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Funding Acknowledgements Type of funding sources: None. Introduction Besides the established class I indication for the evaluation of patients with recurrent syncope of uncertain origin, implantable loop recorders (ILRs) have been increasingly used for other diagnostic purposes (e.g. detection of atrial fibrillation (AF) following cryptogenic stroke). Purpose To describe the main indications to ILR and to investigate procedural parameters, outcomes and diagnostic yield of ILR in a single, high-volume tertiary care centre. Methods All patients undergoing ILR implantation between November 2007 and April 2022 were consecutively enrolled in this study. Clinical characteristics of patients, procedural data and outcomes were collected. The indications to ILR implantation were divided into four categories: 1) AF detection in patients with recent cryptogenic stroke or peripheral thromboembolism [CRYSP], 2) recurrent syncope of uncertain origin [RSUO], 3) monitoring of ventricular arrhythmic events [VAE] in patients with predisposing cardiomyopathy/channelopathy, 4) monitoring of AF burden or relapse [AFB]. The main endpoint of the study was the diagnostic yield (number of definitive diagnoses made) and the time to diagnosis following ILR implantation. The occurrence of acute or subacute complications was used as a secondary safety endpoint. Results Overall, 1442 patients underwent ILR implantation (mean age 65 years, 43% female). The two main indications to ILR were AF detection following CRYSP and RSUO (42% and 34% of all implantations respectively, table 1). The commonest site of implantation was the left parasternal position (902 patients, 63%), median procedural time was 20 minutes (IQR 15-25). During a median follow-up of 397 days (134-1094), infections requiring ILR extraction or pocket revision occurred in 13 patients (0.9%). A definitive diagnosis was achieved in 500 (35%) patients after a median time of 206 days (IQR 60-533) [table 1 shows details and action taken following diagnosis for each indication subgroup]. At multivariable analysis, age and PR interval duration were significantly associated with the need for PM/ICD implantation among patients receiving ILR for RSUO whilst age was associated with AF detection among those with CRYSP (table 2). Conclusions In this cohort of patients use of ILR was associated with a good diagnostic yield regardless of the initial indication, triggered timely therapeutic actions and was overall safe.

Funding Acknowledgements Type of funding sources: None. Background Cardiac Sympathetic Denervation (CSD) has been recently proposed for the treatment of refractory ventricular arrhythmias (VAs) in patients with cardiomyopathy (CMP). A multicentric American case series suggested a greater efficacy of the bilateral (BCSD), compared to the left-side only procedure (LCSD), albeit with a potential impact on chronotropism. The impact of CSD on the risk of electrical storms (ES) in CMP has never been evaluated. Purpose To describe our multicenter experience with CSD in CMP patients with refractory VAs, with a specific focus on ES incidence. Methods Thirty patients with CMP and refractory VAs underwent either LCSD or BCSD between April 2016 and June 2022. Among them, one patient received first LCSD and then right-side CSD due to ES recurrence after LCSD: to properly assess the risk of ES after LCSD and BCSD he was included in both groups, leading to 5 cases of LCSD and 26 cases of BCSD. All patients had a Video-Assisted Thoracoscopic Surgery, in 8 cases with the robotic technique. The main reason (3/5 cases, 60%) to perform LCSD instead of BCSD since the beginning was sinus bradycardia in single ICD lead recipients. Results 87% of pts were male, mean age was 56 ± 16 yrs and mean LVEF 31± 12%; most (n=26, 85%) suffered non-ischemic CMP and 37% were in NYHA class ≥3. Main indications for CSD were refractory polymorphic/fast VAs in 60% of pts and refractory monomorphic VAs in the rest. Except for 5 patients (17%) with previous thyrotoxicosis, the majority were either on amiodarone (n=19, 63%) or on sotalol (n=3, 10%) and 53% had previously undergone ≥1 catheter ablation for VAs. The median follow-up (FU) after CSD was 16 months (IQR 6-42 months). No major complications occurred. Eleven patients (37%) either died during FU (n=8, 27%), mostly due to end-stage heart failure, or underwent heart transplant (n=3, 10%). After CSD, the percentage of patients with ES decreased from 77% to 40% (p Conclusions Our case series of CSD in CMP represents the largest reported in Europe and the first one to evaluate the impact of CSD on electrical storms. The occurrence of electrical storms was more than halved by BCSD confirming the powerful protective effect also on this ominous phenomenon. The greater antiarrhythmic benefit observed among patients with better functional class suggests the opportunity to perform this procedure earlier on in the trajectory of patients with progressive heart failure.

Funding Acknowledgements Type of funding sources: None. Background Genotype-phenotype correlation and risk stratification for heart failure progression in patients with cardiolaminopathies are poorly defined. Purpose The primary aim of the present study is to characterize and correlate phenotype with genotype and sex. The secondary aim is to test the two main existing prognostic scores (the Arbustini and the Whabi score), both developed to predict ventricular arrhythmic events in cardiolaminopathies, for both major ventricular arrhythmias (MVA) and end-stage heart failure (ESHF). Methods This is a retrospective, single-center study, including patients with lamin (LMNA) and/or emerin (EMD) genetic variants. Data were collected from the first medical contact (FMC) to the last follow-up (FU). Results 28 patients (57% male, 82% probands, 68% with a family history of sudden death) were included: 96% harbored LMNA heterozygous variants, 15% had non-missense variants, 11% had variant previously never described. Functionally, 50% were variant of undetermined significance (VUS, C3), the rest were either pathogenetic or likely pathogenic (C4/C5) variants. Median age at FMC was 41 years (IQR 30-55 years), median FU was 11 years (IQR 8-18 years). At FMC, all patients had cardiac involvement, 54% had muscle involvement. By the last FU, 54% developed atrial fibrillation, 43% atrioventricular block (AVB) > I degree, 50% carried an implantable cardioverter defibrillator (21% with resynchronization), 50% had suffered at least one episode of MVA, 25% developed ESHF: 11% died due to refractory HF, 14% underwent heart transplantation (mean age 43.5 ± 9 years). The age of onset of the different types of cardiac phenotype was not influenced by sex. The penetrance of atrioventricular (AV) conduction defects (Figure 1 Panel A) and of atrial tachyarrhythmias (Figure 1 Panel B) was higher and earlier in subjects with non-missense variants. Subjects with VUS, compared to those with pathogenetic/likely pathogenetic variants, showed a significantly lower and later penetrance of MVA (Figure 2 Panel A) and a later penetrance of non- sustained ventricular tachycardia (NSVT, Figure 2, Panel B), but not of AV conduction disturbances, atrial arrhythmias, or contractile dysfunction. Arbustini score at FMC proved to be a predictor of both MVA and ESHF, while Whabi score only predicted MVA. Conclusions In our series, the prevalence and the age of appearance of the different cardiac phenotypes of cardiolaminopathies were not influenced by sex, while the presence of VUS correlated with a lower risk of ventricular arrhythmias, but not of the other cardiac manifestations including contractile disfunction and heart failure. Our data suggest the importance of a close cardiac monitoring and of larger prospective studies even in patients with VUS. All patients developed a sever cardiac phenotype by the age of 60.

Long term survival and its determinants after Percutaneous Coronary Intervention (PCI) on Unprotected Left Main Coronary Artery (ULMCA) remain to be appraised. In 9 European Centers 470 consecutive patients performing PCI on ULMCA between 2002 and 2005 were retrospectively enrolled. Survival from all cause and cardiovascular (CV) death were the primary end points, while their predictors at multivariate analysis the secondary ones. Among the overall cohort 81.5% of patients were male and mean age was 66 ± 12 years. After 15 years (IQR 13 to 16), 223 patients (47%) died, 81 (17.2%) due to CV etiology. At multivariable analysis, older age (HR 1.06, 95%CI 1.02 to 1.11), LVEF < 35% (HR 2.97, 95%CI 1.24 to 7.15) and number of vessels treated during the index PCI (HR 1.75, 95%CI 1.12 to 2.72) were related to all-cause mortality, while only LVEF

Background Cardiogenic shock (CS) is the most severe form of acute heart failure, characterized by life-threatening end-organ hypoperfusion resulting from a low cardiac output state. Data on epidemiology of CS has been mostly drawn from registries focusing on acute myocardial infarction (AMI). However, recent evidence in a contemporary cohort in North America has shown that more than two thirds of all CS cases were related to causes other than AMI and that these patients had outcomes at least as poor as patients with AMICS. Purpose To provide data on profile, management, outcome, and evolution over time of CS patients admitted to ICCU/ICU and to compare them between patients with AMICS and acute decompensated heart failure (ADHF-CS). Methods The Altshock-2 Registry is a multicenter national prospective data collection, part of the Italian Altshock-2 program. Recruitment started on 2 March 2020 with 11 Italian Centers contributing to patients' enrolment. A total of 238 patients were hospitalized with confirmed diagnosis of CS between March 2020 and February 2022 in a multicenter national initiative. The mean age of this patient population was 64 years (interquartile range [IQR] 54–74) and 76% were male. Ninety-seven patients (41%) were admitted for AMICS, whereas 84 patients (35.3%) had ADHF-CS; 57 patients (24%) had other causes. As compared to AMICS patients, those admitted for ADHF-CS were younger, but with a higher burden of comorbidities (renal, liver, thyroid disease, atrial fibrillation, anemia), pre-existing decreased ejection fraction and a higher number of chronic drugs. Patients with ADHF-CS had a prevalent cardio-metabolic phenotype upon admission with prevalent congestion. Mechanical ventilation was more commonly used in patients with AMICS, compared to ADHF-CS, along with an increased inotropic score. Conversely, sodium nitroprusside was used in about sixty percent of patients with ADHF-CS. Sixty percent of the included population received a temporary mechanical circulatory support (MCS) device, which was intra-aortic balloon pump (IABP) in the eighty percent of the supported patients. Pulmonary artery catheter was used for monitoring only in the 18% of the included patients whereas an extensive echocardiographic approach was applied. Twenty-one patients (25%) underwent heart replacement therapy in the ADHF-CS patients versus 2 (2%) in the AMICS. Thirty-day mortality occurred in 32 patients (33%) in the AMICS group versus 23 (27%) in the ADHF-CS group (p=0.41). Conclusions Different diagnostic approaches and uses of mechanical circulatory support devises and inotropes are implemented in transatlantic settings. Uniform definitions and more homogenous protocols tailored on CS etiologies and clinical and biochemical phenotypes are needed in prospective initiatives in order to effectively compared results and outcome. Funding Acknowledgement Type of funding sources: None.

Background Even if prevalent among patients with severe aortic stenosis (AS), the clinical suspicion for transthyretin cardiac amyloidosis (ATTR-CA) remains difficult in this subset. Methods Consecutive severe AS patients undergoing transcatheter aortic valve replacement (TAVR) evaluation at a single center were prospectively included. Those with suspected ATTR-CA based on clinical assessment underwent 99mTc-DPD cardiac scintigraphy. The RAISE score, a novel screening tool with high sensitivity for ATTR-CA in AS, was retrospectively calculated to rule-out ATTR-CA in the remaining patients. Patients were categorized as follow: “ATTR-CA+”: patients with confirmed ATTR-CA at 99mTc-DPD cardiac scintigraphy; “ATTR-CA−”: patients with negative 99mTc-DPD cardiac scintigraphy or a negative RAISE score; c) “ATTR-CA indeterminate”: patients not undergoing ATTR-CA assessment with a positive RAISE score. The characteristics of ATTR-CA+ and ATTR-CA− patients were compared. Results Of 107 included patients, ATTR-CA suspicion was posed in 13 patients and confirmed in 6. Patients were categorized as follow: 6 (5.6%) ATTR-CA+, 79 (73.8%) ATTR-CA−, 22 (20.6%) ATTR-CA indeterminate. Excluding ATTR-CA indeterminate patients, the prevalence of ATTR-CA was 7.1%. As compared to ATTR-CA− patients, ATTR-CA+ patients were older, had higher procedural risk and more extensive myocardial and renal damage. They had higher left ventricle mass index and lower ECG voltages, translating into a lower voltage to mass ratio. Moreover, bifascicular block was more common. No difference in procedural outcomes and 1-year mortality was observed between groups. Conclusions Among severe AS patients, ATTR-CA is prevalent and presents with phenotypic features that may aid to differentiate it from lone AS. A clinical approach based on routine search of amyloidosis features may effectively lead to selective 99mTc-DPD cardiac scintigraphy with a satisfactory positive predictive value. Funding Acknowledgement Type of funding sources: None.

Background Cardiogenic shock (CS) includes several phenotypes of congestion or hypoperfusion with heterogenous hemodynamic features. Timely prognostication with scoring tools is warranted to identify patients requiring escalation to mechanical circulatory support (MCS) and to avoid futility. Purpose Accordingly, we explored the role of the updated Society for Cardiovascular Angiography and Interventions (SCAI) stages classification on in-hospital mortality using a prospective national registry. Methods The Altshock-2 Registry includes 237 patients with CS of all etiologies enrolled between March 2020 and February 2022 in 11 Italian Centers. Patients were classified according to the admission SCAI stages (assigned prospectively and independently updated according to the most recently released version); 24-hour re-assessment was prospectively performed in 201 patients. In-hospital mortality was evaluated for association with admission and 24 hours SCAI stages adjusted for the most relevant clinical covariates. Results Of the 237 patients included, 20 (8.4%) had SCAI shock stage B, 132 (55.8%) SCAI stage C, 60 (25.3) SCAI stage D and 25 (10.5%) SCAI stage E. Patients in stage B had the worst reclassification at 24-hours, with 42% of them showing worsened status and only 8% improving. In-hospital mortality was 38%. The revised SCAI stages at baseline were not independently associated with in-hospital mortality, whereas the SCAI classification at 24-h correctly and independently predicted mortality (the rate of in-hospital death was 18% for patients in SCAI shock stage B, 27% for SCAI shock stage C, 64% for SCAI shock stage D, 100% for SCAI shock stage E). At the multivariate analysis (adjusted for age, gender, eGFR, inotropic score and MCS) only SCAI classification at 24-hour evaluation was an independent predictor of in-hospital mortality (OR and 95% CI were, respectively, 3.32, 0.36–30.63, p=0.290 for SCAI stage C and 13.07, 1.69–146.3 for SCAI stage D, with E perfectly predicting because all patients died). Conclusions The revised SCAI stage classification may improve prognostication only at 24-hour evaluation. Aggressive treatment (either pharmacological or with MCS escalation) should be tailored in order to achieve prompt clinical improvement within the first 24-hours; refractory SCAI stage E at 24 hours portends dismal prognosis. Funding Acknowledgement Type of funding sources: None.

Background The clinical value of high-risk coronary plaque characteristics (CPCs) to inform intensified medical therapy or revascularization of non-flow-limiting lesion remains uncertain. Purpose We performed a systematic review and meta-analysis to study the prognostic impact of CPCs on patient-level and lesion-level major cardiovascular adverse events (MACE). Methods We systematically reviewed MEDLINE, EMBASE, and the Cochrane database for studies evaluating the association of CPC with patient-level and lesion-level MACE. CPCs included high plaque burden, low minimal lumen area, thin cap fibroatheroma, high lipid core burden index, low attenuation plaque, spotty calcification, napkin ring sign, or positive remodelling. Results Thirty studies (21 retrospective, 9 prospective) with 30,369 patients were included. CPCs were evaluated by invasive intravascular techniques in 9 studies (optical coherence tomography=4, intravascular ultrasound imaging=3, near-infrared spectroscopy intravascular ultrasound imaging=2) and by coronary computed tomography angiography (CCTA) in 21 studies. CPCs significantly predicted patient-level and lesion-level MACE in both unadjusted and adjusted analyses. For each CPC, the risks were higher for lesion-level (HR range 3.2–16.8) as compared with patient-level MACE (HR range 1.8–4.1). Accuracy was modest to good for most CPCs at the patient-level (AUC for MACE ranging between 0.53 and 0.84) and moderate to good for most CPCs at the lesion-level (AUC for MACE ranging between 0.71 and 0.83). Plaques with more than one CPC had the highest accuracy for lesion-level MACE (AUC 0.87, 95% CI 0.84–0.90). The pooled sensitivities of CPCs for lesion-level MACE ranged between 40% and 63% and specificities between 73% and 98%. As the pooled prevalence of CPCs among plaques was low (3% to 28%), the estimated positive predictive values for lesion-level MACE were modest (range 1% to 26%). Conclusions CCTA and intravascular imaging characterization of CPCs identifies high-risk atherosclerotic plaques that place lesions and patients at risk for future MACE, albeit with modest sensitivity and positive predictive value (PROSPERO identifier: CRD42021251810). Funding Acknowledgement Type of funding sources: None.

Introduction Mitral transcatheter edge-to-edge repair (TEER) is a widespread option to treat mitral regurgitation in high-risk patients. The sudden reduction of mitral regurgitation (MR) following TEER abruptly eliminates the low-impedance regurgitant flow into the left atrium, leading to an increase in left ventricle (LV) afterload with possible impairment of LV systolic function, defined afterload mismatch (AM). Purpose To explore a new definition of AM and to analyze the determinants and prognostic role of AM in patients with functional MR (FMR) undergoing TEER. Methods This was an international multicenter case-control study including adult patients with severe FMR and LVEF ≤35% undergoing TEER between 2012 and 2020. AM was defined as the acute need to initiate or increase inotropic support by a vasoactive inotropic score ≥3 or the need for a mechanical circulatory support following TEER. Results 80 patients with AM were compared to 80 consecutive patients undergoing TEER not meeting the criteria for AM. Median age was 67 years, 79% of patients were male, had a median LVEDV of 240 ml with severely reduced LVEF (median 26%) and pulmonary hypertension (median 48 mmHg). Median EROA/LVEDV ratio was 0.17 (IQR 0.12–0.24) based on which 37% of the total population presented with proportionate MR. Levosimendan was administered before TEER in 42% of patients while intravenous vasodilators in 43%. In most patients more than 1 clip were needed (2 clips in 88 patients, 3 clips in 11). Patients presenting AM more commonly had a lower EROA/LVEDV ratio (0.14 vs. 0.18, p Conclusions In patients with LVEF ≤35% and severe FMR undergoing TEER, the development of AM predicted in-hospital mortality, while long-term outcomes were not affected by acute AM. The use of levosimendan or intravenous vasodilators during the pre-procedural phase reduced the risk of acute AM. Funding Acknowledgement Type of funding sources: None.

Background The structural alterations of arrhythmogenic right ventricular (RV) cardiomyopathy (ARVC) mainly involve the RV outflow tract (RVOT), but RVOT systolic function has been poorly investigated. Purpose We aimed to evaluate the Doppler Velocity Ratio (DVR) as a novel echocardiographic parameter for ARVC diagnosis. Methods 30 consecutive ARVC adult patients, 45 asymptomatic healthy volunteers and 45 consecutive patients with RV dysfunction due to ARVC mimics were prospectively enrolled between May 2019 and December 2021 and received complete transthoracic echocardiography examinations. The DVR was calculated as the ratio of RV free wall systolic velocity to RVOT systolic velocity at Doppler tissue imaging. The main study outcomes were to compare the DVR among ARVC patients, healthy controls, and mimics and to assess its diagnostic value in ARVC. Results 120 patients were included. Mean age was 55±17 years; 46 (38.3%) patients were female. The DVR was significantly higher in ARVC subjects (1.59±0.41) compared to both healthy controls (1.16±0.14, P Conclusions The DVR is a simple novel echocardiographic parameter with high accuracy for ARVC diagnosis. Funding Acknowledgement Type of funding sources: None.

Background Lenticulostriate arteries (LSAs) are small perforating arteries (0.1–1 mm diameter), perpendicularly departing from middle cerebral artery (MCA) and supplying blood flow to important cerebral subcortical and basal ganglia areas. LSAs are involved in silent strokes and cerebral small vessel disease, potentially leading to cognitive decline and vascular dementia. There is growing evidence that atrial fibrillation (AF), the most common cardiac arrhythmia, increases the risk of dementia even in the absence of clinical strokes. AF also increase the risk of small vessel disease. AF may alter deep cerebral hemodynamics per se, however no data exists regarding a possible impact of AF on MCA-LSA branching sites hemodynamics. Purpose To use computational fluid dynamics (CFD) analysis to study the hemodynamics of LSAs-MCA branching sites. Methods 7T high-resolution magnetic resonance imaging (HR-MRI) brain scans (Figure 1, panel a) were used to derive detailed geometrical models of LSAs-MCA branching sites. CFD analysis was then conducted, simulating AF conditions as well as sinus rhythm (SR), at different ventricular rates (from 50 to 130 bpm). Results Geometrical models were retrieved from HR-MRI scans of 7 patients. By means of the most significant metrics, such as wall shear stress (WSS; Figure 1, panel b), wall shear stress gradient (WSSG), and flow velocity (FV), a comparison between SR and AF was performed. Conclusion CFD analysis of LSAs-MCA branching sites using geometrical models derived from HR-MRI brain scans was feasible and allows to quantify the impact of AF on these critical ramifications of the MCA. Funding Acknowledgement Type of funding sources: None.

Background Data about long-term clinical outcomes of young patients experiencing an acute myocardial infarction (MI), along with the potential impact of gender on incidence and prognosis in such subset are scant and mostly including USA populations. Thus, there is a paucity of data about European patients suffering from a juvenile MI. Purpose The purpose of the current study was to investigate temporal trends, survival, MI recurrence and sex differences among subjects who experienced their first MI at young age in the Piedmont region (Italy) between 2007 and 2018. Methods Hospital Discharge Register records of Piedmont region (Italy) from 2007 to 2018 were interrogated to identify incident juvenile MI cases and MI recurrences (ICD-9-CM codes: “410”, “411” and their subcodes). Patients were considered young if the first MI occurred before or at 47 years of age. Incidence of first Juvenile MI event and subsequent overall survival among patients who survived to hospital discharge were defined as primary outcomes of interest. Subgroup analysis were performed according to sex category, comorbidities and clinical intervention (obtained from the HDRs records). Incidence of MI recurrence among patients who survived to hospital discharge was defined as secondary outcome of interest. Lastly, we evaluated whether experiencing a MI recurrence was associated with a lower overall survival at follow-up. Results Out of 114.816 hospitalizations due to MI, 4482 occurred in people aged ≤47, with median age 44 years old. At baseline, men had more hypertension (13% vs 9.4%, p Conclusions In young patients with a MI, women had more in-hospital mortality compared to men, but among patients who survived to hospital discharge, overall long-term prognosis did not differ. MI recurrences were more common in men and were associated with lower long-term survival rate. Funding Acknowledgement Type of funding sources: None.

Introduction Despite limited to short and mid-term outcomes, Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) has emerged as a less invasive alternative to redo surgery for high and intermediate-risk patients with good outcomes across different surgical risk profiles. Purpose The aim of the resent meta-analysis is to compare short and mid-term outcomes of VIV and surgical redo fo patients with a degenerative aortic bioprosthesis. Methods All studies comparing with multivariate adjustment between ViV TAVI and re-SAVR were screened. All-cause mortality at 30-day and at follow-up were the primary endpoints, while Valve Academy research Consortium (VARC) endpoints at 30 days including stroke, myocardial infarction (MI), major vascular complications, major bleeding, new onset atrial fibrillation (AF) and permanent pacemaker implantation (PPI) during the index hospitalization were the secondary endpoints. Subgroup analysis were performed according to the surgical risk. All the analyses were stratified according to the design of the study (observational vs propensity-matched study). Results We obtained data from 11 studies, encompassing 8570 patients, 4224 undergoing ViV TAVI and 4346 re-SAVR. Four studies included intermediate-risk patients and seven high-risk patients. Mean age was 76 and 71.5 years in the ViV and re-SAVR group respectively, with a 60.2% and 61.3% of male. For the ViV procedure, BE prostheses were used in the 49.6% of patients and SE prostheses in the 45.8%. The ViV group have higher prevalence of previous CAD (53.8% vs 41.1%) and CABG (35% vs 23.6%) and more history of HF (72.1% vs 65.6%), CKD (26.6% vs 14.8%) and COPD (25.4 vs 14.8%). 30-day all-cause and CV mortality were significantly lower in ViV (OR 0.43, 0.29–0.64 and OR 0.44, 0.26–0.73 respectively), while after a mean follow-up of 717 (180–1825) days, there were no difference between the two groups (OR 1.04, 0.87–1.25 and OR 1.05, 0.78–1.43 respectively). The result were consistent both in intermediate and high-risk classes. The risk of stroke (OR 1.03, 0.59–1.82), MI (OR 0.70, 0.34–1.44), major vascular complications (OR 0.92, 0.50–1.67) and permanent pacemaker implantation (OR 0.67, 0.36–1.25) at 30 days did not differ, while major bleedings and new onset atrial fibrillation were significantly lower in ViV patients (OR 0.41, 0.25–0.67 and OR 0.23, 0.12–0.42 respectively, all CI 95%). Conclusions In patients with a degenerated aortic bioprosthesis, ViV TAVI is associated with better short-term outcomes, including all-cause mortality, without any difference in all-cause and cardiovascular mortality at mid-term follow-up compared to surgical redo. Funding Acknowledgement Type of funding sources: None.

Objective The aim of the present analysis was to evaluate the incidence and predictors of in-hospital adverse outcomes in nonagenarian patients undergoing primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI). Methods Consecutive nonagenarian patients undergoing pPCI for STEMI from 2009 to 2019 were retrospectively included in an international multicenter registry. In-hospital all-cause death was the primary outcome. Results A total of 308 patients were included (mean age 92.5±2.5 years, 65.6% female). Mean systolic blood pressure (SBP) at hospital admission was 130.7±33.5 mmHg, 46 (17%) patients presented with a Killip class III-IV, mean left ventricle ejection fraction (LVEF) was 40.0±11.5% and 147 (58%) patients were independent in everyday activities. In-hospital death occurred in 99 patients (32%). [Figure 1] After multivariate adjustment, lower LVEF (OR per unit reduction 1.08, 95% CI 1.03–1.11, p-value Conclusion Nonagenarian patients presenting with STEMI and undergoing pPCI have high in-hospital mortality. Independency in everyday life is a strong independent predictor of survival to hospital discharge. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Background Incessant pericarditis is defined as pericarditis with persistent symptoms without a symptom-free interval of 4 to 6 weeks despite therapy. On the contrary, recurrent pericarditis is characterized by recurring symptoms after a symptom-free interval of at least 4 to 6 weeks, allowing the completion of therapy. Aims The aim of this study is to assess the risk of complicated pericarditis and related hospitalizations according to the clinical pattern of incessant or recurrent pericarditis. Methods From January 2017 to December 2018, all consecutive patients admitted to AOU Città della Salute (Turin, IT) for pericarditis were included in a prospective cohort study with a clinical and echocardiographic follow-up at 1, 3, and 6 months, and then every 6 months. Results We included 147 patients (median age, 50.9 years [IQR, 28.5]; 49.7% women, 89% had idiopathic aetiology, 11% had pericarditis related to systemic inflammatory disease/postcardiac injury syndrome, 80% had pericardial effusion, and 62% had elevated C-reactive protein >5 mg/L). Patients were treated according to ESC guidelines. After a median follow-up of 14 months (IQR, 9 months), adverse events were recorded in 54/147 patients (36.7%): nonidiopathic/viral aetiology in 16 of 147 cases (10.9%), recurrent pericarditis/persistent symptoms in 53 of 147 cases (36.1%), cardiac tamponade in 4/147 cases (2.7%), persistent CP in 4/147 cases (2.7%), and hospitalization related to pericarditis in 38/147 cases (25.9%). An incessant course was reported in 18 of 147 cases (12%). The risk of complications was higher in patients with incessant pericarditis (Figure) – especially CP – compared to nonincessant course (22.2% versus 0%, respectively; P5 mg/L (hazard ratio, 5.55 [95% CI, 1.87–16.44]), and incessant course (HR, 17.10 [95% CI, 7.63–38.33]). Conclusions This study highlights that an incessant course of pericarditis is a possible new risk factor for complications and especially for developing constriction. In clinical practice, the detection of an incessant course, as well as imaging findings of constriction and pericardial thickening, should prompt more diagnostic testing, a close follow-up, and more aggressive therapy to prevent complications and persistent constriction. Funding Acknowledgement Type of funding sources: None. Figure 1

Background Colchicine has an emerging role in the cardiovascular field (e.g. acute and chronic coronary syndromes, pericarditis, atrial fibrillation), although, concerns for side effects, especially gastrointestinal, may limit its prescription. Aims We aimed at evaluating reported side effects of colchicine for cardiovascular indications. Methods We performed a meta-analysis of published randomized controlled trials on colchicine for the treatment of cardiovascular diseases. Random-effects meta-analysis was used to assess the risk of adverse events and drug withdrawal. Publication bias was assessed using the Egger test, and meta-regression was performed to assess sources of heterogeneity. Results Among 14 188 patients, 7136 patients received colchicine while the other 7052 received placebo. The occurrence of any adverse event with colchicine was reported in 15.3 vs. 13.9% patients [relative risk (RR) 1.26, 95% confidence interval (CI) 0.96–1.64, P=0.09, see figure]. Gastrointestinal events were reported in 16.1 vs. 12.2% (RR 2.16, 95% CI 1.50–3.12, P Conclusions Colchicine is associated with increased risk of gastrointestinal events and myalgias, but not of other adverse events. The risk of gastrointestinal events may be avoided with lower dose (0.5 mg/daily) and is inversely related to treatment duration, possibly due to early drug discontinuation or drug tolerance. Funding Acknowledgement Type of funding sources: None.

Background Exercise restriction is a non-pharmacological treatment of pericarditis that could reduce symptoms by slowing heart rate (HR). Beta-blockers allow pharmacological control of HR. Aim To explore the possible efficacy of beta-blockers to improve control of symptoms in patients with pericarditis. Methods We analysed consecutive cases with pericarditis referred to our centre. Beta-blockers were prescribed on top of standard anti-inflammatory therapy in symptomatic patients (chest pain and palpitations) with rest HR>75 beats/min. The primary end point was the persistence of pericardial pain at 3 weeks. The secondary end point was the occurrence of recurrent pericarditis at 18 months. Propensity score matching was used to generate 2 cohorts of 101 patients with and without beta-blockers with balanced baseline features. A clinical and echocardiographic follow-up was performed at 3 weeks, 1, 3, 6 months and then every 12 months. Results A total of 347 patients (mean age 53 years, 58% females, 48% with a recurrence, 81% with idiopathic/viral aetiology) were included. Among them, 128 patients (36.9%) were treated with beta-blockers. Peak C-reactive protein values were correlated with heart rate on first observation (r=0.48, p Conclusions The use of beta-blockers on top of standard anti-inflammatory therapies was associated with improved symptom control. Additional studies are warranted to verify the efficacy of these drugs in this setting. Funding Acknowledgement Type of funding sources: None.

Background Higher risk of bleeding with ticagrelor over clopidogrel in elderly patients with acute coronary syndrome (ACS) has been suggested. Purpose We assessed the incidence of major bleeding (MB), reinfarction (REAMI), and all-cause death in elderly patients to evaluate the safety and efficacy of ticagrelor versus clopidogrel in a population at high risk of bleeding and ischemia treated with percutaneous coronary intervention (PCI). Methods RENAMI and BleeMACS, real-world registries of patients with ACS who underwent PCI and received dual antiplatelet therapy, were merged. The pooled cohort was divided into two groups, clopidogrel versus ticagrelor and propensity score matching (PSM) analysis performed. Statistical analysis considered two age groups ( Endpoints were BARC 3–5 MB, REAMI and all-cause death at 1 year. Independent risk factors of MB were identified. Results The study included 16,653 patients (13,153 Conclusions Ticagrelor did not significantly increase MB compared with clopidogrel in elderly patients hospitalized for ACS and treated with PCI, significantly improving 1-year survival. Further studies on elderly patients are required. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Astra Zeneca

Atrial fibrillation (AF) is the most common cardiac arrhythmia, inducing irregular and faster heart beating. Aside from disabling symptoms—such as palpitations, chest discomfort, and reduced exercise capacity—there is growing evidence that AF increases the risk of dementia and cognitive decline, even in the absence of clinical strokes. Among the possible mechanisms, the alteration of deep cerebral hemodynamics during AF is one of the most fascinating and least investigated hypotheses. Lenticulostriate arteries (LSAs)—small perforating arteries perpendicularly departing from the anterior and middle cerebral arteries and supplying blood flow to basal ganglia—are especially involved in silent strokes and cerebral small vessel diseases, which are considered among the main vascular drivers of dementia. We propose for the first time a computational fluid dynamics analysis to investigate the AF effects on the LSAs hemodynamics by using 7 T high-resolution magnetic resonance imaging (MRI). We explored different heart rates (HRs)—from 50 to 130 bpm—in sinus rhythm and AF, exploiting MRI data from a healthy young male and internal carotid artery data from validated 0D cardiovascular-cerebral modeling as inflow condition. Our results reveal that AF induces a marked reduction of wall shear stress and flow velocity fields. This study suggests that AF at higher HR leads to a more hazardous hemodynamic scenario by increasing the atheromatosis and thrombogenesis risks in the LSAs region.

Background Significant tricuspid regurgitation (TR) is a common valvular heart disease worldwide. Purpose We aimed to assess the pooled clinical and echocardiographic outcomes of different isolated transcatheter tricuspid valve repair (ITTVR) strategies for significant (≥ moderate) TR. Methods We systematically searched the literature for studies evaluating the efficacy and safety of ITTVR for significant TR in adult. The primary outcomes were the improvement of New York Heart Association (NYHA) functional class and 6-minutes walking distance (6MWD) and the presence of severe or greater TR at the last available follow-up of each individual study. Random-effect meta-analysis was performed comparing outcomes before and after ITTVR. Results 14 studies with 771 patients were included. Mean age was 77±8 years and mean EuroScore II was 6.8%±5.4%. At a weighted mean follow-up of 212 days, 209 (35%) patients had a NYHA III to IV functional class compared to 586 (84%) patients at baseline (risk ratio: 0.23, 95% CI 0.13 to 0.40, P-value Conclusion Patients undergoing ITTVR for significant TR experienced a significant improvement in NYHA functional status and 6MWD and a significant reduction in TR severity at mid-term follow-up. Funding Acknowledgement Type of funding sources: None.

Background Brugada syndrome (BrS) is an inherited channelopathy with an increased risk of supraventricular, ventricular arrhythmias (VAs) and sudden cardiac death (SCD). Implantable cardioverter-defibrillator (ICD) is a cornerstone of SCD prevention, but it does not reduce the incidence of life-threatening VAs and it can carry substantial complications. Hydroquinidine (HQ) is a class IA antiarrhythmic drug used for electrical storms, to reduce ICD's appropriate discharges and as an alternative to ICD in children with BrS or in patients with a contraindication to ICD. Nevertheless, HQ's side effects may undermine treatment compliance. Purpose The aim of this study was to evaluate the efficacy and safety of HQ in reducing VAs (ventricular fibrillation, sustained and non-sustained ventricular tachycardia) inducibility at electrophysiology study (EPS) and atrial fibrillation/flutter (AF/AFL) or VAs recurrence in patients with BrS. Methods From the prospective Piedmont Brugada Registry, patients treated with HQ were selected and divided into three groups according to the indication for HQ initiation: index EPS positive for VAs induction (group 1), secondary prevention of AF/AFl (group 2), secondary prevention of VAs (group 3). In group 3 recurrence of VAs was monitored by implantable devices or by periodic 24-hour ECG Holter monitoring. In 5 patients HQ was started for reasons different from the above mentioned, so they were considered only for safety outcomes. Safety was assessed considering the occurrence of HQ side effects and their impact on treatment discontinuation. Results A total of 98 patients (79 males, 80,6%) were included. Median follow-up was 61 months (IQR 31–89 months). None of the baseline clinical characteristics was associated with arrhythmic recurrences. Among 46 patients in group 1 HQ was effective in reducing EPS inducibility in 91.9% of patients (p Overall, 28.6% of patients presented HQ-related side effects, mainly due to gastrointestinal intolerance (18.3%). Treatment discontinuation rate was 25% but only about half of these patients discontinued HQ for adverse events (29.2% for GI intolerance, 16.7% for drug-induced QTc prolongation, 8.3% for elevated liver enzymes; 45.8% self-discontinuation). Conclusions In patients with BrS, HQ was effective in reducing VAs inducibility at EPS, AF/AFL and VAs recurrences; moreover, it was effective in reducing symptoms. Overall, HQ proved to be safe and well-tolerated. Funding Acknowledgement Type of funding source: None

Background About 40% of patients undergoing transcatheter aortic valve replacement (TAVR) have a history of atrial fibrillation (AF) and an additional 10% develop AF after TAVR. However, there is paucity of data regarding the optimal antithrombotic regimen following TAVR in patients with a clinical indication for oral anticoagulants (OAC). Purpose To compare the prognostic impact of OAC plus at least one antiplatelet agent (APT) versus OAC therapy alone in patients undergoing TAVR. Methods We systematically searched the literature for studies evaluating the comparative efficacy and safety of OAC + APT versus OAC alone in TAVR. Random-effect meta-analysis was performed comparing clinical outcomes between the two groups. All-cause mortality and cardiovascular mortality were the efficacy outcomes. Stroke and major bleeding, defined as Bleeding Academic Research Consortium bleeding types 3 to 5, constituted the safety outcome. Results Overall, 398 titles and abstracts were identified through database searching. Four observational studies were selected, for a total of 1929 patients. After a median follow-up of 18.5 months (IQR 11.3–29.3), OAC + APT increased major bleeding events compared to OAC alone (OR=1.79; 95% CI 1.21–2.66; P=0.004) with no difference in stroke (OR 01.02; 95% CI 0.52–2.01; P=0.95), all-cause mortality (OR=1.07; 95% CI 0.78–1.47; P=0.66) and cardiovascular mortality (OR=1.08; 95% CI 0.79–1.47; P=0.62). Conclusion A combination strategy of OAC + APT provides increased risk of bleeding compared to OAC therapy alone in patients undergoing TAVR with similar outcomes in terms of stroke, all-cause mortality and cardiovascular mortality; therefore, when feasible, it should be advised not to add APT on top of OAC therapy in patients without other clinical indications for APT treatment. Funding Acknowledgement Type of funding source: None

Background Surgical aortic valve replacement has been the treatment of choice for patients with aortic valve disease before the arrival of transcatheter aortic valve replacement (TAVI), although limited by degeneration of the bioprosthesis. “Redo” intervention itself is burdened by high risk of complications and valve-in-valve (ViV) TAVI could be a valid strategy of redo for patients with comorbidities. The aim of this meta-analysis is to give an overview of the state of the art of ViV TAVI in high-risk patients, analyzing efficacy, safety, intra-hospital outcomes and 1-year outcomes and assess predictors of survival at short and mid-term follow up. Methods Two independent reviewers screened all studies investigating patients undergoing ViV TAVI. PubMed database was searched for reports published in English according to the following highly sensitive strategy: (Transcatheter[All Fields] AND “aortic”[All Fields]) AND valve-in-valve[All Fields] AND “implantation”[All Fields] NOT (review[pt] OR editorial[pt] OR letter[pt])AND “humans”[MeSH Terms]). Mortality at 30 days and at 1 year were the primary end point, while procedural and short-term outcomes and echocardiographic parameters at hospital discharge were the secondary end points. Results Of 286 studies identified, 26 articles were included, with a total of 1448 patients. Median age was 78.8 years, 57.7% of the patients were male. Median STS-predicted risk of mortality was 9.4% while median Logistic EuroSCORE was 31.3%. Median age of bioprosthesis was 10 years with 84.6% of stented valves. Stenosis (45%), followed by regurgitation (31%) and mixed defects (21%) were the causes of prosthesis failure. Diameter of the degenerated valve was ≤21 mm in 25.4%, 22–25 mm in 55% and >25mm in 11.7% of the patients. Transfemoral approach was preferred (76%), with a prevalence of balloon expandable valve (73.3%). Mean post procedural gradient was 16.7±0.8 mmHg. Mean follow up was 376 days. Overall and cardiovascular mortality at 30 days was 6.5% and 5.5% respectively, while at 1 year it was 14.5% and 8.9% respectively. Regarding short-term outcomes, overall bleeding (10.4%), pacemaker implantation (9.4%) and vascular complications (8.3%) were the most common peri-procedural complications, while stroke (2.3%), myocardial infarction (2.7%) and coronary obstruction (2.8%) were less frequent. At meta-regression analysis study year (p Conclusions Percutaneous valve-in-valve aortic valve implantation offers a valid strategy to treat high risk patients with a degenerative bioprosthesis. Short and mid-term outcomes are substantially superimposable to those of TAVI, except for coronary obstruction which appears more frequent. Future studies are needed to find predictors of long- term survival and outcomes in lower risk patients. Outcome of VIV TAVI Funding Acknowledgement Type of funding source: None

Background Heart transplantation (HTx) is considered the best available treatment for patients with end stage heart failure. Candidate evaluation with right heart catheterization (RHC) is fundamental in order to exclude pulmonary hypertension with irreversible high pulmonary vascular resistance (PVR), which is associated with elevated post-HTx mortality. PVR, rather than directly measured, is derived by cardiac output and pulmonary artery pressures, which are strictly dependent on right ventricular (RV) function. The pulmonary artery pulsatility index (PAPi) is a hemodynamic parameter integrating the information of RV function and of pulmonary circulation, which could be useful in pre-HTx evaluation. Purpose We designed this study to evaluate the potential predictive influence of pre-HTx PAPi on post-HTx survival and to assess whether this index could add useful information in the pre-HTx evaluation of patients with advanced heart failure. Methods Consecutive adult HTx recipient at two medium-large tranplant centers between 2000 and 2017 with available data on pre-HTx RHC were retrospectively included. PAPi was calculated as the ratio of pulmonary artery pulse pressure to right atrial pressure. PAPi values in the lowest quartile were defined as reduced (PAPi Results Among 655 HTx recipients (female 20,8%, age 53±11 years), median pre-HTx PAPi was 3.0 (interquartile range 1.67–5.32). Patients in the lowest versus the remaining PAPi quartiles had significantly reduced 1-year survival (78.0% vs 87.2%, p=0.006), also after adjusting for age, estimated glomerular filtration rate, total bilirubin, high PVR and urgent transplantation (adj-hazard ratio: 0.64; 95% confidence interval 0.51–0.82). When stratifying patients by estimated PVR status, reduced PAPi was associated with worse 1-year survival among patients with normal PVR (78.3% vs. 88.3% p=0.011), but not in those with increased PVR (78.0% vs. 82.6%, p=0.36) (Figure 1). Conclusions Pre-HTx PAPi, integrating information of RV function and pulmonary circulation, provides incremental prognostic value over traditional clinical and hemodynamic parameters among HTx recipient. The prognostic value appears important among patients with normal estimated PVR, possibly due to an underestimation of PVR in patients with impaired RV function. The integration of PAPi in the pre-HTx evaluation may lead to better patient selection and post-HTx survival. Figure 1. 1 year survival stratified by PVR status Funding Acknowledgement Type of funding source: None

Background and aim Myotonic Dystrophy (MD) is the most common inherited muscular dystrophy of the adult. Cardiac manifestation, including arrhythmias and conduction disorders, contributes significantly to the morbidity and mortality of the disease. The transition from a subclinical form of cardiac involvement to potentially life-threating manifestations is highly variable and not yet entirely understood. Aim of this work is to evaluate whether PQ interval (PQi) prolongation could be a reliable marker to predict left and right ventricle impairment and the necessity of a stricter monitoring. Methods In this retrospective cohort study, we selected all consecutive patients with a confirmed diagnosis of MD (type 1 and type 2) referred to our Centre. We performed clinical, laboratoristic and instrumental assessments (every 3, 6 or 12 months), tailored on each patient's features. Every patient was treated according to the latest guidelines for pharmacological and device therapy. ECG (recorded at 25 and 50 mm/sec), 24h ECG Holter and transthoracic echocardiography were performed at least yearly. Cardiac Magnetic Resonance was requested to better stratify intermediate risk patients to implantable device therapy. Results A total of 72 patients (age 48±15 years, 39% female) were included in the analysis. Patients with MD type 1 and type 2 were referred to our Centre after a mean period of 12 years (SD ±8 years) from initial diagnosis. After a mean follow-up of 5 years (±4 years), 8 patients died (mean age at death: 60±12.4 years), all of them for respiratory insufficiency. We evaluated PQ interval (PQi) evolution and type I AVB onset. No statistically significant differences emerged when stratifying for type I AVB. Nevertheless, a PQi increase of more than 20 ms during the follow-up (even if PQ Conclusions Although relatively rare, MD is a challenge for present Cardiologists. How and when to treat those patients is not codified in guidelines or consensus papers. This study suggests PQi variation as a proxy for critical evolution of MD cardiac involvement. ECG and its modification during lifetime seem pivotal for these patients' care, qualifying as a red flag for stringent follow-up. Further evidences, on larger cohorts, are needed to validate these findings. Funding Acknowledgement Type of funding source: None

Background Atrial fibrillation (AF) is a common finding in patients with ST elevation myocardial infarction (STEMI). However, its prognostic influence in MI remains controversial. Almost all previous studies were performed before the era of primary percutaneous coronary intervention (pPCI), and there is a lack of data in patients with STEMI complicated by cardiogenic shock (CS). The aim of our study was to evaluate the prognostic impact of AF in a large real-world population of STEMI undergoing pPCI stratified by the presence of CS. Methods Our registry included 3017 consecutive patients with STEMI undergoing pPCI in our department in 2005-2017. The presence of a persistent (>30 min) systolic blood pressure < 90 mmHg associated with signs of pulmonary congestion/impaired end organ perfusion needing catecholamine infusion or mechanical support devices qualified for CS. Firstly we performed mortality analysis in all patients with AF during hospitalization; secondly, we compared patients with the first episode of AF and patients with AF during hospitalization but known AF in anamnesis. The analysis was stratified for the presence of CS. Univariate (cross-tables and Kaplan-Meier curves with log-rank test) and multivariate mortality analysis (Cox regressions) were performed. In STEMI patients without CS we also performed a propensity-matched analysis including all variables known before STEMI that could influence the occurrence of a first episode of AF. Results AF was present in 337 (11.3%) patients during hospitalization; in 193 (57.3%) of them was the first episode. CS occurred in 250 patients (8.4%), 27.2% of whom were affected by an AF episode (86.5% as the first episode). Among patients without CS, AF occurred in 269 patients (9.7%) and for the 77.5% was the first episode. In CS patients, AF was not associated with increased mortality, neither at 30 days (43.5% vs 43.7%, p = 0.867) nor at 1 year (47.5% vs 53.1%, p = 0.633). In the population without CS, AF was an independent predictor of mortality both at 30 days (HR 2.25 (1.05; 4.82), p = 0.037) and at 1 year (HR 1.87 (1.094; 3.18), p = 0.022); only new-onset AF was an independent predictor of mortality. We successfully matched 175 pairs of patients with similar propension to experience the first episode of AF. Among them the first episode of AF was confirmed to be an indipendent predictor of mortality (figure). Conclusion In the present large real-world cohort of unselected patients with STEMI, the presence of an episode of AF during hospitalization was an independent predictor of mortality in patients not complicated by cardiogenic shock. Conversely, AF did not show a significant prognostic impact in patients with STEMI complicated by CS. Furthermore, the presence of a first episode of AF was confirmed to be an independent predictor of mortality, while an AF episode in patients with known AF was not found to have prognostic impact. Abstract Figure

Funding Acknowledgements None of the author have conflict of interest to disclose. Background As transcatheter aortic-valve implantation (TAVI) procedures have increased, the need of a permanent pacemaker (PPM) is a complication to be taken into account. Objective The aim of this study is to identify clinical, electrocardiographic (ECG) and procedural predictors for PPM requirement after TAVI. Methods The present is a single centre, retrospective study. All consecutive patients with severe symptomatic aortic stenosis who underwent TAVI had continuous ECG monitoring. Pre and post TAVI 12-leads ECG were analysed. We arbitrarily divided the patients into early and late PPM implantation (beyond the 3rd day after TAVI). The primary endpoint of the study was to identify electrocardiographic predictors of PPM implantation after TAVI, and the secondary endpoint was to identify other clinical or procedure-related predictive factors. Results Of 431 patients who underwent TAVI, 77 (18%) required a PPM, and 30 (7%) had late PPM implantations. Pre-operative RBBB implies more than five-fold increase of the risk of PPM implantation after TAVI (OR 5,43, CI 2.11 - 13.99, P = 0.000), whereas the history of syncope is associated with a two-fold increase of the risk (OR 2.00, CI 1.01 - 3.96, P = 0.044), and maintains its predictive value also in the late PPM subgroup (OR 2.76, CI 1.11 – 6.82, P = 0.028). Conclusions It is hard to predict the need of a PPM in the individual patients, but careful evaluation of pre-operative 12-lead ECG looking for pre-existing RBBB and an history of syncope, can individuate the group of patients with an increased risk of PPM requirement.

Background Survival beyond 1-month after an out-of-hospital cardiac arrest (OHCA) is still considered a challenge for OHCA registries and it is often unexplored. However, a longer follow-up could help to better comprehend the long-term issues of OHCA survivors. Purpose Our aim was to evaluate the long-term outcome after OHCA via an Utstein-based cardiac arrest registry with a long follow-up (up to 5 years). Methods We enrolled all the people with an OHCA of any aetiology in our Province (about 55ehz748.1138 inhabitants in northern Italy) in whom CPR was attempted. The primary endpoint was the survival at 1 month, and the secondary endpoints were the survival at 6 months and then every year until 5 years after OHCA. Results In the first 45 months (October 2014–June 2018) 1774 resuscitation attempts for confirmed OHCAs were enrolled. Baseline characteristics: male 59.7%; mean age of 73.4±16 years; mean EMS response time was 11:31±5:09 mins; home location 78.8%; bystander-witnessed events were 56.1%; EMS witnessed event 15.6%; bystander CPR 39.5%; AED use before EMS arrival 2.5%; medical etiology 93%; first shockable rhythm 18.2% (90.7% VF, 2.5% VT without pulse, 6.8% AED shockable). When considering survival from the event (Figure 1 – left panel), survival was significantly higher for shockable Utstein categories (p Figure 1 Conclusions Our results demonstrated that survival after OHCA can change over the time in all the Utstein categories, so we believe that a longer follow-up should be encouraged by next Utstein style revision.

Background Left cardiac sympathetic denervation (LCSD) is an established therapy for refractory ventricular arrhythmias (VAs) in channelopathies. A multicentric American and Indian case series suggested a greater efficacy of bilateral denervation (BCSD) in patients with structural heart disease (SHD). Purpose To describe our single-center experience with BCSD in SHD. Methods Nine patients (78% male, mean 55±18 yrs, mean LVEF 31±14%) with SHD and refractory VAs underwent BCSD. All had a Video-Assisted Thoracoscopic Surgery (VATS), in 2 cases associated with the robotic technique. The underlying cardiomyopathy (CMP) was non-ischemic (NICMP) in most cases (n=5, 55%), ischemic in 2 cases, arrhythmogenic right ventricular (ARVC) in one and related to lamin A/C deficiency in one. All patients had an ICD, 44% (n=4) a CRT-D. NYHA functional class I was present in 4 patients, the rest were in NYHA class II (n=3) or III (n=2). Three patients were candidates to heart transplant/LV assistance device. The arrhythmic burden pre BCSD included in 7 pts (78%) a history of electrical storm (ES); the median number of shocks/patient in the 12 months before BCSD was 5 (IQ range 3–18). Except for 2 patients with previous thyrotoxicosis, the remaining were either on amiodarone (n=6) or on sotalol (n=1) before BCSD. Main BCSD indications were represented by drug refractory fast VT in 7 pts (cycle Results No major complication occurred. One patient (NICMP, NYHA II), has an uneventful follow up (FU) of less than 1 month and was excluded from the efficacy analysis. The median FU in the remaining 8 patients is 10 months (IQ range 6–19), during which the median number of shocks/patients was 0.5 (IQ range 0–3). Overall, 4 patients (50%) had ICD shock recurrences. Two cases (mean LVEF 17.5%, NYHA class III) had an ES during severe hemodynamic instability and subsequently died because of cardiogenic shock respectively 1 and 7 months after BCSD. One case had three, not consecutive ICD shocks 20 months after BCSD in the setting of severe amiodarone-induced thyrotoxicosis. Finally, one patient received a single intra-hospital ICD shock 5 days after BCSD before reintroduction of full-dose beta-blockers. The figure summarizes ICD shocks burden in the 6 months before and after BCSD. Among the 5 patients with NICMP/ARVC (4 in NYHA class I), only 1 had a single ICD shock recurrence. ICD shocks pre versus post BCSD, n=8 Conclusions Our case series, although numerically small, has a good follow-up and is the first reported in Europe. The results are in agreement with the suggested remarkable efficacy of BCSD in patients with good functional capacity and fast VAs. Therefore, cardiac sympathetic denervation should always be considered in patients with SHD and refractory ventricular tachyarrhythmias, especially in case VT ablation is either not indicated or fails.

Background The implantation of an implantable cardioverter defibrillator (ICD) in secondary prevention is a class I indication for patients with an estimated survival more than 1 year with a good functional status. However, in the elderly population, it is often difficult to estimate the expected survival, especially after an acute event such as an out-of-hospital cardiac arrest (OHCA). Purpose To evaluate 1-year survival after OHCA of patients older than 80 compared to those younger than 80. Methods We considered all the patients who suffered an OHCA in our Province (55ehz748.1135 inhabitants in northern Italy) from October 1st 2014 to November 30th 2017 stratified in two groups accordingly to their age at the moment of OHCA: elderly group (≥80 years old) and non-elderly group ( Results In the period analysis resuscitation was attempted in 1464 OHCA patients: 632 of the elderly group (mean age of 86.4±4.4 years) and 832 of the non-elderly group (mean age of 63.4±13.8 years). The two groups were different at baseline. In the non-elderly group there were more males (74.5% vs 42.4%, p Conclusions Elderly patients have a worst prognosis in the acute phase after an OHCA. However, after hospital discharge, older and younger patients showed a similar 1-year survival. This result highlights how age should not be considered alone to decide whether an ICD in secondary prevention could be indicated or not in older OHCA survivors.

Background Cardiac conduction disturbances frequently occur following transcatheter aortic valve replacement (TAVR). As this procedure is getting more and more common, more research efforts should focus on post procedural rhythm disturbances and their evolution over time Purpose To evaluate the percentage of pacing in patients who underwent a TAVR procedure and developed a conduction disturbance requiring a transvenous pacemaker (PM) implantation Methods We considered all the patients who underwent a TAVR procedure between march 2009 and november 2018 in our centre. Patients implanted with a PM or an ICD before the TAVR procedure or 30 days after the TAVR were not considered eligible for our analysis, because likely not related to TAVR. The percentage of effective right ventricular pacing was assessed both at mid- and long-term follow-up Results 265 patients underwent TAVR in the study period (45% males, 81±6 years). 20 patients already had a PM and were excluded. 39 of the 245 patients (16%) were implanted with a PM after TAVR, 26 of them were implanted within 30 days (median time TAVR-PM implant: 8±7 days). The rate of PM implant within 30 days after TAVR was 8% (20/246) for patients implanted with an Edward Sapien valve, 25% (4/16) for patients with an Evolute Pro valve and 66% (2/3) in patients with a Lotus Edge valve. The indication for PM implant was a permanent 3rd degree A-V block in 12 patients, a paroxysmal A-V block in 4, a bifascicular A-V block with an infra-hisian disease in 5, a II degree Mobitz II A-V block in 2, an atrial fibrillation with slow A-V conduction in 2 and a 2:1 A-V block with infra-hisian disease in 1. The first follow-up after the PM implantation was available in 24 patients (mean 78±87 days after PM implant) and the second in 15 patients (372±267 days after PM implant). The patients were divided into two groups based on the presence/absence of permanent 3rd degree AV block at the time of implantation. At the first follow-up the percentage of pacing was significantly higher in patients implanted with vs. without a permanent 3rd degree AV block (98.5% vs 11%, p Conclusion Patients implanted with a PM after TAVR in the absence of a permanent 3rd AV block have a very low likelihood of progression to a permanent AV conduction disturbance and show a negligible percentage of pacing during follow-up. Our results may impact the choice of the correct timing of PM implantation after TAVR and the potential indication for a leadless PM.

Background Improved outcomes after percutaneous edge-to-edge mitral valvuloplasthy with MitraClip implantation were recently observed in patients with heart failure (HF) and functional severe mitral regurgitation (MR). Nonetheless, its efficacy in end-stage heart failure (HF) are lacking. Purpose Our aim was to investigate feasibility, preliminary efficacy on hemodynamics and follow-up of MitraClip implantation in a cohort of patients with very advanced HF. Methods Patients were retrospectively included in the present analysis if already in HT list, unsuitable for HT despite optimal medical and device therapy, or if implantation was a “bridge-to-candidacy”. Results Baseline and procedural characteristics are listed in Table 1; MR etiology was predominantly functional (n=7). No major complications were observed in the peri-operative period. At 6-month follow-up, invasive hemodynamics was available for 8 patients. A significant increase in cardiac index was observed (Least Square Mean Difference, LSMD = +0.47 L/min/m2; p=0.03; Figure 1), in conjunction with a numerical reduction in pulmonary vascular resistance (LSMD = −1.02 WU; p=0.3), a trend towards lower mean pulmonary arterial pressure (LSMD = −6.5 mmHg; p=0.053) and lower ejection fraction (LSMD = −6.5%; p=0.053). At a median follow-up of 772 days (IQR 156–1,578), all three patients unsuitable for HT at baseline could be eligible to HT list and one of them received LVAD. Moreover, two patients were transplanted, four experienced unplanned rehospitalization for HF, and one died of non-cardiac cause. Table 1. Baseline clinical evaluation (n=10) Age (y) 53.67±8.43 HF Etiology – post ischemic 4 (40) Male sex 6 (60) HF Etiology – no CAD 4 (40) Body Surface Area (m2) 1.76±0.22 HF Etiology – other 2 (20) Chronic Resynchronization Therapy 5 (50) Euroscore II 6.00±2.74 Baseline MR grade (+) 4 (40) STS mortality 1.71±2.65 Residual MR grade (+) 1.71±0.49 Clips implanted (number) 1.78±0.67 Data are expressed as mean ± SD or count (valid %). MR scored on a scale from 0+ to 4+. STS, Society of Thoracic Surgeons. Figure 1 Conclusions Percutaneous edge-to-edge mitral valvuloplasty with MitraClip appears safe and effective in end-stage patients, impacts on clinical decision-making and therefore might be considered as a “bridge” towards a more definite strategy. Acknowledgement/Funding None

Background The prediction of the possibility of return of spontaneous circulation (ROSC) in the individual patient is one of the major challenges confronting resuscitation science. The RACA score has been proposed to predict the achievement of a ROSC longer than 20 seconds in field (out-of-hospital, OH). However, no score exists to predict a ROSC sustained until arrival at the emergency department, using the standardized Utstein-based categorization of variables. Purpose To create a new Utstein-based score to predict the survival to hospital admission of an OH cardiac arrest (CA) victim. Methods We performed a retrospective analysis of all prospectively collected OHCAs occurred between 2015 and 2017 in two regions, one in northern Italy and the other in southern Switzerland. All consecutive patients who suffered an OHCA of any aetiology between 01/01/2015 and 31/12/2017 in whom CPR was attempted were included. We used random effect logistic regression to model survival to hospital admission after an OHCA. We included the same variables used in the RACA score, re-categorized following Utstein recommendations. For model validation, we computed the model area under the ROC curve (AUC ROC) for discrimination. We derived the TICINUM score using the coefficients estimated in the regression model (multiplied by 10 and rounded to the nearest integer). We plotted the score against the probability of hospital ROSC. Results 1961 patients were included in our analysis (62% males, mean age 73±16 years old). Age, aetiology, witnessed OHCA, site of OHCA, time of EMS arrival and shockable rhythm were independently associated with survival to hospital admission. The model showed a good discrimination (AUC 0.83, 95% CI 0.81–0.85) for predicting survival to hospital admission. The model variables and their odd ratios are presented in Figure 1 (left). The score value is obtained summing a coefficient calculated for each variable. The nomogram of the probability of survival to hospital admission associated to the different score values is presented in the Figure 1 (right). Figure 1 Conclusion The TICINUM score is a new score, which allows to predict with good discrimination the probability of survival to hospital admission of an OHCA victim. The simple calculation and the fact that it is Utstein based makes it easily applicable by EMS personnel during an OHCA scenario.

Introduction Elevated serum uric acid (eSUA) has been identified as independent risk factors for cardiovascular diseases, including coronary artery disease, and it has been associated with increased mortality in the general population. However, whether eSUA is associated with adverse outcomes in the setting of ST-segment elevation myocardial infarction (STEMI) is still controversial. Although the mechanisms of this possible relationship is similarly unsettled it has been suggested that eSUA could trigger oxidative stress and inflammatory response. Aim This study sought to investigate the association between eSUA with short- and long-term mortality and with inflammatory response in patients with STEMI treated with primary percutaneous coronary intervention (pPCI). Methods We prospectively enrolled all STEMI patients undergoing pPCI in our hospital between 2005 and 2017. Blood samples were collected on admission and at 24 and 48 hours after pPCI: SUA and the inflammatory biomarkers C-reactive protein (CRP), neutrophil count and neutrophil to lymphocytes ratio (NLR) were parameter of interest. NLR was obtained by dividing the total count of neutrophil by the total count of lymphocyte. eSUA was defined as >6.8 mg/dl. Cumulative 30-days and 1-year mortalities were estimated using the Kaplan-Meyer analysis and compared with the long-rank test. Landmark analysis was set at 365 days. Multivariable analyses were performed by Cox proportional hazard models. Results Out of the dataset of 2959 STEMI patients treated with pPCI, we analyzed 2369 patients who had SUA data. Overall age was 63 (p25-p75: 54–73) years, men were 2295 (75.5%), anterior MI 1390 (45.8%). eSUA was present in 563 patients (23.8%). 30-day mortality was 5.8% (n=31) among patients with eSUA and 2% (n=34) among patient with normal SUA level (p2 (30-day mortality HR 1.196, 95% CI 1.006–1.321, p=0.042; 1-year mortality HR 1.178, 95% CI 1.052–1.320, p=0.005). On admission CRP was higher in the group with eSUA as compared with the group with normal SUA levels (respectively, 1.27 [0.57–3.37] mg/dl vs 0.72 [0.30–1.8] mg/dl, p Figure 1 Conclusions Elevated serum uric acid is associated with higher short- and long-term mortality and with a greater inflammatory response after reperfusion in patients with STEMI treated with primary PCI.

Background and aim Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Its efficacy to prevent recurrent arrhythmias in patients nonresponsive to antiarrhythmic drugs is proven. This procedure has a higher efficacy rate in patients with paroxysmal AF (PAF) compared with persistent AF (sustained AF - SAF). Radiofrequency (RF) ablation represents a standard of care for PVI, while, cryoballoon (CB) ablation has emerged as a valid alternative therapy. The aim of the present meta-analysis was to explore the comparative efficacy, and safety of CB compared with RF ablation for AF. Methods We searched PubMed and EMBASE for studies that investigated the comparative efficacy and safety of CB versus RF ablation for AF. The efficacy outcome was AF recurrence after the procedure. The safety outcomes were: incidence of pericardial effusion or cardiac tamponade, permanent phrenic nerve palsy, transient phrenic nerve palsy, vascular complications and major bleedings. The performance outcomes were: procedural time and fluoroscopy time. Random-effects Risk Ratios (RRs) were estimated using a DerSimonian-Laird model. Two subgroup sensitivity analyses were performed to stratify the result on the efficacy outcome according to type of AF (PAF versus SAF) and study design (randomized clinical trial (RCT) versus observational study (OS)). Results 12 RCT and 34 OS were included in the analysis (n=13103). Mean follow-up was 14±6 months. 37 studies included only patients with PAF, while, 2 studies included only patients with SAF and the remaining 7 studies included both patients with SAF or PAF. Overall, CB ablation reduced the incidence of AF recurrence compared with RF ablation (RR 0.85; 95% CI 0.77–0.95; P=0.002 - Figure). However, this reduction was not consistent in the RCT subgroup (RR 0.90; 95% CI 0.72–1.13) and it was marginally non-significant in the SAF subgroup (RR 0.76; 95% CI 0.57–1.01). Regarding the safety outcomes, although CB had a significantly higher rate of transient nerve palsy compared with RF procedure (RR 7.46; 95% CI 4.67–11.90) this difference became non-significant when considering permanent phrenic nerve palsy (RR 1.24; 95% CI 0.66–2.34). Moreover, CB was related to a lower incidence of pericardial effusion or cardiac tamponade compared with RF (RR 0.51; 95% CI 0.37–0.69) and there was no significant difference in vascular complications or major bleedings between the two strategies. Focusing on performance outcomes, CB ablation had a shorter procedural time compared with RF (mean difference −20 minutes; 95% CI −30 to −10; P CB vs. RF in preventing AF recurrence Conclusions This large study level meta-analysis demonstrates that CB is at least as effective as RF ablation in preventing arrhythmic recurrence both in patients with PAF and SAF. Moreover, our study suggests that CB has a safer profile and shorter procedural time compared with RF ablation.

Background and aim Hypertrophic cardiomyopathy (HCM) is a genetic based cardiomyopathy with heterogeneous phenotypic expression. Since it is one of the most common cause of sudden cardiac death (SCD) in the young different risk score have been proposed to properly identify the patients that would benefit from a primary prevention with an implantable cardioverter-defibrillator (ICD). ESC guidelines on HCM suggest to estimate the risk of SCD considering clinical and echocardiographic parameters and mention the use of cardiac magnetic resonance (CMR) only in the case of poor echo windows. The aim of the present study-level meta-analysis was to explore the prognostic value of late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) for adverse fatal events. Methods We searched PubMed and EMBASE for studies that investigated the prognostic value of LGE in patients with HCM. The outcomes of interest were SCD or aborted SCD, all-cause mortality and cardiovascular (CV) mortality. Random-effects Odds Ratios (ORs) were estimated using a DerSimonian-Laird method with a person-year approach. Moreover, an univariate meta-regression was performed to assess the moderator effect of mean age, LGE % of left ventricle (LV) and gender (expressed as male percentage). Results A total of 7 studies (n=3351) were included in the analysis. Mean follow-up was 3±0.63 years. Mean age was 47.7±14.6 years and 56.9% were male. LGE was detected in 1845 (55%) patients with a mean LGE percentage of LV of 7%. The presence of LGE was associated with an increased incidence of SCD or aborted SCD (OR 3.44; 95% CI 2.02–5.86; p Prognostic value of LGE for SCD Conclusions The presence of LGE at CMR in patients with HCM exhibited a substantial prognostic value in fatal events and, in particular, in the prediction of SCD. LGE assessment is an effective tool to stratify the arrhythmic risk in HCM. Therefore, it should be considered, especially in borderline cases, to improve the identification of HCM patients who could benefit from ICD implantation.

Incomplete ST segment resolution (iSTR) is a well-known marker of poor outcome in patients undergoing primary percutaneous coronary intervention (pPCI) for ST elevation myocardial infarction (STEMI). The use of glycoprotein IIbIIIa inhibitors (GPIs) was suggested to be associated with a survival benefit in high-risk patients. A simple score to predict the risk for developing iSTR could help early identification of these patients and could allow a tailored use of pharmacological tools, such as GPIs. The aim of this study was to create and validate a numerical score to predict iSTR occurrence in STEMI patients undergoing pPCI and to assess its association with the potential benefit of GPIs use. We prospectively enrolled all STEMI patients undergoing pPCI in our University Hospital (2005–2017). iSTR was defined as a Out of a total of 2959 patients, 1774 were included in the derivation: 480 (27%) of them presented iSTR. All-cause mortality at 30 days was significantly higher in patients with iSTR (OR 3.2, 95% CI 2.1–4.9, p198 mg/dl at admission (OR 1.77, 95% CI 1.29–2.49, p75 years (OR 1.54, 95% CI 1.15–2.10, p=0.004, score 1.5), female sex (OR 1.41, 95% CI 1.06–1.88, p=0.02, score 1.5) and Killip class >2 (OR 1.44, 95% CI 1.05–1.98, p=0.024, score 1.5) were identified as independent predictors of iSTR, creating a ISTR-score that ranged from 0 to 11. The validation cohort consisted in 1185 patients, with 31% showing iSTR. The c-statistic was 0.67 and 0.66 in the derivation and validation cohorts. Patients with score ≥4 versus A simple pre-procedural risk score may predict iSTR following pPPCI, allowing a rapid risk stratification and the identification of patients who show a favorable risk/benefit ratio for the use of more aggressive strategies such as GPIs. These findings deserve a prospective, randomized evaluation.

Background Evidence from a large randomized clinical trial has led international guidelines to downgrade to Class III the recommendation level for the routine use of intra-aortic balloon pump (IABP) in patients with STEMI complicated by cardiogenic shock (CS). Despite this, its use in clinical practice remains high. Purpose The aim of our study was to evaluate whether IABP use could provide a prognostic benefit in a large real-world population of STEMI patients undergoing primary PCI (pPCI). Methods Our registry included 2958 consecutive patients undergoing primary pPCI for STEMI in our department from 2005 to 2017. The presence of a persistent (>30 min) systolic blood pressure Results CS occurred in 246 patients (8.3%); among these patients, 145 (60%) had anterior AMI. Mortality at 30 days was 3.7 in inferior vs 7.1% in anterior STEMI (p3 mg/dL) during hospital stay. In the subgroup of patients with anterior STEMI, there was a marked survival benefit at univariate analysis (30-day mortality 41% vs 61%, p=0.013 – see figure panel B), confirmed at multivariable analysis (HR 0.40, 95% CI 0.19–0.88, p=0.023) after adjusting for the same variables of the previous model. In the subgroup of patients with inferior STEMI, IABP use was not significantly associated with a lower 30-day mortality (32% vs 41%, p=0.380). Figure 1 Conclusion In the present large real-world cohort of unselected patients with STEMI, the use of IABP in case of CS was found to improve survival. This finding suggests that IABP could still play a role in patient with STEMI complicated by CS, especially when additional risk features are present, such as anterior MI. We suggest that additional careful prospective studies are needed before abandoning or markedly limiting the use of IABP in this clinical setting.

Background According to the European Society of Cardiology guidelines secondary prevention ICD implantation is a class I indication only for those patients with an estimated survival >1 year with a good functional status. However, it is not specified how to assess the functional status and its evaluation could be quite difficult in the case of Out-of-Hospital Cardiac Arrest (OHCA) survivors. Cerebral Performance Category (CPC) scale is the most widespread scale to define the neurological and functional outcome, but it is not known if it can be used to guide ICD implantation. Purpose To evaluate whether the presence of a bad neurological outcome (CPC >2) in OHCA survivors at discharged could be used as a prognostic index in order to evaluate the implantation of an ICD. Methods We considered all the patients enrolled in the Cardiac Arrest Registry of our Province (55ehz746.0583 inhabitants in northern Italy) from the 1 October 2014 to the 31 January 2018 presenting a CPC >2 at discharge. We evaluated the survival and the neurological status variation at 1-year. Results In the study period CPR was attempted in 1565 confirmed OHCA (60.2% males, 73.4±15.8 years). Of these, 119 (7.6%) were discharged and 26 of them (21.8%) showed a CPC more than 2 (13 CPC = 3, 11 CPC = 4 and 2 CPC A). 1-year survival of CPC>2 patients was significantly lower than those with a CPC≤2 (46.1% vs 92.5% p2 survived at 1 year; a good cerebral performance (CPC 1) was recovered in 2 of them, whilst a moderate cerebral disability (CPC 2) was present in 1 of them. A severe cerebral disability (CPC 3 or 4) persisted in the other 9 patients. The neurological prognosis of patients based on CPC at hospital discharge is presented in Figure 1. Figure 1 Conclusions Our results highlight that 1-year survival is quite low in patients with a CPC >2 at discharge and an improvement in cerebral performance occur in a minority of them. The prognosis of the patients was very variable and unpredictable for all the CPC scale values at hospital discharge. This evidence suggest that an ICD implantation should carefully evaluated in this kind of patients and a clinical and neurological re-evaluation can be reasonable some time after the event to decide if implant an ICD.