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Cor triatriatum is a rare yet important anomaly. We want to highlight the importance of ICE for realtime assessment of the cardiac anatomy during interventional electrophysiology procedures especially when ancillary imaging modalities have failed to detect abnormalities. In these cases, ICE with color flow Doppler imaging guidance was essential for prompt diagnosis of cor triatriatum including definition of the membrane structure with fenestrations or identifying modest atrial obstruction, and guiding proper and uneventful catheter manipulation around the membrane, especially when manipulating near the pulmonary vein orifices. The development of symptoms in patients with cor triatriatum may be insidious and may be delayed even until late adult life. In our patients the cor triatriatum was an incidental ICE finding without significant hemodynamic consequences, because of the sizable defect in the membrane allowing communication. The incidence of cor triatriatum in our adult patients population is 0.09% (4 of 4269) using ICE during radio frequency ablation procedures for tachyarrhythmias. [ABSTRACT FROM AUTHOR]

Multispline catheters were recently introduced and have led to significant improvements in electrogram acquisition and analysis. Omnipolar mapping is now able to be performed with these multispline catheters. Omnipolar mapping has the advantages of mapping a focal segment without needing the entire chamber of interest to be mapped, does not need a stable reference and is cycle length independent. This article will review the mechanism of omnipolar mapping and show how this technology can be used for multiple arrythmias. [ABSTRACT FROM AUTHOR]

Peripartum cardiomyopathy is an idiopathic cardiomyopathy that most commonly affects women in the third trimester of pregnancy or in the first five months of the postpartum period. It has been associated with a myriad of different findings on electrocardiograms and arrhythmias. This review discusses these electrocardiogram changes and arrhythmias in regards to prevalence, genetic landscape, screening and prognostication implications, and management. [ABSTRACT FROM AUTHOR]

Background: Robotic systems have been used in a diverse spectrum of cardiac interventions, mainly in the field of invasive cardiology, namely interventional cardiology and electrophysiology (EP). The state-of-the-art robotic systems allow mapping and ablation of various arrhythmias without the need for manual conventional catheter steering. The aim of robotic procedures is to achieve the same effectiveness and safety as conventional procedures, whilst reducing the radiation exposure for patients and operators, and to be able to reach targets within the heart that are otherwise unreachable conventionally with greater precision and catheter stability. Purpose: We aimed to demonstrate the feasibility of 3D electroanatomical mapping (EAM) using the remote magnetic navigation (RMN) system (Niobe ES, Stereotaxis Inc) by comparing the mapping performance of 2 operators (one located in the electrophysiology catheter lab control room and the second ~1200 km away via remote online connection). Methods: Two operators were tasked to perform 3D fast anatomical maps (FAM, CARTO 3 RMT, Biosense Webster) of the right and left atrial and ventricular chambers, as well as the aorta of a 3D phantom representing normal cardiac anatomy. All procedures were recorded on the Odyssey Cinema system for further analysis. Parameters compared were duration of FAM, total volume acquired and average distance of surface match to a contrast enhanced computed tomography (CT) of the same phantom. A composite endpoint of map completeness, mapping time and surface match accuracy was calculated to demonstrate if quality of the maps between operators were comparable. Results: A total of 60 maps were created (6 maps for each right atrium (RA), left atrium (LA), right ventricle (RV), left ventricle (LV) and aorta (Ao) per operator) in an alternating fashion. Average mapping time was 16:08±3:36 min for all chambers with shorter mapping times for right atrial chamber 14:28±3:47 min. Total volumes did not significantly differ between operators. Match statistics also revealed no difference between map completeness. Comparing the composite endpoint, both operators achieved the same accuracy. Conclusion: A distant operator located more than 1200 km away from the RMN laboratory connected online to perform 3D electroanatomical maps of all cardiac chambers of a phantom with equal accuracy and procedure parameters as compared to an operator located in the control room. These results support the feasibility of truly remote-controlled procedures which would allow an expert operator to actively support a local team in EP interventions. [ABSTRACT FROM AUTHOR]

Introduction: Symptoms like syncope or palpitations frequently present a diagnostic challenge. An implantable loop recorder (ILR) is an important aid in the management of these patients. Methods: A retrospective study of patients that underwent ILR implantation from November 2007 to 2014. For each patient the indication for implantation, baseline characteristics, previous study, complications, recorded tracing and interventions were evaluated. Results: A total of 62 patients were included, 50% men, with a mean age of 62.5±18.8 years old. Previously to ILR implantation 88.7% of patients had performed Holter, 17.7% external events recorder, 33.9% Tilt test and 29% an electrophysiological study. The implantation indications were recurrent syncope in 90.3%, palpitations 8.1% and ischemic stroke in one patient. Mean follow-up time was 17.1±16.3 months. Symptoms were reported in 66.1% of the patients, 46.8% of those yielding a diagnostic finding. In all cases of palpitation complaints with diagnosis we found atrial fibrillation (AF). In patients with syncope atrioventricular conduction disturbance was demonstrated in 19.6%, sinus node dysfunction in 16.1%, paroxysmal supra-ventricular tachycardia 7.1% and AF in 1.8%. These finding resulted in 19 pacemaker and one CRT-D implantation, introduction of anticoagulation in five patients and one ablation of accessory pathway. There were no major complications. Conclusion: ILR proved to be safe and efficient. It has enabled the identification or exclusion of serious rhythm disturbances in more than half of patients and provided a targeted therapeutic intervention. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is a complex arrhythmia, that has been studied non-invasively assessing atrial refractory period, atrioventricular node (AV) node refractory period, and ventricular response. The AV node plays a fundamental role as it filters many of the numerous irregular atrial impulses bombarding the node. Despite its importance, the electrophysiological (EP) characteristics of the AV node are not routinely evaluated since conventional EP techniques for assessment of refractory period or conduction velocity of the AV node are not applicable in AF. Since rate-control drugs control ventricular response through their effect on the AV node, noninvasive assessment of AV node electrophysiology may be useful. The RR series, though being highly irregular, contains information that can be used for risk stratification and prediction of outcome. In particular, RR irregularity measures during AF have been shown to be related to clinical outcome. This paper reviews the attempts done to noninvasively characterize the AV node and the ventricular response, highlighting clinical applications and limitations of the noninvasive techniques. [ABSTRACT FROM AUTHOR]

Atrial fibrillation continues to be a challenging arrhythmia. There are some conventional, time-tested explanations of atrial fibrillation genesis, however some uncertainty of its complete understanding still exists. We focused on atrial ischemia which, hypothetically, could be responsible for manifestation of the arrhythmia, irrespective of the underlying heart disease. Evidences abounds that atrial fibrillation has an extremely strong association with nutritional/oxidative status of myocardium. This arrhythmia seemingly may stem from the electrophysiological differences taking place in the boundary areas. To validate such assumptions we have surveyed widely accepted theories based on clinical and experimental evidence. There was an attempt to integrate some well-known theoretical explanations (focal, multifocal, ectopic, reentrant activity, atrial remodeling, etc.) into a new conceptually systematized arrhythmogenesis. Confronting ischemic and non-ischemic atrial zones electrophysiologically on their borderlines presumably creates a substrate vulnerable to the development of atrial fibrillation. The behavior of these interrelated areas is likely ischemia-dependent; the separating borderline(s) may be treated as conflictogenic, releasing triggers/drivers to commence and to perpetuate the arrhythmia. Ischemically damaged and non-damaged myocardial areas likely participate in the relay-race carousel of arrhythmogenicity due to their mutual interactions, accompanied by the "fireworks" at the separating borderlines. It could be concluded that myocardial ischemia as a nonspecific proarrhythmic factor presumably plays a key role in the genesis and sustenance of atrial fibrillation. Theoretically the most important step in eradication of arrhythmogenic substrate might be an overall abolition of ischemia regardless of the characteristics of underlying heart disease. Innovative intellectual and explorative research is needed to render innocuous the ischemia that might help us win the century's cardioarrhythmological battle. [ABSTRACT FROM AUTHOR]

In patients with recurrent atrial fibrillation (AF), the hallmark of treatment has been the use of antiarrhythmic drugs (AADs). Goals of therapy include reduction in the frequency and duration of episodes of arrhythmia as well an emerging goal of reducing mortality and hospitalizations associated with AF. Safety and efficacy are important factors when choosing an antiarrhythmic drug for the treatment of AF, hence, if AAD are required for maintenance of sinus rhythm, their safety profi le, together with individual patient characteristics, should be of utmost concern. In the next paragraphs we would like to review some aspects (electrophysiologic effects, metabolism, side effects, current evidence and indication) of the most commonly used AAD for the management of patients with AF, following the Vaughan-Williams classification. However, this system is mainly based on ventricular activity, therefore, and due to its relatively atrial selective actions, some agents will not readily fit in the Vaughan Williams AAD classification. For that reason, in the final part of the manuscript, new promising agents will be reviewed separately. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is the most common sustained atrial arrhythmia conferring a higher morbidity and mortality. Despite the increasing incidence of AF; available therapies are far from perfect. Dietary fish oils, containing omega 3 fatty acids, also called polyunsaturated fatty acid [PUFA] have demonstrated beneficial electrophysiological, autonomic and anti-inflammatory effects on both atrial and ventricular tissue. Multiple clinical trials, focusing on various subsets of patients with AF, have studied the role of PUFA and their potential role in reducing the incidence of this common arrhythmia. While PUFA appears to have a beneficial effect in the primary prevention of AF in the elderly with structural heart disease, this benefit has not been universally observed. In the secondary prevention of AF, PUFA seems to have a greater impact in the reducing AF in patients with paroxysmal or persistent AF, stages of AF associated with less atrial fibrosis and negative structural remodeling. However, AF suppression has not been consistently demonstrated in clinical trials. In patients undergoing heart surgery, increasing PUFA intake has yielded mixed results in terms of AF prevention post-operatively; however, increased PUFA has been associated with a reduction in hospital stay. Therefore recommending the use of PUFA for the purpose of AF reduction remains controversial. This is in part attributable to the complexity of AF. Other conflicting variables include: heterogeneous patient populations studied; variable dosing; duration of follow-up; comorbidities; and, concomitant pharmacotherapy. This review article reviews in detail available basic and clinical research studies of fish oil in the treatment of AF, and its role in the treatment of this common disorder. [ABSTRACT FROM AUTHOR]

Currently, post-ablation Atrial Tachycardias (ATs) represent a growing clinical problem particularly in patients with persistent AF undergoing a more extensive substrate ablation. Understanding mechanisms and location of potentially widely located arrhythmogenic substrates in the left atrium is crucial for successful ablation. Mapping and ablation are challenging since complex and multiple ATs may frequently develop during the index procedure and before conversion to sinus rhythm. Use of irrigated ablation guided by detailed 3-D electroanatomic activation maps combined with entrainment pacing is effective with excellent acute and long-term success rates, rarely requiring multiple procedures. [ABSTRACT FROM AUTHOR]

Ablation of peristent AF remains challenging with questions unanswered about what the ideal next step after pulmonary venous isolation should be. Ibutilide is a highly effective class III agent for cardioversion of acute-onset atrial flutter and fibrillation, with limited clinical use due to risks of ventricular pro-arrhythmias. However, results from the on-going MAGIC-AF trial may re-invigorate its role in clinical electrophysiology as an invaluable adjunct to facilitate controlled substrate modification during ablation of persistent AF. [ABSTRACT FROM AUTHOR]

The article offers the authors' opinion on a study regarding the demonstration of structural and electrophysiological abnormalities in the atria of patients with paroxysmal lone atrial fibrillation (AF). It notes that AF has been considered as the commonest arrhythmia found in clinical practice associated with a poor clinical outcome and a high healthcare cost. The authors also discuss the findings of the study including the electroanatomical mapping that showed larger volumes, lower mean bipolar voltage, a slower mean conduction velocity, and a prolonged total atrial activation time in the AF group as compared to the reference group.

Atrial fibrillation (AF) is the most common arrhythmia in clinical practice. The prevalence of AF increases dramatically with age and is seen in as high as 9% of individuals by the age of 80 years. In high-risk patients, the thromboembolic stroke risk can be as high as 9% per year and is associated with a 2-fold increase in mortality. Although the pathophysiological mechanism underlying the genesis of AF has been the focus of many studies, it remains only partially understood. Conventional theories focused on the presence of multiple re-entrant circuits originating in the atria that are asynchronous and conducted at various velocities through tissues with various refractory periods. Recently, rapidly firing atrial activity in the muscular sleeves at the pulmonary veins ostia or inside the pulmonary veins have been described as potential mechanism,. AF results from a complex interaction between various initiating triggers and development of abnormal atrial tissue substrate. The development of AF leads to structural and electrical changes in the atria, a process known as remodeling. To have effective surgical or catheter ablation of AF good understanding of the possible mechanism(s) is crucial. Once initiated, AF alters atrial electrical and structural properties that promote its maintenance and recurrence. The role of atrial remodeling (AR) in the development and maintenance of AF has been the subject of many animal and human studies over the past 10-15 years. This review will discuss the mechanisms of AR, the structural, electrophysiologic, and neurohormonal changes associated with AR and it is role in initiating and maintaining AF. We will also discuss briefly the role of inflammation in AR and AF initiation and maintenance, as well as, the possible therapeutic interventions to prevent AR, and hence AF, based on the current understanding of the interaction between AF and AR. [ABSTRACT FROM AUTHOR]