Role of Cardiac Magnetic Resonance in the Assessment of Patients with Premature Ventricular Contractions: A Narrative Review.

Premature ventricular contractions (PVCs) are a common finding in clinical practice, requiring a full diagnostic work-up in order to exclude an underlying cardiomyopathy. Still, in a substantial proportion of patients, these investigations do not identify any substrate, and the PVCs are labelled as idiopathic. Cardiac magnetic resonance (CMR) has proven in the last decades as the method of choice for the exploration of patients with cardiomyopathies, since it can identify subtle changes in the myocardial tissue and help with risk stratification. In patients with idiopathic PVCs and a high PVC burden, several studies report the presence of late gadolinium enhancement (LGE) at CMR, which can offer additional diagnostic and prognostic benefits, as well as assistance in catheter ablation procedures, as the risk for adverse cardiac and risk for arrhythmic events events is higher compared to patients without scar. This paper focuses on the impact of the presence of LGE in patients with idiopathic PVCs, reviewing all the relevant studies published so far, including randomized controlled clinical trials, prospective or retrospective cohort studies, case series and case reports as well as systematic reviews.

Non-invasive electrocardiographic mapping on the ward to guide ablation of premature ventricular contractions.

Premature ventricular contracts (PVCs) are commonly encountered in clinical practice, but their ablation can prove difficult. In 15 patients with idiopathic PVCs, non-invasive mapping system View Into Ventricular Onset ™ (VIVO) in combination with 12­lead Holter monitoring on the ward accurately guided catheter ablation via the creation of 'electrical roadmaps' of ventricular activation. This allowed for better discussions of risks and benefits with the patient prior to the procedure, and is likely to have particular advantages for patients with a low PVC burden, multiple morphologies, or difficult to reach origins. CLINICAL PERSPECTIVE: PERSONALISED APPROACH: A novel non-invasive mapping tool in combination with technology, such as 12 lead Holter monitoring, allows for individualised, accurate prediction of PVC origin outside the electrophysiology (EP) lab. NON-INVASIVE MAPPING: An "electrical road map" can be implemented into 3D electroanatomical mapping systems, shortening procedure times and resulting in excellent clinical outcomes. POTENTIAL BENEFITS: VIVO could be used to improve catheter ablation outcomes for patients with infrequent PVCs, multiple morphologies and/or difficult to reach origins.

Zero-Fluoroscopy Ablation for Atrial Re-Entry Via a Vein of Marshall Connection Using a Visible Sheath.

We describe a zero-fluoroscopy ablation of a left atrial re-entry tachycardia in a patient with a previous atrial fibrillation ablation procedure. The critical isthmus was demonstrated to use an epicardial connection via the ligament of Marshall after failed endocardial and epicardial ablation along the mitral isthmus line. (Level of Difficulty: Intermediate.).

Autonomic modulation of the arrhythmogenic substrate in the evolution of atrial fibrillation and therapeutic approaches.

The autonomic nervous system (ANS) plays an important role in atrial arrhythmogenesis and is one of the factors responsible for the initiation and maintenance of atrial fibrillation (AF). Over the past few decades, neuromodulation has been shown to help in the management of AF. This review focuses on the correlation between AF and the ANS and how different approaches to identifying and modulating the autonomic substrate impact outcomes in AF. The authors conclude that the ANS is one of the key components in the development of AF and that modulation of autonomic nerve function may contribute to the management of AF. Therapeutic approaches such as catheter ablation of ganglionated plexi (GP), renal denervation and transcutaneous vagus nerve stimulation are viable treatment options that need further confirmation in larger randomised controlled trials. In addition, new imaging technologies were able to identify GPs accurately and reproducibly, which promises exciting prospects for the future.

Catheter mapping and ablation during pregnancy.

A substantial number of pregnant women at some point experience cardiac arrhythmia, which is mostly treated by antiarrhythmic medication. In some instances, arrhythmias can be drug-resistant and pose a relevant risk to both mother and unborn child as they can result in hemodynamic compromise. In recent years, invasive electrophysiology procedures have been carried out with ever reducing exposure to ionising radiation, and multiple techniques have been established to achieve ZERO exposure. Of course, these techniques should all be applied when contemplating an invasive mapping and ablation procedure during pregnancy. The role of the cardio-obstetrics team in planning and performing such procedures is paramount. Careful assessment of the pregnant mother and her unborn child is mandatory. Only with good preparation is a complete understanding of both cardiac anatomy and physiology achievable, which is a pre-requisite of a successful ablation outcome. Various aspects of the ablation procedure itself are discussed and evaluated from the perspective of all team members involved, including the obstetrician, the anaesthetist and the electrophysiologist. This review aims to inform the reader about the techniques available and reports on the published outcomes for ablations during pregnancy in the last decade.