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Background: Intracardiac echocardiography (ICE) is increasingly employed in atrial fibrillation (AF) ablation procedures, with the potential to enhance procedural efficacy. Nevertheless, there is currently a lack of evidence assessing the impact of ICE on the efficiency, effectiveness, and safety outcomes in the context of novel pulsed-field ablation (PFA) for AF., Purpose: We aimed to assess whether the use of ICE could improve procedural parameters in a large population undergoing AF ablation with FARAPULSE™ catheter., Methods: Consecutive patients who had undergone PFA of AF from nine Italian centers were included. In procedures where the ICE catheter was employed for guidance (ICE-guided group), it was used to maneuver the PFA catheter within the left atrium to achieve optimal contact with atrial structures., Results: We analyzed 556 patients: 357 (66%) with paroxysmal AF, 499 (89.7%) de novo PVI. ICE-guided procedures (n = 138) were propensity matched with patients with a standard approach (n = 138), and their outcomes were compared. During ICE-guided procedures, no improvement in procedural metrics was recorded (ICE vs Standard, 23 ± 6 min vs 18.5 ± 9 min for time to PVI, p < 0.0001; 38.8 ± 7 vs 32.5 ± 5 number of PFA deliveries to achieve PVI, p < 0.0001; 68.8 ± 19 min vs 71.8 ± 29 min for primary operator time, p = 0.5301; 16.1 ± 8 min vs 18.2 ± 10 min for fluoroscopy time, p = 0.5476) except for support time (76.8 ± 26 min vs 91.4 ± 37 min, p = 0.0046). No major procedure-related adverse events were reported., Conclusion: Our findings confirmed that PFA could be consistently performed in a rapid, safe, and efficacious manner. The use of ICE to guide PFA was not associated with an improvement in procedural metrics., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Several novel technologies allowing catheter ablation (CA) with a favorable safety/efficacy profile have been recently developed, but not yet extensively clinically tested in the setting of ventricular tachycardia CA., Methods: In this technical report, we overview technical aspects and preclinical/clinical information concerning the application of three novel CA technologies in the ventricular milieu: a pulsed field ablation (PFA) generator (CENTAURI™, Galaxy Medical) to be used with linear, contact force-sensing radiofrequency ablation catheters; a contact force-sensing radiofrequency ablation catheter equipped with six thermocouples and three microelectrodes (QDOT Micro™, Biosense-Webster), allowing high-resolution mapping and temperature-controlled CA; and a flexible and mesh-shaped irrigation tip, contact force-sensing radiofrequency ablation catheter (Tactiflex, Abbott). We also report three challenging VT cases in which CA was performed using these technologies., Results: The CENTAURI system was used with the Tacticath™ (Abbott) ablation catheter to perform ventricular PFA in a patient with advanced heart failure, electrical storm, and a deep intramural septal substrate. Microelectrode mapping using QDOT Micro™ helped to refine substrate assessment in a VT patient with congenitally corrected transposition of the great arteries, and allowed the identification of the critical components of the VT circuit, which were successfully ablated. Tactiflex™ was used in two challenging CA cases (one endocardial and one epicardial), allowing acute and mid-term control of VT episodes without adverse events., Conclusion: The ideation and development of novel technologies initially intended to treat atrial arrhythmias and successfully implemented in the ventricular milieu is contributing to the progressive improvement in the clinical benefits derived from VT CA, making this procedure key for successful management of increasingly complex patients., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: A novel method to measure atrial fibrillation cycle length (AF-CL) was recently described, based on the average of 10 consecutive signals (FARS10). FARS10 accurately identified pulmonary vein isolation (PVI)-responders among patients with persistent AF. Whether this method is applicable to patients with paroxysmal AF is unknown., Objective: The aim of this study is to evaluate the prognostic value of FARS10 measurements in patients with paroxysmal AF., Methods and Results: We enrolled paroxysmal AF patients undergoing PVI in a prospective multicenter study. After AF induction with a standardized protocol, the AF-CL was measured using FARS-10 method. The primary endpoint was AF/AT-recurrence. One-hundred and four patients were included (61 ± 14 years, 25% females). After a mean follow-up of 12 ± 4 months, AF/AT recurrence rate was 20%. The fastest PV CL (fPV-CL) was independently associated with the primary endpoint at multivariate analysis (HR 1.02, p < 0.001). Every 10 ms increase in fPV-CL, AF recurrences increased by 20%. The value of 160 ms was found to be the optimal cut-off (specificity 81%, sensitivity 76%). Patients with fPV-CL < 160 ms experienced lower AF recurrences as compared to patients with fPV-CL > 160 ms (8% vs. 32% at 1 year; HR = 0.17, p < 0.001). Progression to persistent AF was observed in 13% of patients with fPV-CL > 160 ms., Conclusion: fPV-CL measured with the FARS-10 method accurately predicts PVI success in paroxysmal AF patients undergoing PVI. Patients with slow PV activity (fPV-CL > 160 ms) experience higher AF recurrence rate after PVI and more frequent progression to persistent AF., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Recent data on pulsed field ablation (PFA) for atrial fibrillation (AF) ablation suggest a progressive reduction in procedural times. Real-world data regarding the relationship between the learning curve of PFA and clinical outcomes are scarce. The objective was to evaluate the PFA learning curve and its impact on acute outcomes., Methods: Consecutive patients undergoing AF ablation with the FARAPULSE™ PFA system were included in a prospective, non-randomized multicenter study. Procedural times were stratified on the operators' learning curve. Comparative analysis of skin-to-skin time was conducted with radiofrequency (RF) and cryoablation (CB) pulmonary vein isolation (PVI) procedures performed by the same operators in the previous year., Results: Among 752 patients, 35.1% were females, and 66.9% had paroxysmal AF; mean age was 62.2 ± 10 years. A total of 62.5% of procedures were performed by operators with > 20 PFA procedures. Both time to PVI (25.6 ± 10 min vs 16.5 ± 8, p < 0.0001) and fluoroscopy time (19.8 ± 8 min vs 15.9 ± 8 min, p = 0.0045) significantly improved after 10 associated with consistent linear trend towards procedural time reduction (R 2 0.92-0.68 across various procedural metrics). Current PFA skin-to-skin time was lower than the historical skin-to-skin one in 217 (62.4%) procedures; it was similar in 112 (32.2%) cases and higher than the historical skin-to-skin one in 19 (5.5%). No major complications were reported., Conclusions: In this nationwide multicentric experience, the novel PFA system proved to be fast, safe, and acutely effective in both paroxysmal and persistent AF patients. The learning curve appears to be rapid, as improvements in procedural parameters were observed after only a few procedures., Clinical Trial Registration: Advanced TecHnologies For SuccEssful AblatioN of AF in Clinical Practice (ATHENA). URL: http://clinicaltrials.gov/ Identifier: NCT05617456., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The clinical performance of high-power, short-duration (HPSD) pulmonary vein isolation (PVI) with the novel flexible tip TactiFlex™ (TFSE) catheter, as compared to standard-power, long-duration (SPLD) PVI using the TactiCath™ (TCSE) catheter among patients undergoing catheter ablation (CA) of atrial fibrillation (AF) is currently unknown., Methods: We conducted a prospective, observational, single-centre study including 40 consecutive patients undergoing PVI for paroxysmal/persistent AF, using HPSD ablation with the novel TFSE catheter (HPSD/TFSE group). Based on propensity score-matching, forty patients undergoing SPLD PVI with the TCSE catheter were identified (SPLD/TCSE group). In the HPSD/TFSE group, RF lesions were performed by delivering 40-50 W for 10-20 s, while in the SPLD/TCSE group, RF power was 30-35 W, targeting a lesion size index (LSI) of 4.0-5.5. The co-primary study outcomes were time required to complete PVI and first pass isolation (FPI)., Results: PVI was achieved in 100% of patients in both groups, and no major adverse events were observed. Remarkably, PVI time was shorter in the HPSD/TFSE, compared to the SPLD/TCSE group(9 [7-9] min vs. 50 [37-54] min; p < 0.001), while FPI rate was non-significantly higher in the former group(91% [146/160] vs 83% [134/160]; p = 0.063). Shorter procedural (108 [91-120] min vs. 173 [139-187] min, p < 0.001), total RF (9 [7-11] min vs. 43 [32-53] min, p < 0.001), fluoroscopy times(15 [10-19] min vs. 18 [13-26] min, p = 0.014), and lower DAP (1461 [860-2181] vs. 7200 [3400-20,800], p < 0.001) were recorded in the HPSD/TFSE group. A higher average impedance drop was obtained with HPSD/TFSE CA(17[17-18]Ω vs. 16 [15-17] Ω, p < 0.001)., Conclusions: In our initial clinical experience, HPSD PVI with the TFSE catheter proved faster than SPLD PVI with the TCSE catheter, at least equally effective in terms of FPI, and it was associated with greater impedance drop., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Adoption and outcomes for conduction system pacing (CSP), which includes His bundle pacing (HBP) or left bundle branch area pacing (LBBAP), in real-world settings are incompletely understood. We sought to describe real-world adoption of CSP lead implantation and subsequent outcomes., Methods: We performed an online cross-sectional survey on the implantation and outcomes associated with CSP, between November 15, 2020, and February 15, 2021. We described survey responses and reported HBP and LBBAP outcomes for bradycardia pacing and cardiac resynchronization CRT indications, separately., Results: The analysis cohort included 140 institutions, located on 5 continents, who contributed data to the worldwide survey on CSP. Of these, 127 institutions (90.7%) reported experience implanting CSP leads. CSP and overall device implantation volumes were reported by 84 institutions. In 2019, the median proportion of device implants with CSP, HBP, and/or LBBAP leads attempted were 4.4% (interquartile range [IQR], 1.9-12.5%; range, 0.4-100%), 3.3% (IQR, 1.3-7.1%; range, 0.2-87.0%), and 2.5% (IQR, 0.5-24.0%; range, 0.1-55.6%), respectively. For bradycardia pacing indications, HBP leads, as compared to LBBAP leads, had higher reported implant threshold (median [IQR]: 1.5 V [1.3-2.0 V] vs 0.8 V [0.6-1.0 V], p = 0.0008) and lower ventricular sensing (median [IQR]: 4.0 mV [3.0-5.0 mV] vs. 10.0 mV [7.0-12.0 mV], p < 0.0001)., Conclusion: In conclusion, CSP lead implantation has been broadly adopted but has yet to become the default approach at most surveyed institutions. As the indications and data for CSP continue to evolve, strategies to educate and promote CSP lead implantation at institutions without CSP lead implantation experience would be necessary., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: The difficulty of laparoscopic right liver resections (LRLR) is mainly associated with their poor accessibility. Anthropometric data rather than BMI was reported to predict transection time and blood loss. Aim of the study was to evaluate the correlation between anthropometric data and preparatory manoeuvres difficulties during LRLR., Methods: All patients who underwent LRLR requiring full right liver mobilization from November 2019 to March 2021 were prospectively included in the study. Data on surgeons' difficulty perceptions on liver mobilization (LM), isolation of right hepatic vein (RHVI), liver manageability and visibility were rated with a 5-point scale. Data on cranio-caudal liver diameters (CCliv), CHALLENGE Index (CCliv/latero-lateral abdomen diameter), times needed to LM and RHVI were collected., Results: Sixty-five patients (29 wedge and 36 anatomical resections) with a median BMI of 25.5 were analysed. One patient required open conversion due to oncological reason. No correlations between BMI and CCliv or CHALLENGE Index were found. Larger CCliv diameter correlated with longer time for both RHVI (r = 0.589, p = 0.002) and LM (r = 0.222, p = 0.049). Higher CHALLENGE index correlated with longer time for RHVI (r = 0.589, p = 0.002). The CHALLENGE index showed a linear correlation with difficulty to the isolation of RHV (r = 0.327, p = 0.045), whilst the liver manipulation difficulty increased with latero-lateral liver diameter (r = 0.244, p = 0.033). BMI had no correlation with the duration of preparatory maneuvers neither with surgeons' difficulties., Conclusions: Anthropometric data can help to anticipate the difficulty of preparatory maneuvers during laparoscopic right liver resections., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Cardiac magnetic resonance (CMR) findings suggesting a suspected left-dominant arrhythmogenic cardiomyopathy (LDAC) may be difficult to distinguish from those related to previous myocarditis; however, especially in patients with ventricular arrhythmias (VA) with ECG morphology consistent with a left ventricle (LV) origin differential diagnosis is fundamental. Aim of the study was to identify potential imaging features at CMR specific for LDAC diagnosis. Between January 2011 and December 2019, we enrolled 15 consecutive stable patients with a recent diagnosis of significant VA and ECG morphology consistent with a LV origin, detection of potential LV arrhythmic substrate at CMR and undergoing a clinically-indicated LV endomyocardial biopsy showing tissue abnormalities consistent with the diagnosis of LDAC. From the same CMR-endomyocardial biopsy registry, a second group of 30 consecutive patients who underwent CMR and biopsy with a histological diagnosis of previous myocarditis were identified. (1) Subepicardial LGE at the level of the posterolateral wall of the LV was detected in 13 cases of LDAC vs. 21 cases of myocarditis; (2) fat infiltration, and particularly subepicardial posterolateral fat infiltration, was found in almost all LDAC patients vs. one myocarditis only (p < 0.01). (3) No differences in other CMR findings or in any clinical or echocardiographic parameters were found between patients with a biopsy consistent with LDAC vs. myocarditis. In patients with significant VA and ECG morphology consistent with a LV origin, the presence of morpho-functional involvement of the subepicardial layer of LV posterolateral wall at CMR (LGE, fat infiltration, wall dyskinesis) supports LDAC diagnosis., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: Catheter ablation (CA) procedures are characterized by exposure to ionizing radiations (IR). IR can cause DNA damage and may lead to carcinogenesis if not efficiently repaired. The primary endpoint of this study is to investigate whether intravenous administration of N-acetylcysteine prior to CA procedure may prevent systemic oxidative stress and genomic DNA damage induced by exposure to IR., Methods: The "Cardiac Arrhythmia catheter ablation procedures guided by x-Ray imaging: N-Acetylcysteine Protection Against radiation induced Cellular damagE" (CARAPACE) study is a prospective, randomized, single-blinded, parallel-arm monocenter study enrolling 550 consecutive patients undergoing CA at the Arrhythmology Unit of Centro Cardiologico Monzino (CCM). Inclusion criteria are age ≥ 18, indication for CA procedure guided by IR imaging, and written informed consent. IR levels will be measured via fluoroscopy time, effective dose, and dose area product. Glutathione and glutathione disulfide concentrations will be measured, and urinary levels of 8-iso-prostaglandin-F 2α and 8-hydroxy-2-deoxyguanosine will be quantified. The enrolled patients will be randomized 1:1 to the N-acetylcysteine group or to the control group., Results: We expect that pre-operative administration of N-acetylcysteine will prevent IR-induced systemic oxidative stress. The study will provide data on oxidative DNA damage assessed by urinary 8-hydroxy-2-deoxyguanosine levels and direct evidence of genomic DNA damage in blood cells by comet assay., Conclusion: Catheter ablation procedures can lead to IR exposure and subsequent DNA damage. N-acetylcysteine administration prior to the procedure may prevent them and therefore lead to less possible complications., Trial Registration: www.clinicaltrials.gov (NCT04154982)., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The high technical difficulty of using a laparoscopic approach to reach the posterosuperior liver segments is mainly associated with their poor accessibility. This study was performed to analyze correlations between anthropometric data and intraoperative outcomes., Study Design: All patients who underwent segmentectomy or wedge laparoscopic liver resection (LLR) of segments seven and/or eight from June 2012 to November 2019 were retrospectively analyzed. The exclusion criteria were intrahepatic cholangiocarcinoma, associated resection, multiple concomitant LLR, redo resection, and lack of preoperative imaging. Anthropometric data were correlated with intraoperative outcomes., Results: Forty-one patients (wedge resection, n = 32; segmentectomy, n = 9) were analyzed. A strong correlation was found between the craniocaudal liver diameter (CCliv) and liver volume (r = 0.655, p < 0.001). The anteroposterior liver diameter was moderately correlated with both the laterolateral abdominal diameter (LLabd) (r = 0.372, p = 0.008) and anteroposterior abdominal diameter (r = 0.371, p = 0.008). The body mass index (BMI) was not correlated with liver diameters. Women had a longer CCliv (p = 0.002) and shorter LLabd (p < 0.001) than men. The liver and abdominal measurements were combined to reduce this sex-related disparity. The CCliv/LLabd ratio (CHALLENGE index) was significantly correlated with the time of transection (r = 0.382, p = 0.037) and blood loss (r = 0.352, p = 0.029). The association between the CHALLENGE index and intraoperative blood loss was even stronger when considering only anatomical resection (r = 0.577, p = 0.048). A CHALLENGE index of > 0.4 (area under the curve, 0.757; p = 0.046) indicated a higher bleeding risk. The BMI predicted no intraoperative outcomes., Conclusion: Anthropometric data rather than the BMI can help anticipate the difficulty of LLR of segments seven and eight., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Intraoperative liver ultrasound appears superior to liver-specific contrast-enhanced magnetic resonance imaging (MRI) to stage colorectal liver metastases (CRLMs). Most of the data come from studies on open surgery. Laparoscopic ultrasound (LUS) is technically demanding and its reliability is poor investigated. Aim of the study was to assess the accuracy of LUS staging for CRLMs compared to MRI., Methods: All patients with CRLMs scheduled for laparoscopic liver resection (LLR) between 01/2010 and 06/2019 who underwent preoperative MRI were considered for the study. LUS and MRI performance was compared on a patient by patient basis. Reference standards were final pathology and 6 months follow-up results., Results: Amongst 189 LLR for CRLMs, 146 met inclusion criteria. Overall, 391 CRLMs were preoperatively detected by MRI. 24 new nodules in 16 (10.9%) patients were found by LUS and resected. Median diameter of new nodules was 5.5 mm (2-10 mm) and 10 (41.6%) were located in the hepatic dome. Pathology confirmed 17 newly detected malignant nodules (median size 4 mm) in 11 (7.5%) patients. Relationships between intrahepatic vessels and tumours differed between LUS and MRI in 9 patients (6.1%). Intraoperative surgical strategy changed according LUS findings in 19 (13%) patients, requiring conversion to open approach in 3 (15.8%) of them. The sensitivity of LUS was superior to MRI (93.1% vs 85.6% whilst specificity was similar (98.6% MRI vs 96.5% LUS)., Conclusions: Laparoscopic liver ultrasound improves liver staging for CRLMs compared to liver-specific MRI.

Purpose: To provide a brief overview of some relevant technological advances in the field of three-dimensional electroanatomical mapping (3D-EAM) that have recently entered the clinical arena and their role in guiding catheter ablation (CA) of complex atrial and ventricular arrhythmias., Methods: In this technical report, we describe the general features of three novel algorithms featured in the updated CARTO PRIME™ mapping module for CARTO®3 version 7 3D-EAM system (Biosense Webster Inc., Diamond Bar, CA, USA): local activation time (LAT) hybrid, coherent mapping and map replay modules. We also report three challenging arrhythmia cases in which CA was successfully guided by these softwares., Results: The LAT hybrid module was used in a case of premature ventricular complex originating from the right coronary cusp. This algorithm facilitated safe positioning of the ablation catheter away from the right coronary ostium, avoiding potential harm to this vital structure. The coherent mapping module helped to identify the critical as well as a bystander isthmus of an atrial macro-re-entrant tachycardia in a grown-up patient with congenital heart disease. The map replay module allowed rapid retrospective activation mapping of two unstable ventricular tachycardias in a case of nonischemic cocaine-associated cardiomyopathy., Conclusion: 3D-EAM systems offer significant advantages in the management of challenging arrhythmias, and the introduction of novel algorithms underpins improvements in patients' outcomes. Given the increasing sophistication of these systems, however, a close collaboration among cardiac electrophysiologists, engineers and technicians is highly needed in order to get the best from the available technology.

Purpose: Since the introduction of catheter ablation as a mainstream treatment for atrial fibrillation (AF), several technical improvements have been put forward. In this contest, Ablation Index (AI) is an accurate ablation quality marker by incorporating power, delivery time, contact force (CF), and catheter stability in a weighted formula. The aim of our study is to evaluate the efficacy of AI-guided AF ablation over 24 month follow-up., Methods: We evaluated 72 consecutive patients with drug-refractory paroxysmal (66.7%) and early-persistent AF (33.3%) undergoing AI-guided ablation, compared to 72 propensity-matched control patients who underwent CF-guided procedure. All procedures were performed by three skilled operators. Data concerning procedural characteristics and long-term freedom from AF recurrence were analyzed., Results: At 24-month follow-up, Kaplan-Meier curves of AF recurrence were significantly lower in AI group than in CF group (15.5% vs. 30.6%; p 0.042). These findings were confirmed in a sub analysis regardless of the continued use of antiarrhythmic drugs in the follow-up (42.2% in AI-guided group and 66.7% in CF-guided group, p 0.004). At 24-month follow-up, a positive trend in the decrease of arrhythmia recurrences was observed in AI-guided ablation for all operators., Conclusions: AI-guided ablation results more effective than CF-guided ablation as demonstrated by a lower incidence of AF recurrences regardless of the use of antiarrhythmic drugs in the follow-up. Each operator seems to improve the long-term success using an AI-guided ablation, thus showing both the efficacy and the reproducibility of this approach.

Purpose: Previous studies indicate force time integral (FTI) as a radiofrequency (RF) lesion quality marker, while not considering power supply. Tacticath™ Quartz catheter provides Lesion index (LSI), a lesion quality marker derived by contact force (CF), power supply, and RF time combined. Our aim is to assess LSI and FTI correlation and a LSI-related cutoff of atrial fibrillation (AF) recurrences 12 months after pulmonary vein isolation (PVI)., Methods: We retrospectively enrolled 37 patients who underwent RF ablation using Tacticath™ Quartz catheter. AF recurrence rate was evaluated 3, 6, and 12 months after PVI procedure., Results: AF recurrence was detected in 32% of patients. FTI mean value was significantly lower in left superior pulmonary vein (LSPV: 256 ± 86 gs vs 329 ± 117 gs, p = 0.05) and right inferior pulmonary vein (RIPV: 253 ± 128 gs vs 394 ± 123 gs p = 0.006) in patients with AF recurrences; no significant differences were found in right superior pulmonary vein (RSPV) and left inferior pulmonary vein (LIPV). LSI instead was significantly higher for all veins in patients without AF recurrences: LSPV (5.2 ± 0.7 vs 4.6 ± 0.8, p = 0.03), LIPV (5.0 ± 0.8 vs 4.5 ± 0.6, p = 0.04), RSPV (5.5 ± 0.6 vs 5.1 ± 0.6, p = 0.05), and RIPV (5.5 ± 0.7 vs 4.7 ± 0.8, p = 0.006). Receiver operator characteristic curve suggests 5.3 as LSI overall cutoff value predicting freedom from disease at 1-year follow-up., Conclusions: Our preliminary data suggest that a LSI mean value higher than 5.3 can be considered a good predictor of AF freedom at 1-year follow-up.

Arrhythmogenic cardiomyopathy (ACM) is a genetic cardiac condition characterized by the replacement of the ventricular myocardium with fibro-fatty tissue, by arrhythmias and sudden death. Adipogenesis in ACM is considered an aberrant remodeling following myocardial loss. Which cell type(s) is (are) responsible for the adipose replacement is still matter of debate. A systematic overview of the different cells that have been, over time, considered as main players in adipose replacement is provided. The comprehension of the cellular component giving rise to arrhythmogenic cardiomyopathy substrate defects may represent both an essential tool for mechanistic studies of disease pathogenesis and a novel possible therapeutic target.

Purpose: In the present study, we aimed to test the value of CAAP-AF score for prediction of atrial fibrillation (AF) recurrence at follow-up in a group of our patients treated by balloon cryoablation., Methods: A total of 283 symptomatic drug-refractory AF patients [261 (92%) with paroxysmal AF] who underwent pulmonary vein isolation (PVI) with second-generation cryoballoon between April 2012 and October 2016 were included. The CAAP-AF score was calculated for every patient., Results: A total of 283 patients [68 female (20%), mean age 59.8 ± 11.4 years] were included in the present analysis. Eighty-nine patients (31%) had hypertension and 13 (4%) had coronary artery disease. The mean left atrial diameter and left ventricular ejection fraction were 40.6 ± 7.0 mm and 60.0 ± 9.1%, respectively. The mean CHA 2 DS 2 -VASc score was 1.2 ± 1.1, and mean number of prior failed antiarrhythmic drugs was 1.4 ± 0.8. At 18 ± 6 months follow-up, 25 patients (8.87%) developed AF recurrence. The recurrence rate was as follows: 3.17% (score 0-3), 8.47% (score 4), 16.28% (score 5), 6.67% (score 6), 23.08% (score 7), and 36.36% (score ≥8). The recurrence rate was 4.86% at a score <5 and 16.49% at a value ≥5; a score cutoff ≥5 predicted AF recurrence with a sensitivity 64% and specificity 68%., Conclusions: The present analysis suggests the usefulness of CAAP-AF scoring system, with its simple and easily obtained six clinical variables, to predict AF recurrence after PVI by means of second-generation cryoballoon. A score value ≥5 predicted AF recurrence with a sensitivity 64% and specificity 68%.

Purpose: Contact with cardiac tissue is an important determinant of lesion efficacy during atrial fibrillation (AF) ablation. The Sensei X™ robotic navigation system (RNS) (Hansen Medical, Mountain View, CA, USA) has been validated for contact force (CF) sensing expressed in grams (g). The Thermocool® SmartTouch™ catheter enables the measurement of catheter tip CF and direction inside the heart. We aimed to investigate the catheter CF with and without RNS during pulmonary vein isolation (PVI) procedures., Methods: Eighty patients with symptomatic AF (56 males, age 63 ± 18) were enrolled in this study. Fifty-seven patients had paroxysmal AF and 23 early persistent AF. All procedures were performed with the Thermocool® SmartTouch™ ablation catheter. Forty patients were randomized to perform PVI with the Sensei X™ RNS (group 1), while in the other 40 patients (group 2), PVI was performed without the RNS., Results: AF ablation was performed successfully in all patients without complications, while contact force was kept in the established 10-40 g range. A significantly higher CF was documented on the PVs in group 1 compared to group 2. The 1-year freedom from AF recurrence was higher in group 1 compared to group 2 (90 vs. 65 %, p = 0.04). Moreover, a significant reduction of fluoroscopy time was noted in the RNS group (13 ± 10 vs. 20 ± 10 min, respectively, p = 0.05)., Conclusions: The Sensei X™ RNS permits a significantly higher CF during transcatheter AF ablation with a low rate of AF recurrence at clinical follow-up.

Background: Previous studies reported the usefulness of an irrigated circular radiofrequency ablation catheter (nMARQ(TM), Biosense Webster) for pulmonary vein isolation (PVI). We evaluated the role of intracardiac echocardiography (ICE) to optimize the manipulation of nMARQ(TM) catheter., Methods: Thirty-seven patients (pts), (mean age 55 ± 12 years; 28 males) were enrolled to perform PVI. All pts underwent PVI with the nMARQ(TM) catheter. In 20 pts (group 1), we utilized ICE to guide nMARQ(TM) catheter positioning at the PV ostia; in the other 17 pts (group 2), nMARQ(TM) catheter was positioned at the PV ostia guided by fluoroscopy and TissueConnect(TM) technology., Results: Radiofrequency (RF) applications were significantly lower in group 1 compared to group 2 [left PVs: 6 (range 3 to 12) in group 1 and 12 (range 5 to 16) in group 2 (p < 0.001); right PVs: 7 (range 4 to 14) in group 1 and 10 (range 5 to 16) in group 2 (p = 0.04)]; similarly regarding the time of RF delivery [left PVs: 318 ± 194 s in group 1 vs. 542 ± 104 s in group 2 (p < 0.001); right PVs: 410 ± 270 s in group 1 vs. 550 ± 156 s in group 2 (p = 0.05)]. Fluoroscopy time (23 ± 9 min vs. 28 ± 5 min; p = 0.05), procedural time (83 ± 23 min vs. 160 ± 42 min; p < 0.001), and radiation dose (109 ± 20 Gy/cm(2) vs. 127 ± 29 Gy/cm(2); p = 0.04) were significantly lower in group 1 compared to group 2., Conclusion: ICE might be a useful tool to guide nMARQ(TM) catheter position in the left atrium during atrial fibrillation (AF) ablation procedures.

Purpose: Contact with cardiac tissue is a determinant of lesion efficacy during atrial fibrillation (AF) ablation. The Sensei®X Robotic Catheter System (Hansen Medical, CA) has been validated for contact force sensing. The electrical coupling index (ECI) from the EnSite Contact™ system (St. Jude Medical, MN) has been validated as an indicator of tissue contact. We aimed at analyzing ECI behavior during radiofrequency (RF) pulses maintaining a stable contact through the robotic navigation contact system., Methods: In 15 patients (age, 59 ± 12) undergoing AF ablation, pulmonary vein (PV) isolation was guided by the Sensei®X System, employing the Contact™ catheter., Results: During the procedure, we assessed ECI changes associated with adequate contact based on the IntelliSense® force-sensing technology (Hansen Medical, CA. Baseline contact (27 ± 8 g/cm(2)) ECI value was 99 ± 13, whereas ECI values in a noncontact site (0 g/cm(2)) and in a light contact site (1-10 g/cm(2)) were respectively 66 ± 12 and 77 ± 10 (p < 0.0001). Baseline contact ECI values were not different depending on AF presentation (paroxysmal AF, 98 ± 9; persistent AF, 100 ± 9) or on cardiac rhythm (sinus rhythm, 97 ± 7; AF,101 ± 10). In all PVs, ECI was significantly reduced during and after ablation (ECI during RF, 56 ± 15; ECI after RF, 72 ± 16; p < 0.001). A mean reduction of 32.2% during RF delivery and 25.4% immediately after RF discontinuation compared with baseline ECI was observed., Conclusions: Successful PV isolation is associated with a significant decrease in ECI of at least 20 %. This may be used as a surrogate marker of effective lesion in AF ablation.

Purpose: Cardiac resynchronization therapy (CRT) reduces symptoms and improves survival in patients with advanced heart failure (New York Heart Association (NYHA) functional class III-IV), reduced ejection fraction, and wide QRS complex. Whether CRT has the same benefit also in asymptomatic or mildly symptomatic heart failure patients is controversial. Our objective is to summarize the available evidence on the effects of CRT in asymptomatic or mildly symptomatic (NYHA I-II) heart failure patients., Methods: We searched major web databases for randomized controlled trials of CRT in patients with mild heart failure (NYHA functional class I-II). Data regarding all-cause mortality, heart failure events, left ventricular (LV) volumes and ejection fraction, and worsening of NYHA functional class were extracted., Results: We identified five trials (CONTAK-CD, MIRACLE ICD-II, REVERSE, MADIT-CRT, and RAFT) that enrolled 4,213 patients (91% with NYHA II functional class). Primary analysis excluded the CONTAK-CD, which was not specifically conducted on patients with mild heart failure. At pooled analysis, CRT decreased mortality (odds ratio (OR), 0.78 [95% confidence interval (CI)], 0.63 to 0.97; p = 0.024) and heart failure events (OR, 0.63 [95% CI, 0.52 to 0.76], p < 0.001), induced a significant LV reverse remodeling (weighted mean difference (WMD) of LV ejection fraction [Formula: see text], p = 0.015 and WMD of LV end-systolic volume index [Formula: see text], p < 0.001) and prevented the progression of heart failure symptoms (OR for worsening of NYHA functional class = 0.54 [95% CI, 0.31 to 0.93], p = 0.026). Inclusion of the CONTAK-CD did not change the results., Conclusions: Among patients with mild (NYHA II) heart failure, CRT reduces mortality and the risk of heart failure events, induces a favorable LV reverse remodeling and slows the progression of heart failure symptoms.

Purpose: Radiofrequency catheter ablation (RFCA) of supraventricular tachyarrhythmias carries a small but non-negligible radiation risk. Studies in children already showed the feasibility of using three-dimensional mapping systems as the primary guide for catheter visualization and positioning in these RFCAs. We aim to demonstrate the feasibility and safety of such an approach in young and middle-aged patients., Methods: Fifty patients (age 34 ± 12) with supraventricular tachyarrhythmias underwent electrophysiological study; of these, 47 patients proceeded to RFCA guided by the EnSite NavX(TM) system (23 with atrioventricular nodal reentry tachycardia, 16 with an accessory pathway, six with typical atrial flutter, and two with right atrial tachycardia)., Results: In 38/50 cases (76%), electroanatomical mapping avoided fluoroscopy entirely, including four cases requiring access to the left heart chambers by a retrograde approach. In the remaining 12/50 cases (24%), fluoroscopy use was limited to 122 ± 80 s, with a correspondingly low radiation exposure (dose area product 1.3 ± 1.1 mGy × m(2)). All procedures were acutely successful, with a procedural time of 113 ± 37 minutes, and without incurring in any major complication. Over a mean follow-up of 12 ± 3 months, we observed one recurrence of pre-excitation and one relapse of atrial flutter., Conclusions: Our study shows that non-fluoroscopic RFCA of supraventricular tachyarrhythmias using the EnSite NavX(TM) system is feasible, safe, and effective in a population of relatively young adults. Our experience of a non-fluoroscopic approach in these procedures deserves consideration, particularly in the young or in other patients at higher radiation risk.

Atrial fibrillation (AF) is a growing epidemic associated with a variety of adverse outcomes, including death, stroke, impaired quality of life, and increased rate of hospitalizations. Achieving a definite cure for this disease is highly desirable, as this would have outstanding social and economic implication. Catheter ablation is the only treatment demonstrated capable of eliminating AF in a substantial proportion of patients. Over the years, intense research has been directed toward the identification of the optimal ablation strategy, with the aim of increasing procedural success while minimizing complications. Multiple clinical trials have established pulmonary vein antrum isolation (PVAI) as the mainstay of treatment for paroxysmal AF patients. In these patients, the addition of superior vena cava isolation has been demonstrated to increase long-term freedom from AF recurrence compared to PVAI alone. In patients with persistent and long-standing persistent AF, a more extensive set of lesions targeting the entire left atrial posterior wall and complex fractionated electrograms (CFAE) is necessary, while those presenting for redo procedure may also benefit from ablation of other trigger sites of AF initiation, such as the left atrial appendage. With regard to safety, the most notable advances have been the introduction of open-irrigated ablation catheters and of ablation without interruption of oral anticoagulation. Both strategies have been demonstrated to reduce dramatically periprocedural thromboembolic complications, without increasing the risk of bleeding. Beyond outstanding advances in defining the optimal ablation strategies to increase the effectiveness and safety of catheter ablation, in recent years outcomes of AF treatment trials have been widely reconsidered. In addition to the prevention of AF recurrence, additional end-points have been considered important. These include reduction of hospitalization, stroke, and mortality, as well as economic factors. A correct evaluation of such end-points has required the introduction of AF ablation registries, and the design of new trials with adequate power to address such issues. This article will provide an overview of AF ablation trials that have constituted the basis for current clinical practice and will discuss the contribution of ongoing studies and registries to the future of AF ablation.

We report the case of a 50 year-old woman referred for extraction of an infected biventricular implantable cardioverter defibrillator (ICD) who underwent device and leads extraction. Due to adhesions at the level of the subclavian-innominate vein angle, manual traction with locking stylet was ineffective. A new mechanical sheath provided with a stainless steel bladed tip, the Evolution Mechanical Dilator Sheath (Cook Medical), was successfully used to complete lead extraction. As far as we know, this is the first report on the use of this new tool; its safety should be ascertained by increasing the number of cases but its simple use and its low cost make the Evolution Mechanical Dilator Sheath a new interesting tool that can be added to the instruments available for lead extraction.

A 65-year-old man was referred for atrial fibrillation ablation to our center. Routine pre-procedure transthoracic and transoesophageal echocardiography and cardiac computed tomography examinations showed a normal interatrial septum and fossa ovalis anatomy. Access to left atrium was initially planned using a conventional transseptal needle puncture. During the procedure, several consecutive attempts in conjunction with intracardiac echocardiography support, failed to cross the septum. The procedure was then successfully carried out using a specifically designed radiofrequency transseptal catheter.

Background: Atrial fibrillation (AF) drivers outside pulmonary veins (PV) may account for failure after PV isolation. The aim of this study was to characterize pre-existent areas of complex fractionated atrial electrograms (CFAEs) recorded in right atrium (RA) and in coronary sinus (CS) during catheter-based PV isolation and to assess their relation to outcome., Methods and Results: With a tricuspid annulus and CS mapping, CFAEs were retrospectively identified in consecutive patients who underwent PV isolation. Of 224 patients, 161 were found to have CFAEs (81%). No clinical variable was found to be predictive of CFAEs presence. By Kaplan-Meier analysis, following a median follow-up of 23.7 months after a single ablation procedure, 62.8% of patients in the CFAEs+ group and 85.4% of those in the CFAEs- group were free from recurrent atrial tachyarrhythmias (p=0.013). Multivariable Cox regression analysis showed that CFAEs evidence was an independent predictor of recurrence (p=0.007)., Conclusions: Pre-existent CFAEs, that can be easily identified in RA and CS during PV isolation, are a powerful independent predictor for AF recurrence. This finding may be helpful for refining AF ablation strategies.