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Atrial Fibrillation (AF) is the most commonly described cardiac arrhythmia found in the general population and can lead to adverse outcomes. Its onset and maintenance requires the presence of an arrhythmogenic substrate that predisposes the patient for risk of these types of arrhythmias and the occurrence of a trigger event. A major characteristic of AF-related structural remodelling is atrial fibrosis, a process closely related to inflammation. Autoimmune rheumatic diseases constitute systemic inflammatory disorders that can also present with cardiovascular manifestations, including a high incidence of AF, thus supporting the idea of a link between AF and inflammation. A vicious cycle exists in which inflammation leads to a higher prevalence of structural cardiovascular disease, which in turn leads to more inflammation and AF; in fact, inflammation is known to affect signalling pathways that lead to the development of AF. Therapy must first target systemic inflammation, since decreasing the inflammatory burden has consistently shown to positively ameliorate the prognosis. When this approach is not sufficient, rhythm or, when not feasible, rate control is indicated in addition to anticoagulant therapy. As far as the rhythm control strategy is concerned, antiarrhythmic drugs and/or catheter ablation should be considered. New mapping techniques allowing the characterization of the arrhythmic substrate have opened new perspectives and may help in the treatment of AF in these patients, since atrial tissue is the target of inflammation-induced arrhythmic alterations. In cases where the natural history of the arrhythmia itself is more advanced, in order to minimize the impact of AF on cardiac function as well as quality of life, a device-based therapy, including an "ablate and pace" approach could be adopted.

Resumen Objetivo Auditar la calidad de la prevencion, deteccion y manejo de las conductas aberrantes inducidas por opioides (CAIO) en los pacientes atendidos en una consulta externa (CE) de Cuidados Paliativos Precoces. Metodo Presentamos los datos correspondientes a los pacientes con CAIO detectadas, provenientes de un segundo estudio descriptivo observacional retrospectivo en el que analizamos a 100 pacientes consecutivos con cancer atendidos en nuestra CE entre noviembre 2015 y junio 2016. Respecto de la descripcion de la CE de Cuidados Paliativos Precoces y la metodologia empleada para la seleccion de la muestra, variables y ejecucion de la auditoria clinica, son similares a las usadas para la primera auditoria ya publicada. Resultados De los 100 pacientes recogidos en la muestra, 52 estaban en tratamiento cronico con opioides, y de ellos 10 presentaron CAIO y 4 cumplian criterios DSM-V de adiccion –por tanto, la prevalencia de CAIO fue del 19,2% y de adiccion a opioides del 7,7%. Los pacientes con CAIO se caracterizaron por: su juventud (edad media 58 anos), la presencia de factores de riesgo conocidos para CAIO (fundamentalmente trastorno por abuso de sustancias y enfermedad psiquiatrica), la gran diversidad de opioides de base implicados (morfina oral de liberacion retardada, oxicodona oral de liberacion retardada, hidromorfona oral de liberacion retardada, fentanilo transdermico y buprenorfina transdermica), asi como los elevados consumos de opioide de base (dosis diarias equivalentes de morfina 259,5 mg) y por tiempos prolongados (2,75 anos de media). El 80% de los pacientes con CAIO empleaban ademas «fentanilos rapidos» como opioides de rescate en dolor irruptivo oncologico, estando presentes estos farmacos en la genesis insidiosa de los 4 casos de adiccion a opioides. Los test de orina y herramientas/escalas disponibles en la actualidad no resultaron utiles para la deteccion y manejo de los pacientes. Como parte esencial de la estrategia terapeutica efectuamos rotaciones opioides a buprenorfina o/y metadona al 70% de los pacientes –todas ellas eficaces desde el punto de vista analgesico y de control de la CAIO, pero complejas y de curso tormentoso para los pacientes, algunos de los cuales presentaron sintomas de abstinencia prolongados. En 3 casos hubo de prohibirse totalmente el rescate de las crisis de dolor irruptivo oncologico con fentanilos rapidos u opioides de liberacion inmediata. El 40% de los pacientes con CAIO siguen en activo a dia de hoy en nuestra CE, y se preve un seguimiento prolongado al presentar perfil de largo superviviente oncologico. Discusion Nuestros resultados confirman la importancia emergente de las CAIO en poblaciones con dolor cronico oncologico y dolor irruptivo oncologico. Las cifras de prevalencia de CAIO y adiccion a opioides en nuestra serie duplican los datos de series previas. Ello puede explicarse por la generalizacion de un uso medico opioide adecuado en nuestro entorno, junto con la facilidad para remitir precozmente estos casos complejos a nuestra CE de Cuidados Paliativos Precoces. En nuestra experiencia, una buena practica clinica y profesionales cualificados muy expertos en el manejo de opioides han sido la base de nuestro exito en el control de las CAIO. Los test de orina y las herramientas de screening indicadas en la literatura no fueron de utilidad, y sin embargo la habilidad clinica en deteccion, y el manejo de rotaciones opioides complejas a buprenorfina o/y metadona resultaron fundamentales para el exito analgesico y de control de las conductas, tal y como habiamos anticipado previamente en nuestro vigente Protocolo. Conclusiones La innegable aparicion de las CAIO parece, hasta cierto punto, un efecto secundario relativamente inevitable de un adecuado consumo de opioides para el manejo del dolor oncologico. Nuestra serie nos confirma en la percepcion de que el problema es manejable con una adecuada practica clinica por profesionales expertos. Por tanto creemos que la solucion no debe pasar por limitar el acceso de los pacientes cancerosos a los opioides (incluidos los fentanilos rapidos) por temor a una expansion de las CAIO, sino por aumentar nuestros esfuerzos por prevenir la aparicion de estas conductas, y organizar una adecuada atencion especializada una vez detectadas.

Objectives This study investigates the electrocardiographic-electrophysiological effects of administration of anesthetic drugs for general anesthesia (GA) in patients with BrS at high risk of sudden cardiac death (SCD). Background The safety of anesthetic agents in Brugada syndrome (BrS) is under debate. Methods All consecutive patients with spontaneous type 1 BrS electrocardiographic (ECG) patterns undergoing epicardial ablation of the arrhythmogenic substrate (AS) under GA were enrolled. Anesthesia was induced with single bolus of propofol and maintained with sevofluorane. ECG measurements were collected before, immediately after, and 20 min after induction of GA. Three-dimensional maps during GA and after ajmaline indicated the epicardial AS before ablation. Results Thirty-six patients with BrS (32 male, 88.9%; mean age 38.8 ± 12.0 years) with a spontaneous type 1 ECG pattern underwent GA. Induction was performed using propofol at mean dose of 1.6 to 2.6 mg/kg (2.1 ± 0.3 mg/kg). Twenty-eight (28 of 36, 77.8%) patients showed a reversion to a nondiagnostic pattern. ST-segment elevation (0.32 ± 0.01 mV vs. 0.19 ± 0.02 mV, p 2 vs. 20.3 ± 0.8 cm 2 ). No patient developed malignant arrhythmias during GA induction and maintenance. Conclusions This study shows that GA using single-bolus propofol and volatile anesthetics is safe in high-risk patients with BrS, and it may exert a modulating effect by reducing the manifestation of type 1 BrS pattern and AS in the form of epicardial abnormal ECGs. (Epicardial Ablation in Brugada Syndrome: An Extension Study of 200 BrS Patients; NCT03106701).

Background: Multipoint left ventricular (LV) pacing (MultiPoint™ Pacing [MPP], Abbott, Sylmar, CA, USA) improves the response rate to cardiac resynchronization therapy (CRT). We evaluated the feasibility of noninvasive radial artery tonometry (RAT) to characterize arterial pressure morphology changes (pre-ejection period [PEP] and ejection duration [ED]) between conventional CRT and MPP pacing interventions. Methods: Patients with a MPP-enabled CRT device (Quadra Assura MP™, Abbott) underwent noninvasive RAT assessment (SphygmoCor CVMS, AtCor Medical Inc., Itasca, IL, USA) at 3–6 months after implantation. A pacing protocol was performed in a randomized order including one optimized conventional biventricular CRT (CONV) configuration using the distal electrode and five MPP configurations. The PEP, ED, and PEP/ED ratio were determined for each intervention from the RAT pressure waveform and electrocardiogram. Results: Pressure waveforms were successfully recorded in 19 patients (89% male, QRS 147 ± 16ms, 63% ischemic). In 17/19 (89%) patients, at least one MPP intervention resulted in improved PEP, ED, and PEP/ED compared to CONV. The MPP intervention with greatest separation of LV cathodes and minimum intra-LV delay significantly improved PEP (mean PEP –15 ± 33%vs –8 ± 32% [CONV], P=0.04) and ED (mean ED +8 ± 8% [MPP] vs +4 ± 7% [CONV], P=0.02), and PEP/ED (–0.07 ± 0.14 [MPP] vs –0.04 ± 0.13 [CONV], P=0.02) compared with CONV. Conclusions: Noninvasive RAT efficiently characterizes changes in PEP and ED between CONV and MPP interventions. MPP configurations using the widest separation among LV cathodes and minimum intra-LV delay may significantly improve RAT-derived parameters as compared to conventional CRT.

Aims To define the clinical characteristics and long-term clinical outcomes of a large cohort of patients with idiopathic ventricular fibrillation (IVF) and normal 12-lead electrocardiograms (ECGs). Methods and results Patients with ventricular fibrillation as the presenting rhythm, normal baseline, and follow-up ECGs with no signs of cardiac channelopathy including early repolarization or atrioventricular conduction abnormalities, and without structural heart disease were included in a registry. A total of 245 patients (median age: 38 years; males 59%) were recruited from 25 centres. An implantable cardioverter-defibrillator (ICD) was implanted in 226 patients (92%), while 18 patients (8%) were treated with drug therapy only. Over a median follow-up of 63 months (interquartile range: 25–110 months), 12 patients died (5%); in four of them (1.6%) the lethal event was of cardiac origin. Patients treated with antiarrhythmic drugs only had a higher rate of cardiovascular death compared to patients who received an ICD (16% vs. 0.4%, P = 0.001). Fifty-two patients (21%) experienced an arrhythmic recurrence. Age ≤16 years at the time of the first ventricular arrhythmia was the only predictor of arrhythmic recurrence on multivariable analysis [hazard ratio (HR) 0.41, 95% confidence interval (CI) 0.18–0.92; P = 0.03]. Conclusion Patients with IVF and persistently normal ECGs frequently have arrhythmic recurrences, but a good prognosis when treated with an ICD. Children are a category of IVF patients at higher risk of arrhythmic recurrences.

Aims Clinical outcomes after radiofrequency catheter ablation (RFCA) remain suboptimal in the treatment of non-paroxysmal atrial fibrillation (AF). Electrophysiological mapping may improve understanding of the underlying mechanisms. To describe the arrhythmia substrate in patients with persistent (Pers) and long-standing persistent (LSPers) AF, undergoing RFCA, using an integrated mechanism mapping technique. Methods and results Patients underwent high-density electroanatomical mapping before and after catheter ablation. Integrated maps characterized electrogram (EGM) cycle length (CL) in regions with repetitive–regular (RR) activations, stable wavefront propagation, fragmentation, and peak-to-peak bipolar voltage. Among 83 patients (72% male, 60 ± 11 years old), RR activations were identified in 376 regions (mean CL 180 ± 31 ms). PersAF patients (n = 43) showed more RR sites per patient (5.3 ± 2.4 vs. 3.7 ± 2.1, P = 0.002) with faster CL (166 ± 29 vs. 190 ± 29 ms; P 75% of RR sites (Q4 82.6%, Q3 63.1%, Q2 35.1%, and Q1 0%; P Conclusion The integrated mapping technique allowed characterization of multiple arrhythmic substrates in non-paroxysmal AF patients. This technique might serve as tool for a substrate-targeted ablation approach.

Background: Idiopathic ventricular fibrillation (IVF) in patients with normal baseline electrocardiograms (ECGs) is a rare disease. Little information is available on the clinical features and long-term follow-up of out-of-hospital cardiac arrest (OHCA) survivors presenting with "true" IVF and 12-lead ECGs that remain normal over time. Objective: To define the clinical and ECG characteristics, as well as long-term clinical outcomes of a large cohort of survivors of OHCA due to "true" IVF. Methods: OHCA survivors with VF as the presenting rhythm, normal baseline and follow-up ECGs with no signs of cardiac channelopathy including early repolarization or atrioventricular (AV) conduction abnormalities, and without structural heart disease were included in a registry. Results: A total of 245 OHCA survivors with IVF (median age: 38 years; males 59%) were recruited from 25 centres. All had normal baseline and follow-up ECGs, and no evidence of structural heart disease. An implantable cardioverter-defibrillator (ICD) was implanted in 226 patients (92%), while 18 patients (8%) were treated with drug therapy only. Over a median follow-up of 63 months (interquartile range: 25-110 months), 12 patients died (5%); in 4 of them (1.6%) the lethal event was of cardiac origin. Patients treated with antiarrhythmic drugs (AADs) only had a higher rate of cardiovascular death compared to patients who received an ICD (16% vs. 0.4%, p=0.001). The ECG and echocardiogram of all patients remained unchanged over time. Fifty-two patients (21%) experienced an arrhythmic recurrence. Age ≤ 16 years at the time of the first ventricular arrhythmia was the only predictor of arrhythmic recurrence on multivariable analysis (HR 0.41, 95% CI 0.18-0.92, p=0.03). Discussion: OHCA survivors of "true" IVF with normal baseline and follow-up ECGs frequently have arrhythmic recurrences, but a good prognosis when treated with an ICD. Children are a category of IVF patients at higher risk of arrhythmic recurrences. Funding: The study was supported by a grant of the Swiss Heart Foundation. Declaration of Interest: G.C. has received a research grant from the Swiss National Foundation. P.L. has received speaker fees and research grants from Boston Scientific, Abbott and Medtronic Research support from UCLH Biomedicine NIHR. F.L. is consultant and has received research support from Medtronic Plc, Abbott, Boston Scientific and Microport. S.B. has received speaker’s bureau from Medtronic and Microport. C.P. has received research grant from Biotronik and Biosense Webster. P.B. is consultant for Biotronik. A.A. is consultant to Abbott, Biosense Webster, Daiichi-Sankyo, Boston Scientific, Medtronic, Microport-CRM; and has received speaker fee from Daiichi-Sankyo, Boston Scientific, Medtronic, Microport-CRM Ethics Approval Statement: Data were collected in accordance with regulations set by the local Institutional Ethics Committee and/or Institutional Review Board.

Purpose: Cardiac resynchronization therapy (CRT) with multipoint left ventricular (LV) pacing (MultiPoint™ Pacing [MPP]) improves long-term LV reverse remodeling, though questions persist about how to program LV pacing vectors and delays. We evaluated if an empirical method of programming MPP vectors and delays between pacing pulses improved CRT response similar to pressure-volume loop (PVL) optimized MPP programming. Methods: Patients undergoing CRT implant (Quadra Assura MP™ CRT-D and Quartet™ LV lead) received MPP with programmed settings optimized either by PVL measurements at implant (PVL-OPT group) or empirically determined by maximizing the spatial separation between the two cathodes and minimal delays between the three ventricular pacing pulses (MAX-SEP group). CRT response was prospectively defined as a reduction in end-systolic volume (ESV) of ≥ 15% relative to baseline at 6months as determined by a blinded observer. Results: Patient characteristics at baseline (NYHA II–III, ejection fraction [EF] 27 ± 6%, QRS 151 ± 17ms) were not significantly different between the PVL-OPT (n = 27) and MAX-SEP (n = 26) groups. During the follow-up period, there were no differences in the number of patients requiring reprogramming due to phrenic nerve stimulation or a high threshold for PVL-OPT vs. MAX-SEP (5/27 [19%] vs. 7/26 [27%], p= 0.53). After 6months, ESV reduction, EF increase, and CRT response rate (RR) were similar for PVL-OPT vs. MAX-SEP (ESV − 20 ± 11 vs. − 22 ± 11%, p = 0.59; EF + 10 ± 4 vs. + 9 ± 7%, p = 0.53; RR 20/27 [74%] vs. 21/26 [81%], p = 0.74), while fewer patients in the PVL-OPT group experienced NYHA class reduction ≥ 2 (4/27 [15%] vs.15/26 [58%], p = 0.002). Conclusions: Both evaluated methods of MPP programming resulted in similar CRT outcomes. Empirical MPP programming by maximum spatial separation of LV cathodes may be an effective, simple, and non-invasive alternative to pressure-volume optimization.

Aims Continuous rhythm monitoring is valuable for adequate atrial fibrillation (AF) management in the clinical setting. Subcutaneous leadless implantable cardiac monitors (ICMs) yield an improved AF detection, overcoming the intrinsic limitations of the currently available external recording systems, thus resulting in a more accurate patient treatment. The study purpose was to assess the detection performance of a novel three-vector ICM device equipped with a dedicated AF algorithm. Methods and results Sixty-six patients (86.4% males; mean age 60.4 ± 9.4 years) at risk to present AF episodes, having undergone the novel ICM implant (BioMonitor, Biotronik SE&Co. KG, Berlin, Germany), were enrolled. External 48-h ECG Holter was performed 4 weeks after the device implantation. The automatic ICM AF classification was compared with the manual Holter arrhythmia recordings. Of the overall study population, 63/66 (95.5%) had analysable Holter data, 39/63 (62%) showed at least one true AF episode. All these patients had at least one AF episode stored in the ICM. On Holter monitoring, 24/63 (38%) patients did not show AF episodes, in 16 of them (16/24, 67%), the ICM confirmed the absence of AF. The AF detection sensitivity and positive predictive value for episodes' analysis were 95.4 and 76.3%, respectively. Conclusion Continuous monitoring using this novel device, equipped with a dedicated detection algorithm, yields an accurate and reliable detection of AF episodes. The ICM is a promising tool for tailoring individual AF patient management. Further long-term prospective studies are necessary to confirm these encouraging results.

Resumen Objetivos Auditar la calidad de la atencion brindada por nuestra consulta externa (CE) de Cuidados Paliativos (CP) tras su creacion mediante la incorporacion de un modelo de trabajo de cuidados paliativos precoces (CPP), y comparar nuestra experiencia con la recogida en la literatura. Material y metodos Presentamos un estudio descriptivo observacional retrospectivo en el que analizamos a 100 pacientes consecutivos con cancer avanzado atendidos en nuestra CE en 2013. Se analizan los casos a traves de 20 variables seleccionadas por consenso, y agrupadas en 6 categorias (datos demograficos [2], datos del tumor [1], derivacion a CE [1], diagnosticos clinicos CE [6], datos de actividad CE [7], datos de impacto CE [3]). Resultados La edad media de los pacientes atendidos fue de 75 anos, y el 38% padecia cancer de pulmon. Un 17% de los pacientes cumplia criterios completos de CPP y otro 26%, criterios parciales. Tan solo un 33% de los pacientes cumplia criterios tradicionales de cancer en situacion terminal. Se han detectado diagnosticos clinicos novedosos en la muestra: hipovitaminosis D 35%, insuficiencia suprarrenal 18%, hipogonadismo 5%, encefalopatia quimioterapica y radica 4%, conductas aberrantes asociadas al consumo de opioides 2%. Los pacientes precisaron una media de 3,5 visitas a la CE y 1,14 revisiones telefonicas, y la supervivencia media hasta el fallecimiento fue de 3,7 meses. Los pacientes derivados en tratamiento con quimioterapia (QTP) que cumplian criterios completos de CPP precisaron de mas revisiones presenciales (media 6,12), y presentaron una supervivencia media de 7,7 meses. El 82% de los pacientes preciso de procedimientos diagnosticos o terapeuticos de ambito hospitalario y el 31% recibio radioterapia paliativa. Dos tercios de los pacientes precisaron de ingreso en las camas de la Unidad de Cuidados Paliativos de agudos en algun momento en su evolucion, y la mayoria fallecieron en la misma (44 pacientes para 56 fallecimientos). El numero de visitas a Urgencias en el ultimo mes de vida fue bajo (39 visitas para 56 pacientes), siendo bajo tambien el numero de pacientes tratados con QTP en el ultimo mes de vida (5,3%). Discusion El analisis no estadistico sugiere que la CE atiende a una poblacion de procedencia y supervivencia variadas, pero con la caracteristica comun de una elevada complejidad en sus necesidades paliativas. Los datos preliminares no contradicen la hipotesis vigente, que afirma que los CPP pueden generar ahorros en el gasto sanitario. Conclusiones Nuestra experiencia inicial con una CE de CP sugiere que la aplicacion de los CPP es posible en nuestro entorno. Por otro lado, nuestros resultados preliminares no parecen poner en tela de juicio ninguno de los posibles beneficios ya conocidos con la implementacion de los novedosos programas de CPP.

In this case report, we characterize a novel inherited frameshift mutation c.4700_4701del (p.Phe1567Cysfs*221) in a single copy of the SCN5A gene and its association with Brugada syndrome (BrS). The proband experienced a life-threatening ventricular arrhythmia successfully treated with DC-shock and he also suffered from supraventricular tachycardia. Ajmaline test confirmed the BrS diagnosis. No other mutation nor low frequency variants in the other 23 analyzed genes were detected. The same mutation was found in the father and sister, who were both diagnosed with BrS. We hypothesize that this mutation could be responsible for BrS and potentially linked to supraventricular tachycardias. Further studies are needed to confirm this observation and to assess the clinical relevance of this mutation, in terms of risk-stratification.

Background: Guidelines recommend the use of implanted cardioverter-defibrillators in patients with Brugada syndrome and induced ventricular tachyarrhythmias, but there is no evidence supporting it. Objectives: This prospective registry study was designed to explore clinical and electrophysiological predictors of malignant ventricular tachyarrhythmia inducibility in Brugada syndrome. Methods: A total of 191 consecutive selected patients with (group 1; n = 88) and without (group 2; n = 103) Brugada syndrome–related symptoms were prospectively enrolled in the registry. Patients underwent electrophysiological study and substrate mapping or ablation before and after ajmaline testing (1 mg/kg/5 min). Results: Overall, before ajmaline testing, 53.4% of patients had ventricular tachyarrhythmia inducibility, which was more frequent in group 1 (65.9%) than in group 2 (42.7%; p < 0.001). Regardless of clinical presentation, larger substrates with more fragmented long-duration ventricular potentials were found in patients with inducible arrhythmias than in patients without inducible arrhythmias (p < 0.001). One extrastimulus was used in more extensive substrates (median 13 cm2; p < 0.001), and ventricular fibrillation was the more frequently induced rhythm (p < 0.001). After ajmaline, patients without arrhythmia inducibility had arrhythmia inducibility without a difference in substrate characteristics between the 2 groups. The substrate size was the only independent predictor of inducibility (odds ratio: 4.51; 95% confidence interval: 2.51 to 8.09; p < 0.001). A substrate size of 4 cm2 best identified patients with inducible arrhythmias (area under the curve: 0.98; p < 0.001). Substrate ablation prevented ventricular tachyarrhythmia reinducibility. Conclusions: In Brugada syndrome dynamic substrate variability represents the pathophysiological basis of lethal ventricular tachyarrhythmias. Substrate size is independently associated with arrhythmia inducibility, and its determination after ajmaline identifies high-risk patients missed by clinical criteria. Substrate ablation is associated with electrocardiogram normalization and not arrhythmia reinducibility. (Epicardial Ablation in Brugada Syndrome [BRUGADA_I]; NCT02641431; Epicardial Ablation in Brugada Syndrome: An Extension Study of 200 BrS Patients; NCT03106701)

Background: Clinical outcomes after ablation of persistent atrial fibrillation remain suboptimal. Identification of AF drivers using a novel integrated mapping technique may be crucial to ameliorate the clinical outcome. Methods and Results: Persistent AF patients were prospectively enrolled to undergo high-density electrophysiological mapping to identify repetitive-regular activities (RRas) before modified circumferential pulmonary vein (PV) ablation. They have been randomly assigned (1:1 ratio) to ablation of RRa followed by modified circumferential PV ablation (mapping group; n=41) or modified circumferential PV ablation alone (control group; n=40). The primary end point was freedom from arrhythmic recurrences at 1 year. In total, 81 persistent AF patients (74% male; mean age, 61.7±10.6 years) underwent mapping/ablation procedure. The regions exhibiting RRa were 479 in 81 patients (5.9±2.4 RRa per patient): 232 regions in the mapping group (n=41) and 247 in the control group (n=40). Overall, 185 of 479 (39%) RRas were identified within the PVs, whereas 294 of 479 (61%) in non-PV regions. Mapping-guided ablation resulted in higher arrhythmia termination rate when compared with conventional strategy (25/41, 61% versus 12/40, 30%; P P =0.38), mapping ( P =0.46), and fluoroscopy times ( P =0.69) were not significantly different between the groups. No major procedure-related adverse events occurred. After 1 year, 73.2% of mapping group patients were free from recurrences versus 50% of control group ( P =0.03). Conclusions: Targeted ablation of regions showing RRa provided an adjunctive benefit in terms of arrhythmia freedom at 1-year follow-up in the treatment of persistent AF. These findings might support a patient-tailored strategy in subjects with nonparoxysmal AF and should be confirmed by additional larger, randomized, multicenter studies. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier NCT02571218.

The Remote Monitoring (RM) technology has recently become available in insertable cardiac monitors (ICM) [(1)][1]. The purpose of this analysis was to assess feasibility, clinical reactions, and arrhythmic alerts burden of remote management for patients implanted with the novel long-dipole ICM (

This study investigates the electrocardiographic-electrophysiological effects of administration of anesthetic drugs for general anesthesia (GA) in patients with BrS at high risk of sudden cardiac death (SCD).The safety of anesthetic agents in Brugada syndrome (BrS) is under debate.All consecutive patients with spontaneous type 1 BrS electrocardiographic (ECG) patterns undergoing epicardial ablation of the arrhythmogenic substrate (AS) under GA were enrolled. Anesthesia was induced with single bolus of propofol and maintained with sevofluorane. ECG measurements were collected before, immediately after, and 20 min after induction of GA. Three-dimensional maps during GA and after ajmaline indicated the epicardial AS before ablation.Thirty-six patients with BrS (32 male, 88.9%; mean age 38.8 ± 12.0 years) with a spontaneous type 1 ECG pattern underwent GA. Induction was performed using propofol at mean dose of 1.6 to 2.6 mg/kg (2.1 ± 0.3 mg/kg). Twenty-eight (28 of 36, 77.8%) patients showed a reversion to a nondiagnostic pattern. ST-segment elevation (0.32 ± 0.01 mV vs. 0.19 ± 0.02 mV; p 0.001) and J-wave amplitude (0.47 ± 0.02 mV vs. 0.31 ± 0.03 mV; p 0.001) decreased after propofol. The AS area during GA, in the absence of BrS pattern, significantly enlarged after administration of ajmaline (3.6 ± 0.5 cmThis study shows that GA using single-bolus propofol and volatile anesthetics is safe in high-risk patients with BrS, and it may exert a modulating effect by reducing the manifestation of type 1 BrS pattern and AS in the form of epicardial abnormal ECGs. (Epicardial Ablation in Brugada Syndrome: An Extension Study of 200 BrS Patients; NCT03106701).

A huge thrombus, developing after percutaneous left atrial appendage occlusion, has been successfully treated with dabigatran and aspirin as combination therapy.Although novel oral anticoagulants alone may be effective in thrombus dissolution, the association of an antiplatelet drug may safely enhance this process.

Resumen Objetivos Auditar la calidad de la atencion brindada por nuestra Unidad de Cuidados Paliativos (UCP) a nuestros pacientes de esclerosis lateral amiotrofica (ELA), y comparar nuestra experiencia con la recogida en la literatura. Material y metodos Presentamos un estudio descriptivo observacional retrospectivo en el que analizamos los primeros 14 pacientes de ELA en situacion terminal atendidos por nuestra UCP en un hospital de agudos. Se analizan los casos a traves de 52 variables seleccionadas por el equipo multiprofesional agrupadas en 8 categorias (datos demograficos 2, naturaleza de la enfermedad 8, final de la vida 10, sintomas 11, dimension psicologica 2, dimension etica 9, terapia farmacologica 6, impacto en el equipo 3). Resultados El analisis no estadistico sugiere que se trata de una muestra de gran complejidad para el manejo paliativo, y aporta informacion interesante relativa al lugar del fallecimiento, causa del mismo, presencia de instrucciones previas, empleo de la ventilacion mecanica y retirada de la misma, e impacto del miedo a la muerte por ahogamiento en el manejo del paciente y la familia. La dosis diaria equivalente de morfina oral al inicio de los CP oscilo en un rango de 0 a 90 mg/dia, mientras que al exitus el rango fue de 0 a 2.700 mg/dia. La dosis diaria de midazolam parenteral al inicio de los CP oscilo en un rango de 0 a 45 mg/dia, mientras que al exitus el rango fue de 0 a 415 mg/dia. Las altas dosis de morfina y midazolam se precisaron en los 6 casos con exposicion previa a psicofarmacos, y muy especialmente en los pacientes con consumo previo de opioides. Conclusiones La experiencia inicial avala la importancia de facilitar el acceso de estos pacientes a las UCP de hospitales de agudos, y mas aun si trabajan estrechamente asociadas a Unidades especificas de ELA ubicadas en la misma institucion.