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Introduction The weaning from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) decision involves a meticulous evaluation of different factors, among which echocardiography is a decisive factor. Purpose Evaluate echocardiographic changes from the beginning of the support to the weaning test. Methods Analysis of VA-ECMO cases in a referral hospital which completed a weaning test. We evaluated the changes of echocardiographic parameters during the VA-ECMO support (initial and during weaning test) and successful weaning (survival >24h after explant and no mortality from cardiogenic shock/heart failure or cardiac arrest during admission). Results 85 out of 134 VA-ECMO patients were included from 2013 to Oct-2020 (table 1.1). Successful weaning was achieved in 61.2% and final survival at discharge 49.4%. We observed a significant increase in left ventricular ejection fraction (LVEF), left ventricular outflow tract time–velocity integral (LVOT VTI), tricuspid annular plane systolic excursion (TAPSE) and the percentage of patients with normal qualitative right ventricular function and 1:1 aortic valve opening from the initial to the weaning echocardiography (table 1.2), without significant changes in ventricular diameters. Among these changes, the increase in LVOT VTI was the only parameter that was related to weaning success (p=0.037, table 1.2). A higher LVEF increase from the initial value showed a trend to greater successful VA-ECMO disconnection (p=0.053 table 1.2). Conclusion Left and right ventricular function parameters improved significantly from baseline to weaning test echocardiography in VA-ECMO supported patients. Of these changes, the increase in LVOT VTI was related to successful disconnection from VA-ECMO and the LVEF improvement showed a trend to weaning success. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Instituto de Salud Carlos III in Spain (Co-funded by European Social Fund “Investing in your future”). Characteristics ECMO-VA patients

Introduction Non-sustained ventricular tachycardias (NSVT) are observed frequently among ICD patients with left ventricular dysfunction (LVD). Purpose To analyze the relationship between episodes of NSVTs and monomorphic VTs (MVTs) that subsequently cause appropriate therapies. Methods 416 ICD patients with LVD (LVEF Results During the follow-up, 1441 MVT occurred in 183 patients. After showing a significant correlation between burden of NSVT and the occurrence of appropriate therapies due to MVT (C coefficient=0.68; p5 NSVT presented an excess of adjusted risk: HR=1.97 (95% CI=1.45–2.72); p Among patients who presented NSVTs and MVTs (n=145 subjects), we analyzed the relationship between the adjusted mean CL of the NSVTs (n=1288 episodes) and the CL of the first appropriate therapy due to MVT occurring subsequently. We found a significant and positive correlation between the two (r=0.88; p5 NSVTs (r=0.97, n=52)). The robustness of such correlation was similar in individuals with ischemic (r=0.86; n=91) versus non-ischemic cardiomyopathy (r=0.90; n=54), and in primary (r=0.86; n=75) versus secondary prevention (r=0.90; n=70). The agreement between the CL of first MVT and the adjusted mean CL of NSVT episodes (GEEM) was determined according to the Bland-Altman Method. The difference between the two values was 2±8.3 ms, with only 7.6% (11/145) of patients in whom the difference between the two CL was outside the concordance limits. The agreement was greater, again, in individuals with >5 NSVTs. As shown in the Figure, in more than 95% of patients both values were within the interval of agreement (0.32±4 ms). Conclusions 1-The burden of NSVTs occurring early after an ICD implant, but not their CL, is associated with a higher incidence of appropriate therapies due to MVT at follow-up. 2-The CL of the NSVTs and that of the first and subsequent MVTs is virtually the same in patients with higher NSVT burden. Therefore, it could be the same tachycardia, but with different duration. Figure 1 Funding Acknowledgement Type of funding source: None

Introduction Anthracycline-induced cardiotoxicity (AIC) is a serious adverse effect occurring in a significant proportion of patients. Irreversible mitochondrial damage is a central mechanism of AIC. Despite many efforts, there is a lack of therapies able to prevent AIC. Remote ischemic preconditioning (RIPC) could be a promising therapy to prevent AIC due to the scheduled application of chemotherapy in cancer patients. Purpose To evaluate the cardioprotective efficacy of RIPC in large animal model of AIC. Methods Large-White pigs (n=20) underwent a validated protocol of AIC consisting on five intracoronary doxorubicin injections (0.45 mg/kg), on weeks 0, 2, 4, 6, 8 of the study. Pigs were randomized before the initiation of the study to remote ischemic pre-conditioning (RIPC, 3 cycles of 5 min lower limb ischemia followed by 5 min reperfusion) or sham procedure immediately before doxorubicin injections. An additional group of 10 pigs without any exposure to doxorubicin was carried out as controls. Pigs underwent a comprehensive serial cardiac magnetic resonance (CMR) exam baseline, and on weeks 6, 8, 12, and 16. After 16-week CMR, pigs were sacrificed and tissue samples collected. A second group of 10 pigs (randomized 1:1 for RIPC) underwent the same protocol but were sacrificed 2 weeks after the third doxorubicin dose for early evaluation of tissue changes. Primary endpoint of the study was CMR-based left ventricular ejection fraction on week 16. Results Until week 6 (time of fourth doxorubicin injection), LVEF remained unchanged in both groups. From there on, a progressive decline in LVEF was observed. LVEF depression trajectory was blunted in RIPC animals. Compared to controls, pigs undergoing RIPC before each doxorubicin dose had a significantly higher LVEF at week 16: median (IQR) 45% (27–50%) vs 33% (19–47%) in RIPC and controls respectively, p=0.04. Improvement in LVEF was mainly due to a more preserved contractile function, as evidence by smaller LVESV, and better regional contractile function. After 3 doxorubicin doses, a time where global (LVEF) and regional contractile function was still unchanged, transmission electron microscopy (TEM) showed fragmented mitochondria with remodeled cristae only in control pigs. At the end of the 16 weeks, TEM evaluation in control pigs (as compared to RIPC pigs) showed overt cardiomyocyte's mitochondrial fragmentation with overt structural derangement. At this time, RIPC pigs had significantly less interstitial fibrosis on histology. Conclusions In a translatable large animal model of AIC, RIPC applied immediately before each doxorubicin cycle resulted in a preservation of cardiac contractility with significantly higher long-term LVEF and less cardiac fibrosis. RIPC prevented the deleterious effects of doxorubicin on mitochondria since early stages of AIC. RIPC is a promising intervention to be tested in clinical trials to prevent cardiotoxicity. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): The CNIC is supported by the Instituto de Salud Carlos III (ISCIII), the Ministerio de Ciencia e Innovaciόn and the Pro CNIC Foundation, and is a Severo Ochoa Center of Excellence (SEV-2015-0505)

Aims To evaluate the safety and feasibility of a transradial-access PCI program in CTO and its impact on angiographic and clinical results and in-hospital stay length. Methods Retrospective single-centre cohort-study including 237 consecutive patients undergoing CTO-PCI. From November 2018 onwards, a transradial-access program and all first-attempt CTO-PCI procedures were systematically performed via the radial artery. 47 patients included in the transradial-access CTO-PCI program were compared to a historical cohort of 190 CTO-PCI patients, employing transfemoral access mainly: n=150 (78.9%). Results Mean age was 66.9±11.4 and 199 (83.9%) patients were male, Table 1. Mean J-CTO score (2.5±1.1) was similar in both groups. Successful revascularization was achieved in 208 (87.8%) cases overall, without differences between both cohorts. No differences in periprocedural complications between both groups existed, but in-hospital complications were numerically lower in the transradial cohort (4.3% vs 13.7%, p=0.072). Mean hospital-stay was lower in the transradial-access group (0.89±1.4 vs 2.2±3.2 days, p Conclusion A transradial program for CTO-PCI is safe and effective in most CTO. Adoption of a transradial protocol for CTO-PCI allows same-day hospital discharge in over half of elective procedures and reduces in-hospital stay length. Figure 1. Same-day discharge in both cohorts Funding Acknowledgement Type of funding source: None

Aims Radiofrequency ablation (RFA) of septal accessory pathways (APs) is associated with a significant rate of first procedure failures and complications. Cryoablation is an alternative energy source but there are no studies comparing both ablation techniques. We aimed to systematically review the literature and compare the efficacy and safety of cryoablation vs. RFA of septal APs. Methods and results We conducted two separate meta-analysis of cryoablation and RFA of septal APs and calculated the global estimates of the efficacy and safety. Sixty-four articles were included: 38 articles reporting RFA and 27 articles reporting cryoablation procedures. Additionally, we included the previously non-published cryoablation registry of septal APs performed at our institution. Overall, 4244 septal APs constitute our study population, 3495 in the RFA cohort and 749 in the cryoablation cohort. Acute procedural success rate of cryoablation was 86.0% (95% CI 81.6-89.4%) and RFA 89.0% (95% CI 86.8-91.0%). Recurrence rate of cryoablation was 18.1% (95% CI 14.8-21.8%) and RFA 9.9% (95% CI 8.2-12.0%). Long-term success rate after multiple ablation procedures of cryoablation was 75.9% (95% CI 68.2-82.3%) and RFA 88.4% (95% CI 84.7-91.3%). There were no reported cases of persistent atrioventricular block (AVB) with cryoablation and 2.7% (95% CI 2.2-3.4%) with RFA. Conclusion Studies of RFA for treatment of septal APs report higher efficacy rates than do studies using cryoablation, but a significantly higher rate of AVB.

Extracorporeal membrane oxygenation systems have undergone rapid technological improvements and are now feasible options for medium-term support of severe cardiac or pulmonary failure. We report five cases of electrical storm that was rescued by the insertion of peripheral veno-arterial extracorporeal membrane oxygenation systems. This device could help to restore systemic circulation as well as permitting organ perfusion in patients with cardiogenic shock in relation to electrical storm thus achieving greater electrical stability. Also, in some cases extracorporeal membrane oxygenation support could facilitate electrophysiology study.

Introduction Antitachycardia pacing (ATP) terminates the majority (but not all) of slow VTs (S-VT) with a cycle length (CL) >320 ms. Purpose To analyze the efficacy, safety and predictors of ATP, comparing the first (ATP-1) to the second (ATP-2) and third (ATP-3) attempts. Methods We studied 556 S-VT (CL=354±18 ms; range: 321–415 ms; 1.6% syncopes) occurring in 67 patients. ATP programming was standardized, including three consecutive bursts of 15 pulses at 91% of VT CL. Results ATP effectiveness declined significantly from ATP-1 (436/556: 78%) compared to ATP-2 (24/103: 23%) and ATP-3 (10/79: 13%), p Several predictors of ATP efficacy were found by logistic regression: a) ATP-1: P-RR (OR=7.3; p Patients with a dQRS≥120 ms had a lower adjusted effectiveness of ATP and a higher proportion of S-VT causing syncope. Table. Table 1 Patients with QRS Conclusions The efficacy of ATP in terminating S-VT is mainly due to the ATP-1. The regularization of RR intervals after ineffective ATP-1 underlies the lower efficacy of ATP-2 and ATP-3. Since the dQRS correlated significantly with the PPI-CLd, patients with a dQRS≥120 ms had a lower ATP-1, ATP-2 and ATP-3 effectiveness, leading to a higher incidence of syncope.

Current guidelines recommend sacubitril/valsartan (S/V) for patients (p.) with heart failure and reduced left ventricular ejection fraction (LVEF) but there is lack of evidence of its efficacy and safety in p. with cancer and heart failure. Our aim was to analyze the potential benefit of S/V in specific cardio-oncology clinics. Methods We performed a retrospective multicenter registry (HF-COH) in six Spanish hospitals with cardio-oncology clinics including all p. treated with S/V. Clinical and echocardiographic data, NYHA functional class, type of neoplasms and anti-tumoral treatment were described. Median follow-up was 7.2 [7.9] months. Results Sixty-one p. were included (median age was 64 [21] years old; 64%women, 43% hypertensive, 54% dyslipidemics and 28% diabetics). Most of p. (97%) had cancer therapy related cardiac dysfunction (CTRD) with a median time from anti-cancer therapy to CTRD of 40 [132] months. Breast (46%) and hematological (38%) cancers were the most frequent neoplasms, 31% of p. had metastatic disease and 71% had been treated with anthracyclines. In 5% S/V was initiated at CTRCD diagnosis while in 95% S/V was started to improve clinical status in p. already treated with ACE inhibitors or ARBs. 87% were on beta-blocker therapy and 74% on mineralocorticoid receptor antagonists.Maximal S/V titration dose was achieved in 8.2% of p. (24/26mg: 43%; 49/51mg: 33%) S/V was discontinued in 4 p. (reasons: 2 hypotension; 1: renal failure; 1: pruritus) Baseline NT-proBNP levels, functional class, and LVEF improved at the end of follow-up in p. who continued with S/V (all p values ≤0.01). No statistical differences were found in creatinine clearance or potassium serum levels. Table Patient parameters before and after S/V Before S/V After S/V P value LVEF (%) 33 [7] 39.5 [15] Conclusions Our experience suggests that S/V is well tolerated and improves functional class and left ventricular function parameters in patients with CTRCD.

Background Among ICD patients, the burden of non-sustained ventricular tachycardias (NSVT) occurring during the first 6 months after implant is associated independently with an increase in cardiac death. It is unknown whether there are differences between the incidence of Electrical Storm (ES) and the cause of cardiac mortality (CM) according to the burden of NSVT. Purpose To determine the relationship between the burden of NSVT occurring early after ICD implant and the risk of ES in the long-term among ICD patients with left ventricular dysfunction. Methods In this prospective study, 416 patients (age: 65±11; LVEF: 30±8; ischemic etiology: 62%, primary prevention: 63%) with LVEF 5 beats at ≥150 bpm terminating spontaneously before therapy that occurred within the first six months after ICD implant. Results A total of 31 patients (7.5%) presenting with ES during the follow-up. After classifying the subjects into three groups according to the burden of NSVT (tertiles): no NSVT (N=166, group 1); 1–5 NSVT (n=130, group 2) and >5 NSVT (n=120, group 3), the cumulative incidence of ES was higher in group 3: 2.4% vs. 3.1% vs. 19.2%, with an average of time from implant to ES significantly shorter (mean [95% CI, months]): 97 (94–100) vs. 103 (99–106) vs. 86 (79–93); p5 NSVT (p5 TVNS (HR=4.66; p=0.001) were identified as independent predictors of ES. Cardiac mortality (CM) was independently higher in subjects with >5 NSVT (HR=1.7; p=0.03). The most frequent cause of CM was cardiac failure irrespective of NSVT burden (93% in patients with ≤5 NSVT and 79% in >5 NSVT); however CM due to ES was exclusive of individuals with >5 NSVT: 15% vs. 0% (p Figure 1 Conclusions 1. The burden of NSVT occurring during the first 6 months after an ICD implant is associated independently with a higher risk of ES in the long-term. 2. The adjusted risk of ES is 4-fold higher in individuals with >5 NSVT. 3. The most frequent etiology of CM is heart failure; CM due to ES is exclusive of patients with >5 NSVT causing the 15% of deaths in such population.

This editorial refers to ‘Routine early coronary angioplasty versus ischaemia-guided angioplasty after thrombolysis in acute ST-elevation myocardial infarction: a meta-analysis’, by S. P. D'Souza et al. doi:10.1093/eurheartj/ehq398 Primary coronary intervention (PCI) is the preferred reperfusion therapy in patients with acute ST-elevation myocardial infarction (STEMI). However, many hospitals lack PCI facilities and few provide around-the-clock staffing for these procedures. Therefore, thrombolysis is administered to eligible patients if primary PCI cannot be performed in a timely fashion. Traditionally, the standard approach for a patient who had received thrombolytics and presented signs of reperfusion injury was to assess the risk of future cardiac adverse events before discharge. The two most important parameters used to evaluate short-term and long-term risk following myocardial infarction were left ventricular function and the extent and grade of myocardial ischaemia. Patients with spontaneous or induced severe ischaemia or left ventricular dysfunction were candidates for angiography and revascularization. Outside these circumstances, coronary arteriography was not recommended, as there was no evidence of any benefit to the patient if residual ischaemia or left ventricular dysfunction was not observed. In the late 1980s, before stents and glycoprotein IIb/IIIa inhibitors or thienopyridines began to be used, the results of routine cardiac catheterization and systematized PCI were disappointing.1 However, current interventional practice, which uses stents, thienopyridines, and IIb/IIIa inhibitors, has generated studies that again highlight the role of early routine angioplasty in the management of patients with STEMI receiving thrombolysis. The results of those studies have recently been analysed in two meta-analyses,2,3 one of which has led to this editorial.3 Adjunctive or early elective PCI is used in patients who are initially successfully reperfused with thrombolysis and who undergo early (i.e.

As understanding has grown about what happens when heart muscle cells die en masse after a heart attack, so has the development of treatments aimed at avoiding the loss or failure of cardiovascular function. These treatments include stem cell transplantation. The first pre-clinical and clinical experiences in stem cell transplantation were reported around a decade ago.1,2 However, and although the field has moved quickly in these years, the most important questions—the ‘cell product’ to be used, delivery method, outcome measurement, organizational problems, and funding—remain unanswered. The quest for the best cell type has been wheeled around from bedside to bench and back again.3 The ideal cell type should be capable of differentiating into functional cardiomyocytes and forming new vessels. Cell types from several different sources have already been tested in animal models, and bone marrow-derived cells and skeletal myoblasts have already been used in clinical trials. Each subtype has its advantages and disadvantages, but one important issue is the time needed for their preparation: time-consuming protocols hinder easy implementation in the acute clinical setting and carry a risk of culture contamination and/or genetic modification. Furthermore, whether the beneficial effect is mediated by one specific cell type or many cell types in concert remains unknown. It is obviously of great scientific interest to test all possible combinations of progenitor types, numbers of cells, times of injection after damage, frequencies of injection, mechanisms of action, as well as homing/grafting and survival, all through different routes in animal models and then in man. The report by Bai et al. 4 is significant for different reasons. First, it demonstrates that freshly isolated adipose tissue-derived stem cells (ASCs) transplanted into ischaemic hearts after acute myocardial infarction promote cardiac function as well as do cultured ASCs. Secondly, it indicates that transplanted cells … *Corresponding author. Tel: +34 91 426 5880, Fax: +34 91 586 8276, Email: faviles{at}secardiologia.es

The aim of this study was to determine the mechanisms of atrial fibrillation (AF) in patients with left ventricular systolic dysfunction (LVSD).Dominant frequency (DF) spatiotemporal stability was studied in 15 patients with persistent AF (PEAF) and LVSD (Group I), 15 with PEAF without LVSD (Group II), and 10 with paroxysmal AF (PAAF) without LVSD (Group III). Dominant frequencies were analysed at 536 sites at baseline (DF1) and 26 +/- 12 min later (DF2). A DF1-DF2 difference ofor=0.5 Hz was found in 77, 70, and 48% of sites in Groups I, II, and III (P0.001). Maximal DF1 and DF2 were recorded at the same site in 12/15, 11/15, and 0/10 patients in Groups I, II, and III, respectively (P0.01). Gradient differences: Group I, DFs were higher at left atrium appendage (LAA) than at anterior (A) LA (ALA), pulmonary vein-left atrial junction (PV-LAJ), and posterior (P) LA (PLA) (7.4 +/- 1.1 vs. 6.6 +/- 1 vs. 6.8 +/- 0.8 vs. 6.8 +/- 0.7 Hz, P0.05); Group II, no differences; Group III, DF was higher at PV-LAJ than at LAA, AL, and PLA (6 +/- 1.2 vs. 5.3 +/- 1.1 vs. 5.2 +/- 0.9 vs. 5.4 +/- 1.1 Hz, P0.05).Dominant frequency stability supports stable arrhythmia sources as the mechanism of PEAF with (without) LVSD, but not of PAAF.

Aims In patients with acute myocardial infarction and ST-segment elevation (STEMI), primary angioplasty is frequently not available or performed beyond the recommended time limit. We designed a non-inferiority, randomized, controlled study to evaluate whether lytic-based early routine angioplasty represents a reasonable reperfusion option for victims of STEMI irrespective of geographic or logistical barriers. Methods and results A total of 212 STEMI patients were randomized to full tenecteplase followed by stenting within 3–12 h of randomization (early routine post-fibrinolysis angioplasty; 104 patients), or to undergo primary stenting with abciximab within 3 h of randomization (primary angioplasty; 108 patients). The primary endpoints were epicardial and myocardial reperfusion, and the extent of left ventricular myocardial damage, determined by means of the infarct size and 6-week left ventricular function. The secondary endpoints were the acute incidence of bleeding and the 6-month composite incidence of death, reinfarction, stroke, or revascularization. Early routine post-fibrinolysis angioplasty resulted in higher frequency (21 vs. 6%, P = 0.003) of complete epicardial and myocardial reperfusion (TIMI 3 epicardial flow and TIMI 3 myocardial perfusion and resolution of the initial sum of ST-segment elevation ≥ 70%) following angioplasty. Both groups were similar regarding infarct size (area under the curve of CK-MB: 4613 ± 3373 vs. 4649 ± 3632 µg/L/h, P = 0.94); 6-week left ventricular function (ejection fraction: 59.0 ± 11.6 vs. 56.2 ± 13.2%, P = 0.11; endsystolic volume index: 27.2 ± 12.8 vs. 29.7 ± 13.6, P = 0.21); major bleeding (1.9 vs. 2.8%, P = 0.99) and 6-month cumulative incidence of the clinical endpoint (10 vs. 12%, P = 0.57; relative risk: 0.80; 95% confidence interval: 0.37–1.74). Conclusion Early routine post-fibrinolysis angioplasty safely results in better myocardial perfusion than primary angioplasty. Despite its later application, this approach seems to be equivalent to primary angioplasty in limiting infarct size and preserving left ventricular function.

et al., Different types and routes of stem cell delivery have been used in clinical practice to repair infarcted or ischaemic myocardium. Of these, percutaneous administration of bone-marrow-derived progenitors represents the most optimal method to date, as it allows the evaluation of the cells' effects independent of revascularization and the application of multiple administrations over time. Two different percutaneous catheter-based methods have been used in clinical trials to deliver bone-marrow-derived stem cells: intracoronary infusion and transendomyocardial delivery through a left ventricle catheter. Despite the clinical scenarios investigated (acute myocardial infarction, chronic ischaemia with no revascularization option, and ischaemic cardiomyopathy), in general percutaneous bone-marrow-derived stem cell therapy is feasible, relatively safe (with unresolved concerns regarding arrhythmias, restenosis, and atherosclerosis progresion), and could exert a benefit upon ventricular function and perfusion. At this point, intermediate-size, randomized trials are aimed to well establish the efficacy of this therapy that analyses surrogate endpoints: either perfusion or left ventricular function based on the clinical scenario tested. © The European Society of Cardiology 2006. All rights reserved.

AIM: Experimental animal studies suggest that the use of skeletal myoblast in patients with myocardial infarction may result in improved cardiac function. The aim of the study was to assess the feasibility and safety of this therapy in patients with myocardial infarction. METHODS AND RESULTS: Twelve patients with old myocardial infarction and ischaemic coronary artery disease underwent treatment with coronary artery bypass surgery and intramyocardial injection of autologous skeletal myoblasts obtained from a muscle biopsy of vastus lateralis and cultured with autologous serum for 3 weeks. Global and regional cardiac function was assessed by 2D and ABD echocardiogram. 18F-FDG and 13N-ammonia PET studies were used to determine perfusion and viability. Left ventricular ejection fraction (LVEF) improved from 35.5+/-2.3% before surgery to 53.5+/-4.98% at 3 months (P=0.002). Echocardiography revealed a marked improvement in regional contractility in those cardiac segments treated with skeletal myoblast (wall motion score index 2.64+/-0.13 at baseline vs 1.64+/-0.16 at 3 months P=0.0001). Quantitative 18F-FDG PET studies showed a significant (P=0.012) increased in cardiac viability in the infarct zone 3 months after surgery. No statistically significant differences were found in 13N-ammonia PET studies. Skeletal myoblast implant was not associated with an increase in adverse events. No cardiac arrhythmias were detected during early follow-up. CONCLUSIONS: In patients with old myocardial infarction, treatment with skeletal myoblast in conjunction with coronary artery bypass is safe and feasible and is associated with an increased global and regional left ventricular function,improvement in the viability of cardiac tissue in the infarct area and no induction of arrhythmias.

Introduction: The role of tissue remodeling in the reentrant activity during atrial fibrillation (AF) is not well understood. The aim of this study is to evaluate in an in-vitro model of AF the role of tissue remodeling in the mechanisms of perpetuation of this arrhythmia. Methods: HL-1 cultures were obtained for early stage (6.1 ± 1.3 days in culture, N=10) and late stage (11.7 ± 0.5 days in culture, N=8) AF. Bright field images together with optical calcium mapping (Rhod-2AM staining) were obtained for evaluating remodeling and electrophysiological characteristics of cell cultures. Results: The number of singularity points per square centimeter at baseline was significantly higher in the late stage group (i.e. 0.43±0.19 vs. 1.12±0.14 PS/cm2, p

We describe the appearance of delayed episodes of ventricular arrhythmias in 4 patients out of 72 undergoing intracoronary transplantation of autologous bone marrow mononuclear cells (BMMC) following ST elevated myocardial infarction (STEMI). Two cases with severely depressed systolic function presented electrical storms with monomorphic sustained ventricular tachycardia (SVT) within 2 to 3 days following cell transplantation, even though there were no periprocedural complications. Both patients were implanted with an internal defibrillator (ICD) after ruling out coronary re-occlusion. The remaining 2 patients presented several asymptomatic episodes of non-sustained ventricular tachycardia within one month following cell transfer. Only one of the latter presented syncopal SVT through programmed ventricular stimulation, undergoing ICD implantation afterwards. Neither new arrhythmic episodes nor ICD interventions have occurred during later follow-up of the three ICD patients (639+/-59 days). Information from large multicenter databases and our historical cohort of STEMI patients indicates that the rate of VT occurring within the first weeks after the initial 48 hours of infarction is significantly lower than that observed in our cell-therapy experience. The lack of information regarding the appearance of malignant arrhythmias in patients with severe systolic dysfunction following this type of therapy after STEMI requires us to be extremely cautious. However, any claim of a mechanism related to cell transfer would be completely speculative with the available data. Therefore, our only aim when reporting our findings is to recommend a short but longer stay (2-3 days) following cell transplantation, particularly in patients with a natural tendency to develop arrhythmic events.

‘Structural heart disease’, as defined in this supplement, refers to a diverse group of anatomic and pathological conditions involving the myocardium, pericardium, valvular, and great vascular structures, either acquired or congenital. Therefore, a diverse and heterogeneous group of non-coronary diseases where new minimally invasive imaging tools or devices are on the foreground to diagnose and treat patients. The …

We thank Dr Villata et al. for their thought-provoking comments. Their concern about the suitableness to choose combined endpoints in clinical trials deserves some comment. First of all, if the main advantage of randomized trials, as the GRACIA-2, is that the randomization procedure helps prevent selection bias, we would agree to …