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This report describes the findings of the 2017 Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC).Data collection was retrospective. A standardized questionnaire was completed by each of the participating centers.A total of 15 601 ablation procedures were performed by 91 institutions, with a mean of 184 ± 213 procedures per center. The most frequently treated arrhythmia was atrial fibrillation (34%), followed by atrioventricular nodal reentrant tachycardia (25%) and common atrial flutter (14%). About 10% of overall ablation procedures were performed in patients with ventricular arrhythmias. On-site cardiothoracic surgery was available in 42% of the centers performing ablation and in 49% of the centers performing atrial fibrillation ablation. In most patients, the ablation procedure was guided by a three-dimensional mapping system, and in 15% of patients a near-zero X-ray strategy was used.The Italian Catheter Ablation Registry systematically collected 1-year data on ablation procedures performed in Italy, revealing that atrial fibrillation is the most commonly treated arrhythmia in the ablation centers with an increasing number of patients treated for ventricular tachycardia.

Background The burden of premature atrial beats (PABs) at 24-h electrocardiographic (ECG) monitoring correlates with the risk of atrial fibrillation. It is unknown whether prolonged and intense exercise increases the burden of PABs, thus contributing to the higher prevalence of atrial fibrillation observed in middle-aged athletes. Methods We compared the burden of PABs at 24-h ECG monitoring off therapy in 134 healthy middle-aged (30–60-year-old) competitive athletes who had practised 9 (7-11) h of endurance sports for 8 (4-15) consecutive years, 134 age- and gender-matched healthy sedentary individuals, and 66 middle-aged patients (20 athletes and 46 non-athletes) with ‘lone’ paroxysmal atrial fibrillation. Results More than 50 PABs/24 h or ≥1 run of ≥3 PABs were recorded in 23/134 (17%) healthy athletes and in 29/134 (22%) sedentary controls ( p = 0.61). Healthy athletes with frequent or repetitive PABs were older (median 50 years vs. 43 years, p 50 PABs/24 h or ≥1 run of ≥3 PABs between athletes (40%) and controls (48%, p = 0.74) . Conclusions Middle-aged endurance athletes, with or without paroxysmal atrial fibrillation, did not show a higher burden of PABs at 24-h ECG monitoring than sedentary controls. Age, but not intensity and duration of sports activity, predicted a higher burden of PABs among healthy athletes.

Self-terminating atrial arrhythmias are commonly detected on continuous rhythm monitoring, e.g. by pacemakers or defibrillators. It is unclear whether the presence of these arrhythmias has therapeutic consequences. We sought to summarize evidence on the prevalence of atrial high-rate episodes (AHREs) and their impact on risk of stroke. We performed a comprehensive, tabulated review of published literature on the prevalence of AHRE. In patients with AHRE, but without atrial fibrillation (AF), we reviewed the stroke risk and the potential risk/benefit of oral anticoagulation. Atrial high-rate episodes are found in 10–30% of AF-free patients. Presence of AHRE slightly increases stroke risk (0.8% to 1%/year) compared with patients without AHRE. Atrial high-rate episode of longer duration (e.g. those >24 h) could be associated with a higher stroke risk. Oral anticoagulation has the potential to reduce stroke risk in patients with AHRE but is associated with a rate of major bleeding of 2%/year. Oral anticoagulation is not effective in patients with heart failure or survivors of a stroke without AF. It remains unclear whether anticoagulation is effective and safe in patients with AHRE. Atrial high-rate episodes are common and confer a slight increase in stroke risk. There is true equipoise on the best way to reduce stroke risk in patients with AHRE. Two ongoing trials (NOAH-AFNET 6 and ARTESiA) will provide much-needed information on the effectiveness and safety of oral anticoagulation using non-vitamin K antagonist oral anticoagulants in patients with AHRE.

Aims This registry was created to describe the experience of 76 Italian centres with a large cohort of recipients of multipoint pacing (MPP) capable cardiac resynchronization therapy (CRT) devices. Methods and results A total of 507 patients in whom these devices had been successfully implanted were enrolled between August 2013 and May 2015. We analysed: (i) current clinical practices for the management of such patients, and (ii) the impact of MPP on heart failure clinical composite response and on the absolute change in ejection fraction (EF) at 6 months. Multipoint pacing was programmed to ‘ON’ in 46% of patients before discharge. Methods of optimizing MPP programming were most commonly based on either the greatest narrowing of the QRS complex (38%) or the electrical delays between the electrodes (34%). Clinical and echocardiographic follow-up data were evaluated in 232 patients. These patients were divided into two groups according to whether MPP was programmed to ‘ON’ ( n = 94) or ‘OFF’ ( n = 138) at the time of discharge. At 6 months, EF was significantly higher in the MPP group than in the biventricular-pacing group (39.1 ± 9.6 vs. 34.7 ± 7.6%; P < 0.001). Even after adjustments, early MPP activation remained an independent predictor of absolute increase in LVEF of ≥5% (odds ratio 2.5; P = 0.001). At 6 months, an improvement in clinical composite score was recorded in a greater proportion of patients with MPP-ON than in controls (56 vs. 38%; P = 0.009). On comparing optimal MPP and conventional vectors, QRS was also seen to have decreased significantly ( P < 0.001). Conclusion This study provides information that is essential in order to deal with the expected increase in the number of patients receiving MPP devices in the coming years. The results revealed different practices among centres, and establishing the optimal programming that can maximize the benefit of MPP remains a challenging issue. Compared with conventional CRT, MPP improved clinical status and resulted in an additional increase in EF. Clinical Trial Registration . Unique identifier: [NCT02606071][1]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT02606071&atom=%2Feuropace%2Fearly%2F2016%2F05%2F16%2Feuropace.euw094.atom

Background In addition to the Evolution RL sheath, tools by Cook Medical (Bloomington, IN, USA), supporting lead extraction (LE), are available. Data on their use are not reported in detail in previous studies. Moreover, data regarding outcome are lacking. The aim was to evaluate the safety and effectiveness of the Evolution sheath (Evolution RL and Evolution Shortie, Cook Medical) by using a stepwise approach with the available extraction tools and the outcome. Methods A total of 393 leads in 198 consecutive patients were removed with the Evolution RL sheath and ancillary tools using a stepwise approach. Results The main indication for LE was infection in 125 (63.1%) cases. The mean implant duration was 95.4 ± 59.7 months. According to our stepwise approach, the Evolution Shortie RL sheath was used in all cases and complete LE was achieved in 24 (12.2%) cases. The Evolution RL was used in 174 (87.8%) cases and the SteadySheath Evolution tissue stabilization sheath (Cook Medical) in 87 (44%) because of tenacious fibrosis anchored targeted leads. Compression coil (OneTie, Cook Medical) was used in 141 (71%) cases. Complete procedural success rate, clinical success rate, and lead removal with clinical success rate were 97%, 99%, and 99.5%, respectively. One major complication (0.5%) and 10 (5%) minor complications were encountered. During a mean time follow-up of 12 ± 9 months, 14 (7%) patients died. Predictors of mortality included impaired renal function (HR 5.7; 95% CI 1.9-17.6; P = 0.002), extraction because of infection (hazard ratio [HR] 4.0; 95% confidence interval [CI] 1-18.1; P = 0.045), and diabetes (HR 3.2; 95% CI 1.1-9.8; P = 0.036). Conclusions Lead extraction using the Evolution RL bidirectional rotational mechanical sheath and ancillary tools in a systematic stepwise approach was effective and safe.

Introduction The recently developed second‐generation subcutaneous implantable cardioverter defibrillator (S‐ICD) and the intermuscular two‐incision implantation technique demonstrate potential favorable features that reduce inappropriate shocks and complications. However, data concerning large patient populations are lacking. The aim of this multicentre prospective study was to evaluate the safety and outcome of second‐generation S‐ICD using the intermuscular two‐incision technique in a large population study. Methods and Results The study population included 101 consecutive patients (75% male; mean age, 45 ± 13 years) who received second‐generation S‐ICD (EMBLEM; Boston Scientific, Marlborough, MA) implantation using the intermuscular two‐incision technique as an alternative to the standard implantation technique. Twenty nine (29%) patients were implanted for secondary prevention. Twenty four (24%) patients had a previously implanted transvenous ICD. All patients were implanted without any procedure‐related complications. Defibrillation testing was performed in 80 (79%) patients, and ventricular tachycardia was successfully converted at less than or equal to 65 J in 98.75% (79/80) of patients without pulse generator adjustments. During a median follow‐up of 21 ± 10 months, no complications requiring surgical revision or local or systemic device‐related infections were observed. Ten patients (9.9%) received appropriate and successful shocks for ventricular arrhythmias. Three (2.9%) patients experienced inappropriate shocks due to oversensing the cardiac signal (n = 1), noncardiac signal (n = 1), and a combination of both cardiac and noncardiac signals (n = 1), with one patient requiring device explantation. No patients required device explantation due to antitachycardia pacing indications. Conclusions According to our multicentre study, second‐generation S‐ICD implanted with the intermuscular two‐incision technique is an available safe combination and appears to be associated with a low risk of complications, such as inappropriate shocks.

Background Despite growing use of the subcutaneous implantable cardioverter‐defibrillator (S‐ ICD ), its clinical role in arrhythmogenic right ventricular cardiomyopathy/dysplasia ( ARVC /D) patients remains undefined. We aim to elucidate the cardiac phenotype, implant characteristics, and long‐term efficacy regarding appropriate therapy and complications in ARVC /D patients with an S‐ ICD implant. Methods and Results A transatlantic cohort of ARVC /D patients who underwent S‐ ICD implantation was analyzed for clinical characteristics, S‐ ICD therapy, and long‐term outcome including device‐related complications. The cohort included 29 patients (52% male, 76% probands, 59% with ARVC /D‐associated mutation, 59% primary prevention [no prior sustained ventricular arrhythmias], and 45% first‐generation S‐ ICD devices). At implant, all inducible patients (27/29) had conversion of induced ventricular fibrillation. Two patients (7%) had superficial infections of the incision site that were treated conservatively. Over a median follow‐up of 3.16 years (interquartile range: 2.21–4.51 years), all episodes (6 patients, 4% per year) of sustained ventricular arrhythmias were appropriately detected and treated. Six patients (21%) experienced 39 inappropriate shocks, with 3 requiring device explantation. Oversensing of noncardiac signal (n=4; especially myopotentials) and cardiac signal (n=4) was the most frequent etiology. No lead or device dislodgement, infection, skin erosion, or explantation related to need for antitachycardia pacing was noted. Conclusions S‐ ICD can effectively treat both induced and spontaneous ventricular arrhythmias in patients with ARVC /D. The rate of inappropriate shocks, although considerable, is comparable to that in ARVC /D patients treated with transvenous ICD s. When they occurred, inappropriate shocks were primarily due to cardiac and, uniquely, noncardiac oversensing. We suggest potential strategies for minimizing inappropriate therapy.

Aims This study was designed to assess the prognostic value of clinical and electrocardiographic parameters in Brugada syndrome (BrS). Methods and results The study population included 272 consecutive patients (82% males; mean age 43 ± 12 years), with either a spontaneous (n = 137, 50%) or drug-induced (n = 135, 50%) Type 1 Brugada electrocardiogram (ECG) pattern. The study combined endpoint included sudden cardiac death (SCD), cardiac arrest, and appropriate intervention of implantable cardioverter-defibrillator (ICD). A first-degree atrioventricular (AV) block (PR = 219 ± 17 ms) was documented at basal ECG in 45 patients (16.5%); 27 of these underwent an electrophysiological study with recording in 21 (78%) of an HV interval ≥55 ms (mean 61 ± 3 ms). Patients with first-degree AV block had a wider QRS complex (median 110 ms vs. 95 ms; P = 0.04) and more often showed a left anterior hemiblock pattern (n = 13, 29% vs. n = 35, 16%; P = 0.056). During a mean follow-up of 85 ± 55 months, 17 patients (6.3%) experienced ≥1 major arrhythmic events (appropriate ICD intervention, n = 13 and SCD, n = 4). At univariate analysis, the occurrence of major arrhythmic events was significantly associated with a history of syncope or cardiac arrest (P

Background Despite the improvements in transvenous lead extraction (TLE), patients with cardiac implantable device related infection (CIEDI) have a poor prognosis at long term. We explored the possible role of factors associated with development of CIEDI as predictors of post-TLE survival. Methods We performed a multi-center prospective observational study in a population of consecutive patients referred for TLE for CIEDI. We adopted a previously developed 10-point scale for CIEDI risk stratification and assessed its performance in predicting post-TLE survival. Results We enrolled 169 consecutive patients with CIEDI (systemic infection in 48.5% and vegetations in 24.5%). A Shariff score ≥ 3 was present in 102/169 (60.4%) of the enrolled patients. Complete radiological success of TLE was obtained in 163 patients. Twenty-seven patients (15.9%) died after a mean follow-up of 20.8 ± 12.0 months. Two factors were independently associated with post-TLE death: a Shariff score ≥ 3 (HR 10.833, 95% CI 2.544–46.129; p = 0.001) and the presence of vegetations at transesophageal echocardiography (HR 3.324, 95% CI 1.530–7.221; p = 0.002). Conclusions Risk factors for development of CIEDI are also predictive of post TLE mortality, together with the presence of vegetations. Improvement of our preventive strategies for CIEDI is crucial for enhancing the outcomes of CIED patients overall.

Background To determine whether daily physical activity (PA), as measured by implanted devices (through accelerometer sensor), was related to the risk of developing atrial arrhythmias during long‐term follow‐up in a population of heart failure (HF) patients with an implantable cardioverter defibrillator (ICD). Methods and Results The study population was divided into 2 equally sized groups (PA cutoff point: 3.5 h/d) according to their mean daily PA recorded by the device during the 30‐ to 60‐day period post‐ICD implantation. Propensity score matching was used to compare 2 equally sized cohorts with similar characteristics between lower and higher activity patients. The primary end point was time free from the first atrial high‐rate episode (AHRE) of duration ≥6 minutes. Secondary end points were: first AHRE ≥6 hours, first AHRE ≥48 hours, and a combined end point of death or HF hospitalization. Data from 770 patients (65±15 years; 66% men; left ventricular ejection fraction 35±12%) remotely monitored for a median of 25 months were analyzed. A PA ≥3.5 h/d was associated with a 38% relative reduction in the risk of AHRE ≥6 minutes (72‐month cumulative survival: 75.0% versus 68.1%; log rank P =0.025), and with a reduction in the risk of AHRE ≥6 hours, AHRE ≥48 hours, and the combined end point of death or HF hospitalization (all P Conclusions In HF patients with ICD, a low level of daily PA was associated with a higher risk of atrial arrhythmias, regardless of the patients' baseline characteristics. In addition, a lower daily PA predicted death or HF hospitalization.

Axillary vein puncture is an effective method for pacemaker lead insertion with less complications compared with subclavian vein puncture; however, there are limited data on implantable cardioverter defibrillator (ICD) implantation with this technique. We reported our experience with a blind axillary vein puncture using fluoroscopic landmarks consisting of the outer edge of the first rib and the body surface of the second rib for ICD lead implantation. The study population included 103 consecutive patients (mean age 59 ± 9 years) referred for ICD implantation using axillary vein puncture without contrast venography. An 18-gauge needle was advanced toward the outer edge of the fist rib below the clavicle or the body surface of the second rib. If the vein was not entered, the needle was withdrawn and the puncture was repeated with slight variations of needle direction for a maximum of four times, then contrast-guided vein puncture was performed. The total implanted leads were 152 including 103 right ventricular leads, 35 right atrial leads, and 14 left ventricular epicardial leads. Blind axillary vein puncture was successful obtained in 96 (93.2 %) patients. The rate of success was higher using the body surface of the second rib compared with the outer edge of the first rib (88.7 vs. 100 %; p = 0.04).Contrast venography was required in seven (6.8 %) patients because of vein course abnormality (n = 5) or vasospasm (n = 2). No acute complications or device-related complications were recorded during a mean follow-up of 12 ± 5 months. Axillary vein access using fluoroscopic landmarks, especially the body surface of the second rib, is an effective approach for ICD implantation and offers the potential to avoid complications usually observed with traditional subclavian vein approach

Background Permanent atrial pacing usually involves lead placement in the right atrial appendage (RAA). Anatomical studies addressing features predisposing to complications are scanty. Objective To assess the morphology of RAA in the perspective of pacing, including the morphology of tenia sagittalis (TS) and the spatial relationship with the aorta. Methods The gross anatomy of the RAA has been analyzed in a consecutive series of 100 hearts following a case of iatrogenic perforation of the aorta by active fixation lead located in the RAA. Transmural RAA sections were taken from 40 hearts to assess the wall thickness at the level of pectinate muscles (PMs) and of inter-PMs spaces and the distance between adjacent PMs. Results The TS was present in 90% of cases (single trunk, 76%; double trunk, 13%; and triple trunk, 1%), demarcating the proximal antral RAA region (facing the adjacent aorta) from the distal saccular RAA region (facing the pulmonary infundibulum). The RAA free wall in the inter-PMs spaces is usually paper-thin and translucent. Histomorphometric analysis reveals that the RAA wall mean thickness was 1.38 ± 0.05 mm (range 0.64–4.25 mm) at the level of PMs and 0.39 ± 0.23 mm (range 0.09–1.05 mm) at the level of inter-PMs spaces. The mean distance between adjacent PMs was 0.88 ± 0.99 mm (range 0.04–4.12 mm). Conclusion In 90% of hearts, a well-defined TS separates the distal saccular from the proximal antral RAA, the latter being closely adjacent to the ascending aorta. The paper-thin wall between PMs is potentially at risk of perforation, and aortic injury could occur when active fixation leads are anchored in the antral RAA, as demonstrated in an iatrogenic fatal case.

Randomized and controlled studies have reported the effect of catheter ablation (CA) for atrial fibrillation (AF) over a follow-up of 12-24 months.We report on the effect of CA plus antiarrhythmic drugs in comparison with antiarrhythmic drugs alone on the maintenance of sinus rhythm over 12-year follow-up.We extended the follow-up duration of the 137 patients who were enrolled in the Catheter Ablation for the Cure of Atrial Fibrillation Study between February 1, 2002, and June 30, 2003, and randomized to antiarrhythmic drugs (control group) or antiarrhythmic drugs plus CA (ablation group). The primary end point was time to first symptomatic or asymptomatic recurrence of atrial arrhythmia lasting30 seconds during follow-up.During follow-up, 19 of 68 (27.9%; 95% confidence interval [CI] 18.7%-39.6%) ablation group patients and 3 of 69 (4.3%; 95% CI 1.49%-12.0%) control group patients did not experience any relapse of atrial tachyarrhythmia (P.001). The Kaplan-Meier analysis performed to determine the probability of survival free from atrial arrhythmias showed a statistical difference in favor of the ablation group (log-rank, P.001). The effect of CA was consistent in both patients with paroxysmal AF and those with persistent AF. In the multivariate Cox regression analysis, belonging to the control group (hazard ratio 2.95; 95% CI 1.896-4.726; P.001) and longer time since first AF episode (hazard ratio 1.004; 95% CI 1.002-1.084; P = .041) were predictors of atrial tachyarrhythmia recurrence.In patients with paroxysmal and persistent AF, CA significantly increased time to first recurrence of atrial arrhythmias during 12-year follow-up.

Summary Background Although the effects of air pollution on mortality have been clearly shown in many epidemiological and observational studies, the pro-arrhythmic effects remain unknown. We aimed to assess the short-term effects of air pollution on ventricular arrhythmias in a population of high-risk patients with implantable cardioverter-defibrillators (ICDs) or cardiac resynchronisation therapy defibrillators (ICD-CRT). Methods In this prospective multicentre study, we assessed 281 patients (median age 71 years) across nine centres in the Veneto region of Italy. Episodes of ventricular tachycardia and ventricular fibrillation that were recorded by the diagnostic device were considered in this analysis. Concentrations of particulate matter of less than 10 μm (PM 10 ) and less than 2·5 μm (PM 2·5 ) in aerodynamic diameter, carbon monoxide, nitrogen dioxide, sulphur dioxide, and ozone were obtained daily from monitoring stations, and the 24 h median value was considered. Each patient was associated with exposure data from the monitoring station that was closest to their residence. Patients were followed up for 1 year and then scheduled to have a closing visit, within 1 more year. This study is registered with ClinicalTrials.gov, number NCT01723761. Findings Participants were enrolled from April 1, 2011, to Sept 30, 2012, and follow-ups (completed on April 5, 2014) ranged from 637 to 1177 days (median 652 days). The incidence of episodes of ventricular tachycardia and ventricular fibrillation correlated significantly with PM 2·5 (p 10 . An analysis of ventricular fibrillation episodes alone showed a significant increase in risk of higher PM 2·5 (p=0·002) and PM 10 values (p=0·0057). None of the gaseous pollutants were significantly linked to the occurrence of ventricular tachycardia or ventricular fibrillation. In a subgroup analysis of patients with or without a previous myocardial infarction, only the first showed a significant association between particulate matter and episodes of ventricular tachycardia or ventricular fibrillation. Interpretation Particulate matter has acute pro-arrhythmic effects in a population of high-risk patients, which increase on exposure to fine particles and in patients who have experienced a previous myocardial infarction. The time sequence of the arrhythmic events suggests there is an underlying neurally mediated mechanism. From a clinical point of view, the results of our study should encourage physicians to also consider environmental risk when addressing the prevention of arrhythmic events, particularly in patients with coronary heart disease, advising them to avoid exposure to high levels of fine particulate matter. Funding There was no funding source for this study.

Aims The aim of this prospective multicentre study is to evaluate safety and efficacy of the new bidirectional rotational mechanical lead extraction (LE) sheath (Evolution RL, Cook Medical, USA) in chronically implanted leads (>1-year-old leads). Methods and results Between September 2013 and June 2016, a total of 238 leads in 124 consecutive patients were removed by using the new Evolution RL rotational mechanical sheath. Indications for LE were cardiac device infection in 63 (50.8%) cases, lead malfunction in 41 (33.1%), upgrade in 1 (0.8%) case and for other reasons in the remaining 19 cases (15.3%). Ninety-one leads (38.2%) were implantable cardioverter defibrillator leads (81 dual coil vs. 10 single coil), 38 (16%) right ventricular leads, 86 (36.1%) right atrial leads, and 23 (9.7%) coronary sinus leads. The mean implant duration was 92.2 ± 52.9 months (range 12-336). 91.6% of the leads (218/238) were extracted completely with the Evolution RL alone, with the complete success rate rising to 98.7% (235/238 leads) with combined use of a snare. Overall clinical success rate was 100%. No Evolution sheath-related complications were noted. There were no deaths or major complications. Five minor complications (4%) were encountered. In cases of companion leads no wrapping or lead damage were observed. Conclusion On the basis of our prospective multicentre study, the new hand-powered bidirectional rotational mechanical LE sheath is an effective and safe tool for the extraction of chronically implanted leads without major complications and lead wrapping or lead damage.

Conventional biventricular pacing (BiV) involves pacing from the right ventricle (RV), and the left ventricle (LV) usually using a single bipolar lead at one site via the coronary sinus (CS), with the aimto restore electrical and mechanical synchrony in heart failure (HF) patients.1 However, one-third of patients fail to clinically respond to cardiac resyncronization therapy (CRT), which may be partially due to a suboptimal location of the LV lead position with persistent LV dyssynchrony.2 In search for improvements in CRT, several authors have proposed a multisite LV stimulation using multiple leads in different branches of the CS.3 However, this technique is associated with increased procedure duration, fluoroscopy exposure, and potential complications. A new approach that involves a multisite pacing performed within a single CS branch by using a single quadripolar lead (multipoint pacing, or MPP; St. Jude Medical, Sylmar, CA) has been suggested recently. Benefits in acute haemodynamics using pressure-volume loop analysis and LV dyssynchrony using two dimensional echocardiographic (2DE) have been demonstrated with MPP in comparison with BiV.4-7 Nevertheless, the effects of MPP on LV dyssynchrony using three-dimensional echocardiography (3DE) and on diastolic filling have not been established yet. Echocardiographic particle imaging velocimetry (Echo-PIV) is an emerging imaging technique, which allows intraventricular fluid dynamics blood assessment and characterization of diastolic vortex formation that may play a key role in LV filling efficiency.8-12 Recent fluid dynamics data demonstrated that in normal LV, the blood flow is characterized by a longitudinal alignment along the base-apex direction of the intraventricular hemodynamic fluid dynamics in compliance with the empting-filling process.12 Conversely, HF patients show an irregular vortex formation with local stagnation resulting in transversal forces and loss of the physiological longitudinal orientation of the intraventricular velocites.8-12 Changes in intraventricular flow dynamics by CRT are supposed to result in a longitudinal alignment restoration of LV intraventricular velocities.12 Accordingly, the aim of the present studywas to characterize the effect of MPP compared to BiV on: (i) LV geometry and function assessed by conventional 2DE and 3DE and (ii) LV flow dynamics assessed by Echo- PIV.

The traditional technique for subcutaneous implantable cardioverter defibrillator (S-ICD) implantation, which involves three incisions and a subcutaneous pocket, is associated with possible complications, including inappropriate interventions. The aim of this prospective multicenter study was to evaluate the efficacy and safety of an alternative intermuscular two-incision technique for S-ICD implantation.The study population included 36 consecutive patients (75% male, mean age 44 ± 12 years [range 20-69]) who underwent S-ICD implantation using the intermuscular two-incision technique. This technique avoids the superior parasternal incision for the lead placement and consists of creating an intermuscular pocket between the anterior surface of the serratus anterior and the posterior surface of the latissimus dorsi muscles instead of a subcutaneous pocket.All patients were successfully implanted in the absence of any procedure-related complications with a successful 65-J standard polarity defibrillation threshold testing, except in one, who received a second successful shock after pocket revision. During a mean follow-up of 10 months (range 3-30), no complications requiring surgical revision were observed. At device interrogation, stable sensing without interferences was observed in all patients. Two patients (5.5%) experienced appropriate and successful shock on ventricular fibrillation and in four patients (11%), a total of seven nonsustained self-terminated ventricular tachycardias were correctly detected. No inappropriate interventions were observed.Our experience suggests that the two-incision intermuscular technique is a safe and efficacious alternative to the current technique for S-ICD implantation that may help reducing complications including inappropriate interventions and offer a better cosmetic outcome, especially in thin individuals.

Aims Left atrial ablation fails to prevent symptomatic recurrences of atrial fibrillation (AF) in 20–30% of patients up to 3 years of follow-up despite multiple procedures. Data are lacking on the long-term clinical outcome of those patients for whom the decision was taken to renounce performing further ablation procedures. Methods and results In this multicentre study, 218 (34%) of 631 consecutive patients, who had undergone AF catheter ablation in the years 2001–11 for drug-refractory symptomatic AF, had symptomatic AF recurrences after 1.5 ± 0.6 procedures. Their long-term clinical outcome was assessed in March 2012 (minimum follow-up 1 year). At a mean of 5.1 ± 2.6 years since their last ablation, 82 (38%) patients improved, 103 (47%) remained unchanged and 33 (15%) worsened, but only 17 (8%) had such a severe impairment of their quality of life as to require atrioventricular junction ablation and pacing (#13) or cardiac surgery (#4); 22 (10%) patients had had adverse clinical events (death in five, heart failure in five, stroke and transient ischaemic cerebral attack in four, severe haemorrhage in four, pacemaker or implantable cardioverter-defibrillator implantation in seven) and 98 (45%) patients had developed permanent AF. Compared with patients without permanent AF, fewer patients with permanent AF improved (3% vs. 66%, P = 0.001) and more got worse (28% vs. 5%, P = 0.001). At multivariable logistic regression, single ablation procedure, left atrial diameter, persistent AF and time from the last ablation were independent predictors of permanent AF. Conclusion More than 5 years after a failed AF ablation, a small minority of patients had such an impaired quality of life as to require non-pharmacological interventions. Almost half developed permanent AF, which significantly impaired quality of life. Permanent AF was more common in patients who had left atrial enlargement, history of persistent AF, longer follow-up, and had performed a single ablation procedure, thus hypothesizing that reablation could reduce the chronicization of arrhythmia. A low risk of stroke was observed in the long-term follow-up.

Laboratorio di Elettrofisiologia Dipartimento di Cardiologia Ospedale Civile di Mirano, Mirano, Italy;†Az. Ospedaliera S. Maria della Misericordia, Udine, Italy; ‡Azienda Ospedaliera Sacro Cuore Don Calabria, Negrar,Italy; §Ospedale Mater Salutis di Legnago, Legnago, Italy; ¶Ospedale Santa Maria del Carmine, Rovereto, Italy

Background Cardiac perforation of the right ventricle (RV) is a rare but potentially life-threatening complication of both pacemaker (PM) and implantable cardioverter defibrillator (ICD) implant. Appropriate management is still uncertain. We assessed the incidence of subacute (24 hours–1 month) or delayed (>1 month) cardiac perforation by RV lead and the results of percutaneous lead extraction. Method The study population included all patients diagnosed with subacute or delayed RV-lead perforation during the period 2007–2013. The incidence of perforation according to device type and fixation mechanism was calculated. The outcome of the percutaneous approach, consisting of lead extraction by simple traction, was assessed. Results Cardiac perforation was diagnosed in 14 (eight females, mean age 71 [range 47–83] years) patients out of 3,815 who received an RV-lead implant (0.4%). The overall incidence of RV-lead perforation was similar between ICD (0.3%) and PM (0.4%) implants (P = 1.0) and between active (0.5%) and passive (0.3%) fixation leads (P = 0.3). All perforating leads were originally placed at the RV apex. Five patients were asymptomatic, but all presented altered lead electrical parameters. Surgical removal of the lead was performed in one patient while in the remaining the leads were successfully extracted by direct manual traction in the absence of any complications. In all patients, new active fixation leads were positioned in the RV septum and the follow-up (42 ± 27 months) was uneventful. Conclusions RV perforation is a rare complication of both PM and ICD implants, regardless of the lead fixation mechanism. In most patients, percutaneous lead extraction is a safe and effective management approach.

A variable proportion, up to 30%, of patients who undergo cardiac resynchronization therapy (CRT) do not benefit from treatment. The aim of the Cardiac Resynchronization Therapy MOdular REgistry (CRT MORE) is to determine whether specific electrocardiographic and radiographic parameters can be used to predict clinical and echocardiographic response to CRT.The CRT MORE is a prospective, single-arm, multicenter cohort study designed to evaluate the electrocardiographic and radiographic predictors of response to CRT. All study patients receive a pacemaker or implantable defibrillator for CRT delivery in accordance with current guidelines. Enrollment started in December 2011 and is scheduled to end in November 2013. Approximately 1100 consecutive patients will be enrolled in 30 Italian centers and will be followed up for 60 months after implantation. The primary endpoint is the improvement in clinical (Clinical Composite Score) and echocardiographic (a decrease of ≥ 15% in left ventricular end-systolic volume) parameters at the 6-month follow-up visit.This study might provide important information about which electrocardiographic and radiographic parameters better predict CRT response.

Rhythm-Symptom Correlation in Patients on Continuous Monitoring Introduction Correlation between symptoms and atrial fibrillation (AF) episodes after catheter ablation may have clinical relevance, especially for anticoagulation usage. The aim of our project was to analyze the relationship between symptoms and AF recurrences in unselected patients following AF catheter ablation during long-term follow-up. Methods and Results One hundred and forty-three consecutive patients (mean age 59 ± 9 years, 85% male) were implanted with a continuous cardiac monitor (RevealXT, Medtronic Inc., Minneapolis, MN, USA) following first pulmonary vein ablation procedure. Device data were downloaded every 3 months and correlated to patients’ symptom diary. AF was paroxysmal in 55% and persistent in 45%. At a mean follow-up of 14 ± 6 months, 98/143 (69%) patients had at least one AF recurrence. Among these, 53 (54%) reported AF-related symptoms while 45 (46%) were totally asymptomatic. Conversely, 13 (29%) out of 45 patients without AF recurrences reported symptoms. Globally, a significant reduction of symptoms (from 82% at baseline to 44% at last follow-up; P

Safety of Catheter Ablation for Atrial Fibrillation Introduction Despite catheter ablation (CA) becoming an accepted treatment option for symptomatic, drug-resistant atrial fibrillation (AF), safety of this procedure continues to be cause for concern. Aim of the present multicenter registry was to assess the incidence of early CA complications and detect their predictors in a contemporary, unselected AF population Methods and Results From January 1, 2011 to December 31, 2011, data from 2,323 consecutive patients who underwent CA (median age 60 [52–67]; 72.3% male) for AF in 29 Italian centers were collected. All major complications occurring to the patient from admission to 30th postprocedural day were recorded. No procedure-related death was observed. Major complications occurred in 94 patients (4.0%): 50 patients (2.2%) suffered vascular access complications; 12 patients (0.5%) developed cardiac tamponade; 14 patients (0.6%) presented with pericarditis; 5 patients (0.2%) had transient ischemic attack; 4 patients had stroke; 3 patients (0.1%) had phrenic nerve paralysis; 3 patients (0.1%) had hemothorax. Other isolated but serious adverse events were documented in 3 patients (0.1%). Female gender (OR 2.643; 95% CI 1.686–4.143; P < 0.0001) and longer procedural duration (OR 2.195; 95% CI 1.388–3.473; P < 0.001) independently predicted a higher risk of complications. Conclusion Major complications occurred in 4.0% of the CA procedures for AF, with vascular access complications being the most frequent events.

Aims In candidates for cardiac resynchronization therapy (CRT), the choice between pacemaker (CRT-P) and defibrillator (CRT-D) implantation is still debated. We compared the long-term prognosis of patients who received CRT-D or CRT-P according to class IA recommendations of the European Society of Cardiology (ESC) and who were enrolled in a multicentre prospective registry. Methods and results A total of 620 heart failure patients underwent successful implantation of a CRT device and were enrolled in the Contak Italian Registry. This analysis included 266 patients who received a CRT-D and 108 who received a CRT-P according to class IA ESC indications. Their survival status was verified after a median follow-up of 55 months. During follow-up, 73 CRT-D and 44 CRT-P patients died (rate 6.6 vs. 10.4%/year; log-rank test, P = 0.020). Patients receiving CRT-P were predominantly older, female, had no history of life-threatening ventricular arrhythmias, and more frequently presented non-ischaemic aetiology of heart failure, longer QRS durations, and worse renal function. However, the only independent predictor of death from any cause was the use of CRT-P (hazard ratio, 1.97; 95% confidence interval, 1.21–3.16; P = 0.007). Conclusion The implantation of CRT-D, rather than CRT-P, may be preferable in patients presenting with current class IA ESC indications for CRT. Indeed, CRT-D resulted in greater long-term survival and was independently associated with a better prognosis.

Background Transesophageal echocardiography (TEE) is routinely performed before atrial fibrillation (AF) transcatheter ablation to exclude the presence of left atrial (LA) or LA appendage (LAA) thrombi. The aim of the study is to evaluate if easily accessible clinical parameters may relate to the presence of LA or LAA thrombi to identify patients who could potentially avoid TEE. Methods and results Between January 2012 and September 2014, data from 1539 consecutive patients undergoing TEE, as a work-up before AF transcatheter ablation, in six large volume centers were collected. Baseline clinical features, CHA 2 DS 2 -VASc score, transthoracic echocardiography and presence of thrombi at TEE were recorded. Exclusion criteria were valvular, hypertrophic or dilated cardiomyopathy, previous heart surgery or an ejection fraction ≤35%. Mean age was 59.6±10.4years, 1215 (78.9%) were males; 951 (62.9%) presented in sinus rhythm (SR) on admission, 324 (21.1%) had undergone at least one previous ablation and 900 (58.5%) had CHA 2 DS 2 -VASc score 0–1. Thrombi were encountered in 12 patients (0.8%). SR at TEE independently related to the absence of thrombi (OR 5.15, 95% CI 1.38–19.02, p =0.015); in addition to this, no patient with a CHA 2 DS 2 -VASc score 0–1 and SR on admission presented thrombi at TEE (specificity 100%, p =0.011). Conclusion In a selected population of patients referred for AF ablation, LA/LAA thrombi prevalence is low. No patients in SR with CHA 2 DS 2 -VASc score 0–1 presented LAA thrombi at TEE, identifying a significant subset of patients who could potentially safely be spared from pre-procedural TEE.

AIMS This study was designed to prospectively evaluate the risk-benefit ratio of implantable cardioverter defibrillator (ICD) therapy in young patients with cardiomyopathies and channelopathies. METHODS AND RESULTS The study population included 96 consecutive patients [68 men, median age 27 (22-32) years] with cardiomyopathies, such as arrhythmogenic right ventricular cardiomyopathy (n = 35), dilated cardiomyopathy (n = 17), hypertrophic cardiomyopathy (n = 15), Brugada syndrome (n = 14), idiopathic ventricular fibrillation (n = 5), left ventricular noncompaction (n = 4), long-QT syndrome (n = 4) and short-QT syndrome (n = 2), who were 18-35 years old at the time of ICD implantation. During a mean follow-up of 72.6 ± 53.3 months, one patient with end-stage hypertrophic cardiomyopathy died because of acute heart failure, and 11 patients underwent orthotopic heart transplantation. Twenty patients (20.8%) had a total of 38 appropriate ICD interventions (4%/year), and 26 patients (27.1%) experienced a total of 49 adverse ICD-related events (5.4%/year), including 23 inappropriate ICD interventions occurring in nine patients (9.4%) and 26 device-related complications requiring surgical revision occurring in 20 patients (20.8%). Lead failure/fracture requiring lead extraction was the most common complication (n = 9). A threshold for ICD therapy less than 300 ms was associated with a borderline significant lower probability of inappropriate ICD interventions (hazard ratio = 0.2; 95% confidence interval 0.02-1.2; P = 0.07), whereas underweight status was an independent predictor of device-related complications (hazard ratio = 5.4; 95% confidence interval 1.5-19.4; P = 0.01). CONCLUSION In young patients with cardiomyopathies and channelopathies, ICD therapy provided life-saving protection by effectively terminating life-threatening ventricular arrhythmias. However, because ICD-related adverse events are common, the risk/benefit ratio should be carefully assessed when considering ICD implantation in young people.

Our article on “arrhythmic” mitral valve prolapse (MVP)1 triggered a debate among clinical cardiologists about the implications in terms of diagnosis, risk stratification, and therapy. Thus, the letters by Sheppard et al and Providencia and Lambiase are welcome and give us the opportunity to be back on this hot topic. Sheppard et al, by studying a series of sudden cardiac death (SCD) victims with classic myxoid mitral valve degeneration, found similar features in terms of myocardial fibrosis in one or both papillary muscles and adjacent left ventricular free wall, although they did not specifically assess the inferobasal wall. Their findings further strengthen our hypothesis that left ventricular scarring in targeted areas subjected to higher mechanical stress is the substrate of electric instability in arrhythmic MVP and support a role for contrast-enhanced cardiac magnetic resonance for risk stratification in a selected subgroup of patients. Furthermore, the authors did not find a female preponderance …

Background— Arrhythmic mitral valve prolapse (MVP) is characterized by myxomatous leaflets and left ventricular (LV) fibrosis of papillary muscles and inferobasal wall. We searched for morphofunctional abnormalities of the mitral valve that could explain a regional mechanical myocardial stretch. Methods and Results— Thirty-six (27 female patients; median age: 44 years) arrhythmic MVP patients with LV late gadolinium enhancement on cardiac magnetic resonance and no or trivial mitral regurgitation, and 16 (6 female patients; median age: 40 years) MVP patients without LV late gadolinium enhancement were investigated by morphofunctional cardiac magnetic resonance. Mitral annulus disjunction (median: 4.8 versus 1.8 mm; P P =0.004) and end-diastolic mitral annular diameters (median: 35.5 versus 31.5; P =0.042), prevalence of posterior systolic curling (34 [94%] versus 3 [19%]; P 1.5 (22 [61%] versus 4 [25%]; P =0.016) were higher in MVP patients with late gadolinium enhancement than in those without. A linear correlation was found between mitral annulus disjunction and curling ( R =0.85). A higher prevalence of auscultatory midsystolic click (26 [72%] versus 6 [38%]; P =0.018) was also noted. Histology of the mitral annulus showed a longer mitral annulus disjunction in 50 sudden death patients with MVP and LV fibrosis than in 20 patients without MVP (median: 3 versus 1.5 mm; P Conclusions— Mitral annulus disjunction is a constant feature of arrhythmic MVP with LV fibrosis. The excessive mobility of the leaflets caused by posterior systolic curling accounts for a mechanical stretch of the inferobasal wall and papillary muscles, eventually leading to myocardial hypertrophy and scarring. These mitral annulus abnormalities, together with auscultatory midsystolic click, may identify MVP patients who would need arrhythmic risk stratification.

Different methods for venous access are used for permanent pacemaker or implantable cardioverter defibrillator (ICD), of which subclavian vein puncture technique is the most widely practised. Although this approach is relatively easy to learn, quick and offers high success rates, it may be associated with potential serious acute complications including pneumothorax, emopneumothorax, brachial plexus injury and longer-term complications such as lead fracture, loss of lead insulation and subclavian crush syndrome especially in young patients with ICD leads. Axillary vein approach seems to be a favourable technique not only for the prevention of acute complications but also to reduce lead failure including lead insulation and lead fracture prevention with a consequently better long-term lead survival compared with the classical subclavian approach. Although randomized studies are lacking, recent reports not only evaluated the safety and effectiveness of new fluoroscopic axillary venous puncture technique, but also compared it with the conventional intrathoracic subclavian venous puncture technique for the implantation of leads in permanent pacing. Various techniques of axillary vein puncture have been proposed ranging from a blind percutaneous puncture to the use of different tools such as contrast venography and ultrasound. In this article, we report a case of subclavian crush syndrome, the use of a modified Bellot's technique of axillary vein puncture that we currently use and the potential benefits of axillary vein puncture for pacemaker and ICD leads implantation compared with subclavian approach to avoid acute and long-term lead complications.

Implantable cardiac monitors (ICMs) continuously monitor the patient's electrocardiogram and perform real-time analysis of the heart rhythm, for up to 36 months. The current clinical use of ICMs involves the evaluation of transitory symptoms of possible arrhythmic origin, such as unexplained syncope and palpitations. Moreover, ICMs can also be used for the evaluation of difficult cases of epilepsy and unexplained falls, though current indications for their application in these sectors are less clearly defined. Finally, the ability of new-generation ICMs to automatically record arrhythmic episodes suggests that these devices could also be used to study asymptomatic arrhythmias, and thus could be proposed for the long-term evaluation of the total (symptomatic and asymptomatic) arrhythmic burden in patients at risk of arrhythmic events. In particular, ICMs may have an emerging role in the management of patients with atrial fibrillation and in those at risk of ventricular arrhythmias. (PACE 2012; 35:1169–1178)

We report the case of a 37-year-old man with a definite diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) according with the current Task Force Criteria [(1)][1] referred to our institution for implantable cardioverter-defibrillator (ICD) for secondary prevention of sudden cardiac

Aims Catheter ablation of atrial fibrillation (AF) focuses on pulmonary vein (PV) ablation with or without additional atrial substrate modification. These procedures require significant fluoroscopy exposure. A new 3D non-fluoroscopic navigation system (CARTO® 3 System, Biosense Webster, CA, USA) that allows precise location visualization of diagnostic and ablation catheters was evaluated for its impact on fluoroscopic exposure during AF ablation procedures. Methods and results Two groups of patients were treated by our centres for drug refractory AF. One group was treated using the new CARTO® 3 system to guide catheter ablation (Group A, 117 patients). The other group was treated using the CARTO® XP system (Biosense Webster) 3 months previously (Group B, 123 patients). For both groups, circumferential PV ostia ablation was performed; PV isolation was validated using a circular catheter placed at each ostium. There was no difference in any clinical characteristics (age, sex, AF type, left atrium diameter and volume, and heart disease) among the two study groups. The mean number of PVs identified and isolated per patient was similar in both groups, as were the mean procedural duration and radiofrequency time. However, mean fluoroscopic time was significantly reduced in Group A (15.9±12.3 min) as compared with Group B (26±15.1 min) ( P < 0.001). Conclusion This multicentre observational study demonstrates a significant reduction of fluoroscopy exposure using a new 3D non-fluoroscopic mapping system to guide AF catheter ablation.

Background and Objectives: The reliability of active-fixation atrial leads has been compared with that of passive-fixation leads; comparisons have also been made between straight and J-shaped screw-in lead systems. However, few data are available on procedural and short-term safety. This retrospective study compared the procedural safety of non-pre-shaped screw-in leads with that of passive- and active-fixation J-shaped leads. Patients and Methods: From January 2004 to January 2010, 1,464 patients underwent new pacemaker/implantable cardioverter-defibrillator implantation. Of these, 915 (study population) received a passive- or active-fixation pre-J-shaped lead, or a straight screw-in atrial lead; the remaining 549 patients, who received only a ventricular lead, were excluded. The three study groups were: Group S-FIX (165 patients, 18%), receiving a straight screw-in atrial lead (postshaped in the right appendage); Group J-PASS (690 patients, 75.4%), receiving a passive-fixation J-shaped atrial lead; and Group J-FIX (60 patients, 6.6%), receiving an active-fixation screw-in J-shaped atrial lead. Procedural and short-term complication rates were analyzed up to 3 months postimplantation. Results: One complication occurred in each group (S-FIX 0.6% vs J-PASS 0.1% vs J-FIX 1.6%, P = 0.3, 0.1, and 0.4, respectively, for each comparison). The rate of atrial lead dislodgement was higher in Group J-PASS than in S-FIX but not J-FIX (Group S-FIX 0 vs Group J-PASS 16 vs Group J-FIX 1 dislodgements; P = 0.04 and 0.7, respectively). Conclusion: Straight screw-in atrial leads, “J-post shaped” in the right appendage, offer better stability than passive-fixation J-shaped leads and display a similarly acceptable safety profile compared with both the J-shaped systems. (PACE 2011; 34:325–330)

ACC guidelines recommend an implantable cardioverter defibrillator (ICD) in patients with symptomatic heart failure and left ventricular ejection fraction (LVEF) ≤ 35%. Conventionally, two-dimensional echocardiography (2DE) LVEF has been used, however three-dimensional echocardiography (3DE)