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The COVID-19 post-lockdown period and the subsequent progressive withdrawal of the quarantine measures are currently allowing the gradual resumption of the ordinary clinical activities, which have been suppressed during the COVID-19 pandemic. In this phase, it is crucial to minimize the risk of infection to limit COVID-19-related morbidity and mortality and the number of new cases. Indeed, COVID-19 manifestations may be equivocal, including asymptomatic or mildly symptomatic patients. In order to ensure the safety of patients and healthcare providers, therefore, it is mandatory to stratify the risk of post-COVID-19 pandemic infection during the clinical and instrumental evaluation of cardiac patients, who are at low risk for COVID-19. Here we discuss the most common diagnostic procedures and therapeutic activities, the type of personal protective equipment according to the different tests, the timetable of the different diagnostic examinations, the tele-health services or alternative strategies, and the structural and management requirements, that should be applied to protect patients and healthcare providers in the post-COVID-19 era.

Atrial fibrillation (AF) is the most common arrhythmia and its prevalence is increasing due to the progressive aging of the population. About 20% of strokes are attributable to AF and AF patients are at 5-fold increased risk of stroke. The mainstay of treatment of AF is the prevention of thromboembolic complications with oral anticoagulation therapy. Drug treatment for many years has been based on the use of vitamin K antagonists, but recently newer and safer molecules have been introduced (dabigatran etexilate, rivaroxaban, apixaban and edoxaban). Despite these advances, many patients still do not receive adequate anticoagulation therapy because of contraindications (relative and absolute) to this treatment. Over the last decade, percutaneous closure of left atrial appendage, main site of thrombus formation during AF, proved effective in reducing thromboembolic complications, thus offering a valid medical treatment especially in patients at increased bleeding risk. The aim of this consensus document is to review the main aspects of left atrial appendage occlusion (selection and multidisciplinary assessment of patients, currently available methods and devices, requirements for centers and operators, associated therapies and follow-up modalities) having as a ground the significant evolution of techniques and the available relevant clinical data.

Thromboembolism from the left atrial appendage is the most feared complication in patients with atrial fibrillation (AF). The cornerstone for the management of chronic nonvalvular AF is stroke reduction with oral anticoagulation (OAC). However, poor compliance, maintaining a narrow therapeutic window, and major side effects such as bleeding have severely limited its use, creating a therapeutic dilemma. About 20% of AF patients do not receive OAC due to contraindications and less than half of AF patients are not on OAC due to reluctance of the prescribing physician and/or patient non-compliance. Fortunately, over the past decade, the introduction of percutaneous approaches for left atrial appendage occlusion has offered a viable alternative to the management of nonvalvular AF in patients with OAC contraindication. Occlusion devices such as the Amplatzer Cardiac Plug and Watch man device have shown their noninferiority to OAC for stroke prophylaxis with less bleeding complications, while more recently some new devices have been introduced. The aim of this position paper is to review the most relevant clinical aspects of left atrial appendage occlusion from patient selection to periprocedural and follow-up management. In addition, the importance of a medical team and an organizational environment adequate to optimize all the steps of this procedure is discussed.

Antiarrhythmic agents are among the therapeutic options available for the treatment of atrial fibrillation when a rhythm control strategy is required. Although their efficacy seems to be generally comparable to that of nonpharmacological interventions, the use of these agents remains controversial. In particular, among this class of drugs, the use of dronedarone in clinical practice is a matter of debate. In this paper, the authors aimed to address these issues, involving a team of expert cardiologists who discussed about the potential use of dronedarone in different clinical scenarios. The RAND/UCLA appropriateness method was used to develop appropriateness measures for the optimal management of patients treated with dronedarone, by combining the best available scientific evidence with the collective judgment of experts. To this purpose, a group of experts was identified and asked to rate the benefit-to-harm ratio of 52 clinical scenarios. Each indication was classified as "appropriate", "uncertain" or "inappropriate" in accordance with the panelists' median score. The classification of each scenario has led to the development of several recommendations for clinical practice. The use of dronedarone for the management of paroxysmal and persistent atrial fibrillation has evolved over time: this antiarrhythmic drug appears to be useful not only in monitoring symptoms, but also in reducing hospitalization and mortality rates in patients with atrial fibrillation.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and significantly impact patients' quality of life, morbidity and mortality. The number of affected patients is expected to increase as well as the costs associated with AF management, mainly driven by hospitalizations. Over the last decade, catheter ablation techniques targeting pulmonary vein isolation have demonstrated to be effective in treating AF and preventing AF recurrence. This Health Technology Assessment report of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) aims to define the current role of catheter ablation of AF in terms of effectiveness, efficiency and appropriateness. On the basis of an extensive review of the available literature, this report provides (i) an overview of the epidemiology, clinical impact and socio-economic burden of AF; (ii) an evaluation of therapeutic options other than catheter ablation of AF; and (iii) a detailed presentation of clinical outcomes and cost-benefit ratio associated with catheter ablation. The costs of catheter ablation of AF in Italy were obtained using a bottom-up analysis of a resource utilization survey of 52 hospitals that were considered a representative sample, including 4 Centers that contributed with additional unit cost information in a separate questionnaire. An analysis of budget impact was also performed to evaluate the impact of ablation on the management costs of AF. Results of this analysis show that (1) catheter ablation is effective, safe and superior to antiarrhythmic drug therapy in maintaining sinus rhythm; (2) the cost of an ablation procedure in Italy typically ranges from €8868 to €9455, though current reimbursement remains insufficient, covering only about 60% of the costs; (3) the costs of follow-up are modest (about 8% of total costs); (4) assuming an adjustment of reimbursement to the real cost of an ablation procedure and a 5-10% increase in the annual rate of ablation procedures, after approximately 5-6 years this would result in significant incremental savings for the Italian Healthcare System. In conclusion, catheter ablation of AF is a cost-effective procedure that is inadequately reimbursed in Italy. Insufficient reimbursement may serve as disincentive to perform AF ablation, thereby limiting patient access to this treatment. Considering the healthcare system perspective, higher initial costs for ablation procedures in the short term may be offset by cost savings mainly associated with decreased hospitalizations over time.

Background: Heart period variability is frequently reduced in patients with coronary artery disease. Although the mechanism for this reduction is still unclear, it seems to reflect alterations in cardiac autonomic control. In this study we have evaluated the relation between reversible segmental left ventricular dysfunction and time and frequency domain measures of heart period variability in patients with coronary artery disease., Methods and Results: Echocardiographic segmental left ventricular wall motion and time and frequency domain measures of heart period variability were evaluated in 32 patients with one-vessel coronary artery disease before and 16-24 days after successful percutaneous transluminal coronary angioplasty (PTCA). At baseline examination 12 patients (Group A) had normal and 20 (Group B) abnormal regional wall motion. Prevalence of previous myocardial infarction was higher and mean angiographic ejection fraction lower in Group B than in Group A. At baseline, time domain measures were comparable between the 2 groups, while low frequency (LF) and high frequency (HF) power were lower in Group B than in Group A. After PTCA, in Group A regional wall motion and time and frequency domain measures of heart period variability were unchanged. In Group B summed segment score improved from 17.1 +/- 3.6 to 12.8 +/- 2.0 (p < 0.01) and a significant increase occurred in standard deviation of the average normal RR (NN) intervals for all 5-minute segments of a 24-hour recording (SDNN index), in root mean square successive difference (r-MSSD) and in the percentage of differences between adjacent NN intervals > 50 msec (pNN50). In this group also LF and HF power (logarithmic units) increased from 6.14 +/- 0.23 to 6.35 +/- 0.34 (p < 0.01) and from 5.43 +/- 0.32 to 5.68 +/- 0.52 (p < 0.01) respectively. There was no correlation between measures of heart period variability, summed segment score, and left ventricular ejection fraction., Conclusions: This study demonstrates that segmental left ventricular dysfunction is involved in determining sympathovagal imbalance in patients with one-vessel coronary artery disease; the reversal of left ventricular dysfunction by successful PTCA improves heart period variability. These findings support the hypothesis that alterations in cardiac geometry may influence the discharge of afferent sympathetic mechanoreceptors, thus contributing to the derangement in autonomic control of heart rate.