A. Voskoboinik

Diffuse Ventricular Fibrosis on Cardiac Magnetic Resonance Imaging Associates With Ventricular Tachycardia in Patients With Hypertrophic Cardiomyopathy.

Non‐sustained ventricular tachycardia (NSVT) is a risk factor for sudden cardiac death (SCD) in patients with hypertrophic cardiomyopathy (HCM). We aimed to assess whether diffuse ventricular fibrosis on cardiac magnetic resonance (CMR) imaging could be a surrogate marker for ventricular arrhythmias in patients with HCM.

The Impact of Known Heart Disease on Long-Term Outcomes of Catheter Ablation in Patients with Atrial Fibrillation and Left Ventricular Systolic Dysfunction: A Multicenter International Study.

Catheter ablation for AF is an effective treatment for patients with AF and systolic LV dysfunction; however, the clinical outcome is variable. We evaluated the impact of cardiomyopathy etiology on long‐term outcomes post‐catheter ablation.

Isolation of the posterior left atrium for patients with persistent atrial fibrillation: routine adenosine challenge for dormant posterior left atrial conduction improves long-term outcome.

Aims Catheter ablation to achieve posterior left atrial wall (PW) isolation may be performed as an adjunct to pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (AF). We aimed to determine whether routine adenosine challenge for dormant posterior wall conduction improved long-term outcome. Methods and results A total of 161 patients with persistent AF (mean age 59 ± 9 years, AF duration 6 ± 5 years) underwent catheter ablation involving circumferential PVI followed by PW isolation. Posterior left atrial wall isolation was performed with a roof and inferior wall line with the endpoint of bidirectional block. In 54 patients, adenosine 15 mg was sequentially administered to assess reconnection of the pulmonary veins and PW. Sites of transient reconnection were ablated and adenosine was repeated until no further reconnection was present. Holter monitoring was performed at 6 and 12 months to assess for arrhythmia recurrence. Posterior left atrial wall isolation was successfully achieved in 91% of 161 patients (procedure duration 191 ± 49 min, mean RF time 40 ± 19 min). Adenosine-induced reconnection of the PW was demonstrated in 17%. The single procedure freedom from recurrent atrial arrhythmia was superior in the adenosine challenge group (65%) vs. no adenosine challenge (40%, P < 0.01) at a mean follow-up of 19 ± 8 months. After multiple procedures, there was significantly improved freedom from AF between patients with vs. without adenosine PW challenge (85 vs. 65%, P = 0.01). Conclusion Posterior left atrial wall isolation in addition to PVI is a readily achievable ablation strategy in patients with persistent AF. Routine adenosine challenge for dormant posterior wall conduction was associated with an improvement in the success of catheter ablation for persistent AF.

Atrial Structure and Function and its Implications for Current and Emerging Treatments for Atrial Fibrillation

Left atrial (LA) structure and function are intimately related to the clinical phenotypes of atrial fibrillation (AF), and have direct implications for the success or otherwise of various therapeutic strategies. In conjunction with intrinsic structural characteristics of the LA, pathological remodelling to a large extent dictates the clinical course of AF. Remodelling is a product of the physiological and structural plasticity of the LA in disease states (including AF itself), and manifests as electrical, physical and structural changes that promote the substrate necessary for AF maintenance. The degree of remodelling impacts upon the efficacy of pharmacological, non-pharmacological and interventional treatments for AF. Evolving therapies seek to specifically target these processes although presently, several remain in the development phase. Catheter ablation (CA) is now firmly established as a highly effective treatment for AF, although increasing its efficacy in the remodelled LA of more severe AF phenotypes remains an ongoing challenge.

Ventricular fibrillation storm in a young man with early repolarisation abnormality: the role of isoprenaline and quinidine.

recorded. Atrial myxomas, while histologically benign, can nevertheless cause significant morbidity by impairing cardiac output, or by fragmenting and causing embolic events. Diagnosis of intracardiac tumours is with echocardiography with the transoesophageal approach having a sensitivity demonstrated up to 100%. The patient described in this case report had a primarily histological diagnosis for myxoma as she had tested negative for the PRKAR1A mutation. She is now under ongoing surveillance by the local cardiology team, with her next echocardiogram due in 2 years time. The hereditary nature of the disease was discussed with the patient and her family. They did not want to undergo screening echocardiography at that time but were happy to be referred to a clinical geneticist for ongoing follow up. Stroke or transient ischaemic attack from cardiac myxoma emboli is a condition that, if incorrectly diagnosed, can lead to inappropriate treatment with anticoagulation as opposed to surgical resection. Despite atrial myxoma being a fleetingly rare condition, with a prevalence estimated at 0.0005–0.015%, it should be considered in all patients presenting with stroke or transient ischaemic attack without an obvious precipitous cause. Furthermore, for patients with a previous history of Carney complex atrial myxoma presenting with abnormal neurological findings, a diagnosis of recurrence of the myxoma should be considered.

Cardiac resynchronisation therapy in 2015: keeping up with the pace

Despite improved understanding of the pathophysiology of heart failure (HF) and availability of better medical therapies, HF continues to grow as a cause of morbidity and mortality in Australia and worldwide. Over the past decade, cardiac resynchronisation therapy (CRT), or biventricular pacing, has been embraced as a powerful weapon against this growing epidemic. However, much has changed in our understanding of dyssynchrony in HF, and this has led to a change in guidelines to ensure more appropriate selection of CRT candidates to improve the ‘non‐response’ rate. More data have also emerged about the use of CRT in atrial fibrillation and in pacemaker‐dependent patients. There has also been a growing focus on multimodality imaging to guide patient selection and lead positioning. Exciting new lead technologies are also emerging, with the potential to improve CRT outcomes further.

A multicentre study of AF ablation outcomes in patients with concurrent left ventricular dysfunction - aetiology of cardiomyopathy determines outcome

A. McLellan1,2,3, L. Ling1,2,3, S. Azzopardi 1,2, G. Lee1,2, G. Lee1,2,3, S. Kumar1,2,3, M. Wong1,2,3, T. Walters 1,2,3, J. Lee 3, K. Halloran3, M. Stiles 7, N. Lever 8, S. Fynn9, P. Heck9, P. Sanders 6, J. Morton3,4, J. Kalman3,4, P. Kistler 1,2,3,4,5,∗ 1 Alfred Heart Centre, Alfred Hospital, Melbourne, Victoria, Australia 2 Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia 3Department of Cardiology, Royal Melbourne Hospital, and Department of Medicine, University of Melbourne, Parkville, Victoria, Australia 4 Melbourne Private Hospital, Parkville, Victoria, Australia 5 Avenue Private Hospital, Windsor, Victoria, Australia 6 Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia 7 Waikato Hospital, New Zealand 8 Auckland City Hospital, Auckland, New Zealand 9 Papworth Hospital, Cambridge, United Kingdom

Novel uses of Imaging in AF Ablation

AF represents a significant burden for patients, clinicians and health policy makers alike. Catheter based AF ablation is gaining an increasing role as an effective treatment for AF, capable of reducing or even eliminating the disease. AF ablation relies on isolation of arrhthymogenic triggers and alteration of the atrial substrate by carefully targeted atrial ablation, using a minimally invasive approach. Pre-procedural CT, MRI and echocardiography are crucial in evaluating the degree of atrial remodelling which may impact of procedural success, as well as identification of crucial cardiac and non-cardiac adjacent structures, and LAA thrombus. Electro-anatomical mapping is the cornerstone of intra-procedural imaging, which can be optimised by integration with pre-procedural imaging. Other technologies such as 3D rotational angiograpy, intracardiac echocardiography and real-time MRI are improving the safety and efficacy of the procedure. Post-procedural MRI and CT can effectively monitor and evaluate procedural complications and atrial structure and remodelling. Recent patents demonstrate the wealth of technological advancements in AF ablation and are evident in multiple aspects of the procedure.