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Urolithiasis has high incidence in industrialized countries (0.5% in Europe and North America). Its high incidence along with the severity of clinical symptoms makes nephrolithiasis an important consideration in patients with acute abdominal pain. Imaging has a pivotal role and non-contrast computed tomography scan is the gold standard examination in both the diagnosis and follow-up of patients with urolithiasis. Ultrasound and kidneys, ureters, and bladder radiography are also essential tools in the follow-up of this pathology given its high recurrence rates while MRI can be used in special patient populations such as pregnant women., Competing Interests: Disclosures The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Cystic echinococcosis (CE) is a zoonotic disease caused by Echinococcus granulosus sensu lato, the metacestode of a tapeworm parasite of high medical importance. Infection of the parasite leads to the development of echinococcal cysts, and the spleen is a rarely infected organ. A 46-year-old woman who was born and who resides in Sardinia, Italy, was referred to the Echinococcosis outpatient clinic at the University Hospital of Sassari (Sardinia, Italy) for a pain in the left flank. She used to live in the countryside, in contact with several animals, and for 2 years, she had been working in a family garden, growing vegetables as a hobby. Ultrasounds and X-ray were performed, which evidenced a rounded formation in the upper third of the spleen, while a CT scan confirmed a parasitological cyst. Immunological examinations on serum samples did not detect specific antibodies against Echinococcus spp. Following surgical exportation, the whole spleen with the cystic lesion was delivered to the World Organisation for Animal Health (WOAH) and the National Reference Laboratory for Echinococcosis for further laboratory analyses. Moreover, characterization of the cyst fluid resulted dense and shiny. Observation under a light microscope at ×400 magnification revealed the formation of rectangular crystals and aggregates attributable to cholesterol molecules. Subsequently, through parasitological investigation, molecular biology investigations confirmed E. granulosus sensu stricto G1. We describe cholesterol crystals in a splenic echinococcal cyst for the first time. There is no clear explanation of how the cholesterol crystals formed in this case, but this was attributed to multifactorial causes, including atherosclerosis, chronic inflammation, parasite metabolism, and host responses., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2025 Santucciu, Hajjafari, Sadr, Mastrandrea, Rettaroli, Simbula, Scaglione, Masala, Peruzzu and Masala.)

Background: The combination of highly localized impedance (LI) and contact force (CF) may improve tissue characterization and lesion prediction during radiofrequency (RF) pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF)., Objective: We report the outcomes of our acute and long-term clinical evaluation of CF-LI-guided PVI in consecutive AF ablation cases from an international multicenter clinical setting., Methods: Three hundred twenty-four consecutive patients from 20 European centers undergoing RF catheter ablation with the Stablepoint™ catheter were enrolled in the CHARISMA registry. Of these, 275 had a minimum follow-up of 1 year and were included in the primary analysis., Results: The mean procedure duration was 115 ± 47 min, and the mean fluoroscopy time was 9.9 ± 6 min. At the end of the procedures, all PVs had been successfully isolated in all study patients. Minor complications were reported in 12 patients (4.4%). At 1 year, 36 (13.1%) patients had had an AF recurrence, and freedom from antiarrhythmic drugs and AF recurrence was achieved in 228 (82.9%) patients. The recurrence rate was higher in patients with persistent AF (21/116, 18.1%) than in those with paroxysmal AF (15/159, 9.4%; p = 0.0459). On multivariate logistic analysis adjusted for baseline confounders, only time > 6 months from first diagnosis of AF to ablation (HR = 2.93, 95%CI 1.03 to 8.36, p = 0.0459) was independently associated with recurrences., Conclusion: An ablation strategy for PVI guided by CF-LI technology proved safe and effective and resulted in a low recurrence rate of AF over 1-year follow-up, irrespective of the underlying AF type., Clinical Trial Registration: Catheter Ablation of Arrhythmias with a High-Density Mapping System in Real-World Practice. (CHARISMA). URL: http://clinicaltrials.gov/ Identifier: NCT03793998., Competing Interests: Declarations. Ethics approval: This study was performed in line with the principles of the Declaration of Helsinki. The locally appointed Ethics Committee approved the research protocol. Consent to participate: Informed consent was obtained from all individual participants included in the study. Consent for publication: Patients signed informed consent regarding publishing their data. Conflict of interest: M. Malacrida and R. Ricci Maga are employees of Boston Scientific. The other authors have no conflicts of interest to declare that are relevant to the content of this article., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Primary pelvic peritoneal masses, not arising from major organs, are uncommon in adults. Leiomyomas are a group of benign smooth muscle tumors, most commonly found in the uterus in premenopausal women (70-80%). Extra-uterine locations are very rare and more frequent in women. We highlighted the role of MRI due to its capability in soft tissue characterization, that may positively impact the therapeutical decision-making process. Herein, we present the case of a 66-year-old man with a peritoneal solid mass suspicious for a leiomyoma at Magnetic Resonance Imaging and confirmed at histologic specimen in order to discuss the crucial imaging findings that could raise suspicion of such a rare pathology in man., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

In tandem with the ever-increasing global population, the demand for diagnostic radiology service provision is on the rise and at a disproportionate rate compared to the number of radiologists available to practice. The current "revolution in robotics" promises to alleviate personnel shortages in many sectors of industry, including medicine. Despite negative depictions of robots in popular culture, their multiple potential benefits cannot be overlooked, in particular when it comes to health service provision. The type of robots used for interventional procedures are largely robotic-assistance devices, such as the Da Vinci surgical robot. Advances have also been made with regards to robots for image-guided percutaneous needle placement, which have demonstrated superior accuracy compared to manual methods. It is likely that artificial intelligence will come to play a key role in the field of robotics and will result in an increase in the levels of robotic autonomy attainable. However, this concept is not without ethical and legal considerations, most notably who is responsible should an error occur; the physician, the robot manufacturer, software engineers, or the robot itself? Efforts have been made to legislate in order to protect against the potentially harmful effects of unexplainable "black-box" decision outputs of artificial intelligence systems. In order to be accepted by patients, studies have shown that the perceived level of trustworthiness and predictability of robots is crucial. Ultimately, effective, widespread implementation of medical robotic systems will be contingent on developers remaining cognizant of factors that increase human acceptance, as well as ensuring compliance with regulations., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: H.H. is the Editor-in-Training of Canadian Association of Radiologists Journal. M.N.P. is the Editor-in-Chief of Canadian Association of Radiologists Journal.

Takotsubo syndrome (TS) is a temporary form of left ventricular (LV) dysfunction characterized by a distinct pattern of LV impairment, often triggered by a physical or emotional stressful event. Historically, TS was considered a benign condition due to its prompt restoration of myocardial function and generally excellent outcomes. However, recent studies have shown that complications similar to those seen after myocardial infarction can occur, necessitating careful monitoring of these patients. Among noninvasive imaging techniques, cardiovascular magnetic resonance (CMR) is becoming increasingly important in evaluating patients with TS. CMR offers a unique ability to noninvasively assess myocardial tissue characteristics, allowing for detecting the typical features of TS, such as specific wall motion abnormalities and myocardial edema. Beyond its well-established diagnostic utility in the clinical management of TS, CMR has also proven valuable in prognosis and risk stratification for these patients. Advances in CMR, including myocardial strain and parametric mapping have expanded its role in the diagnosis, prognosis, and follow-up of these patients. This review aims to provide a comprehensive overview of the potential applications of CMR in the diagnostic and prognostic evaluation of TS patients. It explores the emerging use of novel CMR imaging biomarkers that may enhance diagnosis, improve prognostic accuracy, and contribute to the overall management of these patients., (© 2024 Wiley Periodicals LLC.)

Incomplete or irregular fusion of the interatrial septum may result in several anatomic variants, including atrial septal pouches and ridges, whose knowledge and recognition are still poorly widespread in clinical practice. An educational review focused on the definition, clinical significance and diagnostic work-up of these anatomic findings was performed using PubMed, MEDLINE, Embase and Cochrane Central databases up to June 2023. Atrial septal pouches and ridges have been associated with an increased difficulty of catheter-based interventions requiring a transseptal approach, due to procedural challenges for transseptal puncture and the restricted motion of guidewires and catheters through the transseptal access. Additionally, left atrial septal pouch may serve as a thrombogenic nidus and a source of systemic embolism, mostly in the presence of factors leading to higher left atrial pressure and/or atrial blood stasis, which increase the risk of thrombus formation and embolic events, rather than for the only presence of left atrial septal pouch itself. Further investigations are needed in order to better elucidate the implications of such anatomic findings in daily clinical practice, and to provide the most appropriate decision-making strategies., Competing Interests: Declaration of competing interest The authors declare they have no conflicts of interest, financial or otherwise to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Xanthogranulomatous pyelonephritis (XGP) is an uncommon chronic condition characterized by destructive granulomatous disease of the kidney with uncertain etiology. Significant risk factors for XGP are represented by the coexistence of history of nephrolithiasis, diabetes mellitus, recurrent urinary tract infections and other immunocompromised conditions. It is also associated with higher risk of malignancy, reported in up to 11% of patients. We report a case of a 76-year-old female who presented to the emergency department with an insidious onset of abdominal and right lower back pain. She had a history of renal stones and diabetes mellitus. On physical examination, a painful fistulous orifice in skin on the right lumbar region was found. CT images showed a nonfunctioning right kidney replaced by multiple necrotic cavities with inflammatory involvement of the right hepatic lobe and a nephron-cutaneous fistula. These CT findings were strongly suggestive of XGP (III state). CT images obtained before and after the administration of intravenous contrast material showed also a hyper-vascularized renal mass with irregularly thickened walls confirmed by a targeted CEUS examination and suspicious for malignancy. Pathologic examination confirmed the chronic pyelonephritis and revealed evidence of a concomitant sarcomatoid lesion. This case underlines the central role of a multimodality imaging approach in the emergency department and how this affects the correct management and treatment of patients. In fact, MDCT is considered the current gold standard for the diagnosis and the staging of XPG but the contrast-enhanced ultrasound (CEUS) in selected patients can increase the diagnostic accuracy in the uncertain small renal masses detected on CT scans., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

The aim of the present study was to evaluate the safety and efficacy of radionuclide therapy with [ 177 Lu]Lu-DOTA-TATE according to our single center experience at the University of Naples Federico II. For the present analysis, we considered 21 patients with progressive, advanced, well-differentiated G1 and G2 in patients with gastro-entero-pancreatic (GEP) neuroendocrine tumors (NETs) treated with [ 177 Lu]Lu-DOTA-TATE according to the decisions of a multidisciplinary team. All patients underwent four cycles of 7-8 GBq of [ 177 Lu]Lu-DOTA-TATE every 8 weeks. A whole-body scan (WBS) was performed 4, 48, and 168 h after each treatment. The dosimetry towards the organ at risk and target lesions was calculated. For each patient, renal and bone marrow parameters were evaluated before, during, and 3 months after the end of the treatment. Follow-up data were obtained and RECIST criteria were considered as the endpoint. Among 21 patients enrolled (mean age 65 ± 9 years); 17 (81%) were men and the small intestine was the most frequent location of disease (n = 12). A mild albeit significant variation ( p < 0.05) in both platelets and white blood cell counts among all time points was observed, despite it disappearing 3 months after the end of the therapy. According to the RECIST criteria, 11 (55%) patients had a partial response to therapy and 8 (40%) had stable disease. Only one (5%) patient had disease progression 4 months after treatment. Our data confirm that [ 177 Lu]Lu-DOTA is safe and effective in controlling the burden disease of G1/G2 GEP-NETs patients.

Cutaneous squamous cell carcinoma (SCC) is the second most frequent skin cancer, accounting for approximately 20% of all cutaneous malignancies, and with an increasing incidence due to the progressive increment of the average age of life. The diagnosis is usually firstly suspected based on clinical manifestations; however, dermoscopic features may improve diagnostic sensitivity in cases of an uncertain diagnosis and may guide the biopsy, which should be performed to histopathologically prove the tumor. New diagnostic strategies may improve the sensitivity of the cutaneous SCC, such as reflectance confocal microscopy and line-field confocal optical coherence, for which increasing data have been recently published. Imaging has a central role in the staging of the diseases, while its exact role, as well as the choice of the best techniques, during the follow-up are not fully clarified. The aim of this literature review is to describe diagnostic clinical and instrumental tools of cutaneous SCC, with an insight into the role of imaging in the diagnosis and follow-up of cutaneous SCC.

Purpose: To evaluate the impact of a four-month training program on radiology residents' diagnostic accuracy in assessing deep myometrial invasion (DMI) in endometrial cancer (EC) using MRI., Method: Three radiology residents with limited EC MRI experience participated in the training program, which included conventional didactic sessions, case-centric workshops, and interactive classes. Utilizing a training dataset of 120 EC MRI scans, trainees independently assessed subsets of cases over five reading sessions. Each subset consisted of 30 scans, the first and the last with the same cases, for a total of 150 reads. Diagnostic accuracy metrics, assessment time (rounded to the nearest minute), and confidence levels (using a 5-point Likert scale) were recorded. The learning curve was obtained plotting the diagnostic accuracy of the three trainees and the average over the subsets. Anatomopathological results served as the reference standard for DMI presence., Results: The three trainees exhibited heterogeneous starting point, with a learning curve and a trend to more homogeneous performance with training. The diagnostic accuracy of the average trainee raised from 64 % (56 %-76 %) to 88 % (80 %-94 %) across the five subsets (p < 0.001). Reductions in assessment time (5.92 to 4.63 min, p < 0.018) and enhanced confidence levels (3.58 to 3.97, p = 0.12) were observed. Improvements in sensitivity, specificity, positive predictive value, and negative predictive value were noted, particularly for specificity which raised from 56 % (41 %-68 %) in the first to 86 % (74 %-94 %) in the fifth subset (p = 0.16). Although not reaching statistical significance, these advancements aligned the trainees with literature performance benchmarks., Conclusions: The structured training program significantly enhanced radiology residents' diagnostic accuracy in assessing DMI for EC on MRI, emphasizing the effectiveness of active case-based training in refining oncologic imaging skills within radiology residency curricula., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Traumatic vascular injuries consist of direct or indirect damage to arteries and/or veins and account for 3% of all traumatic injuries. Typical consequences are hemorrhage and ischemia. Vascular injuries of the extremities can occur isolated or in association with major trauma and other organ injuries. They account for 1-2% of patients admitted to emergency departments and for approximately 50% of all arterial injuries. Lower extremities are more frequently injured than upper ones in the adult population. The outcome of vascular injuries is strictly correlated to the environment and the time background. Treatment can be challenging, notably in polytrauma because of the dilemma of which injury should be prioritized, and treatment delay can cause disability or even death, especially for limb vascular injury. Our purposes are to discuss the role of computed tomography angiography (CTA) in the diagnosis of vascular trauma and its optimized protocol to achieve a definitive diagnosis and to assess the radiological signs of vascular injuries and the possible pitfalls.

Mesenteric ischemia diagnosis is challenging, with an overall mortality of up to 50% of cases despite advances in treatment. The main problem that affects the outcome is delayed diagnosis because of non-specific clinical presentation. Multi-Detector CT Angiography (MDCTA) is the first-line investigation for the suspected diagnosis of vascular abdominal pathologies and the diagnostic test of choice in suspected mesenteric bowel ischemia. MDCTA can accurately detect the presence of arterial and venous thrombosis, determine the extent and the gastrointestinal tract involved, and provide detailed information determining the subtype and the stage progression of the diseases, helping clinicians and surgeons with appropriate management. CT (Computed Tomography) can differentiate forms that are still susceptible to pharmacological or interventional treatment (NOM = non-operative management) from advanced disease with transmural necrosis in which a surgical approach is required. Knowledge of CT imaging patterns and corresponding vascular pathways is mandatory in emergency settings to reach a prompt and accurate diagnosis. The aims of this paper are 1. to provide technical information about the optimal CTA (CT Angiography) protocol; 2. to explain the CTA arterial and venous supply to the gastrointestinal tract and the relevant ischemic pattern; and 3. to describe vascular, bowel, and extraintestinal CT findings for the diagnosis of acute mesenteric ischemia.

Background: Amyotrophic lateral sclerosis (ALS) is a neuromuscular progressive disorder characterized by limb and bulbar muscle wasting and weakness. A total of 30% of patients present a bulbar onset, while 70% have a spinal outbreak. Respiratory involvement represents one of the worst prognostic factors, and its early identification is fundamental for the early starting of non-invasive ventilation and for the stratification of patients. Due to the lack of biomarkers of early respiratory impairment, we aimed to evaluate the role of chest dynamic MRI in ALS patients. Methods: We enrolled 15 ALS patients and 11 healthy controls. We assessed the revised ALS functional rating scale, spirometry, and chest dynamic MRI. Data were analyzed by using the Mann-Whitney U test and Cox regression analysis. Results: We observed a statistically significant difference in both respiratory parameters and pulmonary measurements at MRI between ALS patients and healthy controls. Moreover, we found a close relationship between pulmonary measurements at MRI and respiratory parameters, which was statistically significant after multivariate analysis. A sub-group analysis including ALS patients without respiratory symptoms and with normal spirometry values revealed the superiority of chest dynamic MRI measurements in detecting signs of early respiratory impairment. Conclusions: Our data suggest the usefulness of chest dynamic MRI, a fast and economically affordable examination, in the evaluation of early respiratory impairment in ALS patients.

Gastric volvulus is a rare condition determined by the rotation of one part of stomach around another. Stomach can rotate around its longitudinal or short axis or both. The presentation can be acute, subacute and chronic due to twisting and untwisting andimaging should be performed in the acute phase. MDCT shows high accuracy in thediagnosis and definition of gastric volvulus being the preferred diagnostic test in emergency settings. Gastric volvulus may be associated or determined by pre-existing hiatal hernia and accurate analysis of CT signs may be evaluated on order to differentiate between a stomach in an abnormal position and a volvulus.At CT, a displaced antrum at the same level or cranial to the fundus and a transition point at the pylorus is diagnostic for mesenteroaxial volvulus. We present a case of a 70 years old woman with mesenteroaxial volvulus in hiatal hernia., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Advancing medical technology revolutionizes our ability to diagnose various disease processes. Conventional Single-Energy Computed Tomography (SECT) has multiple inherent limitations for providing definite diagnoses in certain clinical contexts. Dual-Energy Computed Tomography (DECT) has been in use since 2006 and has constantly evolved providing various applications to assist radiologists in reaching certain diagnoses SECT is rather unable to identify. DECT may also complement the role of SECT by supporting radiologists to confidently make diagnoses in certain clinically challenging scenarios. In this review article, we briefly describe the principles of X-ray attenuation. We detail principles for DECT and describe multiple systems associated with this technology. We describe various DECT techniques and algorithms including virtual monoenergetic imaging (VMI), virtual non-contrast (VNC) imaging, Iodine quantification techniques including Iodine overlay map (IOM), and two- and three-material decomposition algorithms that can be utilized to demonstrate a multitude of pathologies. Lastly, we provide our readers commentary on examples pertaining to the practical implementation of DECT's diverse techniques in the Gastrointestinal, Genitourinary, Biliary, Musculoskeletal, and Neuroradiology systems., Competing Interests: Faisal Khosa is the recipient of the Michael Smith Health research BC award (2023-2028). Vicenza Granata is involved with the following study: PRESTO-1 STUDY: precision therapeutic strategies for the treatment of colorectal cancer and HCC. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Purpose: To identify CT prognostic signs of poor outcomes in acute obstructive colonic cancer (AOCC)., Methods: Demographic, clinical, laboratory, radiological and surgical data of 65 consecutive patients with AOCC who underwent emergency surgery were analyzed. CT exams were reviewed to assess diameters of cecum, ascending, transverse, descending, and sigmoid proximal to the tumor; colon segments' CD/L1-VD ratios, continence of the ileocecal valve, small bowel overdistension, presence of small bowel feces sign and cecal pneumatosis. Post Operative complications (PO), according to the Clavien-Dindo classification, were analyzed., Results: Gender, age and location of the tumor were not predictive factors of complications. Among laboratory exams, CRP was the most important predictive value of PO (OR 8.23). A cecum distension ≥ 9 cm represented the critical diameter beyond which perforation and cecal necrosis were found at surgery. Cecal pneumatosis at CT was correlated with cecal necrosis at surgery in < 50% of patients. Pre-operative transverse colon CD/L1-VD ratio ≥ 1.43 and descending colon CD/L1-VD ratio ≥ 1.31 were associated with the development of PO (grade ≥ III-V). PO (grade ≥ III-V) occurred in 18/65 patients., Conclusion: Postoperative complications in emergency surgery of AOCC were not related to the age, sex and tumor's location. Preoperative PCR values (≥ 2.17) predict the development of postoperative complications. CT resulted a valid diagnostic tool to identify patients at higher risk of complications: a CD/L1-VD ratios with cut-off values of 1.43 (transverse) and 1.31 (descending) predicted major complications (grade ≥ III-V) and a cecum distension ≥ 9 cm represented the critical diameter beyond which perforation occurred in > 84% of patients., (© 2024. Italian Society of Medical Radiology.)

Introduction: Meniscal injuries are a common challenge in orthopedic surgery. For decades, partial or total meniscectomy has been the primary surgical treatment for meniscal tears. In recent years, the increased recognition of menisci's biomechanical importance has progressively shifted the paradigm towards meniscus repair. However, meniscus-sparing surgery remains the treatment of choice for selected lesions in young and active patients, especially for young and active patients. In this study, we evaluated the effectiveness of all-inside sutures in treating meniscus tears in patients over 40., Methods: In our retrospective evaluation, we evaluated the clinical and functional outcomes of cases over 40 years of age with post-traumatic acute meniscus tears that received meniscus repairs using the all-inside technique. The pre-operative and post-operative functionality of treated patients were assessed using the knee injury and osteoarthritis outcome score (KOOS) score. Major complications were recorded., Results: Twenty-three cases met our inclusion criteria. Eight females and fifteen males with a mean age of 44.9 were included in our study. Their mean follow-up was 35.1 months. Before surgery, our patients' mean KOOS score was 55.4 (18-80). At the patients' latest follow-up, the value had risen to 87.4 (63-100). There was no statistical correlation between patients' age and their functional recovery. No surgical failure was recorded at the latest follow-up., Conclusion: The all-inside suture technique can represent a suitable and reliable solution for suturable meniscal tears, even for patients over 40. Preserving the meniscus and restoring patients' functionality allows patients to return to their daily activities and promote their quality of life., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Ciapini et al.)

Adaptive immunity requires the expansion of high-affinity lymphocytes from a heterogeneous pool. Whereas current models explain this through signal transduction, we hypothesized that antigen affinity tunes discrete metabolic pathways to license clonal lymphocyte dynamics. Here, we identify nicotinamide adenine dinucleotide (NAD) biosynthesis as a biochemical hub for the T cell receptor affinity-dependent metabolome. Through this central anabolic role, we found that NAD biosynthesis governs a quiescence exit checkpoint, thereby pacing proliferation. Normalizing cellular NAD(H) likewise normalizes proliferation across affinities, and enhancing NAD biosynthesis permits the expansion of lower affinity clones. Furthermore, single-cell differences in NAD(H) could predict division potential for both T and B cells, before the first division, unmixing proliferative heterogeneity. We believe that this supports a broader paradigm in which complex signaling networks converge on metabolic pathways to control single-cell behavior.

Background: The prognostic impact of catheter ablation (CA) of atrial fibrillation (AF) in hypertrophic cardiomyopathy (HCM) patients has not yet been satisfactorily elucidated., Objectives: The aim of the study was to assess the impact of CA of AF on clinical outcomes in a large cohort of HCM patients., Methods: In this retrospective multicenter study, 555 HCM patients with AF were enrolled, 140 undergoing CA and 415 receiving medical therapy. 1:1 propensity score matching led to the inclusion of 226 patients (113 medical group, 113 intervention group) in the final analysis. The primary outcome was a composite of all-cause mortality, heart transplant and acute heart failure exacerbations. Secondary outcomes included AF recurrence and transition to permanent AF. Additionally, an inverse probability weighted (IPW) model was examined., Results: At propensity score matching analysis, after a median follow-up of 58.1 months, the primary endpoint occurred in 29 (25.7%) patients in intervention group vs 42 (37.2%) in medical group ( P  = 0.9). Thromboembolic strokes and major arrhythmic events in intervention vs medical group were 9.7% vs 7.1% ( P  = 0.144) and 4.4 vs 8.0% ( P  = 0.779), respectively. Fewer patients in intervention vs medical group experienced AF recurrences (63.7% vs 84.1%, P  = 0.001) and transition to permanent AF pattern (20.4% vs 33.6%, P  = 0.026). IPW analysis showed consistent results. Severe complications related to CA were uncommon (0.7%)., Conclusions: After 5 years of follow-up, CA did not improve major adverse cardiac outcomes in a large cohort of patients with HCM and AF. Nevertheless, CA seems to facilitate the maintenance of sinus rhythm and slow the progression to permanent AF, without significant safety concerns., Competing Interests: Prof Olivotto has received research grants from: BMS-Myokardia, Cytokinetics, Boston Scientific, Amicus, Sanofi Genzyme, Shire Takeda, Menarini International, Bayer, and Chiesi, Tenaya; and is on the advisory board for BMS-Myokardia, Cytokinetics, Amicus, Sanofi Genzyme, Chiesi, Tenaya, and Rocket Pharma. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)