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Extended risk stratification and optimal management of patients with a permanently increased risk of sudden cardiac death (SCD) are becoming increasingly important. There are several clinical conditions where the risk of arrhythmic death is present albeit only transient. As an example, patients with depressed left ventricular function have a high risk of SCD that may be only transient if there will be a significant recovery of function. It is important to protect the patients while receiving and titrating to the optimal dose the recommended drugs that may lead to an improved left ventricular function. In several other conditions, a transient risk of SCD can be observed even if the left ventricular function is not compromised. Examples are patients with acute myocarditis, during the diagnostic work-up of some arrhythmic conditions or after extraction of infected catheters while eradicating the associated infection. In all these conditions, it is important to offer a protection to these patients. The wearable cardioverter defibrillator (WCD) is of particular importance as a temporary non-invasive technology for both arrhythmia monitoring and therapy in patients with increased risk of SCD. Previous studies have shown the WCD to be an effective and safe therapy for the prevention of SCD caused by ventricular tachycardia/fibrillation. The aim of this ANMCO position paper is to provide a recommendation for clinical utilization of the WCD in Italy, based upon current data and international guidelines. In this document, we will review the WCD functionality, indications, clinical evidence, and guideline recommendations. Finally, a recommendation for the utilization of the WCD in routine clinical practice will be presented, in order to provide physicians with a practical guidance for SCD risk stratification in patients who may benefit from this device.

Leadless, intracardiac pacemakers are a major innovation in the management of bradyarrhythmia. Both safety and feasibility of leadless pacing have been assessed in acute settings and mid-term follow-up showing a significant reduction of pacing-related complications as compared with standard transvenous pacemakers. There are many advantages of the leadless approach including a reduction of infection risk and malfunction due to the absence of transvenous leads and the pacemaker pocket. Patients at high risk of endocarditis or pocket failure, with compromised venous access, can benefit from the leadless approach. In this review article, the relevant implant indications for leadless pacemaker and patient populations are described.

Background Laser balloon ablation is a promising option for performing pulmonary vein isolation (PVI) which is the cornerstone of invasive atrial fibrillation (AF) treatment. Purpose We aimed to investigate the acute efficacy and safety of the novel third-generation of the laser balloon system in an initial multicenter experience. Methods First and consecutive patients who underwent PVI with LB3 for drug-resistant paroxysmal or persistent AF at 7 Italian sites were included in this analysis. Study endpoints were acute procedural efficacy, defined as successful isolation of all identified PVs without radiofrequency touch-up, total and fluoroscopy times, and periprocedural complications. Results Our population included 86 patients (81% males, mean age 60.6±9.5 years) who underwent a procedure of PVI using LB3 between June 2020 and March 2021. Most patients had paroxysmal AF (74%) and were in sinus rhythm at the beginning of the procedure. The mean procedure time was 138±60 min; fluoroscopy time was 22±17 min and the mean ablation time was 44±40 min. Of the 313 targeted PVs, 311 (99.4%) could be isolated with first-pass LB3 application, while 2 (0.6%) required radiofrequency touchup. At the end of the procedure, all patients were in sinus rhythm and 26 (32%) received electrical cardioversion to achieve stable sinus rhythm. The total rate of major compilations was 1.2% (1/82 patients): one pericardial tamponade requiring epicardial puncture. No surgical intervention was necessary, and the patient recovered without any sequalae. There were no vascular access complications or phrenic nervy palsy. Three pinhole balloon raptures (3.5%) were observed during energy applications that required replacement of the whole system but had no effect on patient safety. Conclusions In a first multicenter experience, the LB3 system for PVI was safe with excellent acute efficacy. Funding Acknowledgement Type of funding sources: None.

Objectives This study evaluated heart failure (HF) patients who underwent cardiac resynchronization therapy (CRT) and who had device-documented sleep-disordered breathing (SDB). We found gender differences in acute changes in SDB due to CRT impact. Background SDB typically occurs in HF patients. However, the role of SDB and its response to CRT in HF patients, as well as the relation with gender are currently not fully researched. Methods Among 63 consecutive patients who received CRT with an SDB algorithm, 23 patients documented SDB at one-month cardiac device interrogation and represented our population. We defined a Sleep apnoea Severity SCore(SSSC), and consequently, patients were categorized to have mild, moderate, and severe sleep apnoea syndrome divided into two groups: Group-1: 18 males (78%); Group-2: 5 females (22%). We evaluated the variation of apnoea burden and CRT response based on gender differences. Results A significantly higher proportion of patients in the male group were non-responders to CRT at 12-months follow-up (p = 0.076) while in the female population 5/5 patients (100%) were responders to CRT at the same follow-up time (p = 0.021). Among Group-2 subjects, we documented a significant linear decrease in SSSC(p > 0,01) while in Group-1 the CRT effect on SSSC was variable. At 12-months follow-up, the difference in SSSC between the two groups was statistically significant (p Conclusions Our study reports a correlation between CRT response and sleep apnoea burden considering gender differences. In particular, HF-women responders to CRT demonstrate a significant linear decrease in sleep apnoea burden determined through a device algorithm, when compared to a similar male population. Further research is needed to confirm these findings.

Premature ventricular complexes (PVCs) are frequently documented in children. To date, few studies report long-term follow-up in pediatric cohorts presenting with frequent PVCs. The aim of this study is to assess the clinical relevance and long-term outcomes of frequent PVCs (≥ 500/24 h) in a large pediatric cohort. From 1996 to 2016, we enrolled all consecutive patients evaluated at Anna Meyer Children Hospital for frequent PVCs. Symptomatic children were excluded together with those patients with known underlying heart diseases; thus, our final cohort of study included 103 patients (male 66%; mean age 11 ± 3.4 years), with a mean follow-up of 9.5 ± 5.5 years. All patients were submitted to complete non-invasive cardiologic evaluation. The mean number of PVCs at Holter Monitoring (HM) was 11,479 ± 13,147/24 h; couplets and/or triplets were observed in 5/103 (4.8%) cases; 3 patients (2.9%) presented runs of non-sustained ventricular tachycardia (NSVT). High-burden PVCs (> 30,000/24 h) was confirmed in 11/103 (10.6%) patients. During the follow-up, only five patients (4.8%) developed clinical symptoms (3 for palpitations, 1 myocardial dysfunction due to frequent PVCs and NTSV; 1 arrhythmogenic cardiomyopathy); no deaths occurred. Basal PVCs were still present in 45/103 (43.7%) patients. Our data suggest that frequent PVCs may be addressed as a benign condition and should not preclude sport participation if not associated with cardiac malformations, heart dysfunction, or cardiomyopathy. This seems to be true also in presence of very frequent/high-burden PVCs. Otherwise, a careful follow-up is mandatory since sport eligibility should be reconsidered in case of onset of symptoms and/or ECG/echocardiographic changes.

The use of the wearable cardioverter-defibrillator, already widely used in the United States and other European countries, is rapidly spreading in Italy. The population of patients who may benefit from this type of device is very heterogeneous, but they share the transient risk of sudden cardiac death, for which temporary, automatic and non-invasive protection is required. By interpreting the latest scientific evidence and clinical experiences reported in the registries, it is clear that this type of tool is safe, effective and could have an important impact on the reduction of arrhythmic and total mortality in certain patient subsets. Starting from the clinical conditions for which even the guidelines have recognized the usefulness of the device, new opportunities open up where the wearable cardiac defibrillator can be used with the double benefit of protecting the patient from the risk of sudden cardiac death in safety and allows clinicians to have the right time to make the most appropriate long-term therapeutic decisions.

Aims Radiation use in medicine has significantly increased over the last decade, and cardiologists are among the specialists most responsible for X-ray exposure. The present study investigates a broad range of aspects, from specific European Union directives to general practical principles, related to radiation management among a national cohort of cardiologists. Methods and results A voluntary 31-question survey was run on the Italian Arrhythmology and Pacing Society (AIAC) website. From June 2019 to January 2020, 125 cardiologists, routinely performing interventional electrophysiology, participated in the survey. Eighty-seven (70.2%) participants are aware of the recent European Directive (Euratom 2013/59), although only 35 (28.2%) declare to have read the document in detail. Ninety-six (77.4%) participants register the dose delivered to the patient in each procedure, in 66.1% of the cases both as fluoroscopy time and dose area product. Years of exposition (P = 0.009) and working in centers performing pediatric procedures (P = 0.021) related to greater degree of X-ray equipment optimization. The majority of participants (72, 58.1%) did not recently attend radioprotection courses. The latter is related to increased awareness of techniques to reduce radiation exposure (96% vs. 81%, P = 0.022), registration of the delivered dose in each procedure (92% vs. 67%, P = 0.009), and X-ray equipment optimization (50% vs. 36%, P = 0.006). Conclusion Italian interventional cardiologists show an acceptable level of radiation awareness and knowledge of updated European directives. However, there is clear space for improvement. Comparison to other health professionals, both at national and international levels, is needed to pursue proper X-ray management and protect public health.

OBJECTIVES: The aim of this study is to demonstrate how Electrophysiology activity has been impacted by the pandemic Coronavirus disease 2019 (COVID-19). METHODS: In this multicenter retrospective study, we analyze all consecutive patients admitted for electrophysiological procedures during the COVID-19 lockdown in the Tuscany region of Italy, comparing them to patients hospitalized in the corresponding period of the previous year. RESULTS: The impact of COVID-19 on cardiac arrhythmia management was impressive, with a reduction of more than 50% in all kinds of procedures. A gender gap was observed, with a more relevant reduction for female patients. Arrhythmic urgencies requiring a device implant showed a reduced time from symptoms to first medical contact but the time from first medical contact to procedure was significantly prolonged. CONCLUSION: Hospitals need to consider how outbreaks may affect health systems beyond the immediate infection. Routine activity should be based on a risk assessment between the prompt performance of procedure and its postponement. Retrospective observational analysis such as this study could be decisive in evidence-based medicine of any future pathogen outbreak.Nonstandard Abbreviations and Acronyms PM= pacemakerICD= implantable cardioverter defibrillatorECV= electrical cardioversionEPS= electrophysiological studyAP= ablations proceduresCIED= cardiac implantable electronic devicesWCD= wearable cardioverter defibrillatorEP Lab= Electrophysiology LaboratoriesAVNRT =atrioventricular nodal reentry tachycardiaAVRT= atrioventricular reentry tachycardiaAFL= atrial flutterAF= atrial fibrillationVT= ventricular tachycardiaAT= atrial tachycardia.

The awareness of radiation doses and risks, also during interventional cardiology procedures, is essential today in order to apply the risk-benefit assessment and to reinforce the principles of justification and optimisation in clinical practice.A voluntary survey with 10 questions and multiple-choice answers was run on a popular cardiology website (www.cardiolink.it) independently by a scientific publisher, in order to evaluate the contemporary level of radiation awareness in a multi-speciality sample of physicians in Italy.One thousand eight hundred and sixty-one physicians completed the test. The survey showed good results since both prescribers and practitioners (mostly cardiologists) working in Italy are largely aware of the cancer and non-cancer risks of medical radiation use, regardless of their subspecialty background.Physicians are largely aware of the cancer and non-cancer risks of medical radiation use, regardless of their subspecialty background. However, there is still broad space for improvement; in the future, the awareness of radiation risk is a prerequisite to create a culture of respect for radiation hazard and a commitment to minimise exposure and maximise protection.

AIMS Anatomical placement of the coronary sinus (CS) lead in basal or mid-ventricular positions of the posterior and lateral walls is associated with a better clinical outcome of cardiac resynchronization therapy (CRT). We hypothesized that optimization of CS lead placement targeted the right-to-left electrical delay (RLD) predicts an additional clinical benefit. METHODS AND RESULTS The CS lead was placed according to current standards in 90 patients (Conventional group) and at the site of the longest RLD in 121 patients (RLD group). Non-responders were defined as those who died or underwent hospitalization for heart failure or did not improve in their Clinical Composite Score within 6 months. There were 67 (32%) non-responders. Compared with Conventional group, the final CS pacing site was more frequently in the basal segments in the RLD group (40% vs. 23%, P = 0.007); moreover, the RLD ratio (%RLD) of the total QRS width was longer (77 ± 13 vs. 73 ± 15, P = 0.05) and biventricular QRS shortened more from the baseline (-31 ± 21 ms vs. -21 ± 26 ms, P = 0.004). Nevertheless, the rate of non-responders was similar in the RLD and Conventional groups (35% vs. 28%, P = 0.30), as was %RLD (76 ± 16 vs. 75 ± 13, P = 0.66). QRS width during right ventricular (RV) pacing was an independent predictors of adverse outcome, with a 2% increase in the risk of failure for each 1 ms increase in QRS (P = 0.006). CONCLUSION Optimization of CS lead placement targeted to latest electrical activation does not provide additional clinical benefit to anatomical placement in basal or mid-ventricular positions of the posterior and lateral walls. QRS width during RV pacing was a strong predictor of CRT failure. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov. Unique identifier: NCT03204864.

Key Clinical Message Effective and stable contact between the catheter tip and the tissue is crucial for both mapping and lesion formation during cardiac ablation procedures. Contact force catheter may be not only a therapeutic approach to arrhythmias, but also a tool for achieving accurate characterization of the arrhythmic substrate.

Radiation exposure related to conventional tachyarrhythmia radiofrequency catheter ablation (RFCA) carries small but definite risk for both patients and operators. Today, non-fluoroscopic mapping systems enable to perform catheter ablation with minimal or zero fluoroscopy. The purpose of this study was to evaluate the long-term outcome of patients who had undergone “Zero X-ray” ablation, since no information is available on the very long-term benefits. A total of 272 arrhythmias in 266 patients have been treated with catheter ablation by means of a zero-ray approach guided only by a nonconventional mapping system (EnSite NavX™, Ensite™ Velocity™ mapping system; subsequently Ensite™ Precision™ Abbott, St. Paul, MN). Fluoroscopy was never used. Over a period of 6 years, patients were followed up for an average of 2.9 ± 1.6 years. A 100% rate of acute success was observed in the study population, with a complication rate of 0.8%. Chronic success was achieved in 90.8% of the total number of procedures (272). Patients in whom the same arrhythmia recurred during follow-up underwent to a redo catheter ablation procedure in 60.0% of cases, while the remaining 40.0% underwent pharmacological treatment. A new post-ablation arrhythmia occurred in 7.7% of the sample. The non-fluoroscopic approach is a feasible and safe alternative to fluoroscopy for arrhythmias ablation. This method ensures low complications rates, high acute procedural success rates, and comparable long-term outcomes with clinical benefits for both patients and physicians. The complete elimination of fluoroscopy during catheter ablation is advantageous and does not reduce patient safety.

Background Fluoroscopic guidance is the standard tool used in device implantation. This means that both the patient and the operator are exposed to radiation, which may sometimes be high. The possibility of single-lead permanent pacemaker implantation without fluoroscopy has already been demonstrated. Objective The aim of our study was to investigate the feasibility and reliability of biventricular device implantation guided only by an electroanatomic navigation system. Methods Sixty-one patients with heart failure underwent implantation of a cardiac resynchronization therapy (CRT) device with or without defibrillator (CRT-D; CRT-P). The procedure was performed with or without fluoroscopy guidance (Rx+; Rx0). In the latter case, the EnSite Velocity system was used; this system is able to reconstruct the anatomy and activation of the cardiac chambers by simultaneously collecting a "cloud" of anatomical points from multiple electrodes. Results Lead positioning was achieved in 24 of 26 patients undergoing CRT implantation without fluoroscopy (92% success). No complications were observed during the procedure and no catheter dislodgment occurred the day after the implantation or during 1-month follow-up. Procedure time progressively decreased from 136 minutes in the first case to 59 minutes in the last one, suggesting that operators gradually gained confidence while using the new technique. Conclusion Our study demonstrates the feasibility, efficacy, and safety of lead positioning guided only by the nonfluoroscopic EnSite Velocity mapping system without the use of fluoroscopy in CRT-P or CRT-D implantation. The benefits in terms of significantly reduced fluoroscopy exposure are associated with technical and clinical advantages.

Key Clinical Message Sleep apnea syndrome (SAS) is a chronic condition associated with cardiovascular disease. In some pacemakers, an advanced algorithm using transthoracic impedance may be used to identify SAS. This algorithm may be also a useful tool for a long‐term monitoring helping physicians to optimize therapy, reducing risk factors, and improving therapeutic compliance.

Aims Left ventricular (LV) lead positioning at the site of delayed electrical activation is associated with better response to cardiac resynchronization therapy (CRT). We hypothesized that a long electrical conduction delay between right ventricular (RV) and coronary sinus (CS) leads during RV pacing (RLD index) is correlated with a better clinical outcome Methods and results RLD is measured intraprocedurally, during RV pacing, as the time interval between the intracardiac electrograms of RV and CS leads. Initially, we did a prove-of-concept, feasibility, acute study in 97 patients who underwent CRT implantation. The CS lead position was assessed in the 40° right anterior oblique and 40° left anterior oblique views and assigned to one of 11 prespecified segments of a schematic eyeball depiction of the LV walls. Acute outcomes were QRS width during biventricular (BIV) pacing. The longest RLD were found in the basal and mid lateral segments; these accounted for 82% and 78%, respectively, of the total QRS width (%RLD). %RLD was inversely correlated with BIV-paced QRS (P = 0.0001). A similar slope was present either in the 78 patients with preserved atrioventricular (AV) conduction and in the 19 without AV conduction (− 0.34 vs − 0.27, P = 0.7). Conclusion We showed that RLD can be used to guide lead placement at the time of CRT implantation and that it is correlated with BIV-QRS width, an indirect predictor of clinical outcome. Based on these findings we started the prospective, multicenter Optimal Pacing SITE 2 (OPSITE 2) trial with the objective to demonstrate a relationship between RLD and clinical outcomes assessed as death, hospitalization for heart failure, New York Heart Association class, and clinical composite score. The protocol is provided.

Background Radiation exposure related to conventional tachyarrhythmia radiofrequency catheter ablation (RFCA) carries small but not negligible stochastic and deterministic effects on health. These effects are cumulative and potentially more harmful in younger individuals. Nonfluoroscopic mapping systems can significantly reduce the radiological exposure and in some cases it can completely eliminate it. Objective The aim of this study was to assess the safety, feasibility, and efficacy of a complete nonfluoroscopic approach for RFCA compared with ablation procedures performed under fluoroscopic guidance. Methods RFCA was performed in 442 consecutive patients (mean age 58 ± 19 years). The first 145 patients (group 1) were treated only under fluoroscopic guidance, and the following 297 patients (group 2) were treated using a nonfluoroscopic electroanatomic mapping system (EnSite Velocity). RFCA was completely performed without fluoroscopy in 255 of 297 patients in group 2 (86%). Results The acute success rate did not differ between group 1 and group 2 (97% vs 96%; P = .46), and there were no differences in either procedure time (87 ± 57 minutes vs 91 ± 52 minutes; P = .41) or complication rate. Fluoroscopic exposure in group 2 was significantly reduced in comparison with group 1 (14 ± 6 seconds vs 1159 ± 833 seconds; P Conclusion Compared with the conventional fluoroscopic technique, the near-zero radiation (RX) approach provides similar outcomes and may significantly reduce or eliminate ionizing radiation exposure in RFCA. These reductions are achieved without altering the duration or compromising the safety and effectiveness of the procedure.

Aims To evaluate the influence of QRS prolongation on the natural history of chronic heart failure (CHF). Methods The results of several studies carried out from 1951 to 2003 were analysed. Results (a) Isolated left bundle branch block (LBBB) is associated with an increased risk of developing cardiovascular disease and increased cardiac mortality; (b) investigations on the effect of right bundle branch block (RBBB) on mortality have yelded conflicting results; (c) the effects of the association of LBBB with left axis deviation (LAD) on further LV function deterioration remain controversial; (d) LBBB in CHF is associated with a significantly higher all-cause and sudden cardiac death mortality. Conclusions LBBB is unequivocably associated with greater disease severity and mortality in patients with CHF.

A 48-year-old patient with myotonic dystrophy (MD) type 1, recurrent typical atrial flutter (AF), and otherwise unremarkable history was hospitalized for an electrophysiological study. The diagnosis of MD type 1 had been made 25 years earlier and was based on typical clinical features and confirmation by genetic analysis. The ECG pattern of AF was characterized by negative waves in the inferior leads and positive waves in V1, a cycle length of 280 milliseconds, and 2:1 atrioventricular conduction. At the time of the study, the patient was asymptomatic and showed normal findings at the cardiac physical examination, ECG, and standard echocardiography. Preablation ECG showed sinus rhythm at 60 bpm with a normal PR interval (180 milliseconds), regular QRS duration and morphology, and normal ventricular repolarization. Average septal-lateral mitral annulus velocities (s′, 9.5 cm/s; e′, 10.3 cm/s; a′, 7.4 cm/s), the E/e′ ratio (7.3), and left ventricular global longitudinal and circumferential strain (−21.5% and −23.2%, respectively) were all normal, as well as right ventricular systolic function (tricuspid annulus systolic excursion and peak systolic velocity, 25 mm and 18.5 cm/s, respectively). Analysis of longitudinal right atrial deformation by speckle tracking showed impaired strain mechanics in the inferior segment of the atrial …

A guideline is a statement by which to determine a course of action. A guideline aims to streamline particular processes according to a set routine or sound practice. By definition, following a guideline is never mandatory. Guidelines are not binding and are not enforced [5]. In effect guidelines are derived from 3 sources of data: 1. randomized clinical trials; 2. observational data from cohorts of high-risk patients with less common diseases; and 3. ex‐ pert opinion on potential benefit for clinical condition or specific circumstances in which da‐ ta are limited or uncertain. For all 3 categories of clinical guidance, there are limitations in available data that reinforce the importance of physician judgment in decision making, based on circumstances of individual cases or subgroups of patients [6]. Understanding the value and limitations of current information is important not only for the clinical electro‐ physiologist, but also for general cardiologists and primary care physicians because of their roles in referring appropriate patients for consideration of implantable cardioverterdefib‐ rillator therapy and for the clinical management of patients at risk of sudden cardiac death. While the high stakes and unpredictable nature of sudden cardiac death justifiably provoke fear and uncertainty, emotional factors should not outweigh scientific evidence. In this con‐ text the obligation to adhere to guidelines could, in effects, to have paradoxically dulled our discriminatory senses as clinicians [7].

Situs viscerum inversus totalis (SVIT) is a congenital disorder characterized by mirror reversal of the thoracic and abdominal organs. Different studies have shown that the ablation procedure can be performed without fluoroscopy with safety and effectiveness, in the setting of supraventricular tachycardia. We successfully performed an anatomical map and a radiofrequency catheter ablation of ventricular arrhythmia in a patient with SVIT without fluoroscopy.

Sudden cardiac death (SCD) is defined as death from cardiac causes occurring unexpectedly within 1 hour of onset of symptoms. About 80% of SCDs are due to ventricular tachyarrhythmia that is, ventricular tachycardia and ventricular fibrillation. The remaining 20% consists of a number of conditions, including cardiomyopathies (10–15%), other structural heart defects (less than 5%) and bradycardia. SCD is responsible for more deaths than cancer, stroke, and AIDS combined (CDC, 2002). The overall incidence of SCD in the United States and Europe is 1 to 2 per 1000 people (0.1% to 0.2%) annually. Almost 80% of all SCDs occur at home. The 10%-25% survival rate is low and has not been improved by the automatic external defibrillator in patients with moderate risk (de Vreede-Swagemakers, 1997; Bardy, 2008; Myerburg, 2001). On the other hand, several clinical trials showed that the implantable cardioverter defibrillator (ICD) could prevent SCD and reduce overall mortality in some patients with severe left ventrocular dysfunction. For these reasons, ICD therapy has become the first choice strategy to prevent SCD from malignant ventricular tachyarrhythmia in high-risk patients. However, there are numerous well-recognized limitations to ICD therapy. These include the effects and the result of appropriate and inappropriate ICD shocks, the cost of the devices, complications related both to the implantation procedure and to subsequent device function, device malfunction, and restricted efficacy despite normal device function in presence of significant concomitant disease and in particular in presence of severe left ventricular disfunction. Several possible solutions have been proposed in the clinical practice, these include better patients’ selection for ICD implantation, better ICD programmation, better medical therapy and arrhythmic substrate ablation. The role of catheter ablation of ventricular tachycardia in patients with structural heart disease has been increasing in the last 2 decades. The mechanisms of ventricular tachycardia are now clearer, and the electroanatomic mapping systems have made precise activation and substrate mapping more feasible; therefore, the potential for doing catheter ablation of ventricular tachycardia has increased dramatically in the past

Objective Postoperative atrial fibrillation (AF) is a frequent complication after cardiac surgery. AF may also occur after hospital discharge during postacute rehabilitation. Several studies have addressed the AF that occurs in the hospital after surgery, and predictors have already been identified. Postoperative AF that occurs after hospital discharge has not been investigated thoroughly, and predictors are still unknown. In this study, we hypothesized that moderate-intensity physical activity in the year before surgery might favorably affect the incidence of AF during postacute rehabilitation. Design We tested our hypothesis in a cohort of 158 older patients admitted to a medical rehabilitation facility for postacute inpatient rehabilitation after coronary surgery and continuously monitored by telemetry for the duration of the rehabilitation. Results Independent of potential confounders, patients who reported low-intensity physical activity in the year before surgery showed a significantly higher incidence of AF during postacute rehabilitation when compared with those who reported moderate-intensity physical activity (32.1% vs. 8.1%; P = 0.029). Other independent predictors of AF during postacute rehabilitation were the occurrence of AF during the patients' stay in hospital, larger left atrial volume, and lower left atrial emptying fraction. Conclusions These findings confirm our hypothesis that physical activity in the year before surgery affects the incidence of postoperative AF during postacute rehabilitation. The results also provide information regarding possible predictors that may assist in identifying patients who could benefit from preventive treatments.

Isolated ventricular premature beats are the most common arrhythmia in clinical practice. Not all ventricular premature beats are equal, as they may evolve into worsening of the arrhythmia and even severe left ventricular dysfunction in some subsets of patients, particularly those with frequent ventricular premature beats originating from the left ventricle. The resulting systolic dysfunction is reversible following arrhythmia termination. Radiofrequency ablation allows us to achieve effective and safe results and should be considered the treatment of choice. We report a case of left ventricular dysfunction without signs of structural heart disease, secondary to left ventricular premature beats evolved into runs of non-sustained ventricular tachycardia, successfully treated with radiofrequency ablation of the arrhythmic focus.

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. It is frequently symptomatic and contributes to significant morbidity and mortality, independent of all other cardiac comorbidities [1]. Providing effective treatment of AF is one of the challenges of electrophysiology, and it is the focus of major research initiatives in the scientific community. The level of concern and interest regarding AF has increased over the years with the advent of curative ablative techniques.

Background Inflammatory markers are involved in heart failure (HF) pathophysiology. However, the link between these markers and reverse remodeling as well as major adverse cardiac events (HF death, sudden death, and unplanned cardiac rehospitalizations) in patients who undergo cardiac resynchronization therapy (CRT) has not been evaluated. Methods and Results We recorded major adverse cardiac events of 140 patients (on optimized medical therapy, left ventricular ejection fraction 29.9 ± 9.6%, New York Heart Association Class III-IV, with intraventricular dyssynchrony) who underwent CRT (enrolled since April 2004). Moreover, we evaluated before and after 6 months of CRT: interleukin-6, high-sensitivity C-reactive protein, New York Heart Association class, quality of life (score on Minnesota Living with Heart Failure questionnaire), 6-minute walking test, left ventricular end-diastolic and end-systolic volumes (nonindexed and indexed by body surface area), and left ventricular ejection fraction. Adverse cardiac events were observed in 40 patients (28.6%): 22 deaths and 18 cardiac unplanned rehospitalizations. Only patients without adverse events during follow-up showed a significant reduction of inflammatory markers and left ventricular volumes (reverse remodeling), despite a significant improvement of clinical status observed in both groups of patients. Conclusions The reduction of inflammatory status seems to be linked to reverse remodeling as well as to a better clinical prognosis in patients with HF who underwent CRT.

“What conclusions can be drawn from these observations of the dying heart? In any case the entry of the vena cava (into the heart) as the region of the ‘Ultimum moriens’ may be excluded. . . . One is therefore almost obliged to come to the conclusion that the last part of the coronary vein and its inlet region, the so called coronary vein funnel, where the stimulus conduction system finds its start and departure, must correspond to the sinus field as the source of the heart’s automatic stimulus”. Walter Karl Koch, 1907.

Cardiac resynchronization therapy (CRT) by biventricular pacing is indicated in patients with severe heart failure and left bundle branch block who remain symptomatic despite optimal medical therapy. The relationship between baseline resting perfusion pattern and hemodynamic response to CRT has not been fully investigated. We tested the usefulness of perfusion gated SPECT for baseline evaluation and follow-up of these patients.In 20 patients, we performed gated SPECT before CRT and at the 3-mo follow up. Left ventricular (LV) ejection fraction (EF), end-diastolic (ED) and end-systolic (ES) volume indexes (VI), and wall motion score index (WMSI) were measured and compared with clinical outcome.One patient died before follow-up. The 19 remaining patients were classified into 1 of 2 groups according to the presence (group A) or absence (group B) of a significant severe perfusion defect at baseline before CRT. At the 3-mo follow-up, 6 of 10 group A and 8 of 9 group B patients had an improvement in New York Heart Association class. In both groups, quality of life, 6-min walking distance, and WMSI significantly improved. In group A, no significant change was registered in LVEF, LVEDVI, or LVESVI. In group B, LVEF increased from 23.1% +/- 8% to 27.1% +/- 11% (P0.03) and LVEDVI and LVESVI decreased from 159 +/- 70 mL to 135 +/- 68 mL (P0.02) and from 127 +/- 67 mL to 104 +/- 65 mL (P0.01), respectively.Perfusion gated SPECT appears useful to characterize and follow up candidates for CRT. Despite clinical improvement, patients with severe resting perfusion defects do not show significant improvement in LVEF or reduction in LV volumes.