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Funding Acknowledgements Type of funding sources: None. Introduction Brugada syndrome (BrS) is a channelopathy confining an increased risk of sudden cardiac death (SCD). Asymptomatic patients (pts) management remains challenging enhancing the necessity for additionally stratification tools. Purpose To evaluate the role of the non-invasive assessment of late potentials (LP) based on SA-ECG as stratification tools in a BrS cohort. Methods Prospective, observational single-center study of pts with BrS with the following criteria (1) Type 1 Brugada ECG pattern, either spontaneous or drug induced; (2) SA-ECG performed before anti-arrhythmic treatment; (3) minimum follow up duration of 12 months. LPs were evaluated by SA-ECG with determination of the total filtered QRS duration (fQRS); root mean square voltage of the 40ms terminal portion of the QRS (RMS40) and duration of the low amplitude electric potential component of the terminal portion of the QRS (LAS40) in conventional and modified right precordial leads. Malignant arrhythmic events (MAEs) were defined as a composite event of SCD or appropriate ICD shocks. Association of relevant risk factors and MAE was conducted with Univariate Cox regression analysis, as well as SA-ECG evaluated as a continuous and categorical divided on standard cut-offs (fQRS >114ms, RMS4038ms). A risk score for predicting MAE was computed incorporating the significant LPs variables. Results A total of 106 pts fulfilled the inclusion criteria (mean age: 48 ± 12 years, 67.9% male), 52 (49.1%) with type 1 spontaneous pattern. The majority were asymptomatic at baseline (81.1%) while 13 presented with syncope and 3 with polymorphic VT/cardiac arrest. A total of 10 (7.1%) pts MAEs were documented during a mean 4.7 years - 4 with SCD and 6 with appropriate ICD shocks. Clinical presentation with a polymorphic VT/cardiac arrest (p Conclusion LPs based on noninvasive assessment SAECG represent an useful prognostic stratification tool in BrS. A LP score based on standard cut-offs identified a subset of pts at a higher risk of events and who may deserve individualized preventive strategies.

Funding Acknowledgements Type of funding sources: None. Introduction Cardiac rehabilitation is currently described as a mainstay when it comes to treatment of cardiac patients (pts), mainly ischemic heart disease. Despite this, referral and implementation suffered a decrease amidst covid outbreak. Purpose To describe, in a cardiac rehabilitation center, the real life data regarding programme effects during covid pandemic and after the release of most sanitary measures. Methods Prospective cohort study which included consecutive pts who were participating in a center-based CR program lasting 8-12 weeks from 2019 to 2021. The CR program included initial evaluation by cardiologist and rehabilitation specialist with collection of clinical characteristics, three times weekly supervised exercise sessions, appointment with rehabilitation nurse, nutritionist and psychologist and educational sessions. Lab tests, echocardiogram and CPET were done before and after completion of the program. Results We analyzed 349 patients, mean age 60 ± 11,14 years, 83% male, most of them referred because of ischemic heart disease (83,6%), followed by valvular heart disease (7,0%). Mean ejection fraction was 48,4 ± 12,8 and most patients were in NYHA class II (65,1%). After program completion we noticed a clear benefit regarding functional class (NYHA before and after CRP: NYHA I 25,7% vs 63,7%; NYHA II 65,1% vs 34,5%; NYHA III 9,2% vs 1,9%; p Conclusions Despite constraints in CR programs during the pandemic, the long term data shows that maintaining such programs has an important effect when it comes to risk factor control and clinical improvement.

Funding Acknowledgements Type of funding sources: None. Introduction Exercise-based cardiac rehabilitation (CR) is part of the management of patients with established cardiovascular disease. Echocardiography and CPET are used to evaluate cardiac function and cardiorespiratory fitness improvement after such interventions. Purpose To analyze the cardiovascular impact of an exercise based CR program on ventricular remodeling and functional capacity. Methods Prospective cohort study which included consecutive pts who were participating in a centre-based CR program lasting 8-12 weeks from 2019 to 2021. The CR program included initial evaluation by cardiologist and rehabilitation specialist with collection of clinical characteristics, three times weekly supervised exercise sessions, appointment with rehabilitation nurse, nutritionist and psycologist and educational sessions. Lab tests, echocardiogram and CPET were done before and after completion of the program. Results We analysed 349 patients (82% male, mean age 60 ±11,4 years) most of which referred by ischemic heart disease (83%) followed by valvular heart disease (7%). After program completion there was a significant improvement in echo ejection fraction (48,4 ± 12,8% vs 52,07 ± 12,8% Z=-5,036 p Conclusions Exercise based cardiac rehabilitation has a very favorable impact in terms of cardiorespiratory fitness evaluated by several CPET parameters and such impact is also present in high risk individuals with reduced ejection fraction. Advocating for increasing referral of these patients is key to better improve cardiorespiratory capacity.

Funding Acknowledgements Type of funding sources: None. Introduction Chronotropic incompetence (CI) is defined as the inability to reach 80% of the expected reserve frequency for age during exertion, and it is frequently observed in stress tests of patients undergoing cardiac rehabilitation programs due to a combination of factors, that include the use of betablockers. Despite the theoretical basis for suggesting that a lower peak heart rate is related to a lower tolerance to exertion, we lack data correlating the CI to the maximal functional capacity, measured in cardiopulmonary tests as the maximal oxygen volume consumption (peak VO2). Purpose To correlate the impact of CI on functional capacity in patients (pts) undergoing a cardiac rehabilitation program and try to find the best value of chronotropic incompetence that could predict a worse prognosis. Methods Prospective cohort study which included consecutive pts who were submitted to cardiopulmonary exercise test (CPET) during 5 years in a tertiary hospital. Demographic data were analyzed and medication with beta blocker was registered. CI and chronotropic index were calculated using the equation (220-age) for estimating maximum HR. ROC curve method and Kaplan-Meier survival analysis were used to evaluate the cut-off efficacy. Results We analyzed 358 CPET and 74,1% patients (n=206) were under beta blocker therapy (7,6% high dose). The majority of the patients had CI (83.5%); CI was more frequent in pts under BB therapy although it didn’t reach statistical significance (p=0.12). A low maximum predicted heart rate (mpHR) was associated with low peak VO2 (p=0.02) and a mpHR < 61% was the best value to predict peak VO2< 12mL/(kg.min) (AUC=0.746, S=72; E=65), despite not showing association with cardiovascular events. Regarding the chronotropism, 96.9% of the pts were categorized as having a low chronotropic index . A CI < 0.38 was the best cut-off to predict a peak VO2 Conclusion This study shows a high percentage of pts with CI. A low cronotropic index was associatated with low peak VO2 and was a predictor of all-cause hospitalizations.

Funding Acknowledgements Type of funding sources: None. Introduction Cardiac Rehabilitation is recommended as secondary prevention in those patients with cardiovascular disease. Efforts to increase referral of patients after hospitalisations have been made in order to increase adherence to phase 2 CR programs. However, there are still few data regarding adherence after completion of phase programs regarging progressing to phase 3 programs. Purpose To characterize a population of patients who enrroled in a phase 3 CR program. Methods Prospective cohort study which included consecutive pts who were participating in a centre-based CR program lasting 8-12 weeks from 2019 to 2021. We analyzed prevalence of risk factors, lab echocardiographic and CPET data at beggining and 6 months after FUP. Possibility of attendance of a phase III CR program on a nearby gym was offered to everyone. Statistical analysis between both groups was performed with Chi-Squeare and Wilcoxon tests. Results We analyzed 336 patients who underwent CR (82% male, mean age 60 ±11,4 years). The majority was referred for ischemic heart disease (83%) followed by valvular heart disease (7%). Mean follow-up was 36,7± 19,2 months. Phase 3 program in a nearby facility was offered to everyone. Of those, 217 pts (mean age 59 +- 11,4 years-old, 80% male) chose not to continue and 119 pts (mean age 61 +- 11,3 years old, 81% male) were enrolled in the program. There were some differences among the two groups: ischemic heart disease was more prevalent in those who didn’t progress to Phase III (83% vs 66%, p=0.02) and, regarding risk factors, we noted a higher prevalence among those who enrolled in phase III, namely hypertension (77% vs 88%, p=0.04) and previous smoking habits (64,2% vs 71,1%, p=0.02). There were no significant differences regarding lab and echo data at the end of the program, especially ejection fraction, NTproBNP and LDL cholesterol. We failed to find differences between CPET data after 6 months follow up, although such findings might be limited by the scarcity of data in the group who transitioned to phase III. Conclusions Patients with a higher burden of risk factors showed higher interest in progressing to a phase III program. We did not find differences in cardiorrespiratory fitness evaluated by CPET, although more robust data would be needed to back such observations.

Funding Acknowledgements Type of funding sources: None. Introduction Peak oxygen uptake (peak VO2) is a strong predictor of mortality and is commonly used in the evaluation of patients for cardiac transplantation. Although guidelines suggest a peak VO2 Purpose To correlate CPET and echo data with outcomes after CR programs and to determine the best cut off for peak VO2 in a population with a high percentage of BB therapeutics. Methods Single center prospective study which included consecutive pts who were participating in a centre-based CR program lasting 8-12 weeks from 2019 to 2021. The CR program included initial evaluation by cardiologist and rehabilitation specialist with collection of clinical characteristics, three times weekly supervised exercise sessions, appointment with rehabilitation nurse, nutritionist and psychologist and educational sessions. Lab tests, echocardiogram and CPET were done before and after completion of the program. Multivariate analysis with Cox regression was used to correlate with events and survival was analyzed with Kaplan Meier curves. Results We analyzed 349 patients who underwent CR (82% male, mean age 60 ±11,4 years). The majority was referred for ischemic heart disease (83%) followed by valvular heart disease (7%). Mean follow-up was 36,7± 19,2 months. During FUP, 7,2% pts had CV related admissions (n=25), 4 of which were myocardial infarction. Sixteen pts died (4,6%) of which 2,3% were from cardiovascular causes. On multivariate analysis peak VO2 (HR 0.827 CI 95% 0.72-0.949, p=0.07), ejection fraction (HR 0.962 CI 95% 0.933-0.991, p=0.01) and test duration (HR 0.756 CI 95% 0.712-0.778, p=0.01) correlated with hospital admissions. Regarding mortality only peak VO2 showed statistical significance (HR 0.8 CI 95% 0.69-0.93, p=0.04). On this matter we further analyzed the best cut-off in predicting events: a peak VO2 > 14 mL/(kg.min) was a better predictor of event free-survival in these patients when comparing with a peak VO2 of 12 mL/(kg.min). Conclusions Cardiac rehabilitation has an established impact in prognosis. Echo and CPET data obtained at the beginning of the CR program can be used to identify patients who might benefit from a more closed surveillance in order to reduce risks of hospitalization. Moreover, in our population, a peak VO2 cut-off of 14mL/(kg.min) seemed to better correlate with event-free survival.

Funding Acknowledgements Type of funding sources: None. Introduction Age is one of the most determinant cardiovascular risk factors and the prevalence of cardiovascular disease is higher after 70 years old. Referral to cardiac rehabilitation programs for elder individuals is often overlooked since such patients are deemed as frail, high risk and may show lack of competence when attending these programs. Purpose To assess differences in clinical characteristics and outcomes between pts >70 years old with younger ones. Methods Prospective cohort study which included consecutive pts who were participating in a centre-based CR program lasting 8-12 weeks from 2019 to 2021. We analysed prevalence of risk factors, lab echocardiographic and CPET data in women who were enrolled in the program. Statistical analysis was performed with Chi-square and Wilcoxon tests. Results From a pool of 349 patients, only 74 (21%) were 70 or more years old. In this group most of pts were male (90,5%), mean age of 75,2 +- 4,34 year-old. 90% pts had arterial hypertension (n=67), 76% had dyslipidemia, 34% were diabetic and 57,5% were smokers or past smokers. Most patients were in NYHA II (64,2%) and the remainder in NYHA I (29,9%) and III (6%). Mean ejection fraction was 52 +- 14%. NTproBNP in first evaluation 1335 pg/mL, LDL-c 80,4mg/dL and HDL 46,8%. Both groups (70years) were relatively homogeneous, except for differences in sex (male sex mor prevalent (p=0.019) and hypertension (p=0.006). Interestingly there were no significant differences in both groups regarding hospital admissions, rate of reinfarction and cardiovascular death. In both groups we noted a significant improvement in echo and CPET, reaching statistical significance in ejection fraction variation (p=0.01), duration of CPET (p=0.048) workload peak; however, in contrast to younger patients, VO2 peak improvement was non significative. Conclusions Although there is a higher prevalence in cardiovascular disease among older people, CR referral is far lower. As we can see, such interventions are safe and effective also in older pts and thus we should identify factors going against their inclusion in CR programs and prioritize risk stratification.

Funding Acknowledgements Type of funding sources: None. Introduction The decrease in the use of linear ablation for atrial fibrillation treatment has reduced the frequency of iatrogenic feft-sided atypical flutters (AFl). However, AFl are becoming increasingly frequent, associated with population age and risk factors for atrial scar. Revising the mechanisms of non-iatrogenic AFl may lead to a better procedure workflow. Purpose To describe the mechanisms of non-iatrogenic AFl. Methods Retrospective single-center study of AFl patients (pts) submitted high-density mapping from 2018 to 2022. Patients submitted to any prior left atrial linear ablation were excluded. Map collection was performed just visualizing the voltage map and a comprehensive workflow was applied for activation map interpretation, starting by facing the mitral annulus and following the sequence of colors to systematically identify all potential circuits, their common-isthmuses, and eventual slow-conduction sites. Entrainment maneuvers were performed to confirm the circuit interpretation if sinus rhythm was not restored with the completion of the planned ablation set. Results A total of 59 pts were included (male: 56% male; 67 ± 13 years), 28 previously submitted to atrial fibrillation ablation, restricted to pulmonary vein (PV) isolation. About 88% presented a macro-reentrant mechanism, either restricted to the left atrium (N=50) or biatrial (N=2) and involving 2 or 3 loops in 61% - Figure 1. Perimitral loop was the most frequent reentrant circuit, representing 60% of macro-reentrant arrhythmias (N=30) and exhibiting an evident out-of-proportion predominance of counterclockwise rotations (73% versus 27%). Among perimitral flutters with at least one additional loop, a balanced distribution was recognized of rotations around the left and right PVs (10 versus 10). As a result of the existence of additional loops producing common-isthmuses locations in various atrial regions, the classical inferior mitral isthmus line (from the mitral annulus to the left inferior PV) would only terminate as much as 53% of the perimitral AFl. The mechanism-tailored ablation strategy, particularly targeting the AFl common-isthmuses, resulted in restoration of sinus rhythm in 96.6% of pts (N=57). Conclusions In pts not previously submitted to linear ablations, AFl are predominantly caused by macro-reentrant circuits involving a perimitral rotation but not necessarily possible to treat with a conventional mitral isthmus line. With current high-density mapping tools, a comprehensive analysis of the substrate and activation maps and a mechanism-tailored ablation strategy results in an unprecedently high acute success rate.

Background Evidences on atrial fibrillation (AF) in patients with cancer are limited, specifically with respect to antithrombotic therapy. Methods BLITZ-AF Cancer is a prospective, non-interventional study of the epidemiology and management of AF in patients with cancer. Patients were included from 112 cardiology units in Italy, Belgium, Netherlands, Spain, Portugal, and Ireland, based on the following criteria: age ≥18 years; documented cancer other than basal-cell or squamous-cell carcinoma of the skin diagnosed within 3 years; electrocardiographically confirmed AF within 1 year; no concomitant interventional study. Follow-up is ongoing. Results From June 26th, 2019 to Sep. 30th, 2021, 1,514 subjects were enrolled. The most frequent cancer locations were lung (14.9%), colorectal (14.1%), breast (13.9%), prostate (8.8%), and non-Hodgkin lymphoma (8.1%); 463 (30.6%) of participants had metastases. AF was first-detected in 323 (21.3%), paroxysmal in 460 (30.4%), persistent in 192 (12.7%), long-standing persistent in 33 (2.2%), and permanent in 506 (33.4%); 590 (39.0%) patients had symptoms attributable to AF. Baseline characteristics are presented in Table 1. Males were more than women and almost half of the subjects was >75 years-old. Cardiovascular risk factors were common and approximately 31% had heart failure or coronary artery disease. Previous thromboembolic and haemorrhagic events had occurred in 14% and 10% of subjects, respectively. The median CHA2DS2VASc score was 3. As shown in Figure 1, the prescription of oral anticoagulants, especially direct-acting ones (DOACs), rose after the cardiology assessment, while the percentage of participants without any antithrombotic therapy declined. Among 1,427 patients with non-valvular AF (i.e., no mitral stenosis or prosthetic mechanical valve), 997 (69.9%) were prescribed on DOACs at discharge/after consultation. At multivariable logistic regression analysis, variables associated with DOAC use were female sex (OR 1.58, 95% CI 1.22–2.05), age (OR 2.00, 95% CI 1.39–2.88 and OR 2.63, 95% CI 1.84–3.76, respectively, for 65–74 years and ≥75 years vs Conclusions BLITZ-AF Cancer provides extensive information on a large, contemporary cohort of individuals with AF and cancer. This baseline snapshot indicates that cardiologists pursue the implementation of DOACs in these patients, although residual use of other antithrombotic therapies or lack of any thrombo-prophylaxis remains substantial. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): This study was supported by an unrestricted grant from Daiichi Sankyo.

Introduction Brugada syndrome (BrS) is an inherited cardiac arrhythmic disorder that can lead to sudden death. Although SCN5A was the first pathogenic associated gene, other potential genes have been described. The relationship between SCN5A, spontaneous type 1 pattern and the predisposition to ventricular arrhythmias is not totally understood. Purpose To characterize mutations in a Portuguese cohort with BrS and explore the genotype-phenotype association in terms of electrocardiographic pattern and arrhythmic risk. Methods Prospective single-center study of patients (pts) with BrS. Genetic test included SCN5A direct sequencing from 2003 a broad panel of 120 genes associated with cardiomyopathies and arrhythmic disorders from 2018. Genetic test results were classified according to pathogenicity: mutations of unknown significance (MUS), mutations potentially pathogenic (MPP) and known pathogenic mutations (KPM). Kaplan-Meyer survival analysis was used to explore the association between genetic test results and the risk of arrhythmic events. Results A total of 94 pts [46±12 years, 67% male,64.9% with type 1 spontaneous pattern] were submitted to genetic testing. No relevant mutations were identified in 68pts and suspicious or pathogenic mutations were recognized in 26pts. The most frequent mutations occurred in SCN5A (N=20,76.9%), and included 8 KPM: 4 in exon 23 (3 of them had the same mutation,c.4018G>A), 2 in exon 26 (c.4534C>T), 1 in exon 28 and 1 in exon 16. All MPP in SCN5A occurred either in exon 23 or 28. Considering MUS, different mutations were described in 6 different exons (8,15,18,23,25 and two in 28). Additionally, 6 pts presented MUS in other genes: SCN10A (N=2), ANK2 (N=2), SFM13A, CAV2 (associated with long QT), CACNA1D and PXDNL. We found no differences in the prevalence of spontaneous type 1 pattern considering gene mutation or mutation pathogenicity. A non-significant trend to higher arrhythmic risk was observed in pts presenting genetic mutations (either KPM, MPP or MUS), Long-Rank: 1.743, p=0.187. Conclusion Gene mutations are identified in a minority of BrS pts, mostly at SCN5A gene. No association was noticed between genetic test results and the ECG pattern. However, pts with identified mutation presented a tendency to higher arrhythmic risk. At present time, genetic tests in BrS are only relevant for familial screening, but long-term collection of data is crucial to elucidate the genotype-phenotype relation and arrhythmic risk. Funding Acknowledgement Type of funding sources: None.

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Funding Acknowledgements Type of funding sources: None. Introduction Right ventricular apical pacing (RVAp) may be deleterious to ventricular function and hemodynamics due to pacing induced dyssynchrony. In the last decades, some studies showed that RVAp has been associated with heart failure, deterioration of left ventricular function and high mortality. Some patients (pts) may need, during the follow up (FUP), an upgrade to cardiac resynchronizaon therapy (CRT). New techniques have emerged such as RV lead implantation in the high septum or outflow RV tract (RVOT) and, more recently, His bundle/LB pacing. Purpose To compare the need for upgrade to CRT in patients with RVAp versus septal/RVOT pacing. Methods Retrospective single-center study of consecutive pts that implanted pacemakers in a tertiary center between January 1995 and December 2020. We collected data regarding pacing indication, RV pacing site (apex versus septum/RVOT) and need for an upgrade to CRT during follow up (FUP). Our primary endpoint was upgrade to CRT during the FU period. In the model, the impact of localization of the implanted lead on the survival free from upgrade was estimated assuming a neutral effect on mortality. Statistical analysis was performed using T-student test and logistic regression. Results We included 8761 pts, 60.2% (n=5275) were male, with a mean age of 76.5±10.7 years. The main indications for pacemaker implantation were (1) complete atrioventricular (AV) block (2239, 25.6%), (2) sick sinus syndrome (2211, 25.2%), (3) atrial fibrillation with AV block or bradycardia with significant pauses (17.4%) and (4) Mobitz II 2nd degree AV block (1467, 16.7%). RVAp was performed in 1746 (20%) patients and RVOT/septal pacing in 6933 patients (80%; RVOT in 657 (9,5%)). During FUP, 26 (1,5%) RVAp pts and 52 (0,8%) RVOT/septal pacing pts underwent upgrade to CRT, in a total of 78 pts (CRT-P in 54 patients and CRT-D in 24 patients). We observed that patients with RVAp had twice the risk of CRT upgrade during FUP (OR: 2,0 (IC 95% 1,25-3,21), p=0,004) when compared to patients with RVOT/septal pacing. Conclusions Patients with RVAp presented a 2-fold higher risk for upgrade to CRT when compared to patients with RVOT/septal pacing in our center. This retrospective analysis shows that lead implantation in the septum/RVOT should be preferred instead of the apex to reduce pacing induced dyssynchrony and need for CRT upgrade.

Funding Acknowledgements Type of funding sources: None. Introduction Brugada syndrome (BrS) is a relevant cause of sudden cardiac death (SCD) in young adults. Several risk factors have been identified, but clinical decision making remains extremely challenging, particularly in asymptomatic patients. Purpose To explore the usefulness of the non-invasive assessment of late potentials (LPs) based signal-averaged ECG (SAECG) for risk stratification in BrS. Methods Prospective single-center study of patients with BrS included from 2003 to 2021. LPs were evaluated by SA-ECG with determination of the total filtered QRS duration (fQRS), root mean square voltage of the 40ms terminal portion of the QRS (RMS40) and duration of the low amplitude electric potential component of the terminal portion of the QRS (LAS40) in conventional and modified right precordial leads. The primary endpoint was the occurrence of malignant arrhythmic events (MAEs), defined as a composite of SCD or appropriate shocks. Uni- and multivariate Cox regression survival analyses were used to identify significant prognostic predictors considering the clinical, genetic, and electrocardiographic characteristics as well as the tercile distribution of the SAECG parameters. A risk score was computed incorporating the significant LPs variables and its usefulness for prognostic stratification was explored using Kaplan Meier survival analysis. Results Our cohort consisted of 117 patients (mean age: 47±13 years, 33% male), including 75 (65%) with type 1 spontaneous pattern and 92 (79%) asymptomatic individuals. Symptoms at presentation included syncope in 16 pts (14%) and polymorphic VT/cardiac arrest in 4 (3.4%). During a median follow-up of 4.1±0.3 years, 8 pts (6.8%) suffered MAEs: 3 (2.6%) with SCD and 5 (4.3%) with appropriate shocks. The risk of events differed in relation to the several SAECG parameters (Table 1), increasing linearly with the fQRS duration determined either in the conventional (HR 1.03, 95% CI 1.01-1.06, p=0.008) or modified leads (HR: 1.03, 95% CI 1.01- 1.05, p=0.003). The SAECG score incorporated as risk markers a fQRS ≥113ms and a RMS40 Conclusion This study shows that the non-invasive assessment of LPs based on SAECG is useful for prognostic stratification of BrS. It was possible to identify a subset of patients presenting a high risk of events who may deserve individualized preventive strategies.

Funding Acknowledgements Type of funding sources: None. Introduction Nowadays 10-15% of CRT implantaon is upgrading from paents (pts) with pacemaker (PMK) who develop reduced LVEF and worsening symptoms from HF. There are few retrospecve studies showing some predictors of pts with single or dual chamber PMK that may need upgrade to CRT, but it is not completely established which pts may benefit the most. Purpose To identify predictors at follow-up of upgrading pacemaker to CRT in a population with pacemaker implantation. Methods Single center case-control study of pts that performed upgrading to CRT-pacemaker (CRT-P) in our hospital. We excluded pts that performed upgrade to CRT-D. We compare to a PMK populaon matched to age at implantaon and cause of PMK implantaon. Demographic, clinic and electrocardiographic (ECG) data were considered at baseline. Echocardiographic evaluation was performed before pacemaker/CRT upgrading implantaon and at follow-up. Predictors of upgrading were evaluated by the Cox regression. Prognosc impact of LVEF was evaluated as upgrading to CRT-P by Kaplan-Meier curves. Results We included 71 pts that performed CRT-P upgrade (mean age 77±10; 49,6% male, mean LVEF before PMK 54.9±9.2%) and 71 pts with pacemaker implantaon (mean age 78 ± 11; 50,4% male; mean LVEF 60.9±7.2%). The clinical characteriscs, ECG and echocardiographic were similar between pacemaker and CRT-P-upgrade, except atrial fibrillaon being more prevalent in PMK group (57.5% vs 42.5% p=0.039). Mortality was not different duringfollow-up between the two groups. In univariate analysis, QRS duraon (PMK: 115ms vs upgrade CRT-P: 132 ms, p=0.038), LVEF (PMK: 60.9% vs upgrade CRT-P: 54.9%, p=0.002) and LV end-diastolic diameter (LVEDD) (PMK: 48.9.4 ± 6.6mm vs upgrade CRT-P: 56.4 ± 6.6mm, p=0.001), LV end-sistolic diameter (LVESD) (PMK: 29.5 ± 6.5mm vs upgrade CRT-P: 37.9 ± 9 mm, p=0.006) were associate to upgrading to CRT. In our population, the unique independent predictor was lower LVEF(Long Rank 6.108, p=0.013) – Figure 1. The best LVEF cut- off to predict upgradingto CRT was 55% (AUC 0.954, sensitivity 64%, specificity 84%) – Figure 2. Conclusion In our populaon of CRT upgrading pts, a broad QRS duraon, lower LVEF and a higher LVEDD and LVESD were associated to upgrade to CTR-P. We try to establish a new value for LVEF that could lead to upgradingto CRT-P, and maybe the classical cut-off of 50% should be reviewed.

Funding Acknowledgements Type of funding sources: None. Introduction In several structural arrhythmogenic diseases that comprise intricate endocardial, intramural and epicardial substrates, endocardial ablation of ventricular tachycardia (VT) is not sufficient and epicardial ablation has lately become a complementary and necessary tool. Purpose To evaluate the clinical characteristics of patients (pts) most suitable for first intention epicardial VT ablation. Methods Single-center prospective study of consecutive pts with structural heart disease undergoing first intention epicardial VT mapping between August 2015 and June 2021. Decision for epicardial approach was based on the etiology, VT electrocardiogram (ECG) and cardiac magnetic resonance (CMR) results. Under general anesthesia, subxiphoid access using a Tuhoy needle was done using fluoroscopic guidance and with high-density epicardial mapping was performed. Epicardial ablation was performed if relevant arrhythmogenic findings were locally confirmed. Results First intention epicardial VT ablation was attempted in 18 pts (mean age 59.8±12 years,94% male) of whom 16 had non-ischemic dilated cardiomyopathy (NICM,idiopathic:11; post-myocardis:4; hereditary:1) and 2 had right ventricular arrhythmogenic cardiomyopathy. Mean LVEF was 33% and 79% had a previous ICD (53% in primary prevenon). 69% were referred for ablation due to arrhythmic storm (1pt in cardiogenic shock). Epicardial access was achieved in 17 pts (94%), without acute complications. In 35% pts with NICM the decision for epicardial approach was based on the detection of subepicardial CMR delayed-hyperenhancement and relevant epicardial arrhythmic substrate was confirmed by mapping in all cases. In 3 pts radiofrequency (RF) applicaons were not performed at epicardium, as no abnormal electrograms were locally detected, and an addional endocardial approach was prosecuted. The mean overall procedure and fluoroscopic time were 123 and 28min, respectively, with a mean RF application me of 51min. After the procedure 1pt required pericardial drainage due to inflammatory pericardial effusion. No other acute complications occurred. During a mean follow-up of 2.8±1.8 years, only 3pts (17%) had VT recurrence; 5pts (28%) died due to end-stage heart failure and 2pts (11%) underwent heart transplantation. Conclusion In NICM a first intention epicardial VT ablation performed by experienced operators/centers is efficient, particularly if guided by CMR findings,and presents a safety profile.

Funding Acknowledgements Type of funding sources: None. Introduction Patients (pts) with non-ischemic cardiomyopathy (NICM) present an increased morbidity and mortality from sustained monomorphic ventricular tachycardia (VT). Implantable cardiac defibrillators effectively terminate VT, but ablation is usually required to prevent recurrences and appropriate shocks. Although several risk factors have been pointed out, clear prognostic predictors need to be established and addressed. Purpose To evaluate risk factors associated with all-cause mortality and ICD shocks in NICM pts submitted to VT ablation. Methods Prospective, observational, single-centre study of pts with NICM submitted to VT ablation using high density mapping tools.The primary outcome was all-cause death or VT recurrence terminated with appropriate ICD shock during long-term follow up. Kaplan-Meier analysis was used to estimate the long-term event-free survival. Uni and multivariate Cox regression analyses were used to determine relevant prognostic predictors. Results A total of 27 consecutive pts with NICM were referred for a first-ever VT ablation procedure between June 2015 and June 2021 (males: 93%; mean age: 61±12 years). The mean left ventricular ejection fraction (LVEF) was 35±12% and 70% of pts had NYHA class I or II. During a mean follow-up of 29 ± 19 months, VT recurrences requiring ICD shocks occurred in 25.9% of pts. VT ablation success and the risk of ICD shocks were not associated with any of the clinical characteristics. Long-term all-cause mortality was 37%. In univariate analysis, LVEF Conclusions In pts with NIDM, VT ablation may be successful even in pts with advanced heart disease. However, long-term survival will depend mostly on the stage of disease progression and is strongly associated with the clinical markers of end-stage heart failure. Therefore, a timely referral is crucial to derive the best clinical benefit from VT ablation in this population.

Funding Acknowledgements Type of funding sources: None. Introduction Age affects the performance of the diagnostic tests to rule out pulmonary embolism (PE), particularly with a decrease in specificity, leading to an overuse of computed tomography pulmonary angiography (CTPA). Current guidelines advice to consider using the age-adjusted cut-off in patients older than 50 years, but no specific recommendation is provided for very old patients. We aimed to compare the age-dependency of the diagnostic accuracy of the standard approach (based on Wells and Geneva scores combined with a D-dimer cut-off of 500 ng/mL), with three alternative strategies (age-adjusted, YEARS and PEGeD algorithms) in patients admitted to the Emergency Department (ED) due to PE suspicion. Methods Consecutive outpatients admitted to the ED who underwent CTPA due to PE suspicion were retrospectively evaluated. The diagnostic accuracy was calculated and compared among the different diagnostic prediction rules and stratified by age. Results We included 1402 patients (mean age 69 years, 54% female). PE was confirmed in 25% (n=353), 86% occurred in patients over 50 years. Table 1 and 2 represents the sensitivity and specificity of diagnostic prediction rules stratified by age. For all diagnostic strategies, specificity decreases with age. In patients over 80 years, the standard approach’s specificity could be as low as 8%. Compared to the standard approach, the age-adjusted strategy was associated with higher specificity over 50 years (p=0.008 for patients aged 51-60 years; p Conclusion Compared to the standard approach, an age-adjusted strategy increased specificity with a non-significant decrease in sensitivity only in patients older than 70. YEARS and PEGeD algorithms had the highest specificity across all ages yet were associated with a significant decrease in sensitivity.

Funding Acknowledgements Type of funding sources: None. Introduction Aortic stenosis is the most common valvular heart disease in Europe and in symptomatic patients, when untreated presents a high rate of morbidity and mortality. Its prevalence is estimated to grow even more, given the aging of the population. Transcatheter aortic valve implantation (TAVI) emerged as a safe and efficient procedure in patients with high or prohibitive surgical risk or in older patients, who are much often frailty, with impaired cognitive function and have poor quality of life. Aim To assess the acute benefits (in 1 moth) of TAVI on cognitive function, anxiety and depression and independence in activities of daily living. Methods Single center prospective study of patients submitted to TAVi between April 2021 and September 2021. Patients were evaluated at baseline (before TAVI) and one month after the procedure. To assess cognitive function, anxiety and depression and independence in activities of daily living we used the Mini Mental State Examination (MMSE), Hospital Anxiety and Depression Scale (HADS); Katz Index of Independence in Activities of Daily Living; and Lawton-Brody Instrumental Activities of Daily Living Scale, respectively. Paired sample t-test and Wilcoxon test were used to statistical analysis. Results We included 20 patients, with a mean age of 85±5,86 years, 40% (8) male. 19 patients undergone TAVI due severe native aortic stenosis and 1 due to bioprosthetic aortic valve dysfunction. The vascular access site was transfemoral in 19 patients and transapical in 1 patient. The median MMSE results were higher 1 month after TAVI (21,3 versus 23,5, p=0,012), essentially due to a better results in the temporal orientation and evocation domains (p=0,011 and p=0,022, respectively). Patients experienced lower levels of anxiety and depression after TAVI, mean score 5,4 versus 3,9 (p=NS) and 7 versus 4,25 (p=0,002) respectively for anxiety and depression, as assessed by HADS scale. No statistical difference was observed on the results of basal and post TAVI evaluation of Katz and Lawton-Brody scales. Conclusion In an elderly population, TAVI appears to have an early and beneficial effect on cognitive function and depression, but no benefits were observed on independence in activities of daily living.

The Fig (Ficus carica L.) is a fruit produced worldwide for in in natura consumption and processing. The aim of this work was to evaluate the effect of edible coatings on the post-harvest qualities of fig fruit. The experiment was conducted at the Instituto Federal Goiano – Urutaí Campus, using figs from a orchard in the municipality of Silvania-GO. The fruits, after washing and sanitization, received edible coatings (polysaccharide, protein and lipid), constituting the treatments together with the control treatment (without cover). The fruits were stored for six days at a temperature of 25 ± 2 º C, in a completely randomized design with 5 replications. Sensory parameters (appearance, aroma and flavor) and physicochemical (weight loss, titratable acidity, soluble solids, ratio, pH and diameter) were analyzed at 0, 3 and 6 days of storage. The data obtained were submitted to MANOVA analysis and the treatments were compared using ellipses of 95% of confidence. The fig fruits, of all treatments, showed no variation of soluble solids over time (10 º Brix), and did not present aroma and alcoholic flavor. For the other variables analyzed there were variations, highlighting the lipid coatings, which maintained better fruit qualities over time, differentiating from the other treatments. The polysaccharide and proteic coatings presented identical behavior, this, intermediate to the lipid coatings and to the control treatment. In the conditions that the study was carried out, there was a rapid loss of fruit quality and, among the covers, the lipid minimized these losses.

The production of good quality seedlings becomes essential strategy for those who wish to become production that is more competitive. To induce dormancy breaking and germination and emergence of these, the imbibing of natural acid in seeds can be an alternative for the optimization of this process. The aim of this study is to evaluate the dormancy breaking in Anonna seeds squamosa immersed in different natural acid in times through the lemon juice Rangpur (Citrus limonia Osbeck). This work is being conducted in Biotecnogia laboratory greenhouse at the Federal Institute Goiano campus Urutaí where the seeds were soaked in lemon juice Rangpur (C. limonia) in five different times, each time constituting a treatment: seeds without soaking in lemon groove variety Cravo '(T1); soaked for 8 hours (T2); soaked for 16 hours (T3); soaked for 24 hours (T4); soaked for 32 hours (T5). The seeds were sown in plastic boxes with dimensions 40 x 27 x 10 cm, containing washed sand substrate, 2 cm deep in spacing of 2 x 2 cm. The germination percentage data were determined up to 45 days after sowing (DAS), and survival to 73 (DAS). After 73 DAS were evaluated after 73 days of sowing, they were evaluated; germination and survival; emergence speed index (EVI); total length of seedlings; shoot length of seedlings and radicle length (cm); Stem diameter (mm); pair of leaf number (MPN); total fresh mass changes (MFT); dry matter of shoot and radicle (g). There was not statistical diseases among treatments. T4 treatment in comparison to others on the numerical difference CTM, NPF, DC and CPA.

Preamble: The present document is an Expert Consensus Document that includes evidence about the standards for the acquisition, measurement, and reporting of intravascular ultrasound studies (IVUS). This document is intended to inform practitioners, payers, and other interested parties of the opinion of the American College of Cardiology (ACC) concerning evolving areas of clinical practice and/or technologies that are widely available or new to the practice community. Topics chosen for coverage by Expert Consensus Documents are so designed because the evidence base and experience with technology or clinical practice are not considered sufficiently well developed to be evaluated by the formal ACC/American Heart Association (AHA) Practice Guidelines process. Often, the topic is the subject of considerable ongoing investigation. Thus, the reader should view the Expert Consensus Document as the best attempt of the ACC to inform and guide clinical practice in those areas where rigorous evidence may not yet be available or the evidence to date is not widely accepted. When feasible, Expert Consensus Documents include indications or contraindications. Some topics covered by Expert Consensus Documents will be addressed subsequently by the ACC/AHA Practice Guidelines Committee. The Task Force on Clinical Expert Consensus Documents makes every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the writing panel. Specifically, all members of the writing panel are asked to provide disclosure statements to inform the writing effort of all such relationships that might be perceived as real or potential conflicts of interest.

Intracoronary ultrasound (ICUS) is a new imaging technique with the unique ability to study vessel wall morphology in vivo, accurately displaying the details of vessel structure. The coronary angiogram represents only a projectional image of the vessel lumen without providing any information concerning vascular wall architecture. Interventional cardiology has developed over the last years with the appearance of new devices and consequently new challenges. The selection of an appropriate device and the assessment of any intervention, as well as the understanding of its mechanisms is essential to perform a better intervention. The use of a tool, such as ICUS, able to identify vessel wall anomalies, complementing coronary angiography, seems to be an appropriate method in the regard. The last years have witnessed an array of studies demonstrating the advantages and disadvantages of ICUS in the setting of interventional cardiology. Despite some contradictions in the literature, the result of a new technology still under scrutiny, it is possible to summarise some of the major achievements: Lesion assessment before coronary interventions for selection of treatment, including calcium detection, plaque eccentricity, diffuse atherosclerotic disease, type of vessel remodelling; ICUS during balloon angioplasty has helped in balloon diameter selection, identification of pseudo successful results and presence/severity of wall dissections, as well as the search of predictors of restenosis; during rotational and directional atherectomy, ICUS can help in the definition of the lesion most suitable for rotational atherectomy, showing if there is a diffuse sub endothelial calcification, excluding unsuitable lesions, selecting cut direction and directly assessing the adequacy of plaque removal; during stent implantation it helps to determine if there was a complete apposition, detect residual narrowing or proximal/distal stenoses or dissections requiring further treatment. Some new concepts have been introduced by ICUS, such as the negative remodelling as one of the mechanisms of restenosis. New developments are under way, including combined devices, looking forward ultrasound, high frequency probes, imaging wires, tissue characterisation and three dimensional technology. Therefore, ICUS has reached enough maturity to be considered an important tool in the catheterization laboratory, complementing the information provided by coronary angiography. However, some more research needs to be done to answer some important questions regarding the whole array of potential applications in an environment of cost containment as the one we live in today.

Contrast angiography is presently the standard for in vivo quantitation and morphologic evaluation of coronary atherosclerosis. Pathologic-angiographic correlation studies have shown marked angiographic underestimation of atheromatous plaques. This is particularly true in the early stages of intimal thickening and atheroma growth where media initially enlarges to accommodate the proliferative process without a chance in lumen size. The miniaturization of transducers allowed to mount them on the tip of a catheter and made it possible to position these catheters inside the arterial lumen and, for the first time, to see in vivo the vessel wall. Intravascular ultrasound is a new imaging technique with the ability to define and measure luminal areas and arterial wall components; therefore it serves as a potential tool to assess vascular wall morphology and dynamic vasomotor responses in epicardial coronary arteries. Its ability to measure luminal areas and diameters and the different components of the arterial wall has been validated by several in vitro, animal and in vivo studies. The definition of normal arterial wall by ultrasound has been defined looking at coronary arteries of young adults. It also showed that young subjects with angiographically normal vessels have a wide range of coronary intimal thickening, including occasional evidence of focal, early atheromatous lesions. Safety studies have shown it does not accelerate progression of angiographically quantifiable coronary artery disease suggesting that it can be safely utilized even in coronary arteries not undergoing interventions. The large potential of intracoronary imaging in the setting of interventional cardiology and future developments are also discussed, including the use of combined devices (ultrasound catheter-balloon angioplasty, ultrasound-atherectomy, ultrasound-laser); three dimensional reconstruction; new devices design, such as looking forward catheters; tissue characterization with the goal of differentiating between different types of plaque, and between soft plaque and thrombus; study of biomechanical properties of the atherosclerotic plaque, trying to distinguish between "good" and "bad" plaques. In conclusion, intravascular ultrasound is a powerful in vivo coronary imaging technique which may serve as a new standard for quantifying coronary atherosclerosis and offers significant potential for enhancing our understanding of the pathophysiology of coronary artery disease.

The hind-body region of Schistosoma mansoni cercariae observed in the scanning electron microscope demonstrates various stages of contraction which may be compared with those of living larvae which are secreting the acetabular gland contents.No evidence for an extensive lesion was found in cercarial bodies which had shed their tails under experimental conditions. Experiments on the permeability of the larvae to sodium fluoride, methylene blue and amino acids demonstrated that tail loss significantly affects the permeability of the bodies although the effect is greater immediately after decaudation than at later times. Subsequent increases in permeability may be correlated with a change in the general body surface.