A clinical approach to arrhythmias revisited in 2018 : from ECG over noninvasive and invasive electrophysiology to advanced imaging

Understanding arrhythmias and their treatment is not always easy. The current straightforward approach with catheter ablation and device therapy is an amazing achievement, but does not make management of underlying or other cardiac disease and pharmacological therapy unnecessary. The goal of this paper is to describe how much of the knowledge of the 1980s and early 1990s can and should still be applied in the modern treatment of patients with arrhythmias. After an introduction, this review will focus on paroxysmal atrial fibrillation and a prototype of 'idiopathic' ventricular arrhythmias, two diseases with a striking similarity, and will discuss the arrhythmogenesis. The ECG continues to play an important role in diagnostics. Both diseases are associated with a structurally normal heart; the autonomic nervous system plays an important role in triggering arrhythmias at both the atrial and ventricular level

Tachycardie avec complexes ventriculaires larges et alternance des complexes QRS et des intervalles RR

A patient with sustained monomorphic ventricular tachycardia developed a second tachycardia of incessant character with alternating RR-interval and alternating QRS-complexes after treatment with amiodarone. A retrograde His bundle deflection was recorded during the latter arrhythmia, that was induced as well with atrial as with ventricular stimulation. The "alternating" tachycardia could be explained by alternating bundle branch reentry and alternating conduction in the myocardium. This view is supported by the finding of an alternating mid-diastolic potential. This case report introduces a new electrocardiographic entity in the spectrum of wide QRS-tachycardias

Transcatheter ablation of arrhythmias associated with congenital heart disease

The improvement of surgical techniques resulted in significant life prolongation of many young patients with congenital heart disease (CHD). However, as these patients reach adulthood, their risk for late complications associated with surgery is also increased. One of the most difficult challenges associated with CHD is the high incidence of cardiac arrhythmias that arise from either the myocardial substrate created by abnormal physiology (pressure/volume changes, septal patches, and suture lines) or the presence of surgical scar. Catheter ablation is proven to be effective in treating atrial and ventricular arrhythmias in structurally normal hearts, and has also been used to treat arrhythmias in adults with congenital heart disease. In this review we provide an overview about diagnostic challenges, mapping and ablation techniques and outcome of patients undergoing transcatheter ablation procedures

Imaging of a coronary artery bypass graft during coronary sinus venography

Retrograde coronary sinus perfusion to maintain viability during cardiac surgery means that a connection via the capillary system to the coronary arteries, and potentially bypass grafts, may be possible. Coronary sinus (CS) venography prior to resynchronisation therapy in this patient with previous bypass grafting was associated with visualisation of these grafts