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The optimized strategy to further increase the success rate of ablation for ventricular arrhythmias (VAs) from the right ventricular outflow tract (RVOT) is challenging. Recent studies have shown that the pulmonary sinus cusp (PSC) region may be the origin of certain RVOT VAs. We evaluated the efficacy of preferential ablation below the pulmonary valve (PV) and alternated radiofrequency delivery in the PSC using remote magnetic navigation (RMN). Sixty-five (65) consecutive patients experiencing VAs with RVOT-like appearance were included in this study. Mapping and ablation were preferentially performed below the PV. Ablation in the PSC would only be attempted when intensified ablation below the PV could not eliminate VAs. Finally, if ablation in the RVOT region failed, the aortic sinus cusp (ASC) would be mapped. Sixty-one (61) of 65 (93.8%) patients achieved procedural success. Except 7 cases of which the VAs were ablated in the ASC, the rest 54 VAs were thought to be originate from the RVOT region. Fifty (50) of 54 VAs were successfully ablated below the PV, and in the presence of a local special signal in the bipolar electrogram a more aggressive ablation was required. Subsequent ablation in the PSC with assistance of the RMN system achieved success in the remaining 4 patients. No complications occurred in this study. Our strategy of using RMN-guided ablation below the PV for VAs of RVOT origin was proved to be effective. PSC mapping and ablation using a magnetic catheter may provide the optimal strategy for treating these types of arrhythmias.

International audience; Electrocardiogram (ECG) acquisition is required during catheter treatment of cardiac arrhythmias. The remote magnetic navigation technology allows the catheter to be moved automatically inside the heart chambers using large external magnets. Each change of position of the catheter requires fast motion of the magnets, therefore magnetic fluxes are created through the ECG cables, causing large distortions of the ECG signals. In this study a novel ECG sensor is proposed for reducing such distortions. The sensor uses short cables to connect the electrodes to the amplification and optical conversion circuit, using a technology similar to that used for magnetic resonance imaging. The proposed sensor was compared to the conventional 12-lead ECG device during various operation modes of the magnets. Quantitative morphological analysis of the different waves of the ECG was performed in two healthy subjects and on a conductivity phantom reproducing various cardiac pathologies. In healthy subjects the beat-to-beat correlation coefficients were improved with the proposed sensor for the PR interval (80-93% vs. 49-89%), QRS complex (93-96% vs. 74-94%), ST segment + T wave (95-98% vs. 67-99%), and whole PQRST wave (82-97% vs. 55-96%). Similar observations were made with the conductive gel in the whole PQRST wave in the pathological morphologies of the ECG for the VT (99% vs. 56-98%), AT (95% vs. 26-89%), STE (96-97% vs. 20-91%) and STD (96% vs. 28-90%). The new sensor might be used for better (uninterrupted) monitoring of the patient during catheter interventions using remote magnetic navigation. It has the potential to improve the robustness and/or duration of certain clinical procedures such as ventricular tachycardia ablation.

There are limited studies on the safety and efficacy of remote magnetic navigation (RMN) versus manual navigation (MAN) in ventricular tachycardia (VT) ablation. A comprehensive literature search was performed using the keywords VT ablation, stereotaxis, RMN and MAN in Pubmed, Ebsco, Web of Science, Cochrane, and Google scholar databases. The analysis included seven studies (one randomized, three prospective observational, and three retrospective) including 779 patients [both structural heart disease (SHD) and idiopathic VT] comparing RMN (N = 433) and MAN (N = 339) in VT ablation. The primary end point of long-term VT recurrence was significantly lower with RMN (OR 0.61, 95% CI 0.44–0.85, p = 0.003) compared with MAN. Other end points of acute procedural success (OR 2.13, 95% CI 1.40–3.23, p = 0.0004) was significantly higher with RMN compared with MAN. Fluoroscopy [mean difference −10.42, 95% CI −12.7 to −8.1, p

Patients with ischemic cardiomyopathy (ICM) are prone to scar-related ventricular tachycardia (VT). The success of VT ablation depends on accurate arrhythmogenic substrate localization, followed by optimal delivery of energy provided by constant electrode-tissue contact. Current manual and remote magnetic navigation (RMN)-guided ablation strategies aim to identify a reentry circuit and to target a critical isthmus through activation and entrainment mapping during ongoing tachycardia. The MAGNETIC VT trial will assess if VT ablation using the Niobe™ ES magnetic navigation system results in superior outcomes compared to a manual approach in subjects with ischemic scar VT and low ejection fraction. This is a randomized, single-blind, prospective, multicenter post-market study. A total of 386 subjects (193 per group) will be enrolled and randomized 1:1 between treatment with the Niobe ES system and treatment via a manual procedure at up to 20 sites. The study population will consist of patients with ischemic cardiomyopathy with left ventricular ejection fraction (LVEF) of ≤35% and implantable cardioverter defibrillator (ICD) who have sustained monomorphic VT. The primary study endpoint is freedom from any recurrence of VT through 12 months. The secondary endpoints are acute success; freedom from any VT at 1 year in a large-scar subpopulation; procedure-related major adverse events; and mortality rate through 12-month follow-up. Follow-up will consist of visits at 3, 6, 9, and 12 months, all of which will include ICD interrogation. The MAGNETIC VT trial will help determine whether substrate-based ablation of VT with RMN has clinical advantages over manual catheter manipulation. Clinicaltrials.gov identifier: NCT02637947

Catheter ablation for idiopathic ventricular arrhythmia (VA) is effective and safe, but efficacy is frequently limited due to an epicardial origin and difficult anatomy. The remote magnetic navigation (RMN) catheter has a flexible catheter design allowing access to difficult anatomy. We describe the efficacy of the RMN for ablation of idiopathic VA after failed manual ablation. Among 235 patients with idiopathic VA referred for catheter ablation, we identified 51 patients who were referred for repeat ablation after a failed manual ablation. We analyzed the clinical characteristics, including the successful ablation site and findings at electrophysiology study, in repeat procedures conducted using RMN as compared with manual ablation. Among these patients, 22 (43 %) underwent repeat ablation with the RMN and 29 (57 %) underwent repeat ablation with a manual ablation. Overall, successful ablation rate was significantly higher using RMN as compared with manual ablation (91 vs. 69 %, P = 0.02). Fluoroscopy time in the RMN was 17 ± 12 min as compared with 43 ± 18 min in the manual ablation (P = 0.009). Successful ablation rate in the posterior right ventricular outflow tract (RVOT) plus posterior-tricuspid annulus was higher with RMN as compared with manual ablation (92 vs. 50 %, P = 0.03). Neither groups exhibited any major complications. The RMN is more effective in selected patients with recurrent idiopathic VA after failed manual ablation and is associated with less fluoroscopy time. The RMN catheters have a flexible design enabling them to access otherwise difficult anatomy including the posterior tricuspid annulus and posterior RVOT.

Background The purpose of this study was to prospectively evaluate the efficacy and safety of remote magnetic navigation (RMN) in comparison with manual catheter navigation (MCN) in performing ventricular tachycardia ablation. Methods An electronic search was performed using PubMed (1948–2013) and EMBASE (1974–2013) studies comparing RMN with MCN which were published prior to 31 December 2013. Outcomes of interest were as follows: acute success, recurrence rate, complications, total procedure and fluoroscopic times. Standard mean difference (SMD) and its 95 % confidence interval (CI) were used for continuous outcomes; odds ratios (OR) were reported for dichotomous variables. Results Four non-randomised studies, including a total of 328 patients, were identified. RMN was deployed in 191 patients. Acute success and long-term freedom from arrhythmias were not significantly different between the RMN and control groups (OR 1.845, 95 % CI 0.731–4.659, p = 0.195 and OR 0.676, 95 % CI 0.383–1.194, p = 0.177, respectively). RMN was associated with less peri-procedural complications (OR 0.279, 95 % CI 0.092–0.843, p = 0.024). Shorter procedural and fluoroscopy times were achieved (95 % CI -0.487 to -0.035, p = 0.024 and 95 % CI -1.467 to -0.984, p

The objectives of this study were to assess the procedural outcomes of persistent and long-standing persistent atrial fibrillation (PsAF and L-PsAF) ablation guided by remote magnetic navigation (RMN), and to detect factors predicting acute restoration of sinus rhythm (SR) by ablation with RMN. A total of 313 patients (275 male, age 59 ± 9.5 years) with PsAF (187/313) or L-PsAF (126/313) undergoing ablation using RMN were included. Patients’ disease history, pulmonary venous anatomy, left atrial (LA) volume, procedure time, mapping plus ablation time, radiofrequency (RF) ablation time, fluoroscopy time, radiation dose, and complications were assessed. Stepwise regression was used to predict which variable could best predict acute restoration from AF to SR by ablation. Compared to PsAF, procedure time and RF ablation time were significantly increased in patients with L-PsAF (P = 0.01 and P

Little is known about the long-term outcomes of catheter ablation of supraventricular tachycardia (SVT) using remote magnetic navigation system (RMN).One hundred twenty patients underwent catheter ablation of SVTs with RMN (Niobe, Stereotaxis, USA): atrioventricular nodal re-entrant tachycardia (AVNRT; n = 59), atrioventricular re-entrant tachycardia (AVRT; n = 45), and focal atrial tachycardia (AT, n = 16). The outcome of AVRT with right free wall accessory pathway was compared with those of a group of 26 consecutive patients undergoing manual ablation.Mean follow-up period was 2.2 ± 1.4 years. Overall arrhythmia-free survival was 86%; AVRT (77%), AVNRT (96%), and focal AT (71%). After the learning period (initial 50 cases), procedural outcomes had improved for AVRT and AVNRT (91% in overall group, 90% in AVRT group, 100% in AVNRT group, and 68% in focal AT group). The recurrence-free rate was higher for the free wall accessory pathways than those of the other sites (92 vs. 73%, log-rank P = 0.06). Furthermore, when it is confined for the right free wall accessory pathway, RMN showed excellent long-term outcome (7/7, 100 %) compared to the results of manual approach (18/26, 69.2%, log-rank P = 0.07).RMN showed favorable long-term outcomes for the ablation of SVT. In our experience, RMN-guided ablation may be associated with a higher success rate as compared to manual ablation when treating right-sided free wall pathways.

In ablation of atrial fibrillation, the single-ring method aims for isolation of the posterior wall of the left atrium (LA) including the pulmonary veins (PVs) but avoiding posterior LA lesions. The aim of this randomized prospective study was to evaluate safety and efficacy of remote magnetic navigation (RMN)-guided single-ring ablation strategy as compared to standard RMN-guided circumferential PV ablation (PVA). Eighty consecutive patients undergoing PVA were enrolled prospectively and randomized equally into two study groups. RMN using the Stereotaxis system and open-irrigated 3.5-mm ablation catheters were used with a 3D mapping system in all procedures. Forty patients underwent RMN-guided single-ring ablation, and 40 patients received RMN-guided circumferential PVA. In the circumferential group, 3.3 ± 1.1 PVs were successfully isolated at the end of the procedure as compared to 3.1 ± 1.3 in the single-ring (box) group (p = 0.38). All patients in the box group required additional posterior lesions in order to achieve electrical isolation of the PVs. Single-ring ablation was associated with longer procedure duration (p = 0.01) and ablation time (p = 0.001). After a single procedure, the proportion of patients free of any atrial tachycardia (AT)/atrial fibrillation (AF) episode at 12-month follow-up was 57 % in the box group and 58 % in the circ group. Using RMN, only minor complications have been observed. RMN-guided single-ring PVA provides comparable acute and long-term success rates as compared to RMN-guided circumferential PVA but requires additional posterior lesions to achieve PV isolation and increased procedure and ablation time. Procedural complication rates are low when using RMN.

Remote magnetic navigation (RMN) is utilized for catheter guidance during pulmonary vein ablation (PVA). We aimed to determine whether the additional use of a circular mapping catheter (CMC) influences efficacy and outcome of RMN-guided PVA. A total of 80 consecutive subjects (65 % male, age 62 ± 9 years) underwent circumferential PVA with a 3D mapping system and an RMN-guided irrigated catheter. Procedural endpoint was complete PV isolation (PVI), total radiofrequency (RF) time >60 min, or procedure duration >5 h. PVI was defined as an entrance and/or exit block, diagnosed with a CMC within the PV ostium or by pacing via the roving RMN-guided catheter (single-catheter technique). Prolonged Holter monitoring after 3 and 6 months was used to detect atrial tachyarrhythmia (AT/AF) recurrences. Complete PVI was achieved in 56 % (45/80) of all subjects (isolated PVs per patient, 3.1 ± 1.2; RF time, 56.3 ± 17.2 min; procedure duration, 3.8 ± 0.8 h). Prospective validation of the single-catheter technique for diagnosing PVI demonstrated high concordance (94 %) with blinded CMC results. CMC use in first-time PVA was associated with similar total RF and procedure times but higher PV isolation rate. Upon multivariate analysis, CMC use, female gender, left PV, smaller PV ostium and repeat PVA predicted PVI during RMN-guided ablation. Persistent AF and mitral regurgitation at baseline and the number of non-isolated PVs predicted AT/AF recurrence during follow-up. Concomitant CMC use for first-time, RMN-guided PVA is associated with similar procedure duration but higher PV isolation rates as compared to a single-catheter approach. Since the number of isolated PVs predicts freedom from AT/AF, CMC utilization appears advisable for first-time, RMN-guided PVA.

Percutaneous epicardial mapping and ablation is an emerging method to treat ventricular tachycardias (VT), premature ventricular complexes (PVC), and accessory pathways. The use of a remote magnetic navigation system (MNS) could enhance precision and maintain safety. This multiple case history demonstrates the feasibility and safety of the MNS-guided epicardial approach in mapping and ablation of ischaemic VT, outflow tract PVCs, and a left-sided accessory pathway. All patients had previously undergone endocardial mapping for the same arrhythmia. MNS could present an advantage from more precise navigation for mapping and maintaining catheter stability during energy application.

Remote magnetic navigation systems are used for catheter navigation in cardiac electrophysiological ablation procedures. In this setting, ferromagnetic particles will be moved by changes in the magnetic field. It is unknown to what extent cardiac implantable electronic devices (CIED) are affected by the magnetic field when using magnetic navigation, and whether these forces may exceed the limit of 5 N that is set forth by German and European norms for implanted electrodes. A total of 121 rhythm devices were examined in a magnetic field of 0.1 T using the NIOBE II® Magnetic Navigation System (Stereotaxis, St. Louis, USA). Forces acting on the devices were measured with the force measurement tool Futek LRF 400 (Futek Advanced Sensor Technology Inc., Irvine, CA, USA). A standardized protocol of different movements of the magnetic field including all three dimensions was performed and maximal forces on the CIED were assessed. Out of 121 devices, 78 different pacemakers (54 different model families from 11 manufacturers) and 43 different cardioverter-defibrillators (26 different model families from 6) were examined. The mean force that could be observed was 0.33 ± 0.13 N for pacemakers (range 0.16–1.12 N) and 1.05 ± 0.11 N for cardioverter-defibrillators (range 0.86–1.38 N) when exposed to the magnetic field. Exposure of pacemakers or implantable cardioverter-defibrillators to a magnetic field of 0.1 T does not result in a force exceeding the regulatory demanded 5 N that could damage the connected leads.

Magnetically guided irrigated ablation has been introduced for atrial fibrillation (AF) ablation. However, data on ablation of persistent AF is scarce, and first-generation platinum–iridium catheters were burdened by char formation at the catheter tip. Furthermore, energy transmission of these catheters may be suboptimal. Irrigated gold-tip catheters have been introduced to overcome these problems. Antral pulmonary vein (PV) isolation (PVAI) was performed using a 5-mm irrigated gold-tip magnetic catheter (power setting, 48 °C maximum, 50 W, 15 s lesion duration; flow-rate, 30 mL/min). The catheter tip was guided by a uniform magnetic field and a motor drive. Left atrial maps were created using an impedance-based left atrial reconstruction and fused with a preprocedural CT or an intraprocedural rotational angiography-based scan. Fifty-seven patients (42 male, 61.9 ± 8.8 years) underwent PVAI for symptomatic, drug-refractory persistent AF. PVAI was performed successfully in all patients confirmed by entrance block. Procedure time (skin-to-skin) was 214 ± 47 min (104–354 min). Fluoroscopy time was 31 ± 21 min. Ablation time was 4,153 ± 1,350 s. No char or thrombus formation was found at the catheter tip. One pericardial tamponade was observed. Freedom from atrial tachyarrhythmias could be achieved in 57.9 % of the patients included in a follow-up of 11.6 ± 4.2 month. There was a trend to a better outcome in patients without previous attempts of AF ablation (n = 48; 60.4 % vs. 44.4 %, p = 0.47). Remote magnetic navigation for PVAI seems to be safe and feasible using an irrigated gold-tip catheter. Effectiveness of this novel technique can be confirmed by mid-term outcome.

Sirs: Patients after device closure of an atrial septal defect (ASD) presenting with left atrial (LA) arrhythmias are a challenge for the electrophysiologist as conventional transseptal puncture might be demanding. In patients with complex congenital heart disease, remote magnetic navigation (RMN) has been used to access anatomical structures that are difficult to reach [1–3]. The present case demonstrates the feasibility and efficacy of a complex LA ablation procedure for persistent atrial fibrillation (AF) via a retrograde aortic approach using RMN [4]. A 46-year-old woman with a history of a large secundum ASD had undergone successful transcatheter ASD occlusion with a 30-mm Amplatzer Occluder (AGA Medical Corp., Plymouth, MN, USA) 5 years ago. In 2012, successful ablation of typical atrial flutter had been performed. Subsequently, the patient developed persistent AF and complained of palpitations and shortness of breath. After electrical cardioversion, AF recurred and neither flecainide nor amiodarone was efficient. The patient was referred to our center for a second opinion. The echocardiogram showed no residual interatrial shunt, a normal ventricular ejection fraction and moderate dilation of both atria (LA anteroposterior diameter of 46 mm) (Fig. 1a). We decided to offer the patient an AF ablation via a retrograde approach using the Niobe II magnetic navigation system (Stereotaxis, St. Louis, MO, USA). The procedure was performed under conscious sedation. A 6F octapolar Bard EP-XT Steerable Catheter was advanced into the coronary sinus (CS). A 3.5-mm-tip irrigated magnetic catheter (Thermocool RMT, Biosense Webster, Diamond Bar, CA, USA) was inserted through a short 8F sheath in the femoral artery and manually advanced just below the subclavian artery. The ablation catheter was maneuvered across the aortic and mitral valve to the LA (Fig. 1b). Heparin was used to maintain the activated clotting time at the level of 300 s. An electroanatomic map of the LA using a three-dimensional (3D) mapping system (Carto3 RMT; Biosense Webster, Diamond Bar, CA, USA) was performed integrating a complex fractionated atrial electrogram (CFAE) software allowing automatical detection of CFAE sites (Fig. 2). After mapping, circumferential pulmonary vein isolation (PVI) was performed. CFAE ablation guided by the CFAE map and the operators’ judgment of local electrograms followed. Details of the CFAE ablation have been described previously [5, 6]. The endpoint of electrogram-guided ablation was elimination of all CFAE areas or AF conversion to atrial tachycardia or sinus rhythm. The effect of ablation was assessed by AF cycle length (AFCL). CFAE ablation was mainly performed at the anterior wall [including left atrial appendage (LAA)], inferior LA and LA roof with 30–35 W and a maximal temperature of 43 with an irrigation rate of 30 mL/min. After CFAE ablation, the AFCL measured in the LAA had prolonged significantly from 140 ms at baseline to 170 ms. Sinus rhythm was restored with direct current cardioversion. PV isolation was confirmed by mapping the ablation line around the PV and assessing the absence of PV potentials with the map catheter. The total procedure duration was 396 min. The total radiofrequency (RF) delivery time was 131 min (min) and the total fluoroscopy time was 6 min. No adverse events were observed. The patient was followed every 3 months in outpatient clinic with repeated 7-day holter ECGs. The endpoint was A. Buiatti (&) G. Hessling V. Semmler S. Ammar Department of Electrophysiology, German Heart Center Munich, Munich, Germany e-mail: elam4@libero.it

Remote magnetic navigation (RMN) has been reported as an effective and safe tool to overcome the need for advanced operator skill in the treatment of complex arrhythmias. We report a series of patients undergoing radiofrequency catheter ablation of ventricular arrhythmias (VAs) using RMN with either a 4-mm catheter tip or an 8-mm catheter tip at four different centers.Sixty-five patients with clinical and symptomatic history of Vas were included. Two different magnetic catheters were used to deliver radiofrequency applications remotely. When ablation with the RMN catheters failed, a manual irrigated catheter was used to eliminate the VAs. Post-ablation pacing maneuvers were utilized to verify the inducibility of Vas.Twenty-eight patients (43%) had ischemic cardiomyopathy [coronary artery disease (CAD)], 16 patients (25%) had non-ischemic cardiomyopathy [idiopathic dilated cardiomyopathy (IDC)], and 21 patients (32%) had structurally normal hearts (SNH) or right ventricle outflow tract tachycardia (RVOT). In patients with structural heart disease (CAD, IDC), success was achieved in 22% with the 4-mm catheter tip and in 59% with the 8-mm catheter tip (p = 0.014). In patients with SNH/RVOT, success was achieved in 85% with the 4-mm catheter tip and in 87% with the 8-mm catheter tip (p = 1.00).Our findings showed that, with RMN, there is an increased success related to the catheter tip utilized. However, in patients with right ventricular outflow origin, the standard 4-mm tip provided adequate lesions for successful ablation in most patients.

Atrial tachycardias (AT) may occur in up to 50 % of patients following modifications of the Fontan operation [1]. The main challenge in patients with an extracardiac total cavopulmonary connection (TCPC) is the access to relevant structures such as the right atrium. Remote magnetic navigation (RMN) may offer the possibility to reach even complex anatomy without the risk of perforation or other complications [2]. A 28-year-old patient with double inlet left ventricle (LV), rudimentary right ventricle (RV), ventricular septal defect (VSD), pulmonary stenosis and ventriculo-arterial discordance had undergone a modified Fontan operation with connection of the pulmonary artery to the right atrium (RA) at the age of 5 years. Three years later, he began to suffer from recurrent ATs which necessitated antiarrhythmic drug (AAD) therapy with amiodarone as well as multiple cardioversions. In 2010, at the age of 25 years, the patient underwent a Fontan conversion operation [3] with a 20-mm extracardiac Goretex total cavopulmonary connection (TCPC). A DDD pacemaker with epicardial leads was implanted for sinus node dysfunction. Two years later, the patient began to suffer again from recurrent symptomatic tachycardia which was documented on the pacemaker Holter. He was taken to the electrophysiological lab for further evaluation and treatment. After venous and arterial puncture, an 8-polar steerable diagnostic catheter was introduced inside the conduit (XPT, C.R. Bard, Lowell, MA; USA). The right atrium could be sensed and captured via this access site. Mapping and ablation was performed with the use of the magnetic navigation system (Niobe II, Stereotaxis Inc, St Louis, MO) and a 3D mapping system (Carto3 RMT, Biosense Webster, Diamond Bar, CA, USA). A 7F irrigated-tip ablation catheter (Navistar RMT Thermocool, Biosense Webster) was introduced via a retrograde aortic approach into the RV. Using RMN, the LV was accessed via the VSD and finally the right and left atrium retrogradely passing the AV-valves (Fig. 1a). 3D-image integration with a previously performed CT scan (Fig. 1b) was used to facilitate the access. The atria were mapped in sinus rhythm (SR) and a scar area was delineated in the antero-lateral RA (Fig. 1c). Using programmed atrial stimulation, AT was induced with a cycle length (CL) of 480 ms and 1:1 AV conduction which corresponded to the pacemaker Holter recorded CL. Positive entrainment was confined to a limited zone of fractionated electrograms on the border region of the scar area, suggesting a localized re-entry mechanism. Irrigated radiofrequency (RF) energy with a maximum power of 38 W, a maximum temperature of 43 C and a flow rate of 30 ml/min was delivered in this zone and achieved termination to SR. For substrate modification, we then performed an ablation of all fragmented signals around the scar zone. After ablation, programmed stimulation and bursts failed to reinduce AT. The total procedure time was 200 min, with a total fluoroscopy time of 9 min and a fluoroscopy dose of 719 cGy/cm (with a total dose including the preinterventional CT scan of 735.1 cGy/cm). The patient has remained free from recurrent arrhythmia off AAD for the last 18 months. This was documented on the pacemaker Holter. S. Ammar (&) I. Deisenhofer T. Reents G. Hessling Deutsches Herzzentrum Munchen, Technische Universitat Munchen, Lazarettstrasse 36, 80636 Munich, Germany e-mail: ammar@dhm.mhn.de

Catheter ablation is nowadays an established treatment modality for both atrial and ventricular tachyarrhythmias. Manual navigation of the ablation catheter can be challenging in patients with a complex cardiac anatomy due to, for example, (surgically corrected or palliated) congenital heart defects, resulting in a long procedure time and excessive X-ray exposure. In the past decades, sophisticated mapping and ablation techniques have been developed in order to improve the outcome of ablative therapy. These technologies include remote navigation systems such as the magnetic navigation system (Stereotaxis Inc.) and the non-magnetic robotic navigation system (Sensei Hansen Medical). In this issue, Roudijk et al. report on the value of remote magnetic catheter navigation and ablation in children and young adult patients with and without congenital heart disease in their paper entitled: ‘Catheter ablation in children and young adults: is there an additional benefit from remote magnetic navigation [1]? In this elegant paper, the outcome of ablative therapy of a variety of tachyarrhythmias was examined.