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Objectives: The aim of this study was to identify the pattern of exercise left atrial (LA) dynamics, its gas exchange correlates, and prognosis in mitral regurgitation (MR) of primary and secondary origin. Background: The adaptive response and clinical significance of LA function during exercise in MR is undefined. Methods: A total of 196 patients with MR (81 with primary MR, 115 with secondary MR) and 54 control subjects underwent exercise stress echocardiography and cardiopulmonary exercise testing with LA function assessment. Patients with MR were divided into 4 groups according to etiology and severity using a cutoff of 3+. Results: LA dynamics was studied using speckle-tracking echocardiography. Compared with control subjects, patients with MR had a lower LA strain and strain rate at rest. Exercise LA strain and LA strain rate progressively worsened from primary MR 3+ (25.5; IQR: 23.4 to 29.0); and those with secondary MR

Objectives: This study investigates the electrocardiographic-electrophysiological effects of administration of anesthetic drugs for general anesthesia (GA) in patients with BrS at high risk of sudden cardiac death (SCD). Background: The safety of anesthetic agents in Brugada syndrome (BrS) is under debate. Methods: All consecutive patients with spontaneous type 1 BrS electrocardiographic (ECG) patterns undergoing epicardial ablation of the arrhythmogenic substrate (AS) under GA were enrolled. Anesthesia was induced with single bolus of propofol and maintained with sevofluorane. ECG measurements were collected before, immediately after, and 20 min after induction of GA. Three-dimensional maps during GA and after ajmaline indicated the epicardial AS before ablation. Results: Thirty-six patients with BrS (32 male, 88.9%; mean age 38.8 ± 12.0 years) with a spontaneous type 1 ECG pattern underwent GA. Induction was performed using propofol at mean dose of 1.6 to 2.6 mg/kg (2.1 ± 0.3 mg/kg). Twenty-eight (28 of 36, 77.8%) patients showed a reversion to a nondiagnostic pattern. ST-segment elevation (0.32 ± 0.01 mV vs. 0.19 ± 0.02 mV; p < 0.001) and J-wave amplitude (0.47 ± 0.02 mV vs. 0.31 ± 0.03 mV; p < 0.001) decreased after propofol. The AS area during GA, in the absence of BrS pattern, significantly enlarged after administration of ajmaline (3.6 ± 0.5 cm2 vs. 20.3 ± 0.8 cm2). No patient developed malignant arrhythmias during GA induction and maintenance. Conclusions: This study shows that GA using single-bolus propofol and volatile anesthetics is safe in high-risk patients with BrS, and it may exert a modulating effect by reducing the manifestation of type 1 BrS pattern and AS in the form of epicardial abnormal ECGs. (Epicardial Ablation in Brugada Syndrome: An Extension Study of 200 BrS Patients; NCT03106701)

BACKGROUND: The second-generation cryoballoon (CB-Adv) is effective in achieving pulmonary vein isolation (PVI) with encouraging result. The mid-term clinical efficacy of a single 3-minutes freeze, without a routine bonus application, has been recently demonstrated. OBJECTIVE: To assess long-term clinical outcome following PVI with the CB-Adv using a single 3-minutes application. METHODS: A total of 143 consecutive patients (93 male, 65%; mean age 59.6±12.0 years) with paroxysmal (PAF; 113/143, 79%) or early persistent AF (30/143, 21%) underwent PVI using CB-Adv with a single 3-minutes freeze. Atrial tachyarrhythmia (ATa) recurrences were defined as symptomatic or documented episodes >30 seconds. RESULTS: After a single freeze, isolation could be reached in 94.1% of all identified PVs. Complete PVI was successfully achieved with 1.1±0.4 mean freezes. Persistent phrenic nerve palsy (PNP) occurred in 5/143 (3.5%) patients. At a mean 12.1±4.4 months of follow-up, after a 3-months blanking period (BP), 80.4% (115/143) were in stable sinus rhythm (93/113, 82.3% for PAF; 22/30, 73.3% for early persistent). Fifteen patients underwent a second procedure with radiofrequency ablation showing reconnection in 7/15 right-sided (46.7%) and in 6/15 (40%) left-sided PVs. Relapses during BP (p CONCLUSIONS: A single 3-minutes freeze is highly effective, determining an ATa freedom of 80.4% at 1-year follow-up. The incidence of persistent PNP is 3.5%. Relapses during BP, time to PVI and longer AF duration are predictors of recurrences. Routine use of an "insurance freeze" may not be needed.

Second-generation Cryoballoon Ablation and PulmonaryVein Reconnections. Introduction: Longer observational time and adenosine challenge have proven to be able to detect pulmonary vein (PV) reconnections. The aim of this study was to assess incidence of spontaneous and adenosine-induced PV reconnection after ablation with second-generation cryoballoon (CB-Adv). Methods and Results: Fifty consecutive patients (76% male, mean age 60.5 +/- 11.9 years) having undergone PV isolation (PVI) using the CB-Adv were enrolled. After isolation, reconnections were evaluated using the Achieve catheter over 30 minutes observation and adenosine administration during isoproterenol infusion (adenosine challenge). Among 200 PVs, isolation was achieved in 190 (95%) during the first application. Lower nadir temperature and longer rewarming time were associated with successful PVI (P = 0.02 and 0.04). Spontaneous (4 veins) and adenosine-induced (4 veins) PV reconnections occurred in the 4% of initially isolated veins (8 veins)in 6 patients (12%). At receiver-operator curve analysis, nadir temperature 28 seconds identified absence of reconnections (sensitivity 100% and 87%, area under the curve 0.75 and 0.72). Patients with right-sided early branching frequently experienced reconnections (P

BACKGROUND: With respect to the first generation Cryoballoon (CB), the second generation (Cryoballoon Advance; Medtronic, USA; CB-A) was designed with technical modifications resulting in a larger and more uniform zone of freezing on the balloons surface aiming at procedural outcome improvement in the setting of atrial fibrillation (AF) ablation. However a comparison between both technologies on a midterm follow-up is missing in today's literature. METHODS: A total of 100 patients (the last 50 patients with the 1st generation CB and the first 50 patients with the 2nd generation CB-A upon its inception in our center) having undergone a single CB ablation for paroxysmal AF (PAF) and having completed a 12-month follow-up were consecutively included in our study. Freedom from AF off-antiarrhythmic drugs (AAD) after a single procedure was 78% (39/50) in CB-A and 58% (29/50) in the CB group (p = 0.03) during the whole follow-up duration. Considering a blanking period of 3 months, freedom from AF off-AAD was achieved in 84% (42/50) in CB-A, while 66% (33/50) were free from recurrence in the CB group (p = 0.038). Right phrenic nerve palsy (PNP) occurred in 8 patients (16%) in CB-A group and in 4 patients (8%) in the CB group. CONCLUSION: Freedom from AF on 12 months follow-up was significantly higher in the CB-A group with respect to the first generation device. The most frequent complication observed was PNP.

BACKGROUND: The clinical course and prognosis of Brugada syndrome (BS) in the elderly is unknown. The purpose of this study was to investigate the clinical characteristics, management and prognosis of BS in an elderly population. METHODS AND RESULTS: A total of 437 patients with BS were included in this study. Patients were categorized in 2 groups according to the age at the time of diagnosis: CONCLUSION: The clinical features and the benign prognosis of BS patients older than 70 years likely identify a lower risk category of patients as compared to younger individuals. The device-guided management in this setting remains individualized and sometimes controversial. Moreover, BS diagnosis in the elderly should not be missed, mainly due to the clinical impact on the family of elderly patients.

Introduction Pulmonary vein (PV) isolation by means of cryoballoon (CB) technology is an effective treatment for symptomatic paroxysmal atrial fibrillation (AF) refractory to antiarrhythmic drug therapy. The CB requires a 15F transseptal sheath that may lead to the creation of a iatrogenic atrial septal defect (IASD). Methods and Results Individuals having undergone PV isolation by the means of CB ablation and a subsequent transesophageal echocardiography (TEE) examination during postablation follow‐up were consecutively included. Thirty‐nine patients formed the study group (31 male, 76.9%; mean age 57.4 ± 13.7 years). IASD was present in 8 (20%) of them after a mean follow‐up time of 11.7 months. Mean diameter of the defect was 0.57 cm × 0.48 cm; only left to right shunt was observed. No adverse events were recorded in these patients during the follow‐up. Conclusion IASD after CB ablation of AF is present in up to 20% of patients after 1 year. Although no adverse clinical events were recorded in patients with persistence of IASD, this complication should not be underestimated and systematic echocardiographic examinations might be advised at regular intervals in the follow‐up period after CB. Further studies with larger population and follow‐up might be required to confirm our findings.