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Aims To determine if adapting the ablation index (AI) to the left atrial wall thickness (LAWT), which is a determinant of lesion transmurality, is feasible, effective, and safe during paroxysmal atrial fibrillation (PAF) ablation. Methods and results Consecutive patients referred for PAF first ablation. Left atrial wall thickness three-dimensional maps were obtained from multidetector computed tomography and integrated into the CARTO navigation system. Left atrial wall thickness was categorized into 1 mm layers and AI was titrated to the LAWT. The ablation line was personalized to avoid thicker regions. Primary endpoints were acute efficacy and safety, and freedom from atrial fibrillation (AF) recurrences. Follow-up (FU) was scheduled at 1, 3, 6, and every 6 months thereafter. Ninety patients [60 (67%) male, age 58 ± 13 years] were included. Mean LAWT was 1.25 ± 0.62 mm. Mean AI was 366 ± 26 on the right pulmonary veins with a first-pass isolation in 84 (93%) patients and 380 ± 42 on the left pulmonary veins with first-pass in 87 (97%). Procedure time was 59 min (49–66); radiofrequency (RF) time 14 min (12.5–16); and fluoroscopy time 0.7 min (0.5–1.4). No major complication occurred. Eighty-four out of 90 (93.3%) patients were free of recurrence after a mean FU of 16 ± 4 months. Conclusion Personalized AF ablation, adapting the AI to LAWT allowed pulmonary vein isolation with low RF delivery, fluoroscopy, and procedure time while obtaining a high rate of first-pass isolation, in this patient population. Freedom from AF recurrences was as high as in more demanding ablation protocols. A multicentre trial is ongoing to evaluate reproducibility of these results.

BACKGROUND Left atrial wall thickness (LAWT) has been related to pulmonary vein (PV) reconnections after atrial fibrillation (AF) ablation. The aim was to integrate 3D-LAWT maps in the navigation system and analyze the relationship with local reconnection sites during AF-redo procedures. METHODS Consecutive patients referred for AF-redo ablation were included. Procedure was performed using a single catheter technique. LAWT maps obtained from multidetector computerized tomography (MDCT) were imported into the navigation system. LAWT of the circumferential PV line, the reconnected segment and the reconnected point, were analyzed. RESULTS Sixty patients [44 (73%) male, age 61 ± 10 years] were included. All reconnected veins were isolated using a single catheter technique with 55 min (IQR 47-67) procedure time and 75 s (IQR 50-120) fluoroscopy time. Mean LAWT of the circumferential PV line was 1.46 ± 0.22 mm. The reconnected segment was thicker than the rest of segments of the circumferential PV line (2.05 + 0.86 vs. 1.47 + 0.76, p

BACKGROUND There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS). OBJECTIVES This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey. METHODS Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention. RESULTS A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001). CONCLUSIONS A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians. (J Am Coll Cardiol 2021;78:2131-2143) (c) 2021 by the American College of Cardiology Foundation.

Funding Acknowledgements Dr Teres was funded by Swiss Heartrhythm Foundation Introduction pulmonary vein (PV) reconnections due to gaps on circumferential ablation lines are responsible for atrial fibrillation recurrences after catheter ablation. We sought to analyze the local left atrial wall thickness (LAWT) of PV line gaps at AF redo ablation during real-time catheter positioning. LAWT was measured on the MDCT 3D reconstruction and fused with the LA anatomy using CARTO-merge. Objective To analyze the relationship between local reconnection gaps and the LAWT during AF redo procedures. Methods Single-Center cohort study that included 41 consecutive patients referred for AF redo procedure. All patients had a MDCT prior to the ablation procedure. LAWT maps were semi-automatically computed from the MDCT as the local distance between the LA endo and epicardium. Each PV line was subdivided into 8 segments and mean LAWT was computed. During the procedure, the local gap was defined as the earliest activation site at the reconnected segment of the circumferential PV line (Figure 1A & 1B). Results 41 patients [31 (75.6%) male, age 60 ± 10 years] were included. Mean LAWT was 1.36 ± 0.20 mm. Mean PV circumferential line WT was higher in left PVs than in the right PVs 1.68 ± 0.57 vs. 1.31 ± 0.39 mm p Conclusions Reconnection points were more frequently present in the thicker segments of the PV circumferential line. The most frequently reconnected segment was the anterior carina in both right and left PVs. Atrial wall thickness maps derived from MDCT are useful to guide AF redo procedures. Abstract Figure. 1) Activation & WT map; 2) Segment WT

Funding Acknowledgements Dr Teres was funded by Swiss Heartrhythm Foundation Introduction Circumferential pulmonary vein isolation (PVI) has become a mainstay in the treatment of atrial fibrillation (AF). The utility of ablation index (AI) to dose radiofrequency delivery for the reduction of AF recurrences has already been proven with a target AI ≥ 400 at the posterior wall and ≥550 at the anterior Wall. Nevertheless, the left atrial wall is a thin, heterogeneous structure with an important inter and intra-patient variability of LAWT. Objective To determine if adapting AI to atrial wall thickness (AWT) is feasible, effective and safe during AF ablation. Methods Single-Center study that included 80 consecutive patients referred for a first paroxysmal AF ablation that was performed with a single catheter approach with the intention to reduce vascular access complication rate. All patients had a MDCT prior to the ablation procedure. LAWT maps were semi-automatically computed from the MDCT as the local distance between the LA endo and epicardium. All procedures were performed under general anesthesia with a high-rate low-volume ventilation protocol for obtaining higher catheter stability. The transeptal puncture was TEE-guided. During the procedure, the WT map was fused with the LA anatomy using CARTO-merge. LAWT was categorized into 1mm-layers and the AI was titrated to the local atrial WT as follows: Thickness < 1 mm (red): 300; 1-2 mm (yellow): 350; 2-3 mm (green): 400; 3-4 mm (blue): 450; > 4 mm (purple): 450 (Figure). Maximal inter-lesion distance was set at 6 mm. VisiTag settings were: catheter position stability: minimum time 3 s, maximum range 4 mm; force over time: 25%, minimum force 3 g; lesion tag size: 3 mm. Respiration training was not possible due to the high catheter stability. The circumferential ablation line was designed in a personalized fashion to avoid thicker regions. Results 80 patients [41 (51,2 %) male, age 60± 11 years] were included. Mean LVEF was 59 ± 5 %, Mean LA diameter 39,1 ± 5,8 mm, Mean LAWT was 1.36 ± 0.63 mm. Mean AI was 352 ± 36 on the RPVs and 356 ± 36 on the LPVs. Procedure time was 60,0 min (IQR 51-70). Fluoroscopy time was 58,5 s (35-97,5). First pass isolation was obtained in 72 (90%) of the RPVs and 75 (93,8%) of the LPVs. Conclusions the present study, assessing a novel, personalized protocol for radiofrequency titration during atrial fibrillation ablation, shows a high rate of first pass isolation with a lower need for RF energy delivery and lower procedure requirements, as compared to previous PV ablation protocols. Further studies are needed to evaluate the long-term results of this approach. Abstract Figure. LAWT-map Visitag points with tailored AI

Anatomic variants of the remnants of the right valve of the sinus venosus in adults are common and usually observed on cardiac imaging studies. Because the anatomy and function of these vestiges are not well known, errors may occur in the differential diagnosis and treatment of patients with unclear images in the right atrium. Clinical implications may arise from (1) differential diagnosis with some diseases, especially when the remnants act as sites of attachment for masses; (2) the need for invasive treatment if the anatomic variant displays obstructive behavior; (3) the association between remnants and patent foramen ovale; and (4) secondary complications related to these structures in invasive procedures. Thus, the aim of this review is to provide cardiologists and radiologists specializing in cardiac imaging techniques with the basic anatomic information and clinical implications required to understand morphologic variants of right sinus venosus valve vestiges in adults.

Tunneling is commonly used in several transition mechanisms. Some of the mechanisms discover the tunnel endpoint automatically by their own means. This paper describes several tunnel discovery mechanisms for IPv6 traversal beyond IPv4 legacy networks and suggests a new mechanism by which the DHCPv4 server can automatically provide configuration information about IPv6-in-IPv4 tunnel. Dual stack nodes attached to IPv4 network can communicate with other IPv6 networks by this mechanism beyond IPv4 networks without user intervention. Implementations have shown that the proposed mechanism can be a convenient and valuable tunnel discovery mechanism in some cases.

Background Loop diuretics are beneficial in heart failure in the short term because they eliminate fluid retention, but in the long-term, they could adversely influence prognosis due to activation of neurohumoral mechanisms. Aims To explore the changes induced by diuretic withdrawal in chronic nonadvanced heart failure. Methods Diuretics were withdrawn in 26 stabilized heart failure patients with systolic dysfunction (ejection fraction [EF]

Fundamento y objetivo El objetivo de este estudio ha sido analizar el curso clinico de una poblacion de pacientes adultos con miocardiopatia hipertrofica (MCH), comparar su mortalidad con la de la poblacion general y valorar las variables clinicas y derivadas de estudios no invasivos que se asocian con un pronostico desfavorable Pacientes y metodo Se ha estudiado consecutivamente a 119 pacientes (60 mujeres, edad media [DE]: 52 [12] anos) con MCH mediante electrocardiograma, Holter, eco-Doppler, prueba de esfuerzo, tomografia computarizada por emision de foton unico de perfusion miocardica y ventriculografia isotopica Resultados Durante un seguimiento medio de 10 (6,7) anos, 7 pacientes (5,8%) fallecieron de causa cardiaca (4 por insuficiencia cardiaca y 3 de muerte subita). La mortalidad anual fue del 0,6% y la curva de supervivencia fue significativamente peor comparada con la esperada en la poblacion general ajustada por edad y sexo (p = 0,008). La presencia de fibrilacion auricular (p = 0,04), de insuficiencia mitral moderada o grave (p = 0,02), de un gradiente dinamico intraventricular superior a 50 mmHg (p = 0,02), de un diametro auricular izquierdo superior a 45 mm (p = 0,02) y de un grosor del septum interventricular mayor de 25 mm (p = 0,04) fueron parametros predictivos de mortalidad Conclusiones La mortalidad de los pacientes con MCH en edad adulta es significativamente mas alta que la de la poblacion general. La insuficiencia cardiaca y la muerte subita son igualmente frecuentes como causa de muerte en estos enfermos. La fibrilacion auricular, la gravedad de la insuficiencia mitral, del gradiente dinamico y de la dilatacion auricular izquierda fueron variables predictivas de muerte de origen cardiaco

Introduccion y objetivos El objetivo del presente estudiofue analizar el valor pronostico y la evolucion delecocardiograma-Doppler en una poblacion hospitalariaadulta con miocardiopatia hipertrofica (MH). Metodos Se estudiaron 119 pacientes consecutivosdiagnosticados de MH (52 ± 12 anos, 60 mujeres) duranteun seguimiento medio de 9,7 ± 6,7 anos. La evolucionecocardiografica se analizo en los 104 pacientes (67 conobstruccion dinamica) en quienes se disponia al menosde 2 ecocardiogramas con un intervalo de 3,7 ± 3 anos(uno a 7 anos) entre ambas exploraciones. Resultados Durante el seguimiento 7 pacientes fallecierony 31 presentaron complicaciones severas (siete fallecimientos,15, sincope, cuatro, angina grado IV, tres,disnea grado IV y dos, infarto). La presencia de insuficienciamitral (p = 0,001) y un gradiente dinamico superior a50 mmHg (p = 0,02) fueron predictores de mortalidad, yun indice de auricula izquierda superior a 25 mm/m2 (p =0,028), de complicaciones severas. En un 15% de los pacientescon MH no obstructiva en el primer registro estapaso a ser obstructiva en el ultimo registro. Tambien seobservo un incremento del numero de pacientes con insuficienciamitral (el 80 frente al 66%; p = 0,01) y en su severidad(p = 0,038) durante el seguimiento. Conclusiones La presencia de insuficiencia mitral, degradiente dinamico superior a 50 mmHg, y un indice deauricula izquierda superior a 25 mm/m2 son variablesde mal pronostico en los pacientes adultos con MH. Duranteel seguimiento se observa la evolucion a formasobstructivas en un 15% de las MH no obstructivas y unatendencia a la progresion de la insuficiencia mitral.

Introduccion y objetivos El proposito de este estudio ha sido comparar los diferentes tipos morfologicos de miocardiopatia hipertrofica observados mediante tomogammagrafia miocardica de perfusion con los del ecocardiograma. Material y metodos En 76 de 119 pacientes (64%) con miocardiopatia hipertrofica, el ecocardiograma permitio una aceptable visualizacion de todos los segmentos del ventriculo izquierdo en la proyeccion paraesternal transversal y la asignacion de los pacientes a alguno de los 6 tipos morfologicos clasicos: tipo I (hipertrofia septal anterior), tipo II (hipertrofia septal anterior y septal posterior), tipo III (hipertrofia septal y anterolateral), tipo IV (hipertrofia septal posterior y/o anterolateral), tipo V (hipertrofia concentrica) y tipo VI (hipertrofia apical). Sin conocimiento de los datos ecocardiograficos, dos observadores experimentados intentaron asignar con las imagenes del eje corto de la tomogammagrafia miocardica de perfusion en reposo con 9 9 mTc-tetrofosmina a alguno de estos tipos. Resultados La concordancia global entre las dos tecnicas fue del 75%. El tipo III fue el mas frecuente, tanto en el ecocardiograma (76%) como en la tomografia miocardica de perfusion (74%), aunque tambien fue el que origino la mayoria de discrepancias. Con la tomogammagrafia miocardica de perfusion se observo en 4 pacientes una hipertrofia localizada en la region septal e inferior que no correspondia a ninguno de los 6 tipos de la clasificacion ecocardiografica clasica y que por ecocardiograma habia sido clasificada como tipo III en 3 casos y en 1 como tipo V. Conclusiones Se observo concordancia entre el ecocardiograma y la tomogammagrafia miocardica de perfusion en la clasificacion morfologica de la mayoria (75%) de los pacientes con miocardiopatia hipertrofica, aunque se hallaron discrepancias con respecto al ecocardiograma, sobre todo en el tipo III.

Introduction and objectives. The aim of this study was to evaluate the diagnostic accuracy of myocardial SPET in patients with hypertrophyc cardiomyopathy (HC). Patients and methods. One hundred and six consecutive patients (aged 53 ± 12 years, 50 women, 66 with dynamic obstruction) with an echocardiographic diagnosis of HC were studied with exercise-rest myocardial SPET with 99m Tc-tetrofosmin. Forty-six (43%) of these patients had chest pain and in 31 (29%) a coronary angiography was performed. Fifty-six per cent of the patients were treated with beta-blockers and 23% with verapamil. Results. Angina during the exercise test was observed in only 8% of the patients. Perfusion defects were observed in 35% of the patients. Only 8 (26%) out of the 31 patients with angiography had coronary artery disease (stenosis > 50%). When fixed and reversible defects were considered as positive, the sensitivity was 50%, the specificity was 65%, the positive predictive value was 33% and the negative predictive value was 79%. Conclusions. Myocardial perfusion defects can be observed in more than one third of medically treated patients with HC. Only a quarter of catheterized patients, even with chest pain, have associated coronary artery disease. The accuracy of SPET for the diagnosis of coronary artery disease in hypertrophic cardiomyopathy is low. Thus, the value of this technique is limited in these patients.

Objectives. We attempted to demonstrate that simultaneous dipyridamole administration and maximal subjective exercise in patients who are unable to achieve a good exercise level can improve the diagnostic efficacy of technetium-99m methoxy isobutyl isonitrile (99mTc-MIBI) myocardial single-photon emisson computed tomography (SPECT).Background. The results of myocardial perfusion scintigraphy are unsatisfactory if the level of exercise achieved by the patient is insufficient. The use of dipyridamole with maximal subjective stress testing has been shown to improve the quality of the thallium-201 myocardial perfusion images, but there are no studies demonstrating that this combination improves the diagnostic accuracy of myocardial perfusion SPECT.Methods. Two hundred thirty-one consecutive patients, without a previous myocardial infarction, were classified into three groups: group 1, 91 patients with an adequate exercise test; group 2, 68 patients with an inadequate exercise test; group 3, 72 patients with an inadequate exercise test who then received intravenous dipyridamole (0.56 mg/kg body weight over 4 min) simultaneously with exercise.Results. Results for sensitivity (89%) and negative predictive value (83%) in group 3 were significantly better than those in group 2 (71% [p = 0.03] and 56% [p = 0.002], respectively) and not significantly different from those in group 1. The polar maps of 20 patients studied with and without dipyridamole at the same exercise level revealed a significantly greater extent of ischemia in each territory and in a global assessment (19 + 20% vs. 8 + 11%, p < 0.0001) when dypiridamole was administered during physical exercise.Conclusions. Intravenous dipyridamole administration during exercise testing is advisable in all patients who are unable to achieve an adequate exercise level. This approach permits physicians to avoid missing ergometric information while optimizing myocardial SPECT results.(J Am Coll Cardiol 1997;29:531–6)

The purpose of this study was to characterize adult patients with hypertrophic cardiomyopathy (HCM), to compare their mortality with that of the general population and to establish a prognosis based on clinical and noninvasive techniques.One hundred nineteen consecutive patients (60 women, mean: 52 [12] years) with HCM were prospectively studied by ECG, Holter, echo-Doppler, exercise testing, myocardial perfusion SPET and radionuclide ventriculography. Prognostic variables included clinical data and parameters derived from these noninvasive techniques.During a mean follow-up of 10 [6.7] years, 7 patients (5.8%) died of cardiovascular causes (4 cardiac failure and 3 sudden death). The annual mortality rate was 0.6% and the actuarial survival curve for patients with HCM was significantly worse compared with the expected survival curve derived from the general population after adjustment for age and sex (p = 0.008). The presence of atrial fibrillation (p = 0.04), moderate or severe mitral regurgitation (p = 0.02), dynamic gradient50 mmHg (p = 0.02), left atrial diameter45 mm (p = 0.02), and interventricular septal thickness25 mm (p = 0.04) were all predictive of mortality.The mortality rate of adult patients with HCM is significantly higher than that expected for the general population and heart failure and sudden death are almost evenly distributed as a cause of death in these patients. Atrial fibrillation, magnitude of mitral regurgitation, dynamic gradient, left atrial dilatation and interventricular septal thickness are the main predictors of death.