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Interventional electrophysiological procedures such as catheter ablation and cardiac implantable electronic device (CIED) implantation have become important treatment options for patients with arrhythmia, but delivering state-of-the-art care can be challenging in developing countries. Romania has 19 million people. Throughout Romania, there are 28 centers that can implant CIEDs and 16 centers that can perform catheter ablation, but they are concentrated in the capital of Bucharest. Interventional arrhythmia procedures are performed less frequently than in other European countries (pacemaker: 301/million; implantable cardioverter-defibrillator: 44/million; cardiac resynchronization therapy: 13/million; catheter ablation: 0.8/million). Cardiologists with expertise in arrhythmia care have increased over the past decade and have formed an active organization that has instituted a national registry for interventional arrhythmia procedures and have been active in research and international arrhythmia organizations. Although significant work remains, our electrophysiology community is energized and is working to develop access to the best arrhythmia care for all Romanians.

Цел: Радиофреквентната катетърна аблация е ефективен метод на лечение на сърдечни аритмии, вкл. комплексни и камерни аритмии. Дистанционната магнитна катетърна навигация (RMN) беше разработена като нов подход с цел подобряване на резултатите и намаляване на честотата на усложнения, както и намаляване на лъчевото натоварване за оператора и пациентите. Целта ни беше да сравним честотата на успех и усложнения при пациенти със или без тежко намалена левокамерна фракция на изтласкване (ФИЛК). Методи: Анализирахме ретроспективно всички пациенти с RMN в нашия център от 2015 до 2021 г. (n = 98). Не са прилагани специални критерии за подбор на пациентите за RMN. Бяха събрани всички клинични, параклинични и процедурни данни. Пациентите бяха разделени в 2 групи – със или без тежко намалена ФИЛК >/= 35%. Система CARTO беше използвана за 3D електроанатомичен мепинг. RMN беше осъществена посредством система Niobe ES и магнитен аблационен катетър с отворена иригация. Успехът беше дефиниран като пълно елиминиране на клиничната аритмия. Неиндуцируемостта след аблация беше оценена при всички пациенти с какъвто и да било вид камерна аритмия извън камерни екстрасистоли. Тестването на индуцируемост беше направено с програмирана камерна стимулация с до 4 екстрастимула. Статистическият анализ беше извършен със софтуерен пакет SPSS. Стойност на р Резултати: Успешна аблация с пълно елиминиране на клиничната аритмия, беше постигната при 92,3% от пациентите с тежко намалена ФИЛК и при 88,1% от пациентите с ФИЛК > 35% (р = 0,73). Общата честота на малки усложнения беше 2,04% със спонтанна резолюция. Не бяха регистрирани тежки усложнения. Неиндуцируемост беше постигната в 56,4% от пациентите с ФИЛК >/=35% и в 79,2% от пациентите с ФИЛК > 35% (р = 0,023). Заключение: Радиофреквентната катетърна аблация чрез RMN е ефективна и безопасна, независимо от наличието или не на тежко намалена ФИЛК. Objective. Radiofrequency catheter ablation is an effective treatment option for cardiac arrhythmias including complex and ventricular arrhythmias. Remote magnetic catheter navigation (RMN) has been developed as a novel way of approach aiming to improve outcome and reduce complication rate, and reduce radiation exposure for both operator and patient. Our aim was to compare success and complication rate in patients with or without severely reduced left ventricular ejection fraction (LVEF). Methods. We retrospectively analyzed all the patients (n = 98) which have undergone RMN in our center between 2015-2021. No selection criteria for RMN procedure have been applied. All clinical and paraclinical, as well as procedural data were collected. Patients were divided into two groups, with or without severely reduced LVEF ≤ 35%. CARTO system was used for 3D electroanatomic mapping. RMN was done using Niobe ES system and an open-irrigated magnetic ablation catheter. Success rate was defi ned by complete elimination of clinical arrhythmia. Non-inducibility following ablation was assessed in all patients presenting with any type of ventricular arrhythmia other than premature ventricular contractions. Testing for inducibility was done by ventricular programmed pacing with up to four extra-stimuli. The statistical analysis was performed using SPSS software. P-value Results. Successful ablation with complete elimination of the clinical arrhythmia was achieved in 92.3% of the patients with severely reduced LVEF and in 88.1% of patients with LVEF > 35% (p = 0.73). Overall minor complication rate was 2.04% with spontaneous resolution. No major complications were reported. Non-inducibility was achieved in 56.4% of the patients with LVEF ≤ 35% and in 79.2% of the patients with LVEF >35% (p = 0.023). Conclusion. Radiofrequency catheter ablation using RMN is effective and safe regardless of the presence or not of a severely reduced LVEF.

Background Achieving long-term successful outcomes with catheter ablation (CA) of persistent atrial fibrillation (PsAF) remains a challenge. Multiple attempts to determine effective ablation strategies besides the pulmonary veins (PV) were made but, so far, there is no agreed standard approach and no clear consensus as to which is the best one. Among the most frequently used techniques was ablation of complex atrial fractionated electrograms (CFAE) but studies showed contradictory results. The optimal procedural endpoint also needs further refinement. Objectives We sought to evaluate outcomes in regard to patient characteristics and procedural termination. We also aimed to assess whether continuation of antiarrythmic therapy in the blanking period (1 to 3 months after the procedure) influences long term results. Methods We enrolled consecutive patients with persistent and long-standing PsAF (LS-PsAF) who underwent one or more radiofrequency catheter ablations (RF CA) - pulmonary vein antral isolation (PVAI), followed by CFAE or resultant atrial tachycardia/flutter elimination, were retrospectively analyzed. Procedural objective was tachyarrhythmia (AF or resultant atrial flutters/tachycardias) termination (TT) to sinus rhythm (SR) during RF delivery. If after extensive substrate based or activation guided ablation sinus rhyhtm was not restored, conversion was performed with antiarrhythmic drugs (AAD), overdrive pacing or electrical shock. Screening for arrhythmia recurrence was performed via clinical interview and 48 hours Holter monitoring at 1,3 and 6 months and then every 6 months. Results The cohort included 94 patients (age 54.5±11.4, 67 (71%) males, CHADSVASc 2.3±2, 11 (12%) LS-PsAF) Acute restoration of sinus rhythm (SR) was achieved in 93.4% of the cases, 43% by ablation of CFAE or resultant atrial tachycardia/flutter(AT/AFL), 36.2% by electric cardioversion, 7.4% by chemical conversion, 3.1 % overdrive pacing, 3.7 % spontaneuous/mechanical. The long term success rate after a mean of 1.7±0.8 procedures was 59% at a mean follow-up period of 80±28 months. Freedom from AF was significantly higher when arrhythmia termination was obtained during RF delivery (p – 0.003). Short-term use of AAD in the blanking period did not lead to improved long term outcomes. Conclusions In patients with PsAF and LS-PsAF restoration of sinus rhyhtm during RF delivery for pulmonary vein isolation, ablation of CFAE or resultant atrial tachyarrhythmia predicts long term procedural success. Further research to determine the best strategy to achieve this outcome is necessary.

BACKGROUND Right ventricular - arterial (RV-PA) coupling can be estimated by echocardiography using the ratio between (TAPSE) and pulmonary arterial systolic pressure (PASP). TAPSE/PASP ratio proved to be a prognostic parameter in patients with heart failure and reduced ejection fraction (HFrEF). OBJECTIVE To evaluate the significance of RV-PA coupling in patients with HFrEF undergoing cardiac resynchronization therapy (CRT). METHODS Patients undergoing CRT in our center between January 2017 and November 2019 were eligible. Response to CRT was defined by a reduction of more than 15% of left ventricle systolic volume (LVESV) one year after CRT. Primary endpoint was a composite of HF hospitalizations and death during follow-up. RESULTS 54 patients (Age 64.0 ± 13.8 years; 58% male; left ventricular ejection fraction (LVEF) 28.4 ± 1.3%) were prospectively included. After a mean follow-up of 31 ± 12.9months, the primary endpoint had occurred in 18 (33.3%) patients. A lower TAPSE/PASP ratio was associated with baseline worse HF symptoms, lower LVEF and long-term less LV reverse remodeling (P

Objectives To provide preliminary data on practice of stress perfusion cardiovascular magnetic resonance (CMR) in a single center in Romania. Methods We retrospectively reviewed the clinical files and CMR reports of patients who underwent stress perfusion CMR in our institution between January 2018 and December 2020. Results A total of 1036 patients underwent CMR examinations during this period in our institution. Of these, 120 patients had stress perfusion CMR. The most common indication was the assessment of myocardial ischaemia in patients with established coronary artery disease (CAD) (77 patients, 64.16%), with either a history of myocardial infarction or previous coronary revascularization, or with intermediate lesions on invasive coronary angiography (ICA). The other indications consisted in detection of ischaemia in patients with suspected CAD (36 patients, 30%), characterization of the substrate of ventricular arrhythmia (5 patients, 4.16%) and assessment of the etiology of dilated cardiomyopathy (DCM) (4 patients, 3.33%). All patients had vasodilator stress with adenosine and an adequate stress response was obtained in 113 patients (94.16%). There were 21 patients (18.58%) with an abnormal stress test and patients with intermediate lesions on ICA had the highest prevalence of positive reports (24.32%). Sixty-three patients had myocardial fibrosis (52.5%): 49 patients (40.83%) had subendocardial (ischaemic) scars, while 14 patients (11.66%) had non-ischaemic scars. There were no serious adverse events related to the procedure. Conclusions This is the first report in Romania on the use of stress perfusion CMR in clinical practice. We report our experience on stress efficiency, acquisition protocol, artifacts, prevalence of positive tests and safety. Most stress CMRs were requested in patients with established CAD.

Funding Acknowledgements Type of funding sources: None. Introduction Catheter ablation of accessory pathways (AP) located in the posterior pyramidal space are often challenging due to its anatomical complexity. Scarce of data are available about the ECG features that might indicate when an epicardial approach is required in the ablation of the posteroseptal AP. Objective The purpose of this retrospective study was to describe the electrocardiographic features of posteroseptal AP which have been successfully ablated with epicardial approach and identify electrocardiographic predictors for epicardial AP location. Methods The 12 leads ECG of 75 patients with posteroseptal accessory pathways who were successfully ablated were retrospectively analyzed. ECG features for epicardial location described already in published studies have been considered (negative delta wave in DII, positive delta wave in aVR, high amplitude S wave in V6). Additionally the characteristics of the initial 40 ms of the delta wave in lead V1 (measured from the earliest QRS deflection in 12 leads) during full pre-excitation have been investigated. Results Of 75 patients with posteroseptal AP that undergone catheter ablation, 40 (53.3%) had successful epicardial ablation. An initial isoelectric or biphasic delta wave in lead V1 proved the highest sensitivity (82.5 %) respectively positive predictive value (97 %) and specificity (97 %) for an epicardial location of the AP. Deep S wave in V6 proved lower sensitivity (37.5%) and positive predictive value (68%) but higher specificity (80%) for epicardial location of AP. The specificity and sensitivity for epicardial location of AP of negative delta wave in DII were lower, however it failed to reach statistical significance. Conclusion This study shows that an initially isoelectric or biphasic delta wave aspect in lead V1 has a higher specificity, sensitivity and positive predictive value than previously described ECG markers for epicardial location of posteroseptal accessory pathways.

BACKGROUND The Shockless IMPLant Evaluation (SIMPLE) trial showed that defibrillation testing (DT) at the time of implantable cardioverter-defibrillator (ICD) implant did not improve shock efficacy or reduce mortality. There are no data regarding the risk of complications, including stroke, among patients with atrial fibrillation (AF) who undergo DT. OBJECTIVE The purpose of this prospectively planned substudy of SIMPLE was to evaluate the effect of DT vs no DT on clinical outcomes among patients with AF. METHODS We compared efficacy (failed appropriate shock/arrhythmic death) and safety between patients who had AF on their immediate preprocedural ECG to the rest of the study patients. Then among patients with AF we compared these outcomes between patients randomized to DT vs no DT. RESULTS Of the 2500 patients enrolled in SIMPLE, 251 (10%) were in AF immediately before ICD implant. AF patients had an increased risk of failed appropriate shock/arrhythmic death adjusted hazard ratio [HR] 1.64; 95% confidence interval [CI] 1.13-2.39; P = .009) and higher all-cause mortality (adjusted HR 1.58; 95% CI 1.2-2.08; P = .001). Among AF patients, perioperative complications and stroke did not significantly differ between DT vs no-DT groups (9.2% vs 5.4 0 /0; P = .2; and 1.7% vs 1.5%; P >.999, respectively). Failed appropriate shock or arrhythmic death occurred in 35 of 251 AF patients (14%), and the no-DT group proved not inferior to the DT group (HR 0.58; 95 0 /0 CI 0.30-1.15; P-noninferiority = .006). CONCLUSION ICD recipients with AF are at increased risk for adverse outcomes; however, DT does not improve arrhythmic survival or shock efficacy. There is no evidence that DT increased the occurrence of perioperative stroke.

Background: The aim of this study was to explore the rare variants in a cohort of Romanian index cases with hypertrophic cardiomyopathy (HCM). Methods: Forty-five unrelated probands with HCM were screened by targeted next generation sequencing (NGS) of 47 core and emerging genes connected with HCM. Results: We identified 95 variants with allele frequency &lt, 0.1% in population databases. MYBPC3 and TTN had the largest number of rare variants (17 variants each). A definite genetic etiology was found in 6 probands (13.3%), while inconclusive results due to either known or novel variants were established in 31 cases (68.9%). All disease-causing variants were detected in sarcomeric genes (MYBPC3 and MYH7 with two cases each, and one case in TNNI3 and TPM1 respectively). Multiple variants were detected in 27 subjects (60%), but no proband carried more than one causal variant. Of note, almost half of the rare variants were novel. Conclusions: Herein we reported for the first time the rare variants identified in core and putative genes associated with HCM in a cohort of Romanian unrelated adult patients. The clinical significance of most detected variants is yet to be established, additional studies based on segregation analysis being required for definite classification.

The aim of this European Heart Rhythm Association (EHRA) survey was to assess the utilization of same-day discharge (SDD) in electrophysiology (EP). An online-based questionnaire was shared with the EHRA community between 12 and 30 June 2020 and recorded institutional information, complication assessment, recent experiences, and opinions regarding possible advantages or concerns with SDD. In total, 218 responses from 49 countries provided information on current SDD management. Overall, SDD was implemented in 77.5%, whereas this proportion was significantly higher in tertiary and high-volume centres (83.8% and 85.3%, both P 75% of respondents already implement SDD following EP interventions with a large heterogeneity with regard to specific procedures. Further research is needed to confirm or disprove existing and expected benefits and obstacles.

Background Electric storm is a life threatening condition, that can complicate multiple cardiac pathologies and is associated with high mortality. Catheter ablation has been shown to reduce ventricular tachycardia (VT) burden in patients with electrical storm but the optimal procedural endpoint and the therapeutic particularities required by different etiologies are still under debate. Purpose Our objective was to determine if there are any periprocedural factors that influence midterm outcomes. We also sought if there were any significant differences between the results for ischemic and nonischemic patients. Methods The study included 66 consecutive patients, mean age 60 years, 82% males, treated for electrical storm in our center with endocardial/endo-epicardial radiofrequncy catheter ablation (with or without remote magnetic navigation). Acute success was defined as elimination of the clinical tachycardia with complete non-inducibility (including ventricular fibrillation) or non-inducibility for monomorphic VT with programmed ventricular stimulation using up to 4 extrastimuli. Mean follow-up duration was 9.4 months and the type of recurrence was catalogued in 3 categories: initial VT (isolated), electric storm and other sustained VT. Results The overall acute success rate was 93%, complete non-inducibility was achieved in 64.5% and non-inducibility for monomorphic VT in 87.5% of the cases. Epicardial approach was used in 44% of the non-ischemic cases vs 10.5% of the ischemic ones (p = 0.005). There were no significant differences between complete noninducibility rates and recurrence/death rates of the ischemic vs nonischemic groups. Among the variables analysed for predicting noninducibility, only two reached statistical significance: mean QRS duration of the clinical tachycardia (160 ± 32 ms vs 240 ± 63.3ms, p = 0.02) and shortest RS complex (124 ± 14.7 ms vs 210 ± 12ms, p = 0.02). Recurrent ventricular arrhythmia occurred in 25% of the patients during follow up, from which: 27.2 % initial VT (isolated), 36.4% electric storm and 36.4% other sustained VT. Death rate was 10.6% (7 patients). Kaplan Meier plot showed that the lot with complete noninducibility after programmed ventricular stimulation had better survival rates (p = 0.01). Conclusions Ablative therapy had a good acute success rate, without significant differences between ischemic and noninschemic patients in our study. Complete noninducibility after programmed ventricular stimulation after ablation was associated with better survival rates. Unsuccessfull ablation is a predictor of inhospital death of these patients.

Background Left ventricular non-compaction (LVNC) is a structural cardiomyopathy (SC) with a high probability of LV systolic dysfunction. Left bundle branch block (LBBB) frequently occurs in SCs. Purpose We sought to analyse the evolution of LVNC-CRT (LC) patients in general and compare it with the non-LVNC-CRT group (nLC). Methods We analysed 40 patients with contrast-MRI documented LVNC (concomitant positive Petersen and Jacquier criteria) implanted with CRT devices in CEHB. The follow-up included 7 hospital visits for each patient (between baseline and 3 years). Demographics, risk factors, usual serum levels, pre-procedural planning factors, clinical, ECG, TTE and biochemical markers were recorded. Statistical analysis was performed using software. Notable differences were reported as either p-values from crosstabs (discrete) or mean differences, p-values and confidence intervals from t-tests (continuous). A p-value of .05 was chosen for statistical significance (SS). Results Subjects in LC were younger (-7.52 ys; Conclusions CRT candidates with LVNC are significantly more severe at the time of implant. After an initial short-term improvement (probably due to acute correction of dyssynchrony) most patients fail to respond in the long term. Severe dilation with important secondary MR probably plays an important role.

Both supraventricular and ventricular arrhythmias may occur in patients without relevant epicardial coronary disease, significant structural heart disease or channelopathies. Their underlying mechanism is often unclear, and may sometimes be attributed to a preexistent coronary microvascular dysfunction which facilitates arrhythmias. Furthermore, arrhythmias may promote coronary microvascular dysfunction. We sought to clarify this relationship, starting from a clinical case of atrial fibrillation in a patient with coronary microvascular dysfunction and no epicardial coronary disease. We then explored various clinical scenarios which include ventricular arrhythmias, non-ischemic structural cardiac disease, cardiac pacing, bradyarrhythmias and conduction abnormalities.

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Background: We aimed to evaluate whether right ventricle (RV) longitudinal strain indexed to pulmonary arterial systolic pressure (PASP) has prognostic significance in patients undergoing cardiac resynchronization therapy (CRT). Methods: Patients undergoing CRT were prospectively included. The primary endpoint was adverse cardiovascular events (death and HF-related hospitalizations). RV global longitudinal strain (RVGLS) and RV free wall strain (RVfwS) were measured by speckle tracking and indexed to echocardiographic estimated PASP. Results: A total of 54 patients (64.0 ± 13.8 years, 58% male) were included. After 33 ± 12.9 months, the primary endpoint occurred in 18 patients. Baseline RVGLS/PASP and RVfwS/PASP showed good discriminative ability for response to CRT (AUC = 0.88, 95% CI (0.74–1) and AUC = 0.87, 95% CI (0.77–1)). RVGLS/PASP and RVfwS/PASP were significantly associated with high risk of events at univariate analysis (HR 0.039, 95% CI (0.001–0.8) p &lt, 0.05, respectively HR = 0.049, 95% CI (0.0033–0.72), p &lt, 0.05). Upon multivariate Cox regression analysis, RVGLS/PASP and RVfwS/PASP remained associated with high risk of events (HR 0.018, 95% CI (0.0005–0.64), p = 0.02 and HR 0.015, 95% CI (0.0004–0.524), p = 0.01) after correction for gender, etiology, QRS duration and morphology. Conclusions: Indexing RV longitudinal strain (global and free wall) by PASP provides a parameter, which independently identifies patients with high risk of cardiovascular events and predicts non-response to CRT.

Aims The present study sought to determine predictors for success and outcomes of patients who underwent cardiac implantable electronic devices (CIED) extraction indicated for systemic or local CIED related infection in particular where complete lead removal could not be achieved. Methods and results ESC-EORP ELECTRa (European Lead Extraction ConTRolled Registry) is a European prospective lead extraction registry. Out of the total cohort, 1865/3510 (52.5%) patients underwent removal due to CIED related infection. Predictors and outcomes of failure were analysed. Complete removal was achieved in 1743 (93.5%) patients, partial (4 cm of lead left) in 32 (1.8%) patients. Removal success was unrelated to type of CIED infection (pocket or systemic). Predictors for failure were older leads and older patients [odds ratio (OR) 1.14 (1.08–1.19), P Conclusion A total of 6.5% of infected CIED patients failed attempted extraction. Only were >4 cm of lead remained resulted in higher procedural complications and mortality rates.

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Background Current lead extraction (LE) devices can harm the blood vessel endothelium, increasing the risk of perforation. Objective Proof of concept for using a solid-state pulsed laser at 355 nm with a hybrid catheter in LE. Methods A hybrid catheter was used comprising optical fibers for the delivery of 355 nm laser pulses at 30 Hz and 6 J/cm2 combined with a blunt mechanical blade. Specific parameters were chosen to enable selectivity in ablation, thereby reducing the risk of blood vessel perforation. The design exploits differences in the mechanical properties of the fibrotic tissue and the normal blood vessel. Ex vivo ablation was performed to evaluate a hybrid catheter operation on various tissues. Two ex/in vivo pig studies used a free-floating electrode to which three bovine tendon pieces were glued. Finally, two in vivo dog model studies were performed on specimens with 4-5-year-old pacing lead implants, followed by a histopathology study. Results Catheter penetration rate in the ex vivo experiments was 0.1 mm/seconds for bovine tendon, 0.025 mm/seconds for porcine superior vena cava and 0.033 mm/seconds for porcine aorta. In the ex/in vivo pig study, the three tissue blocks were successfully dissected. In the in vivo dog study, the two leads were successfully extracted. In all in vivo tests, hemodynamic stability was maintained. Gross histopathology did not reveal any injury. Conclusions Ablation using 355 nm laser pulses in combination with a mechanical blunt blade may potentially constitute a viable alternative for LE. Lasers Surg. Med. © 2015 Wiley Periodicals, Inc.

Response to cardiac resynchronization therapy (CRT) is well-established in patients with typical left bundle branch block (LBBB) but modest or even negative in those with intraventricular conduction delay (IVCD). However, IVCD pattern is heterogeneous, and it is possible that QRS patterns may also respond to CRT. Consecutive baseline ECGs of 239 patients implanted between 2007 and 2010 with CRT were analyzed. ECGs were classified into the following three groups: (a) typical LBBB (TLBBB) according to accepted guidelines (n = 67); (b) IVCD with LBBB pattern criteria in V1, 1, and aVL but with QS or rS in V5–V6 which we defined as atypical LBBB (ALBBB) (n = 74); and (c) all other IVCD (OIVCD) patterns (n = 98). Endpoints were 2 years mortality and echocardiographic response, defined as a decrease of ≥ 10% in indexed LVESV or an increase of ≥ 5% in left ventricular ejection fraction at 1 year of follow-up. Baseline clinical characteristics were similar among all the three groups. Rates of echocardiographic response were lower among those with OIVCD compared to those with LBBB and ALBBB (50% vs. 75% and 72%, respectively, p = 0.01 for both comparisons). A multivariable model showed a lower likelihood of echocardiographic response in OIVCD [HR = 0.40; (0.16–0.98)] and a similar likelihood in ALBBBB [HR = 0.98; (0.40–2.40)] compared to TLBBB. Cumulative 2-year survival was 88% in ALBBB, 86% in TLBBB, and 76% in OIVCD (p value = 0.011). Patients with ALBBB may have a favorable echocardiographic response to CRT and display similar survival rates to typical LBBB. This subgroup of IVCD should be considered for CRT. Atypical left bundle branch morphology defined as QS or rS in lead V1, broad R waves in lead I, and aVL but with QS or rS in V5–V6 is associated with favorable echocardiographic response to CRT and displays similar survival rates to typical LBBB patients.

Interventional electrophysiology (EP) has become the standard of care for arrhythmia management according to current guidelines.1,2 Becoming a heart rhythm specialist can be very challenging in light of a difficult EP curriculum and even more so in the absence of a structured training programme (Table 1).3 The 2017 European Heart Rhythm Association (EHRA) report on the use of EP procedures has shown that in the non-European and Eastern European ESC member countries, procedure rates are still quite low.4 This editorial provides a review of EP training in countries with EP underdevelopment with a focus on finding solutions for young cardiologists interested in EP careers.

Right heart disease can be associated with increased risk for arrhythmias, both ventricular and supraventricular. Right sided arrhythmias may occur in the setting of structural disease predominantly affecting the right heart—such as cardiomyopathies (arrhythmogenic right ventricular dysplasia, cardiac sarcoidosis) and congenital heart disease (corrected tetralogy of Fallot, Ebstein’s anomaly, atrial septal defect), as well as in the absence of structural heart disease, with substrate (Mahaim fibers, Coumel type tachycardia) or without substrate (idiopathic right ventricular outflow tract ventricular tachycardia). The most common cause for right heart failure is secondary pulmonary hypertension due to left heart diseases, a setting in which the underlying left heart condition will be the main determiner for prognosis and risk of arrhythmia. Still, right heart failure secondary to pulmonary arterial hypertension is also associated with increased risk for arrhythmic events. Advanced cardiac imaging, especially cardiac MRI, as well as invasive procedures (right/left heart catherization; electrophysiological study; endomyocardial biopsy) play an important role in the differential diagnosis. Modern treatment relies on interventional techniques (implantable cardioverter defibrillator; radiofrequency ablation).