The epicardial outflow tract can be a site of origin of idiopathic ventricular arrhythmias. These arrhythmias are most commonly perivalvular and can be targeted from within the coronary venous system or from other adjacent structures, such as the right ventricular and left ventricular outflow tracts or the coronary cusp region. The authors report a case of an epicardial idiopathic outflow tract premature ventricular contraction originating from the midseptal epicardial left ventricle. In this case, direct epicardial access was crucial to identify early local activation and achieve successful catheter ablation.

BACKGROUND: Coronary calcium poses a challenge for the interventional cardiologist often leading to stent under-expansion and subsequent ischemic events. Aggressive balloon post-dilatation though helpful is usually inadequate. Multiple plaque ablation techniques are in vogue, but they are technically demanding and are not without complications. Shockwave intravascular lithotripsy (S-IVL) has emerged as a user-friendly and effective mechanism for calcium management with a high safety margin. A series of trials (DISRUPT CAD I-IV) have demonstrated both short-term and long-term safety and efficacy of the technique. As experience with the technique grows more and more, therapy areas like stent restenosis are being covered by the S-IVL.
METHODS: We report a series of 2 cases successfully managed with S-IVL therapy at our center. The first case is of a 57-year-old smoker who presented with acute coronary syndrome. His left anterior descending coronary artery revealed calcified 90% stenosis on angiogram and a combination of superficial-deep calcium on intracoronary imaging. The calcium was treated with 20 pulses of S-IVL to create discontinuity and a sirolimus eluting drug-eluting stent was successfully implanted. The second case is that of an elderly lady who presented with stable angina and demonstrated diffuse calcified lesions in the left anterior descending artery on angiogram. She also demonstrated a mixture of superficial and deep seated calcium zones on imaging. S-IVL therapy was applied to generate fractures in calcium, and two overlapping drug-eluting stents were implanted successfully without any complications.
CONCLUSIONS: S-IVL is an emerging, efficient, user-friendly and safe therapy for managing intracoronary calcium in routine interventional practice.

OBJECTIVE: We performed a meta-analysis to create a quantitative estimate of the association between non-alcoholic fatty liver disease (NAFLD) and the risk of cardiac arrhythmia (including atrial fibrillation (AF), prolonged QT interval, premature atrial/ventricular contraction [PAC/PVC] and heart block).
METHODS: A literature review was conducted using PubMed, Embase, Web of Science and the Cochrane Library database to identify observational studies of the link between NAFLD and cardiac arrhythmia. Effect sizes were expressed as odds ratios (ORs) or hazard ratios (HRs) with 95% confidence intervals (CIs). The method of analysis of AF was also analysed separately, according to the effect estimate (OR or HR).
RESULTS: Nineteen studies of 7,012,960 individuals were included. NAFLD was independently associated with higher risks of AF (OR 1.71, 95% CI: 1.14-2.57; HR 1.12, 95% CI: 1.11-1.13), prolonged QT interval (OR 2.86, 95% CI: 1.64-4.99), PAC/PVC (OR 2.53, 95% CI: 1.70-3.78) and heart block (OR 2.65, 95% CI: 1.88-3.72). The heterogeneity of the data with respect to AF and prolonged QT was moderate on sensitivity analysis.
CONCLUSIONS: We found a significantly higher risk of cardiac arrhythmia in patients with NAFLD, but the observational design of the studies does not permit conclusions regarding causality.

Premature ventricular contractions (PVCs) are one of the most common arrhythmias detected from electrocardiographic (ECG) monitoring. PVCs were thought to cause lethal arrhythmias and thus were closely monitored and treated. However, in current practice, PVCs generally do not required treatment. There is also concern that PVCs contribute to excessive alarms and lead to alarm fatigue. Practice guidelines for in-hospital monitoring state that monitoring for PVCs may be indicated on some patients but do not recommend continuous ECG monitoring. Despite these recommendations, PVC monitoring practices remain part of routine care, especially in the intensive care unit, for worry of missing potentially significant arrhythmia events. A thorough scoping review of the literature regarding the clinical significance of PVC is imperative, precisely to map out the evidence on the diagnostic and prognostic values of PVCs and to identify research gaps on this issue.
The primary question of this review is \"what is the clinical significance of PVCs in adults?\" Preparation of this scoping review will use the PRISMA-P statement. A scoping review framework by Arksey and O\'Malley will be adopted. In identifying relevant studies, the Population-Concept-Context (PCC) framework by the Joanna Briggs Institute will be used. A search strategy will be developed, and four major electronic databases will be searched: CINAHL, Embase, PubMed, and Web of Science Core Collection. Manual searches will also be conducted. The study selection process will adopt the 2009 PRISMA flow diagram. EndNote X8 will be used to manage citations, as well as for duplicates screening in addition to Microsoft Excel 2016. Two independent reviewers will assess potential studies in detail against inclusion criteria. A standardized data extraction form will be developed. Finally, critical appraisal will be conducted using a tool adapted from the Quality Appraisal Checklist by the National Institute for Health Care Excellence (NICE).
We believe this scoping review will provide a general foundation of evidence on the potential significance of PVCs concerning its diagnostic and prognostic value among the adult patient population. The findings will allow us to map out research gaps on this topic that could shape future research and ultimately clinical practice.
This scoping review has been registered in the Open Science Framework (OSF), DOI: https://doi.org/10.17605/OSF.IO/GAVT2 .

Although premature ventricular beats (PVBs) in young people and athletes are usually benign, they may rarely mark underlying heart disease and risk of sudden cardiac death during sport. This review addresses the prevalence, clinical meaning and diagnostic/prognostic assessment of PVBs in the athlete. The article focuses on the characteristics of PVBs, such as the morphological pattern of the ectopic QRS and the response to exercise, which accurately stratify risk. We propose an algorithm to help the sport and exercise physician manage the athlete with PVBs. We also address (1) which athletes need more indepth investigation, including cardiac MRI to exclude an underlying pathological myocardial substrate, and (2) which athletes can remain eligible to competitive sports and who needs to be excluded.

BACKGROUND: To systematically assess the current clinical evidence of Zhigancao (ZGC) Decoction for premature ventricular contractions (PVCs).
METHODS: PubMed, the Cochrane Center Controlled Trials Register, EMBASE, Chinese National Knowledge Infrastructure, Chinese Scientific Journal Database, and Wanfang Med Online Database were searched until June 2014. We included randomized clinical trials testing ZGC Decoction against anti-arrhythmic drugs, ZGC Decoction combined with anti-arrhythmic drugs versus anti-arrhythmic drugs alone. Study selection, data extraction, quality assessment, and data analyses were conducted according to the Cochrane standards. A meta-analysis of improving total effects and reducing number of ventricular premature beats was performed to evaluate the effects of ZGC Decoction on PVCs.
RESULTS: A total of 25 studies (involving 2441 patients) were included. The methodological quality of the included trials was evaluated as generally low. The results of the meta-analysis showed that ZGC Decoction combined with anti-arrhythmic drugs had significant effect on improving total effects (RR: 1.30 [1.22, 1.38]; P<0.00001) and relieving number of ventricular premature beats (MD: -6.66 [-12.94, -0.37]; P=0.04) compared with anti-arrhythmic drugs alone. Our review showed that ZGC Decoction was more effective in improving total effects (RR: 1.22 [1.08, 1.37]; P=0.0009), compared with anti-arrhythmic drugs alone. 13 trials reported adverse events, while the others did not mention them, indicating that the safety of ZGC Decoction remains uncertain.
CONCLUSIONS: ZGC Decoction appears to have beneficial effects on improvement of total effects, reduction of number of ventricular premature beats in participants with PVCs. However, further thorough investigation, large-scale, proper study designed, randomized trials of ZGC Decoction for PVCs will be required to justify the effects reported.