Innovations in Clinical Cardiac Electrophysiology: From Conventional Approaches to Remote Magnetic Navigation

Clinical cardiac electrophysiology (EP) has progressed significantly since the first invasive electrophysiological studies were performed to study normal impulse formation and conduction in the heart and to confirm hypotheses regarding the causation of arrhythmias. The first His bundle recordings in 1969,(1) and later, programmed atrial and ventricular stimulation( 2) to induce tachycardia made detailed analysis of arrhythmias possible. This led to an understanding of reentrant and focal tachycardias on an atrial and ventricular level. Subsequently therapeutic options became available when surgery entered the field with a approach for ventricular tachycardia (VT)(3) and ventricular preexcitation (WPW syndrome). Atrial fibrillation (AF) surgery was also successful but had a relatively high morbidity and a clear mortality risk. At this early stage no therapy could be given via the catheter. Subsequently direct current (DC) shock ablation of the AV node proved to be very successful and led to catheter ablation of ventricular tachycardia and accessory pathways (4). However, the complications of this technique were important. The arrival of radiofrequency was thought to be the solution for the more simple arrhythmias such as atrioventricular nodal reentrant tachycardia (AVNRT), WPW, idiopathic VT and atrial flutter(5). The development of better catheters allowed for successful therapy in excess of 85% in most cases of these arrhythmias(6, 7). The real challenges remained VT on a background of underlying heart disease, and AF in both the normal and abnormal heart. The arrival of mapping systems allowing detailed electro-anatomical mapping(8) helped strategies to develop for more complex arrhythmias. However these approaches are still time consuming and there remain some drawbacks.

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