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Background: Total knee arthroplasty (TKA) for poliomyelitis patients is controversial due to its higher complication rate compared with that of TKA for osteoarthritis. In this study we evaluated the results, at a minimum of 10 years, of a consecutive series of third-generation rotating hinge total knee arthroplasties (RHKs) in patients affected by poliomyelitis. Methods: We conducted a retrospective analysis of 14 patients (15 TKA) performed between January 2000 and October 2021 that underwent a third-generation rotating hinge arthroplasty (Nex Gen RHK Zimmer). The clinical results using the American Knee Society Score (AKSS) were evaluated at an average follow-up of 154 months (min 120–max 216 months). Result: Of the 15 cases, 2 were lost at follow-up and 1 was excluded by the final evaluation due to infection. Of the remaining 12 cases at the final follow-up, the average AKKS clinical score improved from 30.08 points preoperatively, to 78.83 points postoperatively, while the average AKKS function score improved from 29.17 points to 56.25 points. We report only one intraoperative complication consisting of a femoral fracture at the tip of the stem, and a case of patellar fracture occurred 3 months after the index procedure. The presence of radiolucent lines was sporadic, while radiosclerotic lines were commonly visible around the stem extension, predominantly at the tip. Conclusions: The third generation of rotating hinge knee replacement has proved to be effective in polio patients, improving clinical and functional scores, and no cases of mechanical failure occurred.

Abstract Effective site characterization in highly urbanized coastal lowlands requires accurate stratigraphic and geophysical investigations. In these regions, which typically host shallowly buried paleovalley systems formed in response to Quaternary glacio‐eustatic fluctuations, the marked lithologic contrast between soft sediment paleovalley fills and the adjacent, stiff substrate has the potential to modify earthquake motions, and assessment of critical parameters, such as shear wave velocities (VS) and resonance frequencies (f), should be coupled with detailed stratigraphic architecture. To evaluate the potential of the microtremor horizontal‐to‐vertical spectral ratio (mHVSR) for paleovalley recognition and mapping, we performed mHVSR measurements along the Adriatic coastal plain of Italy, where two paleovalley systems (Pescara and Manfredonia) have been recently identified. In both areas, we detected rapid lateral variations in resonance frequencies and highlighted laterally continuous impedance contrasts. Relying on a robust stratigraphic framework, we carefully evaluated the relation between geological and geophysical data and identified the stratigraphic surfaces responsible for the observed resonances. We derived VS models for the sediment fill, reconstructing the geometry of the two buried paleovalleys. We address the importance of evaluating the geological context when designing microzonation studies, for a reliable interpretation of changes in resonance frequencies.

Numerical models have become a useful tool for predicting the potential risk caused by debris flows. Although a variety of numerical models have been proposed for the runout simulation of debris flows, the performances of these models in simulating specific events generally vary due to the difference in solving methods and the simulation of the entrainment/deposition processes. In this paper, two typical depth-averaged models have been used to analyze a well-documented debris-flow event that occurred in the Cancia basin on 23 July 2015. The simulations with and without bed entrainment are conducted to investigate the influence of this process on the runout behavior of the debris flow. Results show that the actual runout can be reproduced only by considering bed entrainment. If basal erosion is not taken into account, part of the debris mass deviates from the main path and both models predict unrealistic bank overflows not observed in the field. Moreover, the comparison between measured and simulated inundated areas shows that both models perform generally well in the terms of simulating the erosion-deposition pattern, although the DAN3D model predicts a greater lateral spreading and a thinner depositional thickness compared to Shen’s model. A simple numerical experiment obtains similar consequences and further illustrates the possible reasons that cause these differences.

The triggering threshold is one of the most important parameters for landslide early warning systems (EWSs) at the slope scale. In the present work, a velocity threshold is recommended for an early warning system of the Gapa landslide in Southwest China, which was reactivated by the impoundment of a large reservoir behind Jinping’s first dam. Based on GNSS monitoring data over the last five years, the velocity threshold is defined by a novel method, which is implemented by the forward and reverse double moving average of time series. As the landslide deformation is strongly related to the fluctuations in reservoir water levels, a crucial water level is also defined to reduce false warnings from the velocity threshold alone. In recognition of the importance of geological evolution, the evolution process of the Gapa landslide from topping to sliding is described in this study to help to understand its behavior and predict its potential trends. Moreover, based on the improved Saito’s three-stage deformation model, the warning level is set as “attention level”, because the current deformation stage of the landslide is considered to be between the initial and constant stages. At present, the early warning system mainly consists of six surface displacement monitoring sites and one water level observation site. If the daily recorded velocity in each monitoring site exceeds 4 mm/d and, meanwhile, the water level is below 1820 m above sea level (asl), a warning of likely landslide deformation accelerations will be released by relevant monitoring sites. The thresholds are always discretely exceeded on about 3% of annual monitoring days, and they are most frequently exceeded in June (especially in mid-June). The thresholds provide an efficient and effective way for judging accelerations of this landslide and are verified by the current application. The work presented provides critical insights into the development of early warning systems for reservoir-induced large-scale landslides.

Background Population‐based data on heart failure (HF)‐related death in patients with atrial fibrillation (AF) are lacking. We assessed HF‐related death in people with AF in the United States over the past 21 years and examined differences by age, sex, race, ethnicity, urbanization, and census region. Methods and Results Data were extracted from the Centers for Disease Control and Prevention Wide‐Ranging Online Data for Epidemiologic Research to determine trends in age‐adjusted mortality rates per 100 000 people, due to HF‐related death among subjects with AF aged ≥15 years. To calculate nationwide annual trends, we assessed the average annual percent change (AAPC) and annual percent change with relative 95% CIs using joinpoint regression. Between 1999 and 2020, 916 685 HF‐related deaths (396 205 men and 520 480 women) occurred among US adults having a concomitant AF. The overall age‐adjusted mortality rates increased (AAPC: +4.1% [95% CI, 3.8–4.4]; P65 years was observed. Conclusions A worrying increase in the HF‐related mortality rate among patients with AF has been observed in the United States over the past 2 decades.

Abstract Aims The HeartLogic algorithm combines multiple implantable defibrillator (ICD) sensor data and has proved to be a sensitive and timely predictor of impending heart failure (HF) decompensation in cardiac resynchronization therapy (CRT‐D) patients. We evaluated the performance of this algorithm in non‐CRT ICD patients and in the presence of co‐morbidities. Methods and results The HeartLogic feature was activated in 568 ICD patients (410 with CRT‐D) from 26 centres. The median follow‐up was 26 months [25th–75th percentile: 16–37]. During follow‐up, 97 hospitalizations were reported (53 cardiovascular) and 55 patients died. We recorded 1200 HeartLogic alerts in 370 patients. Overall, the time IN the alert state was 13% of the total observation period. The rate of cardiovascular hospitalizations or death was 0.48/patient‐year (95% CI: 0.37–0.60) with the HeartLogic IN the alert state and 0.04/patient‐year (95% CI: 0.03–0.05) OUT of the alert state, with an incidence rate ratio of 13.35 (95% CI: 8.83–20.51, P

Arrhythmogenic cardiomyopathy (ACM) is a rare cardiac disease, characterized by the progressive replacement of myocardial tissue with fibrous and fatty deposits. It can involve both the right and left ventricles. It is associated with the development of life-threatening arrhythmias and culminates in sudden cardiac death. Electrocardiography (ECG) has emerged as a pivotal tool, offering diagnostic insights and prognostic information. The specific ECG abnormalities observed in ACM not only contribute to early detection but also hold the key to the prediction of the likelihood of severe complications. The recognition of these nuanced ECG manifestations has become imperative for clinicians as it guides them in the formulation of tailored therapeutic strategies that address both the present symptoms and the potential future risks.

Background: At the same conditions of delivered power and contact force, open-irrigated radiofrequency ablation catheters are believed to create deeper lesions, while non-irrigated ones produce shallower lesions. This ex vivo study aims to directly compare the lesion dimensions and characteristics of an irrigated ablation catheter with a flexible tip and a non-irrigated solid-tip catheter. Methods: Radiofrequency lesions were induced on porcine myocardial slabs using both open-tip irrigated and non-irrigated standard 4 mm catheters at three power settings (20 W, 30 W, and 40 W), maintaining a fixed contact force of 10 gr. A lesion assessment was conducted including the lesion depth, depth at the maximum diameter, and lesion surface diameters, with the subsequent calculation of the lesion volume and area being undertaken. Results: Irrigated catheters produced lesions with significantly higher superficial widths at all power levels (3.8 vs. 4.4 mm at 20 W; 3.9 mm vs. 4.4 mm at 30 W; 3.8 mm vs. 4.5 mm at 40 W; p = 0.001, p = 0.019, p = 0.003, respectively). Non-irrigated catheters resulted in significantly higher superficial areas at all power levels (23 mm2 vs. 18 mm2 at 20 W; 25 mm2 vs. 19 mm2 at 30 W; 26 mm2 vs. 19 mm2 at 40 W; p = 0.001, p = 0.005, p = 0.001, respectively). Irrigated catheters showed significantly higher values of lesion maximum depth at 40 W (4.6 mm vs. 5.5 mm; p = 0.007), while non-irrigated catheters had a significantly higher calculated volume at 20 W (202 µL vs. 134 µL; p = 0.002). Conclusions: Radiofrequency ablation using an irrigated catheter with a flexible tip has the potential to generate smaller superficial lesion areas compared with those obtained using a non-irrigated catheter.

Background: This case report outlines the presentation of an emerging complication arising from left bundle branch area pacing (LBBAP). Case summary: A 43-year-old male with no history of cardiac problems experienced recurrent episodes of syncope with no prodromal symptoms. During monitoring in the emergency department, the patient underwent an episode of asystole, leading to LBBAP implantation. The procedure encountered technical challenges, resulting in an interventricular septal hematoma and subsequent ventricular arrhythmias. Despite initial concerns, conservative management led to resolution, demonstrated through echocardiographic follow-ups. Discussion: This report underscores the significance of ventricular arrhythmias as indicators of interventricular septal hematoma, providing insights into its diagnosis, management, and implications for LBBAP procedures.

Background: Physiological pacing has gained significant interest due to its potential to achieve optimal hemodynamic response. This study aimed to assess left ventricular performance in terms of electrical parameters, specifically QRS duration and mechanical performance, evaluated as myocardial work. We compared His Bundle Pacing (HBP) and Left Bundle Branch Area Pacing (LBBAP) to evaluate their effects. Methods: Twenty-four patients with class I or IIa indications for pacing were enrolled in this study, with twelve patients undergoing HBP implantation and another twelve undergoing LBBAP implantation. A comprehensive analysis of myocardial work was conducted. Results: Our findings indicate that there were no major differences in terms of spontaneous and HBP activation in myocardial work, except for global wasted work (217 mmHg% vs. 283 mmHg%; p 0.016) and global work efficiency (87 mmHg% vs. 82 mmHg%; p 0.049). No significant differences were observed in myocardial work between spontaneous activation and LBBAP. Similarly, no significant differences in myocardial work were found between HBP and LBBAP. Conclusions: Both pacing modalities provide physiological ventricular activation without significant differences when compared to each other. Moreover, there were no significant differences in QRS duration between HBP and LBBAP. However, LBBAP demonstrated advantages in terms of feasibility, as it achieved better lead electrical parameters compared to HBP (threshold@0.4 ms 0.6 V vs. 1 V; p = 0.045—sensing 9.4 mV vs. 2.4 mV; p < 0.001). Additionally, LBBAP required less fluoroscopy time (6 min vs. 13 min; p = 0.010) and procedural time (81 min vs. 125 min; p = 0.004) compared to HBP.

Recent data support the existence of a distinctive ‘vascular’ phenotype with the involvement of both pulmonary parenchyma and its circulation in COVID‐19 pneumonia. Its prompt identification is important for the accurate management of COVID‐19 patients. The aim is to analyse the pro and contra of the different modalities to identify the ‘vascular’ phenotype. Chest computed tomography scan and angiogram may quantify both parenchyma and vascular damage, but the presence of thrombosis of pulmonary microcirculation may be missed. Increased d‐dimer concentration confirms a thrombotic state, but it cannot localize the thrombus. An elevation of troponin concentration non‐specifically reflects cardiac injury. Echocardiogram and electrocardiogram provide specific signs of right ventricular pressure overload. This is particularly relevant for the ‘vascular’ phenotype, which does not necessarily represent the result of thrombo‐embolic venous complications, but more frequently, it is the result of pulmonary microcirculation thrombosis in situ and needs immediate therapeutic action. Condensed abstract Despite diagnosis of the ‘vascular’ phenotype of COVID‐19 pneumonia may be subtle, the evidence indicates a reasonable possibility of identifying it already in the initial stage of the infection. Chest computed tomography scan and angiogram, increased d‐dimer concentration, and elevation of troponin concentration may be not sufficient to identify ‘vascular’ phenotype. Echocardiogram and electrocardiogram provide specific signs of right ventricular pressure overload. This is particularly relevant for the ‘vascular’ phenotype, which does not necessarily represent the result of thrombo‐embolic venous complications, but more frequently, it is the result of pulmonary microcirculation thrombosis in situ and needs immediate therapeutic action.

Abstract Aims There are conflicting data on the benefit of cardiac resynchronization therapy (CRT) in heart failure (HF) patients with permanent atrial fibrillation (AF). We aimed to compare patient outcomes according to the presence or absence of permanent AF at device implantation. Methods and results We retrospectively analysed remote monitoring data from 1141 CRT defibrillators. Propensity score with inverse‐probability weighting method was used to balance AF and sinus rhythm (SR) groups. Analysis endpoints included total mortality, appropriate defibrillation shocks, and CRT percentage. There were 229 patients (20.1%) in the AF group and 912 patients (79.9%) in the SR group. Compared with SR patients, AF patients were older (median age, 77 vs. 72 years, P

Brugada syndrome (BrS) is an inherited cardiac channelopathy first diagnosed in 1992 but still considered a challenging disease in terms of diagnosis, arrhythmia risk prediction, pathophysiology and management. Despite about 20% of individuals carrying pathogenic variants in the SCN5A gene, the identification of a polygenic origin for BrS and the potential role of common genetic variants provide the basis for applying polygenic risk scores for individual risk prediction. The pathophysiological mechanisms are still unclear, and the initial thinking of this syndrome as a primary electrical disease is evolving towards a partly structural disease. This review focuses on the main scientific advancements in the identification of biomarkers for diagnosis, risk stratification, pathophysiology and therapy of BrS. A comprehensive model that integrates clinical and genetic factors, comorbidities, age and gender, and perhaps environmental influences may provide the opportunity to enhance patients’ quality of life and improve the therapeutic approach.

Cardiac pacing technologies have been implemented during the last few decades, including leadless pacemakers and pacing of the conduction system, such as His bundle pacing and left bundle branch area pacing [...]

The aim of this review is to identify possible structural abnormalities of BrS and their potential association with symptoms, risk stratification, and prognosis. (1) Background: BrS has always been considered a purely electrical disease and imaging techniques do not currently play a specific role in the diagnosis of this arrhythmic syndrome. Some authors have recently hypothesized the presence of structural and functional abnormalities. Therefore, several studies investigated the presence of pathological features in echocardiography and cardiac magnetic resonance imaging (MRI) in patients with BrS, but results were controversial. (2) Methods: We performed a systematic review of the literature on the spectrum of features detected by echocardiography and cardiac MRI. Articles were searched in Pubmed, Cochrane Library, and Biomed Central. Only papers published in English and in peer-reviewed journals up to November 2021 were selected. After an initial evaluation, 596 records were screened; the literature search identified 19 relevant articles. (3) Results: The imaging findings associated with BrS were as follows: right ventricular dilation, right ventricular wall motion abnormalities, delayed right ventricular contraction, speckle and feature tracking abnormalities, late gadolinium enhancement, and fat infiltration in the right ventricle. Furthermore, these features emerged more frequently in patients carrying the genetic mutation on the sodium voltage-gated channel α-subunit 5 (SCN5A) gene. (4) Conclusions: Specific imaging features detected by echocardiography and cardiac magnetic resonance are associated with BrS. However, this population appears to be heterogeneous and imaging anomalies emerged to be more frequent in patients carrying genetic mutations of SCN5A. Future studies with an evaluation of BrS patients are needed to identify the specific association linking the Brugada pattern, imaging abnormalities and their possible correlation with prognosis.

Background. Patients with β-thalassemia have a high incidence of atrial fibrillation (AF) and other supraventricular arrhythmias. The use of non-vitamin K antagonist oral anticoagulants (NOACs) for thromboembolic prophylaxis in patients with β-thalassemia has not been systematically evaluated. Methods. We enrolled patients with transfusion-dependent β-thalassemia, who were on treatment with NOACs for thromboembolic prophylaxis of supraventricular arrhythmias. Data on thromboembolic and bleeding events were collected. Results. Eighteen patients were enrolled. The patients had a history of AF (sixteen), typical atrial flutter (five), and atypical atrial flutter (four). The patients were treated with dabigatran (seven), apixaban (five), rivaroxaban (four) or edoxaban (two). The mean follow-up duration was 22 ± 15 months. No thromboembolic events were reported. No major bleedings were observed. Three patients had non-major bleeding events. Two patients reported dyspepsia during treatment with dabigatran and were shifted to a different NOAC. Conclusions. Our study suggests the efficacy and safety of NOACs in patients affected by transfusion-dependent β-thalassemia.

Aims: To explore the impact of the use of intracardiac echocardiography (ICE) in the ablation of supraventricular arrhythmias requiring transseptal catheterization (TSC), whilst analyzing the reduction in periprocedural complications and complications specifically related to TSC. Methods: A retrospective multicenter study collecting data from consecutive atrial fibrillation (AF) and supraventricular ablation procedures that required TSC was performed in five Italian centers. Based on physician discretion, TSC was performed with or without ICE. Periprocedural complications, separating all complications from complications directly related to TSC, were collected. Independent predictors of periprocedural complications and TSC-related complications were investigated. Results: A total of 2181 TSCs were performed on 1862 patients at five Italian centers from 2006 to 2021, in 76% of cases by AF ablation and in 24% by ablation of other arrhythmias with a circuit in the left atrium. Overall, 1134 (52%) procedures were performed with ICE support and 1047 (48%) without ICE. A total of 67 (3.1%) complications were detected, 19 (1.7%) in the ICE group and 48 (4.6%) in the no ICE group, p < 0.001. A total of 42 (1.5%) complications directly related to TSC: 0.9% in the ICE group and 3.1% in the no ICE group (p < 0.001). The independent predictors of all complications were age (OR 1,02 95% C.I 1.00–1.05; p = 0.036), TSC with the use of ICE (OR 0.27 95% C.I 0.15–0.46; p < 0.001) and AF ablation (OR 2,25 95%C.I 1.05–4.83; p = 0.037). The independent predictors for TSC complications were age (OR 1.03 95% C.I 1.01–1.06; p = 0.013) and TSC with the use of ICE (OR 0.24 95% C.I 0.11–0.49; p < 0.001). Conclusions: ICE reduced periprocedural and TSC-related complications during electrophysiological procedures for ablation of left atrial arrhythmias.

Background. Data on leadless pacemaker (LPM) implantation in an emergency setting are currently lacking. Objective. We aimed to investigate the feasibility of LPM implantation for emergency bradyarrhythmia, in patients referred for urgent PM implantation, in a large, multicenter, real-world cohort of LPM recipients. Methods. Two cohorts of LPM patients, stratified according to the LPM implantation scenario (patients admitted from the emergency department (ED+) vs. elective patients (ED−)) were retrieved from the iLEAPER registry. The primary outcome of the study was a comparison of the peri-procedural complications between the groups. The rates of peri-procedural characteristics (overall procedural and fluoroscopic duration) were deemed secondary outcomes. Results. A total of 1154 patients were enrolled in this project, with patients implanted due to an urgent bradyarrhythmia (ED+) representing 6.2% of the entire cohort. Slow atrial fibrillation and complete + advanced atrioventricular blocks were more frequent in the ED+ cohort (76.3% for ED+ vs. 49.7% for ED−, p = 0.025; 37.5% vs. 27.3%, p = 0.027, respectively). The overall procedural times were longer in the ED+ cohort (60 (45–80) mins vs. 50 (40–65) mins, p < 0.001), showing higher rates of temporary pacing (94.4% for ED+ vs. 28.9% for ED−, p < 0.001). Emergency LPM implantation was not correlated with an increase in the rate of major complications compared to the control group (6.9% ED+ vs. 4.2% ED−, p = 0.244). Conclusion. LPM implantation is a feasible procedure for the treatment of severe bradyarrhythmia in an urgent setting. Urgent LPM implantation was not correlated with an increase in the rate of major complications compared to the control group, but it was associated with longer procedural times.

Background. His bundle pacing (HBP) has emerged as an alternative site to right ventricular pacing (RVP) with encouraging outcomes. To date, no study has investigated the systematic approach of three-dimensional electroanatomic mapping (3D-EAM) to guide HBP implantation and to evaluate myocardial activation timing. Furthermore, studies reporting a comprehensive assessment of the ventricular function, using myocardial work (MW) evaluation are lacking. Objectives. (1) To evaluate the systematic use of the 3D-EAM as a guide to HBP; (2) to assess the electrical and mechanical activations with high-density mapping, comparing spontaneous ventricular activation (SVA), HBP and RVP; (3) to assess the myocardial function through speckle-tracking echocardiography (STE) and MW analysis in SVA, HBP and RVP. Methods. 3D-EAM was performed in consecutive patients undergoing HBP implantation with a low use of fluoroscopy. All patients were systematically evaluated with high-density mapping, MW and STE. Results. Fifteen patients were enrolled, of whom three had an implant failure (20%). RV activation time was not statistically different between SVA and HBP (103 vs. 104 ms, p = 0.969) but was significantly higher in RVP (133 ms, p = 0.011 vs. SVA and p = 0.001 vs HBP). Global constructive work was significantly lower during RVP (1191 mmHg%) than during SVA and HBP (1648 and 1505 mmHg%, p = 0.011 and p = 0.008, respectively) and did not differ between SVA and HBP (p = 0.075). Conclusions. 3D-EAM and MW evaluation showed that HBP was comparable to the physiological SVA in terms of activation time and cardiac performance. Compared to both SVA and HBP, RVP was associated with a worse activation timing and ventricular efficiency.

Background: A 70 years-old superobese man (weighted 230 kg) was referred to our hospital for recurrent syncope due to asystole alternating to atrial fibrillation. Convectional pacing was highly challenging; therefore, it was decided to implant a leadless pacemaker in a multidisciplinary intervention with surgical management of the femoral venous access. Methods: In a fully equipped operating room with bariatric table and appropriately dimensioned fluoroscope, a vascular surgeon performed surgical isolation of the right common femoral vein. After that, we proceeded to insert sheaths via the femoral vein, and through that a steerable transcatheter delivery system for the device. Results: The implant was successful without complication. Conclusions: Leadless pacemaker implantation can be effectively and safely performed even in superobese patients. Vascular access, fluoroscopic guidance and electronic interrogation could be easily managed and do not constitute a limit.

Cardiac implantable electronic device (CIED) implants and electrophysiological procedures share a common step: vascular access. On behalf of the AIAC Ricerca Investigators’ Network, we conducted a survey to outline Italian common practice regarding vascular access in EP-lab. All Italian physicians with experience in CIED implantation and electrophysiology were invited to answer an online questionnaire (from May 2020 to November 2020) featuring 20 questions. In total, 103 cardiologists (from 92 Italian hospitals) answered the survey. Vascular access during CIED implants was considered the most complex step following lead placement by 54 (52.4%) respondents and the most complex for 35 (33.9%). In total, 54 (52.4%) and 49 (47.6%) respondents considered the cephalic and subclavian vein the first option, respectively (intrathoracic and extrathoracic subclavian/axillary vein by 22 and 27, respectively). In total, 45 (43.7%) respondents performed close arterial femoral accesses manually; only 12 (11.7%) respondents made extensive use of vascular closure devices. A total of 46 out of 103 respondents had experience in ultrasound-guided vascular accesses, but only 10 (22%) used it for more than 50% of the accesses. In total, 81 (78.6%) respondents wanted to increase their ultrasound-guided vascular access skills. Reducing complications is a goal to reach in cardiac stimulation and electrophysiological procedures. Our survey shows the heterogeneity of the vascular approaches used in Italian centres. Some vascular accesses were proved to be superior to others in terms of complications, with ultrasound-guided puncture as an emerging technique. More effort to produce the standardization of vascular accesses could be made by scientific societies.

Thalassemia is an inherited blood disorder with worldwide distribution. Transfusion and chelation therapy have radically improved the prognosis of β-thalassemic patients in the developed world, but this has led to the development of new chronic cardiac complications like atrial fibrillation (AF). Prevalence of AF in patients with β-thalassemia is higher than in the general population, ranging from 2 to 33%. Studies are lacking, and the little evidence available comes from a small number of observational studies. The pathophysiology is not well understood but, while iron overload seems to be the principal mechanism, AF could develop even in the absence of iron deposition. Furthermore, the clinical presentation is mainly paroxysmal, and patients are highly symptomatic. The underlying disease, the pathophysiology, and the clinical presentation require a different management of AF in β-thalassemia than in the general population. Rhythm control should be preferred over rate control, and the most important antiarrhythmic therapy is represented by chelation drugs. Thromboembolic risk is high, but the available risk scores are not validated in β-thalassemia, and the choice of anticoagulation therapy should be considered early. The main purpose of this review is to summarize the actual knowledge about AF in β-thalassemia, with a specific focus on the clinical management of these complex patients.

Background: A 61-year-old male with Steinert Dystrophy and prior history of cardiac implantable device complained of highly symptomatic right atrial tachycardia. Unresponsive to pharmacological therapy. Methods: The patient underwent catheter ablation procedure aided by high-density mapping. Results: Ablation procedure was succesful. Conclusions: This unique case report highlights the role of high-density mapping in the identification of critical isthmus and management of macro-reentrant tachycardia in complex situations such as the presence of multiple leads in the chamber.

Background and Rationale. A fluoroscopy-based approach to an electrophysiological procedure is widely validated and has been recognized as the gold standard for a long time. The use of fluoroscopy exposes both the healthcare staff and the patient to a non-negligible dose of radiation. To minimize the risks associated with the use of fluoroscopy, it would be reasonable to perform ablation procedures with zero fluoroscopy. This approach is widely used in simple ablation procedures, but not in complex procedures. In atrial fibrillation (AF) ablation procedures, fluoroscopy remains the main technology used, in particular to guide the transseptal puncture. Main results and Implications. We present a workflow to perform a complete zero-fluoroscopy ablation for AF ablation procedures using a 3D electro-anatomical mapping system, intracardiac echocardiography and a novel steerable guiding sheath that can be visualized on the mapping system. We present two cases, one with paroxysmal AF and the other one with persistent AF during which we applied this novel workflow achieving a successful pulmonary vein isolation without complications and complete zero-fluoroscopy exposure.