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Atrial fibrillation in patients with heart failure due to ventricular dyssynchrony needs decision-making on the rate and rhythm control strategies together with cardiac resynchronization therapy and antithrombotic prophylaxis. Transvenous biventricular pacing and percutaneous appendage closure in patients with heart failure and atrial fibrillation with high bleeding risk are valid therapeutic options but anatomical exclusion criteria could be present. Here, we report two patients who underwent successful totally thoracoscopic concomitant left appendage occlusion and epicardial left ventricular lead implantation.

Objective It is unknown whether epicardial and endocardial validation of bidirectional block after thoracoscopic surgical ablation for atrial fibrillation is comparable. Epicardial validation may lead to false-positive results due to epicardial tissue edema, and thus could leave gaps with subsequent arrhythmia recurrence. It is the aim of the present study to answer this question in patients who underwent hybrid atrial fibrillation ablation (combined thoracoscopic epicardial and endocardial catheter ablation). Methods After epicardial ablation of the pulmonary veins (PVs) and connecting inferior and roof lines (box lesion), exit and entrance block were epicardially and endocardially evaluated using an endocardial His Bundle catheter and electrophysiological workstation. If incomplete lesions were found, endocardial touch-up ablation was performed. Validation results were also compared to predictions about conduction block based on tissue conductance measurements of the epicardial ablation device. Results Twenty-five patients were included. Epicardial validation results were 100% equal to the endocardial results for the left superior, left inferior, and right inferior PVs and box lesion. For the right superior PV, 85% similarity was found. Based on tissue conductance measurements, 139 lesions were expected to be complete; however, in 5 (3.6%) a gap was present. Conclusions Epicardial bidirectional conduction block in the PVs and the box lesion corresponded well with endocardial bidirectional conduction block. Conduction block predictions by changes in tissue conductance failed in few cases compared to block confirmation. This emphasizes that tissue conduction measurements can provide a rough indication of lesion effectiveness but needs endpoint confirmation by either epicardial or endocardial block testing.

Introduction Pulmonary vein (PV) isolation is an established treatment for paroxysmal drug-refractory atrial fibrillation (AF). High parasympathetic tone and reconnection of PVs have demonstrated to be possible culprits of AF recurrence after ablation. Our aim was to investigate the association between parasympathetic tone and reconnected PVs in patients with paroxysmal AF. Methods Consecutive patients who underwent a repeated catheter ablation procedure for atrial tachyarrhythmia recurrence by means of 3D electroanatomic mapping with documentation of presence or absence of PVs reconnection following an initial procedure of cryoballoon ablation with for symptomatic drug-refractory paroxysmal AF were screened for the study. Results A total of 92 patients were included, of whom 50(54.35%) were males. Reconnected PVs were found in 64 (69%) patients. PVs reconnection could be predicted by DC(C-statistic = .770), by SDNNI(C-statistic = .714) and by absolute VLF power(C-statistic = .722), while right-sided PVs reconnection could be better predicted by DC(C-statistic = .848) and by SDNNI(C-statistic = .761). In multivariate binary logistic regression analysis, a DC value ≥6.45 ms and an absolute VLF power value ≥160ms2 associated with 3 times and 5 times higher odds of PVs reconnection, respectively. On a vein-per-vein analysis, absolute VLF power ≥160ms2 associated with 3 times higher odds, while reaching of -40°C within 60 seconds associated with 3 times lower odds of PVs reconnection. Conclusion High parasympathetic tonus accurately predicts PVs reconnection. On a vein-per-vein analysis, parasympathetic markers along with biophysical parameters predicted PVs reconnection. On a case-by-case analysis, parasympathetic markers were the only predictors of PVs reconnection, thus being a robust PVs reconnection prediction tool. This article is protected by copyright. All rights reserved.

BACKGROUND: The pathogenesis of Brugada syndrome (BrS) and consequently of abnormal electrograms (aEGMs) found in the epicardium of the right ventricular outflow tract (RVOT-EPI) is controversial. OBJECTIVE: The purpose of this study was to analyze aEGM from high-density RVOT-EPI electroanatomic mapping (EAM). METHODS: All patients undergoing RVOT-EPI EAM with the HD-Grid catheter for BrS were retrospectively included. Maps were acquired before and after ajmaline, and all patients had concomitant noninvasive electrocardiographic imaging with annotation of RVOT-EPI latest activation time (RVOTat). High-frequency potentials (HFPs) were defined as ventricular potentials occurring during or after the far-field ventricular EGM showing a local activation time (HFPat). Low-frequency potentials (LFPs) were defined as aEGMs occurring after near-field ventricular activation showing fractionation or delayed components. Their activation time from surface ECG was defined as LFPat. RESULTS: Fifteen consecutive patients were included in the study. At EAM before ajmaline, 7 patients (46.7%) showed LFPs. All patients showed HFPs before and after ajmaline and LFPs after ajmaline. Mean HFPat (134.4 vs 65.3 ms, P

Background: Ischemic stroke after coronary artery bypass (CABG) has been often linked to aortic manipulation during surgery. Objectives: The objective of the study was to estimate the rate of postoperative ischemic stroke within 30 days from CABG by surgical risk factors alone or in combination. Methods: The multinomial propensity score for multiple treatments was used to create six models with a total of 16,255 consecutive patients undergoing isolated CABG. For each model, a different classification variable was used to stratify patients. Results: Balance achieved in all models was substantial, enabling unbiased estimation of the treatment estimand. Both off-pump techniques with (0.009; 95% CI 0.006–0.011) or without proximal anastomoses (0.005; 0.005–0.003), and surgery performed on the beating heart using cardiopulmonary bypass with (0.009; 0.006–0.011) or without proximal anastomoses (0.024; 0.021–0.029) showed a mean stroke estimate significantly lower than the other techniques. Off-pump surgery and on-pump surgery without an aortic cross-clamp yielded nearly equal incidences of stroke (0.012; 0.008–0.015 and 0.018; 0.012–0.023, respectively). Using an aortic cross-clamp significantly increased the stroke estimate (0.075; 0.061–0.088), whereas using a side-biting clamp did not (0.039; 0.033–0.044). The number of aortic touches (0.029; 0.026–0.031) and the number of proximal anastomoses (0.044; 0.035–0.047) did not significantly increase the incidence of stroke. Conclusions: Aortic cross-clamping was found to be the primary cause of post-CABG ischemic stroke. Instead, additional aortic manipulation from a side-biting clamp, on-pump surgery, multiple aortic touches, number of proximal anastomoses, and aortic cannulation were found not to increase the estimate of stroke significantly. Further research on this topic is warranted., Graphical Abstract Factors increasing post CABG incidence of ischemic stroke (red) and those which were not significant at the multi-model multifactorial analysis that analyzed all technical factors alone or in different combinations (green).

Summary As the mechanisms underlying persistent atrial fibrillation (AF) are still incompletely understood, a ‘gold standard’ strategy for ablation is lacking. The results of catheter ablation, independent of the ablation strategy applied, are disappointing. Hybrid ablation, combining a thoracoscopic epicardial and transvenous endocardial approach, has shown more favourable outcomes. To date, studies comparing both techniques are lacking. Therefore, we conducted a systematic review and meta-analysis of hybrid versus catheter ablation in patients with persistent or longstanding persistent AF. A systematic literature search of studies reporting on catheter and hybrid ablation of persistent or longstanding persistent AF was performed in the PubMed database. All identified articles were screened and checked for eligibility. A meta-analysis was performed on inter-study heterogeneity and pooled correlation between baseline characteristics, primary and secondary outcomes of hybrid and catheter studies. From the 520 articles identified by the search, 34 articles could be included in the analysis. Hybrid ablation resulted in higher freedom of atrial arrhythmias in patients with persistent and longstanding-persistent AF than catheter ablation (70.7% vs 49.9%, P

The connection between atrial fibrillation (AF) and H. pylori (HP) infection is still matter of debate. We performed a systematic review and metanalysis of studies reporting the association between AF and HF. A systematic review of all available reports in literature of the incidence of HP infection in AF and comparing this incidence with subjects without AF were analysed. Risk ratio and 95% confidence interval (CI) and risk difference with standard error (SE) were the main statistics indexes. Six retrospective studies including a total of 2921 were included at the end of the selection process. Nine hundred-fifty-six patients (32.7%) were in AF, whereas 1965 (67.3%) were in normal sinus rhythm (NSR). Overall, 335 of 956 patients with AF were HP positive (35%), whereas 621 were HP negative (65%). In addition, 643 of 1965 NSR patients (32.7%) were HP positive while 1,322 were negative (67.3%; Chi-square 2.15, p = 0.21). The Cumulative Risk Ratio for AF patients for developing an HP infection was 1.19 (95% CI 1.08–1.41). In addition, a small difference risk towards AF was found (0.11 [SE = 0.04]). Moreover, neither RR nor risk difference were influenced by the geographic area at meta-regression analysis. Finally, there was a weak correlation between AF and HP (coefficient = 0.04 [95% CI −0.01–0.08]). We failed to find any significant correlation between H. pylori infection and AF and, based on our data, it seems unlikely than HP can be considered a risk factor for AF. Further larger research is warranted.

OBJECTIVES Epicardial adipose tissue volume (EAT-V) has been linked to atrial fibrillation (AF) recurrences after catheter ablation. We retrospectively studied the association between atrial EAT-V and outcome after hybrid AF ablation (epicardial surgical and endocardial catheter ablation). METHODS On preoperative cardiac computed tomography angiography scans, the left atrium and right atrium were manually delineated using the open source ImageJ. With custom-made automated software, the number of pixels in the regions of interest on each slice was calculated. On the basis of the Hounsfield units, pixel size and slice thickness, EAT-V was computed and normalized in relation to the body surface area (BSA) and the myocardial tissue volume. RESULTS Eighty-five patients were included. Left atrial and right atrial EAT-V normalized to BSA were not significantly different between paroxysmal and persistent AF [0.84 (0.51–1.50) vs 0.81 (0.57–1.18), 1.74 (1.02–2.56) vs 1.55 (1.26–2.18), all P = 0.9], neither between the acute conduction block and no acute conduction block in the epicardial box lesion [0.92 (0.55–1.39) vs 0.72 (0.55–1.24), P = 0.5, right atrium not applicable], nor between the sinus rhythm and arrhythmia recurrence after 12 months [0.88 (0.55–1.48) vs 0.63 (0.47–1.10), 1.61 (1.11–2.50) vs 1.55 (1.20–2.20), all P > 0.1]. Left atrial EAT-V normalized to myocardial tissue volume was not different between the groups. CONCLUSIONS This study could neither confirm that EAT-V was predictive of recurrence of supraventricular arrhythmias in patients undergoing a hybrid AF ablation, nor that EAT-V was different between patients with paroxysmal AF and persistent and long-standing persistent AF. This suggests that EAT-V might not affect the outcome in surgical ablation procedures and therefore should not influence preoperative or intraoperative decision-making.

Background Abnormal delayed electrograms (EGMs) from the anterior wall of the right ventricular outflow tract (RVOT) epicardium have become the ablation target in Brugada syndrome (BrS). Objective The aim of this study was to analyze the safety, feasibility, and efficacy of a novel hybrid thoracoscopic approach to perform epicardial RVOT radiofrequency ablation in BrS. Methods Thirty-six patients with BrS (26 men (72.2%); mean age 36.6±15.8 years; range 3–63 years) who underwent hybrid thoracoscopic epicardial ablation of RVOT from January 2016 to April 2018 were included in this study. Two expert electrophysiologists analyzed the EGMs during ajmaline challenge and guided the surgeon to perform ablation. Ajmaline challenge was repeated after 1 month to assess the absence of the BrS electrocardiographic pattern. Patients were followed by remote monitoring and outpatient visits every 6 months. Results The elimination of all abnormal EGMs was achieved in 94.4% of patients. After a mean follow-up of 16 ± 8 months (range 6–30 months), freedom from ventricular arrhythmias was obtained in 7 (77.8%) patients in secondary prevention 9/36 (25%) and in 24 (100%) patients in primary prevention 24/36 (75%). Major complications were observed in 1 patient (2.8%), who experienced late cardiac tamponade. Conclusion Hybrid thoracoscopic epicardial RVOT ablation in BrS is a safe and feasible approach, allowing direct visualization of ablation during radiofrequency delivery. Because of ventricular arrhythmia recurrences, implantable cardioverter-defibrillator implantation is still mandatory in patients treated in secondary prevention and with high risk.

Introduction Although left atrial appendage (LAA) obliteration is the cornerstone of stroke prevention in surgical treatment of atrial fibrillation (AF), little is known about its direct impact on hemodynamics. In the current pilot study, we evaluated the hemodynamic effect of LAA closure by clipping in patients undergoing hybrid AF ablation. Methods Seven patients with paroxysmal or persistent AF were included. Hemodynamic and intracardiac pressure measurements such as systemic, pulmonary artery (PA), central venous and LA pressure, cardiac output and indexed left ventricular stroke volume (LVSVi) were measured directly before (T0) and after (T1), and 10 minutes after (T2) LAA closure. Results Of the 7 patients (median 66 yrs), 5 were in AF at the time of incision. There were no differences between T0 and T1, T1 and T2 and T0 and T2 for LA pressure, mean PA pressure, LVSVi and other hemodynamic parameters such as central venous oxygenation and pressure, or systemic arterial pressure. Conclusion In this pilot study, the direct hemodynamic effect of LAA closure is evaluated for the first time. Clipping of the LAA is safe and does not directly affect hemodynamic and intracardiac pressures.

IntroductionThe previously published SYNTAX III REVOLUTION trial demonstrated that clinical decision-making between coronary artery bypass graft (CABG) and percutaneous coronary intervention based on coronary CT angiography (CCTA) had a very high agreement with the treatment decision derived from invasive coronary angiography (ICA). The study objective of the FASTTRACK CABG is to assess the feasibility of CCTA and fractional flow reserve derived from CTA (FFRCT) to replace ICA as a surgical guidance method for planning and execution of CABG in patients with three-vessel disease with or without left main disease.Methods and analysisThe FASTTRACK CABG is an investigator-initiated single-arm, multicentre, prospective, proof-of-concept and first-in-man study with feasibility and safety analysis. Surgical revascularisation strategy and treatment planning will be solely based on CCTA and FFRCT without knowledge of the anatomy defined by ICA. Clinical follow-up visit including CCTA will be performed 30 days after CABG in order to assess graft patency and adequacy of the revascularisation with respect to the surgical planning based on non-invasive imaging (CCTA) with functional assessment (FFRCT) and compared with ICA. Primary feasibility endpoint is CABG planning and execution solely based on CCTA and FFRCT in 114 patients. Primary safety endpoint based on 30 day CCTA is graft assessment and topographical adequacy of the revascularisation procedure. Automatic non-invasive assessment of functional coronary anatomy complexity is also evaluated with FFRCT for functional Synergy Between percutaneous coronary intervention With Taxus and Cardiac Surgery Score assessment on CCTA. CCTA with FFRCT might provide better anatomical and functional analysis of the coronary circulation leading to appropriate anatomical and functional revascularisation, and thereby contributing to a better outcome.Ethics and disseminationEach patient has to provide written informed consent as approved by the ethical committee of the respective clinical site. Results will be submitted for publication in peer-reviewed journals and will be disseminated at scientific conferences.Trial registration numberNCT04142021.

Introduction The most appropriate treatment for stroke prevention in standalone atrial fibrillation patients with a high CHADS2VASC score contraindicated for oral anticoagulation (OAC) or novel OAC (NOAC) still needs to be defined. Percutaneous left atrial appendage (LAA) closure devices are available, but because of their endocardial positioning need a period of antiplatelet therapy (APT). This study aimed to evaluate the safety and efficacy of epicardial left atrial appendage clipping in patients contraindicated for (N)OAC and APT. Methods and results We describe a standalone totally thoracoscopic LAA clipping of forty-five consecutive patients with nonvalvular atrial fibrillation (NVAF; 32 males; age, 73.1 ± 7.4 years; CHADVASC, 6.5 ± 1.1; HAS-BLED 4.9 ± 0.9) with absolute contraindications to (N)OAC. The patients were selected by a multidisciplinary Heart Team. Sixty percent had a previous ischemic stroke and 51% a history of the hemorrhagic event and 22% both. All patients were implanted with an LAA epicardial clip, guided by preoperative computed tomography and intraoperative transesophageal echocardiography. The mean procedural duration was 52.3 ± 12.6 minutes with postprocedural extubation interval of 22.8 ± 14.6 minutes. No procedure-related complications occurred. Intraprocedural transesophageal echocardiography (TEE) showed complete LAA occlusion in all patients. At a mean follow-up of 16.4 ± 9.1 months (range, 2-34), with all patients off (N)OAC or APT, no ischemic stroke or hemorrhagic complications occurred. computed tomography or TEE at follow-up demonstrated a correct LAA occlusion in all with mean stumps of 3.3 ± 2.8 mm. Conclusion Thoracoscopic epicardial closure of the LAA with the AtriClip PRO2 device is a potentially safe and efficient treatment for stroke prevention in patients with NVAF contraindicated for anticoagulant therapy or APT.

Introduction: Brugada syndrome (BrS) is an inherited disease characterized by an increased risk of sudden cardiac death (SCD). Therapeutic options in symptomatic patients are limited to implantable cardioverter defibrillator (ICD) and quinidine, but catheter ablation of the right ventricular outflow tract (RVOT) offers a potential cure. Different ablation strategies have been used to treat patients with symptomatic Brugada syndrome. Epicardial radiofrequency substrate ablation of the RVOT/right ventricle (RV) has emerged as a promising tool for the management of the disease.Areas covered: The historical management of BrS, endocardial and epicardial ablation techniques, the use of sodium channel blockers (SCB) and complications are summarized here.Expert opinion: Ventricular fibrillation (VF)-triggering premature ventricular contractions (PVCs) in patients with BrS are unpredictable, spontaneous ones are rarely present to be mapped, making this approach impractical. Furthermore, endocardial mapping for BrS substrates does not seem effective due to the epicardial pathological substrate localization. The size variation of the BrS substrate areas during SCB infusion suggests a dynamic process as arrhythmogenic basis and SCB infusion should guide BrS epicardial ablation of all abnormal potentials areas. If BrS epicardial ablation can truly provide long-term prevention of ventricular arrhythmias it may potentially become an alternative to ICD therapy.

Item does not contain fulltext OBJECTIVES: The single-step hybrid atrial fibrillation (AF) ablation procedure combines a transvenous endocardial and thoracoscopic epicardial approach in 1 procedure. Short-term results are encouraging, but long-term outcome data are not available. METHODS: Hybrid AF ablation was successfully performed in 64 consecutive patients (53% with persistent AF). The mean follow-up period was 1732 +/- 353 days. Perprocedural endocardial touch-up of incomplete epicardial lesions was performed in 17 (26%) patients. RESULTS: In paroxysmal AF patients, arrhythmia-free cumulative survival rates after 1 hybrid AF ablation without Class I or III antiarrhythmic drugs procedure and without redo catheter ablation were 83%, 80% and 80% after 1, 2 and 3 years, respectively. In (long-standing) persistent AF patients, these were 82%, 79% and 79% after 1, 2 and 3 years. Thirteen (20%) patients had at least 1 recurrent episode of supraventricular arrhythmia lasting longer than 30 s: the most frequent recurrent arrhythmias were left atrial flutter and AF. No mortality or conversion to cardiopulmonary bypass, no phrenic nerve palsy and no pacemaker implantation were reported. CONCLUSIONS: Hybrid AF ablation, combining a transvenous endocardial and thoracoscopic epicardial approach in a single procedure, results in a cumulative 3-year freedom from arrhythmia without Class I or III antiarrhythmic drugs and without redo catheter ablation of 80% in paroxysmal AF (24 of 30 patients) and 79% in non-paroxysmal AF (26 of 33 patients).

Patients with drug-induced Brugada syndrome (BS) are considered at a lower risk than those with a spontaneous type I pattern. Nevertheless, they can present arrhythmic events.The purpose of this study was to investigate their clinical characteristics, long-term prognosis and risk factors.A consecutive cohort of 343 patients with drug-induced BS was included and compared with 78 patients with a spontaneous type I pattern.The mean age was 40.7 ± 18.3 years. Sudden cardiac death (SCD) was the clinical presentation in 13 (3.8%) and syncope in 86 (25.1%); 244 (71.1%) were asymptomatic. Patients with drug-induced BS were less frequently men (180 (52.5%) vs 63 (80.8%); P .01), were more frequently asymptomatic (244 (71.1%) vs 44 (56.4%); P.01), and had less ventricular arrhythmias (VAs) induced during electrophysiology study (41 (13.2%) vs 31 (42.4%); P.01). An implantable cardioverter-defibrillator was implanted in 128 patients (37.3%). During a median follow-up of 62.5 months (interquartile range 28.9-115.6 months), 34 patients presented arrhythmic events. The event rate was 1.1% person-year (vs 2.3% person-year in patients with a spontaneous type I pattern; P.01). Presentation as SCD and inducible VAs were independent risk factors significantly associated with arrhythmic events (adjusted hazard ratio 22.0 and 3.5). Drug-induced BS was related to a better prognosis only in asymptomatic individuals.Drug-induced BS has a good prognosis if asymptomatic; however, SCD is possible. Clinical presentation as SCD and inducible VAs during electrophysiology study are independent risk factors for arrhythmic events. In asymptomatic patients, proband status and inducible VAs can help to identify patients at higher risk, but further evidence is needed.

Background: We evaluated the safety and effectiveness of the hybrid thoracoscopic endocardial epicardial ablation technique for the treatment of atrial fibrillation (AF) in obese versus non-obese patients.Methods: Between January 2010 and January 2015, a cohort of 61 patients were retrospectively identified to undergo ablation of AF as a stand-alone procedure using a thoracoscopic, hybrid epicardial-endocardial technique. All patients underwent continuous 7-day Holter monitoring at 3, 6 months, 1 year and yearly thereafter.Results: A total of 40% of the obese cohort had persistent or long-standing AF, compared to 54.9% of the non-obese cohort. There were no deaths or conversion to cardiopulmonary bypass required. At 3-year follow-up, 60% of the obese group were in sinus rhythm (SR) with no episode of AF, atrial flutter or atrial tachycardia lasting 30 s off anti-arrhythmic drugs. This was compared to 70.6% in the non-obese group, with no significant difference between the groups (P= 0.468). For success rates on anti-arrhythmic drugs, this was 80% in the obese group compared to 86% in the non-obese group at 3-year follow-up (P= 0.637). No patient died and no thromboembolic/bleeding events or procedure-related complications occurred during the follow-up.Conclusions: In a retrospective cohort with approximately half with persistent or long-standing AF, thoracoscopic hybrid epicardial endocardial ablation proved to be equally effective and safe in obese versus non-obese patients. Current preliminary findings require further validation in multi-institutional prospective studies with larger sample sizes.

This study analyzes the natural history of a large cohort of probands with Brugada syndrome (BrS) to assess the predictive value of different clinical and electrocardiographic parameters for the development of ventricular fibrillation (VF) or sudden cardiac death (SCD) during a long-term follow-up. Baseline characteristics of 289 consecutive probands (203 men; mean age 45 ± 16 years) with a Brugada type 1 electrocardiogram were analyzed. After a mean follow-up of 10.1 ± 4.6 years, 29 malignant arrhythmias occurred. On multivariate analysis, a history of VF and syncopal episodes, fragmented QRS (f-QRS), spontaneous type 1 electrocardiogram, and early repolarization pattern were significantly associated with later occurrence of VF/SCD. In patients with drug-induced BrS, the accentuation or de novo appearance of f-QRS in other leads was always associated with VF/SCD. Cerebrovascular events occurred in 8 patients with atrial fibrillation (15.1%), most of them (75%) presenting as the first clinical manifestation. The time-to-diagnosis was found to be significantly shorter in those patients who directly came to our center than in those who referred to our center for a second opinion. In conclusion, systematic use of the pharmacologic challenge in patients with unexplained cardiovascular symptoms and/or atrial fibrillation might significantly improve the identification of BrS with a shortening of the time-to-diagnosis. The CHA2DS2VASc score might be inappropriate for predicting transient ischemic attack or stroke in BrS. This study confirms the independent predictive value of previous VF and syncopal episodes, f-QRS, type 1 electrocardiogram, and early repolarization pattern. In BrS a sufficiently long follow-up is necessary before conclusions on prognosis are apparent.

Aim: We evaluated the influence of intra-aortic balloon size and volume on mesenteric and renal flows. Methods: Thirty healthy swine underwent 120-minute ligation of the left anterior descending coronary artery followed by 6 hours of reperfusion. Then, they were randomly assigned to the following five groups of animals, with six animals in each group: no intra-aortic balloon pump (IABP), a short 35-mL IABP, a short 40-mL IABP, a long 35-mL IABP and a long 40-mL IABP. Superior mesenteric artery (SMA) and renal flows were measured at baseline (t0), at 2-hour ischemia (t1) and every hour thereafter until 6 hours of reperfusion (from tR1 to tR6). Results: SMA flows increased significantly at tR1 only in the two short IABP groups (p0.05). Renal flows appeared to be influenced by balloon length, but not by volume. Indeed, flows in the renal arteries rose during IABP treatment; the increase was significantly higher in the short balloon groups and throughout the whole reperfusion (all, pConclusions: Changes in visceral perfusion during IABP assistance were significantly related to balloon length, but not to its volume. This could be relevant for the evolution of balloon engineering design in order to reduce the incidence of mesenteric ischemia following IABP. Further research is necessary to confirm these findings.

Introduction Radiofrequency isolation of pulmonary vein can be accompanied by transient sinus bradycardia or atrioventricular nodal (AVN) block, suggesting an influence on vagal cardiac innervation. However, the importance of the atrial fat pads in relation with the vagal innervation of AVN in humans remains largely unknown. The aim of this study was to evaluate the role of ganglionated plexi (GP) in the innervation of the AVN by the right vagus nerve. Methods and results Direct epicardial high-frequency stimulation (HFS) of the GP (20 patients) and the right vagus nerve (10 patients) was performed before and after fat pad exclusion or destruction in 20 patients undergoing thoracoscopic epicardial ablation for the treatment of persistent AF. Asystole longer than 3 seconds or acute R-R prolongation over 25% was considered as a positive response to HFS. Prior to the ablation, positive responses to HFS were detected in 3 GPs in 7 patients (35%), 2 GPs in 5 patients (25%), and one GP in 8 patients (40%). After exclusion of the fat pads, all patients had a negative response to HFS. All the patients who exhibited a positive response to right vagus nerve stimulation (n = 10) demonstrated negative responses after the ablation. Conclusion The integrity of the GP is essential for the right vagus nerve to exert physiological effects of on AVN in humans.

Owing to a type error during final correction and proof data submission to the journal, there were mistakes introduced into the legends of Fig. 3 and Fig. 4 as well as into the Y-axis title of the plot of Fig. 4.

An atrioesophageal fistula (AEF) is a rare yet devastating complication after atrial fibrillation (AF) ablation. Clinical features are relatively straightforward, but clinical awareness remains low amongst clinicians and surgeons. A delay in presentation, diagnosis and intervention thus exists, all contributing to the high mortality rate of AEF. In addition, we believe that the presence of an atrial septum occluder contributed to AEF formation after epicardial radiofrequency ablation for AF.

Brugada syndrome is responsible for about 20% of sudden cardiac deaths in patients with apparently normal hearts. Basic and clinical research has elucidated some of the mechanisms that are responsible for life-threatening ventricular arrhythmias in this syndrome. Delays in activation and repolarization over the right ventricular outflow tract are the most likely cause of the ECG typical pattern and arrhythmogenesis. Invasive epicardial and endocardial mapping has identified the epicardium as the principal region of interest for these anomalies, and areas of fragmented potentials at invasive mapping are a target for epicardial ablation. Noninvasive mapping systems have been developed to study the epicardial depolarization and repolarization and may be particularly useful in assessing the epicardial arrhythmogenic substrate of Brugada syndrome for both clinical and research purpose. This review focuses on recent advances in this field.

Contains fulltext : 209448.pdf (Publisher’s version ) (Open Access) Background: The long-term results of endocardial and percutaneous epicardial catheter ablation of ventricular tachycardia (VT) in patients with structural heart disease are disappointing. Arrhythmia recurrence after ablation and VTs with an epicardial substrate remain a clinical challenge. The purpose of this manuscript is to elaborate on feasibility and potential advantages of a surgical hybrid ablation (i.e., combined endocardial and surgical epicardial ablation) based on our initial experience consisting of five cases. Methods: Endocardial electro-anatomical voltage and activation maps were created (Carto, Biosense Webster, California, USA), and endocardial radiofrequency (RF) applications were applied at exit sites, low voltage areas and isthmi. Next, after surgical access, epicardial voltage and activation maps were produced in combination with visual assessment of the epicardial substrate. Epicardial low voltage areas, isthmi and exit sites were identified and ablated using RF energy. Results: After the procedure, VT was non-inducible in 80% of the cases (4/5, in one case no induction was performed). No peri-procedural complications occurred. After a mean follow-up of 18 months, one patient remained in sinus rhythm without, and 2 with use of antiarrhythmic drugs. One patient needed a redo procedure after 21 months, and in one patient the amiodarone dose was raised because of 2 sustained VTs. After this additional treatment, both kept sinus rhythm. Conclusions: Hybrid VT ablation is a safe and effective patient tailored procedure that comprises the major advantage of combining direct anatomical visualization and enhanced catheter stability with high-density 3D mapping. As a consequence, this procedure should be considered as a valid treatment option in complex VT management.

Background Sutureless aortic valve replacement surgery (AVR) is a reasonable alternative surgical approach in those patients with aortic stenosis who would benefit from reduced cross clamp time, such as elderly and high-risk patients. We sought to evaluate the incidence of pacemaker (PM) implantation following sutureless AVR and to analyse possible pre-operative electrocardiographic and clinical predictors of PM implantation. Methods and results Between November 2013 and March 2015, 58 patients (male 43%, age 77.9 ± 4.9 years) having undergone sutureless AVR with a Perceval prosthesis (Sorin Biomedica Cardio Srl, Saluggia, Italy) were taken into consideration for our analysis. During a mean follow up of 13.8 ± 5.0 months (median 13 months), 14 patients (24.1%) underwent pacemaker (PM) implantation following sutureless AVR procedure. Among these patients, 12 (86%) presented III degree atrioventricular (AV) block, 1 (7%) presented II degree AV block, and remaining one (7%) severe symptomatic bradycardia. The comparison of pre-operative characteristics between PM group and no PM group highlighted that QRS duration, EuroSCORE II index and chronic renal dysfunction were significantly associated with the development of AV conduction abnormalities/symptomatic bradycardia requiring PM implantation (respectively, p = 0.01, p = 0.02 and p = 0.03). Conclusions The incidence of PM implantation after sutureless AVR was 24.1% in the present study. The EuroSCORE II, QRS duration and renal dysfunction were significantly associated with higher risk of AV conduction abnormalities/symptomatic bradycardia requiring PM placement.

The ideal treatment of Inappropriate Sinus Tachycardia (IST) and Postural Orthostatic Tachycardia Syndrome (POTS) still needs to be defined. Medical treatment yields suboptimal results, endocardial ablation of the sinus node (SN) may risk phrenic nerve damage and open heart surgery may be accompanied by unjustified invasive risks. We describe our first experience of 50 consecutive patients (41 females, 22.83 ± 3.91 years) having undergone a novel hybrid thoracoscopic ablation for drug resistant IST (n = 39, 78%) or POTS (n = 11, 22%). The SN was identified with the help of 3D mapping. Surgery was performed through 3 (5 mm) ports from the right side. A minimally invasive approach with a radio frequency bipolar clamp was utilized to a new target sparing the SN region, to isolate the superior and the inferior caval veins, and a crista terminalis line was made. All lines were interconnected. Normal SR was restored in all patients at the end of the procedure. All patients discontinued medication during the follow-up. After a blanking period of 6 months all patients presented stable SR. At a mean of 28.4 ± 1.2 months, normal SN ruction and chronotropic response to exercise was present. In the 11 patients initially diagnosed with POTS, no syncope occurred. During the follow-up, pericarditis was the most common complication (39 patients; 78%) with complete resolution in all cases. In conclusions the preliminary results of our first experience with a SN sparing novel hybrid ablation of IST/POTS, using surgical thoracoscopic video-assisted epicardial ablation combined with concomitant endocardial 3D mapping may prove an efficient and safe therapeutic option in patients with symptomatic drug resistant IST and POTS. Importantly, in our study all patients had a complete resolution of the symptoms and restored normal SN activity.

BACKGROUND The present study sought to evaluate the incidence of cerebrovascular events in a large cohort of patients with Brugada syndrome (BrS) analysing possible predictors, clinical characteristics and prognosis of cardioembolic events secondary to atrial fibrillation. METHODS A total of 671 consecutive patients (age 42.1 ± 17.0 years; men 63%) with a diagnosis of BrS were retrospectively analysed over a mean follow-up period of 10.8 ± 5.5 years. The diagnosis of ischemic stroke was made according to the AHA/ASA guidelines using computed tomography (CT) and angio-CT in the emergency department. RESULTS Among 671 patients with BrS, 79 (11.8%) had atrial fibrillation. The incidence of cardioembolic stroke in patients with BrS and atrial fibrillation was 13.9% (11 events). These patients had a low CHA2DS2Vasc score (82%, 0 and 1). Patients with transient ischemic attack/stroke were more frequently asymptomatic (91 vs. 25%; P

Background. In the recent ESC/EACTS guidelines, left atrial appendage (LAA) occlusion or exclusion in patients undergoing (thoracoscopic) atrial fibrillation (AF) ablation surgery is recommended. The Watchman device (WD, Boston Scientific, Minnesota) has proved to reduce the risk of thromboembolic events by closing of the LAA, yet no data exist on WD implantation during surgical AF ablation. The objective is to determine if WD implantation is safe and feasible in a hybrid AF ablation setting (i.e., combination of thoracoscopic epicardial surgical and endocardial catheter ablation) and could become subject of further testing to serve as a bail-out in cases in which surgical LAA occlusion methods cannot be applied, due to, for example, severe adhesions. Methods. In this prospective, single center, pilot study, 10 consecutive patients undergoing a hybrid ablation qualifying for LAA exclusion (CHA2DS2-VASc ≥ 1) were included. At the end of the hybrid ablation, the LAA was occluded endocardially using the WD. The feasibility endpoint was successful implantation. The safety endpoint concerned major complications. Results. One patient was excluded and replaced because the LAA was insufficiently visible on transesophageal echocardiography. In 10/11 patients, device delivery was successful (mean time: 35 minutes). No major complications occurred. Transesophageal echocardiography after 6 weeks and 6 months showed successful occlusion of the LAA without significant peridevice flow. Conclusion. Implantation of the WD seems to be feasible and safe in the setting of hybrid AF ablation and could be an alternative to epicardial occlusion in surgical AF ablation procedures. Larger studies are required to confirm these findings. This trial is registered with NCT02471131.

This proof-of-concept study examined the haemodynamic performance as well as the coronary and visceral organ perfusion using a new short balloon for intra-aortic counterpulsation (IABP) in a swine model of myocardial ischaemia. Eighteen healthy pigs underwent 120-min ligation of the left anterior descending coronary artery followed by 6 h of reperfusion, and they were randomly assigned into 3 groups undergoing IABP implantation with a 35-ml short balloon (n = 6), a 40-ml short balloon (n = 6) or no IABP implantation (controls, n = 6). Haemodynamics, and visceral and coronary flows were measured at baseline (t(0)), at 2 h of ischaemia (t(1)) and every hour thereafter until 6 h of reperfusion (from t(R1) to t(R6)), respectively. Mesenteric and renal flows increased significantly at t(R1) only in the IABP groups (all, P 0.05). The new short balloon significantly increased visceral flow, enhanced haemodynamics and improved coronary circulation during reperfusion following myocardial ischaemia in our experimental model.

Objective Visceral ischemia can be a potentially life-threatening complication of intra-aortic balloon pump (IABP) support. A shorter IABP catheter might lead to a reduction of visceral complications. In this animal study, we evaluate the effects of a 35-mL short catheter in comparison with a 40-mL standard-sized catheter. Methods Eighteen healthy swine underwent 120-minute ligation of the left anterior descending coronary artery followed by 6 hours of reperfusion being supported by either a short IABP catheter (short group) (n = 6) or a long IABP catheter (long group) (n = 6) or with no assistance (controls) (n = 6). Hemodynamics, visceral and coronary flows, as well as biochemical markers were evaluated throughout the different phases of the protocol. Results Mesenteric flows increased significantly at reperfusion (P < 0.001 both) remaining constant afterward (all, P > 0.05) in the short group, while remaining significantly lower in the long group at the start of reperfusion, remaining constantly lower than the short group and controls (P < 0.001 vs short, P < 0.003 vs controls). In both long and short groups, catheters improved renal flows at reperfusion (P < 0.001 both) without any further variation (P < 0.05). In the short group, the flows were higher during the whole of reperfusion (all, P < 0.05). Intra-aortic balloon pump support improved hemodynamic indices and coronary blood flows during reperfusion to a similar extent in both the small and the long group (P > 0.05). Conclusions The short IABP catheter proved to be as effective as the standard-sized catheter in supporting hemodynamics and coronary circulation. Furthermore, it even improves visceral flows in comparison with conventional IABP catheters.

Objective We present the first testing study on the ABLA-BOX, a new in vitro module of hybrid atrial fibrillation ablation. Methods ABLA-BOX consists of two chambers that mimic the epicardial and endocardial sides of the heart. The septum between chambers provides catheter access on both sites of the cardiac tissue. A circuit, filled with freshly obtained porcine blood, including a pump, an oxygenator, and a heating device, circulate the blood inside the system. Left atrial fresh tissue is mounted on a tissue holder and magnetically fixed. Epicardial and endocardial catheters are fixed on the catheter holders and blocked with the locker knob. The system allows control of ablation force, flow rate, temperature, and flow pattern. Results Epicardial contact force of 100 g and endocardial force of 30 g resulted in larger lesion volumes (P < 0.001), areas (P < 0.001), and lesion diameters (P = 0.03 and P = 0.008), than the combination of 100/20 g. In addition, with a flow rate of 5 L/min, lesion volumes (P = 0.02), areas (P < 0.001), and diameters (both, P < 0.001) were significantly larger in comparison with those of 3 L/min. Furthermore, dimensions (both, P < 0.001), volume (P < 0.001), and area (P < 0.001) of the lesions at a circulating blood temperature of 38.0°C were larger than with a lower blood temperature (36.0°C). Finally, ablations made under stable flow pattern resulted in greater lesion diameters P = 0.04 and P = 0.03) as well as larger volumes (P = 0.02) and areas (P = 0.03) than under turbulent-like flow reproduced with the system rotor set to 400 rpm. Conclusions The ABLA-BOX allowed easy hybrid ablation with different setups, which can provide cardiologists and cardiac surgeons with reliable and more valuable insights.

Aims Coronary computed tomography angiography (CTA) has emerged as a non-invasive diagnostic method for patients with suspected coronary artery disease, but its usefulness in patients with complex coronary artery disease remains to be investigated. The present study sought to determine the agreement between separate heart teams on treatment decision-making based on either coronary CTA or conventional angiography. Methods and results Separate heart teams composed of an interventional cardiologist, a cardiac surgeon, and a radiologist were randomized to assess the coronary artery disease with either coronary CTA or conventional angiography in patients with de novo left main or three-vessel coronary artery disease. Each heart team, blinded for the other imaging modality, quantified the anatomical complexity using the SYNTAX score and integrated clinical information using the SYNTAX Score II to provide a treatment recommendations based on mortality prediction at 4 years: coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or equipoise between CABG and PCI. The primary endpoint was the agreement between heart teams on the revascularization strategy. The secondary endpoint was the impact of fractional flow reserve derived from coronary CTA (FFRCT) on treatment decision and procedural planning. Overall, 223 patients were included. A treatment recommendation of CABG was made in 28% of the cases with coronary CTA and in 26% with conventional angiography. The agreement concerning treatment decision between coronary CTA and conventional angiography was high (Cohen’s kappa 0.82, 95% confidence interval 0.74–0.91). The heart teams agreed on the coronary segments to be revascularized in 80% of the cases. FFRCT was available for 869/1108 lesions (196/223 patients). Fractional flow reserve derived from coronary CTA changed the treatment decision in 7% of the patients. Conclusion In patients with left main or three-vessel coronary artery disease, a heart team treatment decision-making based on coronary CTA showed high agreement with the decision derived from conventional coronary angiography suggesting the potential feasibility of a treatment decision-making and planning based solely on this non-invasive imaging modality and clinical information. Trial registration number NCT02813473.

BACKGROUND Young patients presenting with symptomatic Brugada syndrome have very high risks for ventricular arrhythmias and should be carefully considered for implantable cardioverter-defibrillator (ICD) placement. However, this therapy is associated with high rates of inappropriate shocks and device-related complications. OBJECTIVES This study investigated clinical features, management, and long-term follow-up of young patients with Brugada syndrome and ICD. METHODS Patients diagnosed with Brugada syndrome, who underwent implantation of an ICD at an age of 25% of patients during follow-up. Appropriate shocks were significantly associated with previously aborted sudden cardiac death and spontaneous type I electrocardiograms. However, ICDs are frequently associated with complications and inappropriate shocks, both of which remain high regardless of careful device implantation and programming. (c) 2018 by the American College of Cardiology Foundation.

Background Systemic lupus erythematosus (SLE) is an autoimmune disease, frequently associated with cardiovascular involvement. One of the most frequent complication is mitral valve regurgitation in more than one-third of the patients. Case summary A 30-year-old woman with arthralgia, butterfly rash, and Raynaud phenomenon presented with a systolic murmur and renal impairment. Based on the kidney biopsy the diagnosis of SLE was made. Echocardiography revealed the presence of pulmonary hypertension, restrictive mitral valve disease with nodular thickening of the anterior leaflet and moderate regurgitation, compatible with Libman Sacks (LS) endocarditis. Immunosuppressive therapy was started and the patient status improved with normalization of systolic pulmonary artery pressure. After 8 years without follow-up, she presented with fatigue and dyspnoea based on a severe mitral valve stenosis. Subsequently, she underwent a minimal invasive mitral valve replacement and the diagnosis of LS endocarditis could be confirmed upon histopathological examination. Discussion This case demonstrates that LS endocarditis can not only lead to mitral regurgitation but occasionally to mitral stenosis due to chronic inflammation with thickening and fusion of mitral valve leaflets. Hereby, comprehensive echocardiography, inclusive stress echocardiography, plays a critical role.

Lessons Learned from the Hybrid Redo ProceduresIntroduction In order to increase success rates of invasive treatment of persistent atrial fibrillation, the hybrid approach was developed, combining video-assisted thoracoscopic epicardial procedure with conventional endocardial catheter ablation. Currently, there are no reports of electrophysiological findings and clinical outcomes of repeat procedures after the hybrid approach. Methods and Results Out of 64 patients who were treated by hybrid ablation for persistent atrial fibrillation (AF), 14 underwent the repeat catheter ablation and were selected for this study. All 14 patients initially presented with longstanding persistent atrial fibrillation and markedly dilated atria. The hybrid procedure was performed in a single act and the mean time to redo procedure was 346 ± 227 days. In 57% of patients indication for redo procedure was regular atrial tachycardia, and the rest presented with recurrent atrial fibrillation. In 36% of patients, recovered conduction was found along the previous ablation lesions. Only 9% of pulmonary veins were reconnected (0.36 veins per patient) and 7% of box lesions were not complete. The overall success rate at 2 years follow-up after the repeat procedure, including second repeat procedure and patients taking antiarrhythmic drugs, was 64% (57% without drugs and further ablation). One case of moderate pulmonary vein stenosis was detected as a consequence of hybrid procedure. Conclusion Hybrid atrial fibrillation ablation results in durable lesions and high rates of chronic pulmonary vein isolation even after long-term follow-up. Most of the repeat procedures after the hybrid approach are related to left atrial flutters that could be successfully treated by catheter ablation.

OBJECTIVES: Concomitant left atrial appendage occlusion (LAAO) during surgical ablation has emerged as a potential treatment strategy to reduce stroke and perioperative mortality in patients with atrial fibrillation (AF). The present meta-analysis aims to assess current evidence on the efficacy and safety between LAAO and LAA preservation cohorts for patients undergoing cardiac surgery. METHODS: Electronic searches were performed using six electronic databases from their inception to November 2013, identifying all relevant comparative randomized and observational studies comparing LAAO with non-LAAO in AF patients undergoing cardiac surgery. Data were extracted and analysed according to predefined endpoints including mortality, stroke, postoperative AF and reoperation for bleeding. RESULTS: Seven relevant studies identified for qualitative and quantitative analyses, including 3653 patients undergoing LAAO (n = 1716) versus non-LAAO (n = 1937). Stroke incidence was significantly reduced in the LAAO occlusion group at the 30-day follow-up [0.95 vs 1.9%; odds ratio (OR) 0.46; P = 0.005] and the latest follow-up (1.4 vs 4.1%; OR 0.48; P = 0.01), compared with the non-LAAO group. Incidence of all-cause mortality was significantly decreased with LAAO (1.9 vs 5%; OR 0.38; P = 0.0003), while postoperative AF and reoperation for bleeding was comparable. CONCLUSIONS: While acknowledging the limitations and inadequate statistical power of the available evidence, this study suggests LAAO as a promising strategy for stroke reduction perioperatively and at the short-term follow-up without a significant increase in complications. Larger randomized studies in the future are required, with clearer surgical and anticoagulation protocols and adequate long-term follow-up, to validate the clinical efficacy of LAAO versus non-LAAO groups.

Background Patients with Brugada syndrome and aborted sudden cardiac death or syncope have higher risks for ventricular arrhythmias (VAs) and should undergo implantable cardioverter-defibrillator (ICD) placement. Device-based management of asymptomatic patients is controversial. ICD therapy is associated with high rates of inappropriate shocks and device-related complications. Objectives The objective of this study was to investigate clinical features, management, and long-term follow-up of ICD therapy in patients with Brugada syndrome. Methods Patients presenting with spontaneous or drug-induced Brugada type 1 electrocardiographic findings, who underwent ICD implantation and continuous follow-up at a single institution, were eligible for this study. Results A total of 176 consecutive patients were included. During a mean follow-up period of 83.8 ± 57.3 months, spontaneous sustained VAs occurred in 30 patients (17%). Eight patients (4.5%) died. Appropriate ICD shocks occurred in 28 patients (15.9%), and 33 patients (18.7%) had inappropriate shocks. Electrical storm occurred in 4 subjects (2.3%). Twenty-eight patients (15.9%) experienced device-related complications. In multivariate Cox regression analysis, aborted sudden cardiac death and VA inducibility on electrophysiologic studies were independent predictors of appropriate shock occurrence. Conclusions ICD therapy was an effective strategy in Brugada syndrome, treating potentially lethal arrhythmias in 17% of patients during long-term follow-up. Appropriate shocks were significantly associated with the presence of aborted sudden cardiac death but also occurred in 13% of asymptomatic patients. Risk stratification by electrophysiologic study may identify asymptomatic patients at risk for arrhythmic events and could be helpful in investigating syncope not related to VAs. ICD placement is frequently associated with device-related complications, and rates of inappropriate shocks remain high regardless of careful device programming.

Aims Surgical ablation performed concomitantly with cardiac surgery has emerged as an effective curative strategy for atrial fibrillation (AF). Left atrial (LA) lesion sets for ablation have been suggested to reduce procedural times and post-surgical bradycardia compared with biatrial (BA) lesions. Given the inconclusive literature regarding BA vs. LA ablation, the present meta-analysis sought to assess the current evidence. Methods and results Electronic searches were performed using six databases from their inception to December 2013, identifying all relevant randomized trials and observational studies comparing BA vs. LA surgical ablation AF patients undertaking cardiac surgery. In 10 included studies, 2225 patient results were available for analysis to compare BA ( n = 888) vs. LA ( n = 1337) ablation. Sinus rhythm prevalence was higher in the BA cohort compared with the LA cohort at 6-month and 12-month follow-up, but similar beyond 1 year. Permanent pacemaker implantations were higher in the BA cohort, but 30-day and late mortality, neurological events, and reoperation for bleeding were similar between BA and LA groups. Conclusions Biatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates. Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year, but this difference was not maintained beyond 1 year. Trends appear to be driven by the preferential selection of long-standing and persistent AF patients for the BA approach. Future randomized studies of adequate follow-up are required to validate risks and benefits of BA vs. LA surgical ablation.

Aims The purpose of this study was to analyse the efficacy and complication rates of the simultaneous hybrid procedure in a series of patients with persistent and long-standing persistent atrial fibrillation (AF) in a midterm follow-up. Methods and results Sixty-four consecutive patients (56 males, 59.7 ± 8.7 years) having undergone isolation of pulmonary veins (PVs) and posterior wall of left atrium (LA) by means of hybrid thoracoscopic ablation for symptomatic persistent ( n = 21, 33%) and long-standing persistent AF ( n = 43, 67%) were analysed. At a mean follow-up of 23.1 ± 14.1 months (median 21; range 6–57), the success rate without antiarrhythmic therapy was achieved in 67.2% of patients. Procedure-related complications were observed in 13 patients (20.3%) including 2 LA perforations (3.1%) requiring, respectively, conversion to sternotomy and small left-sided thoracotomy. The success rate did not significantly differ between persistent and long-standing persistent AF (respectively, 71.4 and 65.1%; P = 0.4). Patients with AF relapse during the blanking period were 4.60 times more likely to have AF recurrence after 3 months from the ablation procedure. Conclusion The hybrid procedure yields promising results in the setting of both persistent and long-standing persistent AF after midterm follow-up, at the expense of a non-negligible rate of adverse events. Our findings need to be confirmed by further larger and prospective studies.

Introduction Patients with atrial fibrillation (AF) with enlarged atria or previous pulmonary vein isolation (PVI) are challenging patients for catheter ablation. Thoracoscopic surgery is an effective treatment for these patients but comes at the cost of an increase in adverse events. Recently, electrophysiological (EP) guided approaches to thoracoscopic surgery have been described which consist of EP guidance by measurement of conduction block across ablation lines. In this study we describe the efficacy and safety of EP-guided thoracoscopic surgery for AF in patients with enlarged atria and/or prior failed catheter ablation. Methods & results A total of 72 patients were included. Two different approaches to EP-guided thoracoscopic surgery were implemented: epicardial or endocardial EP-guidance at the time of surgery. Residual intraoperative conduction requiring additional ablation was detected with epicardial or endocardial mapping techniques in 50% and 11%, respectively. Additional epicardial or endocardial ablation was performed until bidirectional block was confirmed. Follow-up consisted of an ECG and a 24h Holter at 3, 6 and 12months after the procedure. A total of 57 patients (79%) had freedom of AF and were off anti-arrhythmic drugs at one year follow-up (30 paroxysmal (83%), 27 persistent AF (75%)). Adverse events occurred in 13 patients (6 major). None of our patients died and all events were reversible. Conclusion EP-guidance of thoracoscopic surgery can be safely performed both epicardially and endocardially and is associated with a high rate of long-term maintenance of sinus rhythm in patients with enlarged atria and/or a previously failed ablation.

The hybrid approach combines an epicardial ablation with a percutaneous endocardial ablation in a single-step or sequential procedure. This study provides an overview of the hybrid procedure for the treatment of stand-alone atrial fibrillation (AF). Papers selected for this review were identified on PubMed and the final selection included nine studies. The total number of patients was 335 (range 15-101). Mean age ranged from 55.2 to 62.9 years. The hybrid approach achieved satisfactory results, with AF-antiarrhythmic drug-free success rates higher than those in isolated procedures. In particular, the bilateral approach with a bipolar device showed a high success rate independently of the AF type and seems to be the better choice for the hybrid procedure. Despite good preliminary results, large, multicentre trials of hybrid AF ablation that target a population of patients with long-standing persistent disease are necessary to establish whether this approach may represent, in the future, a gold-standard treatment for AF.

Objective: The present study was aimed at demonstrating the beneficial effect of minimally invasive radiofrequency surgical ablation on left atrial remodeling using 2-dimensional speckle-tracking echocardiography. Methods: The study population consisted of 33 patients (mean age, 64.6 +/- 6.9 years; 84.8% men) with paroxysmal lone atrial fibrillation undergoing minimally invasive radiofrequency surgical ablation at our institution (University Hospital Maastricht, Maastricht, The Netherlands) from 2007 to 2011. The control group included 20 age- and gender-matched healthy adults. The left atrial peak systolic strain, peak strain rate, peak early diastolic strain rate, and peak negative strain rate were measured. Left atrial reverse remodeling was defined as a reduction in the left atrial volume index of 15% or greater. Results: The peak systolic strain was lower in patients with atrial fibrillation than in the controls (P

Minimally invasive atrial fibrillation surgery (MIAFS) has become a well established and increasingly used option for managing patients with stand-alone arrhythmia. Pulmonary veins (PVs) isolation continues to be the cornerstone of ablation strategies. Indeed, in most cases, atrial fibrillation (AF) is triggered in or near the PVs. Nevertheless, ectopic beats initiating AF may occasionally arise from non-PV foci. The knowledge of the anatomy and underlying morphology of PVs and non-PV foci is essential for cardiac surgeons treating AF patients with epicardial minimally invasive procedures. The anatomical structures relevant to the pathogenesis and the epicardial treatment of AF include the PVs, the pericardial space, the pericardial sinuses, the phrenic nerve, the left atrium, the retro-atrial and caval ganglionated plexuses, the ligament of Marshall, the caval veins and the left atrial appendage. In this review, we briefly describe the basic anatomy of these structures and discuss their specific correlations for cardiac surgeons interested in performing MIAFS.

Background: We investigated the impact and the predictive value of sinus rhythm at 12 months (SR12) on subscales of three different HrQoL questionnaires: SF-36., EuroQoL and MFI 20. Methods: Data of 125 cardiac surgery patients with pre-operative AF from our previous randomized trial were used. Based on their rhythm outcome patients were divided in two groups: SR12 or AF at 12 months follow up (non-SR12). All questionnaires were self-administered pre-operatively and at 3 months, 6 months and 12 months after surgery. Results: Synus rhytm at 12 months was predictive of improvement of SF36-mental score (MS, p = 0.021), Euro-QoL-MS (p = 0.009), VAS (p = 0.006), and MFI 20-MS (p = 0.009). We failed to find any significant interactions between SR12 and any of the other significant risk factors: age 0.05) which were predicted by age

OBJECTIVES: We compare a short and a standard-size balloon with same filling volumes to verify the differences in terms of visceral flow, coronary circulation and haemodynamic performance during aortic counterpulsation in an animal model of myocardial ischaemia-reperfusion injury. METHODS: Eighteen healthy pigs underwent 120-min ligation of the left anterior descending coronary artery followed by 6 h of reperfusion, and they were randomly assigned to have intra-aortic balloon counterpulsation (IABP) with a 40-ml short-balloon (n = 6) or a 40-ml standard-length balloon (n = 6), or to undergo no IABP implantation (controls, n = 6). Haemodynamics and visceral and coronary flows were measured at baseline (t(0)), at 2 h of ischaemia (t(1)) and every hour thereafter until 6 h of reperfusion (from t(R1) to t(R6)), respectively. RESULTS: Mesenteric flows increased significantly at tR1 only in the short-balloon group (P 0.05). CONCLUSIONS: The short balloon prevents visceral ischaemia and, compared with the standard-size balloon, it does not lose IABP beneficial cardiac and coronary-related effects. Further studies are warranted to confirm our findings.

Aims Risk stratification in Brugada Syndrome (BS) remains challenging. Arrhythmic events can occur life-long and studies with long follow-ups are sparse. The aim of our study was to investigate long-term prognosis and risk stratification of BS patients. Methods and results A single centre consecutive cohort of 400 BS patients was included and analysed. Mean age was 41.1 years, 78 patients (19.5%) had a spontaneous type I electrocardiogram (ECG). Clinical presentation was aborted sudden cardiac death (SCD) in 20 patients (5.0%), syncope in 111 (27.8%) and asymptomatic in 269 (67.3%). Familial antecedents of SCD were found in 184 individuals (46.0%), in 31 (7.8%) occurred in first-degree relatives younger than 35 years. An implantable cardioverter defibrillator (ICD) was placed in 176 (44.0%). During a mean follow-up of 80.7 months, 34 arrhythmic events occurred (event rate: 1.4% year). Variables significantly associated to events were: presentation as aborted SCD (Hazard risk [HR] 20.0), syncope (HR 3.7), spontaneous type I (HR 2.7), male gender (HR 2.7), early SCD in first-degree relatives (HR 2.9), SND (HR 5.0), inducible VA (HR 4.7) and proband status (HR 2.1). A score including ECG pattern, early familial SCD antecedents, inducible electrophysiological study, presentation as syncope or as aborted SCD and SND had a predictive performance of 0.82. A score greater than 2 conferred a 5-year event probability of 9.2%. Conclusions BS patients remain at risk many years after diagnosis. Early SCD in first-degree relatives and SND are risk factors for arrhythmic events. A simple risk score might help in the stratification and management of BS patients.