For over 3 decades, it has been known that reentry circuits for ventricular tachycardia (VT) are not limited to the subendocardial myocardium. Rather, intramural or subepicardial substrates may also give rise to VT, particularly in those with non-ischemic cardiomyopathy. Percutaneous epicardial mapping and ablation has been successfully introduced for the treatment of such subepicardial VT. Herein, we review the indications for epicardial ablation and the identification of epicardial VT by electrocardiographic and imaging modalities. We also discuss the optimal technique for epicardial access and the implications of epicardial fat which has the potential to mimic scar, decreasing the specificity of electrogram morphology and impeding energy delivery to the tissue. Finally, we also report on possible complications of the procedure and strategies to mitigate adverse events.
Cardiomyopathies ; Catheter Ablation ; Cicatrix ; Electrocardiography ; Epicardial Mapping ; Myocardium ; Sensitivity and Specificity ; Tachycardia, Ventricular

For over 3 decades, it has been known that reentry circuits for ventricular tachycardia (VT) are not limited to the subendocardial myocardium. Rather, intramural or subepicardial substrates may also give rise to VT, particularly in those with non-ischemic cardiomyopathy. Percutaneous epicardial mapping and ablation has been successfully introduced for the treatment of such subepicardial VT. Herein, we review the indications for epicardial ablation and the identification of epicardial VT by electrocardiographic and imaging modalities. We also discuss the optimal technique for epicardial access and the implications of epicardial fat which has the potential to mimic scar, decreasing the specificity of electrogram morphology and impeding energy delivery to the tissue. Finally, we also report on possible complications of the procedure and strategies to mitigate adverse events.

Background and Objectives: The efficacy of sodium-glucose cotransporter-2 inhibitors (SGLT2i) may depend on renal function, and this raises theoretical concern over its effects on cardiovascular outcomes in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). Methods: This systematic review and updated meta-analysis of randomized controlled trials (RCTs) compared cardiovascular outcomes of patients with T2DM and CKD treated with SGLT2i to placebo. PubMed, Embase, and Cochrane were systematically searched. Prespecified subgroup analyses were performed in strata of estimated glomerular filtration rate (eGFR) of <45 mL/min/1.73 m2 and 45 to 59 mL/min/1.73 m2 . Results: Nine RCTs comprising 29,146 patients were selected. Average follow-up ranged from 0.75 to 4.2 years. SGLT2i were shown to reduce the risk of all-cause mortality (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.79–0.97; p=0.01), the composite of cardiovascular mortality or hospitalizations for heart failure (HHF: HR, 0.71; 95% CI, 0.65–0.78; p<0.001), cardiovascular mortality (HR, 0.86; 95% CI, 0.76–0.98; p=0.02), HHF (HR, 0.62; 95% CI, 0.55–0.71; p<0.001), major adverse cardiovascular events (HR, 0.85;95% CI, 0.77–0.94; p=0.002), stroke (HR, 0.76; 95% CI, 0.59–0.97; p=0.03), and myocardial infarction (HR, 0.78; 95% CI, 0.67–0.91; p=0.001). These findings were consistent over strata of eGFR, albeit with a lower incidence of stroke in patients treated with SGLT2i with eGFR <45 mL/min/1.73 m2 (p-value for interaction=0.04). Conclusions Compared with a placebo, patients with T2DM and CKD treated with SGLT2i experience a reduction in all-cause mortality, cardiovascular mortality, and HHF.

Background and Objectives: The efficacy of sodium-glucose cotransporter-2 inhibitors (SGLT2i) may depend on renal function, and this raises theoretical concern over its effects on cardiovascular outcomes in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). Methods: This systematic review and updated meta-analysis of randomized controlled trials (RCTs) compared cardiovascular outcomes of patients with T2DM and CKD treated with SGLT2i to placebo. PubMed, Embase, and Cochrane were systematically searched. Prespecified subgroup analyses were performed in strata of estimated glomerular filtration rate (eGFR) of <45 mL/min/1.73 m2 and 45 to 59 mL/min/1.73 m2 . Results: Nine RCTs comprising 29,146 patients were selected. Average follow-up ranged from 0.75 to 4.2 years. SGLT2i were shown to reduce the risk of all-cause mortality (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.79–0.97; p=0.01), the composite of cardiovascular mortality or hospitalizations for heart failure (HHF: HR, 0.71; 95% CI, 0.65–0.78; p<0.001), cardiovascular mortality (HR, 0.86; 95% CI, 0.76–0.98; p=0.02), HHF (HR, 0.62; 95% CI, 0.55–0.71; p<0.001), major adverse cardiovascular events (HR, 0.85;95% CI, 0.77–0.94; p=0.002), stroke (HR, 0.76; 95% CI, 0.59–0.97; p=0.03), and myocardial infarction (HR, 0.78; 95% CI, 0.67–0.91; p=0.001). These findings were consistent over strata of eGFR, albeit with a lower incidence of stroke in patients treated with SGLT2i with eGFR <45 mL/min/1.73 m2 (p-value for interaction=0.04). Conclusions Compared with a placebo, patients with T2DM and CKD treated with SGLT2i experience a reduction in all-cause mortality, cardiovascular mortality, and HHF.

Background and Objectives: The efficacy of sodium-glucose cotransporter-2 inhibitors (SGLT2i) may depend on renal function, and this raises theoretical concern over its effects on cardiovascular outcomes in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). Methods: This systematic review and updated meta-analysis of randomized controlled trials (RCTs) compared cardiovascular outcomes of patients with T2DM and CKD treated with SGLT2i to placebo. PubMed, Embase, and Cochrane were systematically searched. Prespecified subgroup analyses were performed in strata of estimated glomerular filtration rate (eGFR) of <45 mL/min/1.73 m2 and 45 to 59 mL/min/1.73 m2 . Results: Nine RCTs comprising 29,146 patients were selected. Average follow-up ranged from 0.75 to 4.2 years. SGLT2i were shown to reduce the risk of all-cause mortality (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.79–0.97; p=0.01), the composite of cardiovascular mortality or hospitalizations for heart failure (HHF: HR, 0.71; 95% CI, 0.65–0.78; p<0.001), cardiovascular mortality (HR, 0.86; 95% CI, 0.76–0.98; p=0.02), HHF (HR, 0.62; 95% CI, 0.55–0.71; p<0.001), major adverse cardiovascular events (HR, 0.85;95% CI, 0.77–0.94; p=0.002), stroke (HR, 0.76; 95% CI, 0.59–0.97; p=0.03), and myocardial infarction (HR, 0.78; 95% CI, 0.67–0.91; p=0.001). These findings were consistent over strata of eGFR, albeit with a lower incidence of stroke in patients treated with SGLT2i with eGFR <45 mL/min/1.73 m2 (p-value for interaction=0.04). Conclusions Compared with a placebo, patients with T2DM and CKD treated with SGLT2i experience a reduction in all-cause mortality, cardiovascular mortality, and HHF.

Background and Objectives: The efficacy of sodium-glucose cotransporter-2 inhibitors (SGLT2i) may depend on renal function, and this raises theoretical concern over its effects on cardiovascular outcomes in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). Methods: This systematic review and updated meta-analysis of randomized controlled trials (RCTs) compared cardiovascular outcomes of patients with T2DM and CKD treated with SGLT2i to placebo. PubMed, Embase, and Cochrane were systematically searched. Prespecified subgroup analyses were performed in strata of estimated glomerular filtration rate (eGFR) of <45 mL/min/1.73 m2 and 45 to 59 mL/min/1.73 m2 . Results: Nine RCTs comprising 29,146 patients were selected. Average follow-up ranged from 0.75 to 4.2 years. SGLT2i were shown to reduce the risk of all-cause mortality (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.79–0.97; p=0.01), the composite of cardiovascular mortality or hospitalizations for heart failure (HHF: HR, 0.71; 95% CI, 0.65–0.78; p<0.001), cardiovascular mortality (HR, 0.86; 95% CI, 0.76–0.98; p=0.02), HHF (HR, 0.62; 95% CI, 0.55–0.71; p<0.001), major adverse cardiovascular events (HR, 0.85;95% CI, 0.77–0.94; p=0.002), stroke (HR, 0.76; 95% CI, 0.59–0.97; p=0.03), and myocardial infarction (HR, 0.78; 95% CI, 0.67–0.91; p=0.001). These findings were consistent over strata of eGFR, albeit with a lower incidence of stroke in patients treated with SGLT2i with eGFR <45 mL/min/1.73 m2 (p-value for interaction=0.04). Conclusions Compared with a placebo, patients with T2DM and CKD treated with SGLT2i experience a reduction in all-cause mortality, cardiovascular mortality, and HHF.