendations should be modi ed. In general, full revisions are posted in 5-year cycles (1). Jonathan L. Halperin, MD, FACC, FAHA Chair, ACC/AHA Task Force on Clinical Practice Guidelines The scope of this focused update is limited to consider- ations relevant to multivessel percutaneous coronary intervention (PCI) and thrombus aspiration in patients with ST-elevation myocardial infarction (STEMI) under- going primary PCI. 1.1. Methodology and Evidence Review Clinical trials presented at the major cardiology organi- zations 2013 to 2015 annual scienti c meetings and other selected reports published in a peer-reviewed format through August 2015 were reviewed by the 2011 PCI and 2013 STEMI GWCs and the Task Force to identify trials and other key data that might affect guideline rec- ommendations.


Methodology and Evidence Review Clinical trials presented at the major cardiology organi- zations 2013 to 2015 annual scienti c meetings and other selected reports published in a peer-reviewed format through August 2015 were reviewed by the 2011 PCI and 2013 STEMI GWCs and the Task Force to identify trials and other key data that might affect guideline rec- ommendations. The information considered important enough to prompt updated recommendations is included in evidence tables in the Online Data Supplement. J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Levine et al. Consult the full-text versions of the 2011 PCI and 2013 STEMI guidelines (9,10) for recommendations in clinical areas not addressed in the focused update. The individual recommendations in this focused update will be incor- porated into future revisions or updates of the full-text guidelines. 1.2. Organization of the GWC For this focused update, representative members of the 2011 PCI and 2013 STEMI GWCs were invited to partic- ipate. Members were required to disclose all RWI relevant to the topics under consideration. The entire membership of both GWCs voted on the revised recommendations and text. The latter group was composed of experts represent- ing cardiovascular medicine, interventional cardiology, electrophysiology, heart failure, cardiac surgery, emer- gency medicine, internal medicine, cardiac rehabilitation, nursing, and pharmacy. The GWC included representatives from the ACC, AHA, American College of Physicians, American College of Emergency Physicians, and Society for Cardiovascular Angiography and Interventions (SCAI). 1.3. Review and Approval This document was reviewed predominantly by the prior reviewers from the respective 2011 and 2013 guidelines. These included 8 of cial reviewers jointly nominated by the ACC and AHA, 4 of cial/organizational reviewers nominated by SCAI, and 25 individual content reviewers.


These included 8 of cial reviewers jointly nominated by the ACC and AHA, 4 of cial/organizational reviewers nominated by SCAI, and 25 individual content reviewers. Reviewers RWI information was distributed to the GWC and is published in this document (Appendix 3). Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015) Levine et al. J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 This document was approved for publication by the governing bodies of the ACC, the AHA, and the SCAI and was endorsed by the Latin American Society of Interven- tional Cardiology. 2. CULPRIT ARTERY ONLY VERSUS MULTIVESSEL PCI (See Section 5.2.2.2 of 2011 PCI guideline and Section 4.1.1 of 2013 STEMI guideline for additional recommendations.) Approximately 50% of patients with STEMI have mul- tivessel disease (25,26). PCI options for patients with STEMI and multivessel disease include: 1) culprit artery only primary PCI, with PCI of nonculprit arteries only for spontaneous ischemia or intermediate- or high-risk nd- ings on predischarge noninvasive testing; 2) multivessel PCI at the time of primary PCI; or 3) culprit artery only primary PCI followed by staged PCI of nonculprit arteries. Observational studies, randomized controlled trials (RCTs), and meta-analyses comparing culprit artery only PCI with multivessel PCI have reported con icting results (11,12,14 24,27,28), likely because of differing in- clusion criteria, study protocols, timing of multivessel PCI, statistical heterogeneity, and variable endpoints (Data Supplement). Previous clinical practice guidelines recommended against PCI of nonculprit artery stenoses at the time of primary PCI in hemodynamically stable patients with STEMI (9,10).


Previous clinical practice guidelines recommended against PCI of nonculprit artery stenoses at the time of primary PCI in hemodynamically stable patients with STEMI (9,10). Planning for routine, staged PCI of non- infarct artery stenoses on the basis of the initial angio- graphic ndings was not addressed in these previous guidelines, and noninfarct artery PCI was considered only in the limited context of spontaneous ischemia or high- risk ndings on predischarge noninvasive testing. The earlier recommendations were based in part on safety concerns, which included increased risks for procedural complications, longer procedural time, contrast nephrop- athy, and stent thrombosis in a prothrombotic and proin- ammatory state (9,10), and in part on the ndings from many observational studies and meta-analyses of trends toward or statistically signi cant worse outcomes in those who underwent multivessel primary PCI (12 16,21 23). Four RCTs have since suggested that a strategy of multivessel PCI, either at the time of primary PCI or as a planned, staged procedure, may be bene cial and safe in selected patients with STEMI (17,18,24,27) (Data Supple- ment). In the PRAMI (Preventive Angioplasty in Acute Myocardial Infarction) trial (n 465) (24), the composite primary outcome of cardiac death, nonfatal myocardial infarction (MI), or refractory angina occurred in 21 pa- tients (9%) treated with multivessel primary PCI, compared with 53 patients (22%) treated with culprit artery only PCI (HR: 0.35; 95% CI: 0.21 to 0.58; p<0.001). In the CvLPRIT (Complete Versus Culprit-Lesion Only Primary PCI) trial (18), 296 patients were randomized to culprit artery only or multivessel PCI during the index hospitalization (72% underwent multivessel primary PCI).


In the CvLPRIT (Complete Versus Culprit-Lesion Only Primary PCI) trial (18), 296 patients were randomized to culprit artery only or multivessel PCI during the index hospitalization (72% underwent multivessel primary PCI). The composite primary outcome of death, reinfarction, heart failure, and ischemia-driven revascularization at 12 months occurred in 15 patients (10%) who underwent multivessel PCI, compared with 31 patients (21%) receiving culprit artery only PCI (HR: 0.49; 95% CI: (Third Danish Study of Optimal Acute Treatment of Patients with ST-segment Elevation Myocardial Infarc- tion) trial (17), the composite primary outcome of all-cause death, nonfatal MI, or ischemia-driven revas- cularization of nonculprit artery disease occurred in 40 of 314 patients (13%) who underwent multivessel staged PCI guided by angiography and fractional ow reserve before discharge, versus 68 of 313 patients (22%) treated with culprit artery only PCI (HR: 0.56; 95% CI: 0.38 to in Patients Transferred From General Community Hospi- tals to Specialized PTCA Units With or Without Emer- gency Thrombolysis) trial (27), 214 patients with STEMI were randomized to staged (3 to 40 days after the index procedure) revascularization of all $70% diameter ste- nosis noninfarct lesions or culprit-only PCI. Preliminary results at 38 months mean follow-up showed no between-group differences in the composite primary endpoint of all-cause death, nonfatal MI, and stroke. On the basis of these ndings (17,18,24,27), the prior Class III (Harm) recommendation with regard to multi- vessel primary PCI in hemodynamically stable patients with STEMI has been upgraded and modi ed to a Class IIb recommendation to include consideration of multivessel PCI, either at the time of primary PCI or as a planned, staged procedure. The writing committee emphasizes that this change should not be interpreted as endorsing the routine performance of multivessel PCI in all patients with STEMI and multivessel disease.


The writing committee emphasizes that this change should not be interpreted as endorsing the routine performance of multivessel PCI in all patients with STEMI and multivessel disease. Rather, when considering the indications for and timing of multivessel PCI, physicians should integrate clinical data, lesion 2015 Focused Update Recommendation Comment Class III: Harm Class IIb PCI should not be performed in a noninfarct artery at the time of primary PCI in patients with STEMI who are hemodynamically stable (11 13). (Level of Evidence: B) PCI of a noninfarct artery may be considered in selected patients with STEMI and multivessel disease who are hemodynamically stable, either at the time of primary PCI or as a planned staged procedure (11 24). (Level of Evidence: B-R) Modi ed recommendation (changed class from III: Harm to IIb and expanded time frame in which multivessel PCI could be performed). PCI indicates percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction. J A C C V O L . 6 7 , N O . 1 0 , 2 0 1 6 Levine et al. severity/complexity, and risk of contrast nephropathy to determine the optimal strategy. The preceding discussion and recommendations apply to the strategy of routine PCI of noninfarct related arteries in hemodynamically stable patients. Recommendations in the 2013 STEMI guideline with regard to PCI of a non infarct-related artery at a time separate from primary PCI in patients who have spontaneous symptoms and myocardial ischemia or who have intermediate- or high- risk ndings on noninvasive testing (Section 6.3 of that guideline) remain operative.


Recommendations in the 2013 STEMI guideline with regard to PCI of a non infarct-related artery at a time separate from primary PCI in patients who have spontaneous symptoms and myocardial ischemia or who have intermediate- or high- risk ndings on noninvasive testing (Section 6.3 of that guideline) remain operative. Although several observational studies (19,20) and a network meta-analysis (13) have suggested that multi- vessel staged PCI may be associated with better outcome than multivessel primary PCI, there are insuf cient observational data and no randomized data at this time to inform a recommendation with regard to the optimal timing of nonculprit vessel PCI. Additional trial data that will help further clarify this issue are awaited. Issues related to the optimal method of evaluating nonculprit lesions (e.g., percent diameter stenosis, fractional ow reserve) are beyond the scope of this focused update. 3. ASPIRATION THROMBECTOMY (See Section 5.5.2 of the 2011 PCI guideline and Section 4.2 of the 2013 STEMI guideline for additional recommendations.) The 2011 PCI and 2013 STEMI guidelines (9,10) Class IIa recommendation for aspiration thrombectomy before pri- mary PCI was based on the results of 2 RCTs (29,31,32) and 1 meta-analysis (30) and was driven in large measure by the results of TAPAS (Thrombus Aspiration During Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction Study), a single-center study that randomized 1071 patients with STEMI to aspiration thrombectomy before primary PCI or primary PCI only (29,32). Three multicenter trials, 2 of which enrolled signi cantly more patients than prior aspiration thrombectomy trials, have prompted reevaluation of this recommendation.


Three multicenter trials, 2 of which enrolled signi cantly more patients than prior aspiration thrombectomy trials, have prompted reevaluation of this recommendation. In the INFUSE-AMI (Intracoronary Abciximab and Aspiration Thrombectomy in Patients With Large Anterior Myocardial Infarction) trial (37) of 452 patients with anterior STEMI due to proximal or mid-left anterior descending occlusion, infarct size was not reduced by aspiration thrombectomy before primary PCI. The TASTE (Thrombus Aspiration During ST-Segment Elevation Myocardial Infarction) trial (n 7,244) incorporated a unique design that allowed randomization within an existing national registry, resulting in enrollment of a remarkably high proportion of eligible patients (34,36). No signi cant 30-day or 1-year differences were found between the group that received aspiration thrombectomy before primary PCI and the group that received primary PCI only with regard to death, reinfarction, stent thrombosis, target lesion revascularization, or a composite of major adverse cardiac events. The TOTAL (Trial of Routine Aspiration Throm- bectomy With PCI Versus PCI Alone in Patients With STEMI) trial randomized 10,732 patients with STEMI to aspiration thrombectomy before primary PCI or primary PCI only (35). Bailout thrombectomy was performed in 7.1% of the primary PCI only group, whereas the rate of cross- over from aspiration thrombectomy before primary PCI to primary PCI only was 4.6%. There were no differences between the 2 treatment groups, either in the primary composite endpoint of cardiovascular death, recurrent MI, cardiogenic shock, or New York Heart Association class IV heart failure at 180 days, or in the individual components of the primary endpoint, stent thrombosis, or target-vessel revascularization. There was a small but statistically sig- ni cant increase in the rate of stroke in the aspiration thrombectomy group.


There was a small but statistically sig- ni cant increase in the rate of stroke in the aspiration thrombectomy group. An updated meta-analysis that included these 3 trials among a total of 17 trials (n 20,960) found no signi cant reduction in death, reinfarction, or stent thrombosis with routine aspiration thrombectomy. Aspiration thrombectomy was associated with a small but nonsigni cant increase in the risk of stroke (33). Several previous studies have found that higher thrombus burden in patients with STEMI is independently associated with higher risks of distal embolization, no- re ow phenomenon, transmural myocardial necrosis, major adverse cardiac events, stent thrombosis, and death (38 42). However, subgroup analyses from the TASTE and TOTAL trials did not suggest relative bene t from aspira- tion thrombectomy before primary PCI in patients with higher thrombus burden or in patients with initial Throm- bolysis in Myocardial Infarction (TIMI) ow grade 0 1 or left anterior descending artery/anterior infarction (34,35). On the basis of the results of these studies, the prior Class IIa recommendation for aspiration thrombectomy has been changed. Routine aspiration thrombectomy before primary PCI is now not recommended (Class III: No Bene t, LOE A). There are insuf cient data to assess the Recommendation 2015 Focused Update Recommendations Comments Class IIa Class IIb Manual aspiration thrombectomy is reasonable for patients undergoing primary PCI (29 32). (Level of Evidence: B) The usefulness of selective and bailout aspiration thrombectomy in patients undergoing primary PCI is not well established (33 37). (Level of Evidence: C-LD) Modi ed recommendation (Class changed from IIa to IIb for selective and bailout aspiration thrombectomy before PCI). Class III: No Bene t Routine aspiration thrombectomy before primary PCI is not useful (33 37).