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Funding Acknowledgements Type of funding sources: None. Introduction Transcatheter atrial fibrillation (AF) ablation is in most centres commonly carried out with continuous invasive radial arterial blood pressure (BP) monitoring. Novel devices enable continuous non-invasive BP monitoring, with acceptable agreement and optimal safety profile when compared to standard of care invasive BP monitoring, leading to improved patient comfort in the electrophysiology lab. Purpose Aim of the study was to assess in terms of procedural efficiency continuous non-invasive BP monitoring during transcatheter atrial fibrillation ablation. Methods We prospectively enrolled 42 consecutive patients (age 61±9 years, 80% male) undergoing transcatheter AF ablation (60% paroxysmal, 40% persistent) at our centre undergoing AF ablation with continuous BP measurement using a non-invasive finger volume clamp device. We then compared them with an historical cohort of 42 consecutive patients undergoing AF ablation (62% paroxysmal, 38% persistent) with standard of care invasive BP monitoring with a radial cannula. We compared the two groups in terms of total procedural duration (in and out from the EP lab). Results Mean total procedural duration was 165,29±54,95 minutes in the non-invasive group and 196,55±46,67 minutes in the invasive group (P=0,006). Conclusion In patients undergoing AF ablation, non-invasive finger volume-clamp continuous BP monitoring allowed for a significant reduction of total procedural duration when compared to standard of care invasive BP monitoring. Larger studies are needed to confirm these results.

Funding Acknowledgements Type of funding sources: None. Background The specific and well-known design features of leadless pacing system (Micra Transcatheter Pacing System, M-TPS) have suggested his use in patients that previously underwent transvenous lead extraction (TLE) for any reason. The study aimed to investigate feasibility and long-term outcomes of M-TPS implant in patients underwent TLE. Methods Patients undergone M-TPS implantation in our Institution from May 2014 to September 2022 were included in the study. All patients fulfilled standard criteria for PM implantation (VVI or VDD mode). Follow-up (FU) was scheduled at discharge, after 1 month and every 6 months thereafter and electrical parameters were checked. Major complications were defined as life-threatening events, requiring surgical intervention or any event causing significant hemodynamic instability or resulting in death. Study population was divided between "naïve pacing" and "post-extraction" patients. Results We enrolled 193 patients (76.7% males), 57 (29.5%) received M-TPS implantation after TLE, needed because of infection in 91.4% of cases. Indications for pacing were permanent AF with bradycardia in 107 (55.5%) patients, complete AVB in 59 (30.5%), symptomatic sinus node dysfunction in 20 (10%), and advanced AVB or bifascicular bock in 7 (4%). There were no statistically significant differences between groups for demographics characteristics and primary PM implant indications, except mean age at implant that was significantly inferior in the post-extraction group [80 (IQR 75-84) vs 78 (IQR 72-83), p=0.04]. Implant procedure was successful in all and no complications were recorded. No differences between groups in procedure duration [40 (IQR 30-50) vs 45 (30-65) min, p=0.34], fluoroscopy time [9 (6-14) vs 9 (6-11) min, p=0.31] and single device delivery (64.9% vs 67.9%, p=0.35) were observed. The mean FU was 12 (1-36) months, maximum 8 years. Pacing variables at implantation [pacing threshold 0.5 (0.38-0.63) vs 0.5 (0.38-0.88) V/0.24 ms, p=0.15; impedance 720 (600-837) vs 675 (615-825) Ohm, p=0.51; R wave amplitude 9 (6.25-12.87) vs 8.2 (5.65-12) mV, p=0.47], discharge [pacing threshold 0.38 (0.38-0.63) vs 0.38 (0.38-0.63) V/0.24 ms, p=0.27; impedance 685 (580-770) vs 610 (560-750) Ohm, p=0.16; R wave amplitude 10.25 (7.2-14.5) vs 9.3 (6.5-16.5) mV, p=0.6], and at 6 months [pacing threshold 0.5 (0.38-0.5) vs 0.5 (0.38-1.25) V/0.24 ms, p=0.64; impedance 580 (520-680) vs 570 (510-640) Ohm, p=0.63; R wave amplitude 11.9 (8.2-16.4) vs 11.7 (9-20) mV, p=0.68; battery voltage 3.09 (3.05-3.11) vs 3.09 (3.04-3.13) V, p=0.71] did not show differences. Conclusion M-TPS is an efficacious and safe alternative to conventional PM, with the main advantage of the absence of transvenous leads and a surgically created subcutaneous pocket, avoiding all the related complications. These devices are a reliable alternative after TLE, with similar electrical performances than those observed in patients who did not previously received pacing.

Funding Acknowledgements Type of funding sources: None. Early detection of atrial fibrillation is a major opportunity for mobile health, as portable devices nowadays available can detect multiple-lead electrocardiogram (ECG). The study aims to validate the in-ear region as a new anatomical site for ECG signal detection in patients (pts) affected by atrial fibrillation (AF). Methods We performed the ECG using KardiaMobile 6L device on 40 patients affected by AF and admitted to our hospital for elective electrical cardioversion. All the digital ECGs were detected in a modified modality or using the left in-ear region instead of the right hand. All the recorded ECGs were analyzed by the device and the results checked by two cardiologists. Results We successfully collected all 40 modified digital ECGs performed on the group of 40 pts: age 69.4 ± 9.4 years; male 28 (70)%; medium HR 95±25.4bpm; 26 (65%) affected by hypertension; 2 (5%) affected by diabetes mellitus; 37 (92,5%) in NOACs. In all cases, the KardiaMobile 6L automatic diagnosis of the ECG detected by this modified modality was correct in 100% of cases. Conclusion The in-ear region could be a reliable novel anatomical site for ECG signal detection in patients affected by atrial fibrillation. These data could support the development of new portable mobile ECG devices using the left in ear region and so leaving at least one hand free.

Funding Acknowledgements Type of funding sources: None. Introduction A previously validated algorithm allows to accurately identify ventricular tachycardia (VT) exit site in a 17-segments American Heart Association left ventricle model in patients with structural heart disease (SHD). ADAS3D is a novel artificial-intelligence cardiac magnetic resonance (CMR) post-processing software which enables heterogeneous tissue channel (HTC) identification. Purpose The aim of this study is to compare inferred VT exit site between QRS-axis based model and HTC identification from CMR post-processing. Methods All subjects allocated to a CMR-guided or aided approach from a multicenter randomized clinical trial were analyzed. Patients with available 12-lead ECG of clinical VT obtained before ablation were analyzed in terms of concordance between VT site of origin inferred from a QRS-axis and location of HTCs in a 17-segments model. Results 10 out of 15 patients had 12-lead ECG of clinical VT (80% male, 60% with ischemic cardiomyopathy, mean age 63,5±16,95 years, mean tachycardia cycle length 373,7±99,55 ms). 7 out of 10 patients (70,00%) had at least one HTC located at VT exit site as predicted by a QRS axis-based algorithm. In all remaining cases (3 out of 10) HTC location was found in a segment adjacent to ECG-derived exit site. All patients underwent CMR-guided or CMR-aided VT ablation with acute clinical success (noninducibility of the clinical VT). Conclusion VT site of origin prediction via a QRS axis-based algorithm allows for reasonable prediction of HTC presence at inferred site of origin. Larger studies are needed in order to confirm such findings and their potential clinical implications.

Funding Acknowledgements Type of funding sources: None. Background Electrical storm is a specific clinical presentation yielding to high morbidity and mortality. Acute development of electrical storms results from the underlying myocardial substrate, autonomic activation, and trigger factors. Main therapeutic approaches range from pharmacological to interventional treatment. Methods We enrolled in a prospective single center registry all patients admitted from March 2018 to March 2022 at our Centre who satisfied diagnostic criteria for electrical storm. Demographic, instrumental, and interventional data were obtained from local electronic health record. Results A total of 87 patients (79% male sex, mean age 72,21±10,49 years) were enrolled. Mean left ventricular ejection fraction was 37,27±11,62%. Underlying cardiomyopathy was ischemic in 57,47%; dilated cardiomyopathy in 20,69%, arrhythmogenic cardiomyopathy in 8%, other in 13,84%. A definite trigger was identified in 34 cases (39%), most frequent ones were sepsis (11 events, 32,4%), acute heart failure (6 events, 17,6%), myocardial ischemia (5 events, 14,7%), thyrotoxicosis (5 events, 14,7%), ionic disorder (4 events, 11,8%). An ICD was already implanted in 89,66% of patients, all remaining patients were implanted during index hospitalization. An ablation strategy was pursued in 65,52% of cases. Mean days from hospitalization to ablation were 7±5. Median hospital stay was 11 days (IQR 8-18). Conclusion In our single referral centre experience, in patients with electrical storm, ischemic cardiomyopathy was the dominant underlying heart disease. An identifiable trigger was found in a large cohort of patients, with sepsis being the most frequent. An ablation strategy was pursued in most cases.

Funding Acknowledgements Type of funding sources: None. Background the leadless pacing system, like Micra Transcatheter Pacing System (M-TPS) is precisely designed to reduce peri- and post-procedural complications, like pneumothorax, lead dislodgement, infections, and lead fracture.Previous studies have already demonstrated its good safety profile and the excellent electrical performance during the follow up. The study aimed to investigate feasibility and long-term electrical outcomes of M-TPS implant and estimate sex differences in leadless pacing. Methods All patients undergone M-TPS implantation in our Institution from May 2014 to October 2022 were included. All patients fulfilled standard criteria for VVI or VDD pacing according to guidelines. Device FU was scheduled at discharge, after 1 month and then every 6 months. Electrical performance was checked. Major complications were defined as life-threatening events, requiring surgical intervention or significant hemodynamic instability or resulting in death. Study population was divided between genders in order to analyze potential differences during the FU Results One hundred ninety-three consecutive patients [148 males, 76.7%, mean age 79 (IQR 73-84) y] were enrolled in this study. Indications for pacing were permanent AF with bradycardia in 107 (55.5%) patients, complete AV block in 59 (30.5%) patients, symptomatic sinus node dysfunction in 20 (10%) patients, and advanced AV block or bifascicular bock in 7 (4%). One hundred seventy-seven patients received VVI pacing, while 16 VDD. There were no statistically significant differences between groups for demographics characteristics (mean age at implant 79 vs 81, p=0.12), except gender. The mean was FU 12 (IQR 1-36) months, maximum 8 years. The implant procedure was successful in all patients and no complications were recorded. We observed no differences between groups in procedure duration [40 (IQR 30-60) min vs 40 (IQR 29-50), p=0.64], fluoroscopy time [9 (6-14) min vs 9 (7-11), p=0.81] and single device delivery (65.7% vs 65.9%, p=0.34). Electrical performance, except for pacing threshold at implantation [0.5 (IQR 0.38-0.75) V/0.24ms vs 0.38 (IQR 0.25-0.63) V/0.24ms, p=0.02), was similar between groups at discharge [pacing threshold 0.38 (IQR 0.38-0.63) V/0.24 ms vs 0.38 (IQR 0.25-0.55) V/0.24 ms, p=0.30; impedance 650 (IQR 560-760) Ohm vs 675 (IQR 580-780) Ohm, p=0.71; R wave amplitude 10.1 (IQR 7-16.2)mV vs 9.5 (IQR 7-14.45) mV, p=0.71] and during the FU [pacing threshold 0.5 (IQR 0.38-0.63) V/0.24 ms vs 0.5 (IQR 0.38-0.5) V/0.24 ms, p=0.11; impedance 570 (IQR 490-630) Ohm vs 580 (IQR 510-640) Ohm, p=0.46; R wave amplitude 11.5 (IQR 7.8-15.7)mV vs 12.7 (IQR 9-18) mV, p=0.26]. Conclusion Leadless pacing therapy is a feasible and safe alternative to conventional pacemakers with similar electrical performance and outcomes during a long-term FU. No differences were found between genders making it a good option especially in women who are often considered fragile in surgical procedure.

Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) results in electrical and structural remodeling of the atria, and the extent of remodeling has already been found to be associated with higher AF recurrence rate after catheter ablation (CA). Recently, a novel echocardiographic parameter derived from tissue Doppler imaging (TDI), called PA-TDI, has been introduced to assess the total atrial activation time, as a non-invasive surrogate of fibrosis and atrial cardiomyopathy. The aim of the study was to investigate the role of PA-TDI interval as predictor of AF ablation efficacy. Methods Consecutive patients with persistent or paroxysmal symptomatic AF referred to our Center to perform radiofrequency ablation or cryoablation procedures were prospectively enrolled. In these patients, a complete transthoracic echocardiographic examination was performed before and after the ablation procedure, including assessment of the PA-TDI interval. Results From October 2018 to May 2020, 221 consecutive patients (mean age 61 ± 9 years, 74% male, mean BMI 26.5 ± 3.6, mean Ejection Fraction 61 ± 6%) symptomatic for AF, undergoing the procedure ablation (first procedure or re-do) were enrolled. Out of the blanking period, 25% of patients experienced recurrence of arrhythmia during follow-up (mean 16 months). Compared to patients who did not relapse, patients with AF recurrence have a generally longer post-procedural PA-TDI interval (139.6 ± 22.1 msec vs 153.9 ± 33 msec, respectively). In the multivariable analysis only post-procedure PA-TDI and re-do interventions were found to be independent predictors of AF recurrence. A PA-TDI cut-off>144msec identifies patients at risk of post ablation AF recurrence with sensitivity 58.7% and specificity 73.5% (AUC 0.697). Conclusions The PA-TDI interval is an independent predictor of AF recurrence after catheter ablation. This echocardiographic parameter is easily obtainable, low-cost, reproducible, and accessible even in peripheral centers.

Funding Acknowledgements Type of funding sources: None. Background The need for cardiac pacing progressively increases with age and the elderly constitute a special subset of patients, being often very fragile and at a greater risk for procedural complications. Leadless pacing systems appear to be a safe and effective option, being devoid of most complications associated with traditional transvenous pacing systems. Purpose This study aimed to analyze a single-center experience with M-TPS (Micra Transcatheter Pacing System) implantation in terms of safety and efficacy in a long-term follow-up. Methods Between May 2014 and November 2022, 193 patients underwent M-TPS implantation in our Center, all patients fulfilled standard criteria for pacemaker implantation with indication to receive either VVI or VDD pacing. We divided the study population into two groups according to age (group 1 < 79 y vs group 2 >= 80 y) and analyzed procedural outcomes, electrical performance of the system at follow-up (FU), rate of procedural major complications and of device-related events at FU. Results In 95/193 cases (69 males, 73%) M-TPS was implanted in patients > 80 y. There were no statistically significant differences between groups in baseline characteristics. Implant procedure was successful in all cases and no device-related events were registered during FU. Patients were followed-up for an average of 18 months, up to 7 years. No differences were observed between groups in procedure duration, single device delivery (group 1 vs group 2: 62.1 vs 69.6%, p=0.17), fluoroscopy time [10 (IQR 6-14) vs 8.5 (IQR 6-12.5) minutes, p=0.27], electrical performance at implant: pacing threshold [0.44 (0.38-0.63) vs 0.5 (0.38-0.75) V/0.24 ms, p=0.39]; impedance [710 (610-840) vs 700 (600-810) Ohm, p=0.56]; R wave amplitude [9.3 (6 -13.5) vs 8.2 (6 -11.9) mV, p=0.68] and at 6 months follow-up : pacing threshold [0.5 (0.38-0.5) vs 0.38 (0.38-0.5) V/0.24 ms, p=0.25]; impedance [580 (500-640) vs 570 (530-680) Ohm, p=0.38]; R wave amplitude [13.2 (9.5-17) vs 9.7 (7.8-16.7) mV, p=0.17]. The only statistically significant difference was found in the percentage of ventricular pacing (Vp%), which was higher in group 2 [5.3 (IQR 0.5-35) vs 38% (IQR 14-83), p=0.001] and stayed higher at a 12 months follow-up [11 (1-53) vs 60% (10-94)], p=0.001). High pacing threshold (>= 1mV@0.24ms) at implant was present in thirty-one patients (14 vs 19%, p=0.43). Conclusions As the population ages the incidence of rhythm disturbances raises, increasing the need for cardiac pacing. It is imperative to find a therapeutic solution that suits the elderly offering them high efficacy and a low rate of complications. MTP-S implant is an effective and safe procedure in elderly patients with similar electrical performance and outcomes compared with younger patients at long-term follow-up. While initially thought for patients that could not undergo traditional pacing interventions, MTP-S is now emerging as a valid substitute.

Funding Acknowledgements Type of funding sources: None. Introduction Atrial Fibrillation (AF) ablation is associated with continuous blood pressure (BP) variations related to anesthesiological regimen and energy delivery. Conventional BP monitoring with non-invasive periodic brachial BP controls can miss potential hypotensive events. Continuous non-invasive blood pressure (CNBP) measurement using the volume-clamp method (Clearsight) was demonstrated to be a reliable and effective tool for the assessment of BP during AF ablation. Purpose Aim of the study was to investigate the incidence of hypotensive events during AF ablation. Methods We included consecutive patients scheduled for AF ablation and monitored in parallel with a periodic (10 minutes) brachial BP cuff and in continuous with the CNBP System (Clearsight). All CNBP data were analyzed with the Acumen Analytics software for hypotension evaluation. According to the anesthesiological regimen, patients were divided in 2 Groups, the General Anesthesia (GA) and the Deep Sedation (DS) group. Area under the threshold (AUT, mmHg x min) of 65 mmHg and Time Weighted Average (TWA, mmHg, i.e., the AUT divided by the total duration of procedure in minutes) of area under threshold (MAP Results Forty-eight patients were included, 10 (21%) in the General Anesthesia Group and 38 (79%) in the Sedation Group. Hypotension was detected in 18 patients, 9/10 (90%) were recorded in the GA group and 9/38 (23.7%) in the DS one. A total of 85 hypotensive events were recorded, 68 (80%) in the GA and 17 (20%) in the DS Group. In the overall population, mean duration of hypotensive events was 4.87 minutes (range 0 – 14.73 minutes), mean MAP < 65 mmHg was 54.25 ± 7.2 mmHg, mean AUT (MAP Conclusions CNBP demonstrated a high incidence of hypotension during AF ablation, specially under GA, which are usually missed by the standard intermittent brachial non-invasive BP monitoring. Real time hypotension predictive CNBP indexes could be valuable in this setting.

Background In the early post transcatheter aortic valve replacement (TAVR) discharge era, rate of readmission for permanent pacemaker implantation (PPM-I) due to delayed conduction disturbances (CDs) has significantly increased. This issue has powered post procedural ambulatory electrocardiogram (AECG) monitoring by using implantable cardiac monitors or mobile cardiac telemetry devices, despite several disadvantages as frequent electrode changes and costs. Purpose In this scenario we aimed to evaluate the incidence of post-TAVR new onset arrhythmias and delayed CDs, performing an AECG monitoring through a 30s spot digital ECG (AeECG), by using a mobile electrocardiogram 6 lead (ME6L) device in a 30 days period after a TAVR procedure. Methods Between March 2021 and February 2022 we consecutively enrolled all patients undergoing a TAVR at the University Hospital of Pisa, excepting who already had a PM. At discharge, all patients received ME6L device and were asked to record a spot eECG for 1 month: 1 eECG per day during the first week and then 1 eECG per week. Clinical and follow-up data were collected and analyzed, and eECG scheduling compliance and quality recordings were explored. Results Among 185 consecutive TAVR patients, 12 were excluded due to pre-existing pacing device and 33 due to PPM-I Conclusion Delayed CDs requiring PPM-I are the most important drawback of TAVR procedure. In our study, AeECG was seen to be safe and helpful in the identification and treatment of delayed CDs requiring PPM-I, with a very high eECG schedule level of compliance and quality. Further prospective studies are needed to better identify patient selection for outpatient monitoring, making safer and safer the early post TAVR discharge approach. Funding Acknowledgement Type of funding sources: None.

Introduction PVI isolation confirmation after RF ablation is often time-consuming, especially in case of a single transeptal catheter approach into the left atrium. A novel Live View (LV) dynamic display mapping software, utilized in combination with the High Density (HD) Grid mapping catheter, allows to display beat-to-beat, dynamic regional mapping data. Purpose We evaluated the feasibility and the procedural impact of a procedural left atrial workflow with a single transeptal-single HD catheter analysis, incorporating the LV Mapping Software for the assessment of PVI after ablation. Methods Paroxysmal and persistent AF patients scheduled for AF ablation were prospectively enrolled. All patients underwent only PVI under LSI guidance (LSI between 5.5 and 6 anteriorly; LSI between 4.5 and 5 posteriorly) with a point by point strategy and an inter-lesion distance Results Forty-six patients with AF (58% paroxysmal) were prospectively enrolled. Twenty-five patients were included in the HD-LV Group and 21 in the HD-SM Group. PVI was successful in all patients. LV dynamic display analysis was feasible in all patients and allowed a simple and fast validation of right and left PVI, without the necessity of introducing a second catheter into the left atrium. The split screen modality, with a dynamic activation map on the left and a dynamic voltage map on the right, allowed to switch from CS pacing to sinus rhythm without the necessity of a remap. The overall mapping time (27±10 vs 37±14 min, p=0.006), total procedure time (138±33 vs 178±50 min, p=0.006) and fluoroscopy time (14±5.3 vs 23±11 min, p=0.006) were significantly lower in the HD-LV Group. No complication was seen in either group. Conclusions A simplified clinical utilization of LiveView dynamic display with a single transeptal-single HD catheter approach is feasible and efficient after PVI, potentially simplifying the procedural workflow. A real-time dynamic mapping in daily practice may further enhance the clinical benefits of HD mapping during radiofrequency (RF) catheter ablation procedures. Funding Acknowledgement Type of funding sources: None.

Background The use of a leadless pacing system, like Micra Transcatheter Pacing System (M–TPS), is nowadays a convincing alternative to transvenous pacemaker. PURPOSE: The study aimed to investigate feasibility and long–term electrical outcomes of M–TPS implant in a real–world population and to estimate sex differences in leadless pacing. Methods All patients undergone M–TPS implantation in our Institution from May 2014 to October 2022. Device follow–up was scheduled at discharge, after 1 month from procedure and then every 6 months. Electrical performance was checked. Major complications were defined as life– threatening events, requiring surgical intervention or any event causing significant hemodynamic instability or resulting in death. Study population was divided between genders to analyze potential differences and those observed during the follow–up (FU). Results One hundred ninety–three consecutive patients [148 males, 76.7%, mean age 79 (IQR 73–84) years] were enrolled in the study. There were no statistically significant differences between groups for demographics characteristics (mean age at implant 79 vs 81, p=0.12), except gender. The mean FU was 12 (IQR 1–36) months, maximum 8 years. The implant procedure was effectuve in all patients and no complications were recorded. We observed no differences between groups in procedure duration [40 (IQR 30–60) min vs 40 (IQR 29–50), p=0.64], fluoroscopy time [9 (6–14) min vs 9 (7–11), p=0.81] and single device delivery (65.7% vs 65.9%, p=0.34). Electrical performance, except for pacing threshold at implantation [0.5 (IQR 0.38–0.75) V/0.24ms vs 0.38 (IQR 0.25–0.63) V/0.24ms, p=0.02), was similar between groups at discharge [pacing threshold 0.38 (IQR 0.38–0.63) V/0.24 ms vs 0.38 (IQR 0.25–0.55) V/0.24 ms, p=0.30; impedance 650 (IQR 560–760) Ohm vs 675 (IQR 580–780) Ohm, p=0.71; R wave amplitude 10.1 (IQR 7–16.2)mV vs 9.5 (IQR 7–14.45) mV, p=0.71] and during the FU [pacing threshold 0.5 (IQR 0.38–0.63) V/0.24 ms vs 0.5 (IQR 0.38–0.5) V/0.24 ms, p=0.11; impedance 570 (IQR 490–630) Ohm vs 580 (IQR 510–640) Ohm, p=0.46; R wave amplitude 11.5 (IQR 7.8–15.7)mV vs 12.7 (IQR 9–18) mV, p=0.26]. Conclusion Leadless pacing therapy is a feasible and safe alternative to conventional pacemakers with comparable electrical performance and outcomes even during a long–term FU. No differences were found between genders making it a good option especially in women who are often considered fragile in surgical procedures.

A 66 year old woman with dilated cardiomyopathy, carrier of CRT–D device in secondary prevention since 2013 and a mitralic mechanical prosthesis, suffered of CIED infection, confirmed by PET imaging exam. She was scheduled in our Hospital Unit for transvenous lead extraction. The procedure was performed by the subclavian approach, and the transvenous lead extraction was staged using mechanical telescopic sheats. After the extraction of the atrial and ventricular leads, the advance of the sheats was hampered by tenacious adherences along the site of vascular subclavian access of the coronary sinus lead. Firstly the portion of the lead running inside the coronary sinus was retracted with a pigtail by femoral vein approach. The inability to pass over the tenacious adherences at the point of the subclavian vein access were overcome expanding the surgical field with the help of the Vascular Surgeon, finding out that the adherence was determined by the presence of an osteophyte embracing the lead to the clavicle. The osteophyte was then surgically removed and the lead was finally extracted by jugular vein access. In this case the CIED leads were implanted using a intrathoracic subclavian venous access, where the vein lies behind the medial region of the clavicle. This approach could rarely lead to a periosteal penetration during needle advance that can generate osteophytes between the lead and the bone. In those circumstances the transvenous lead extraction could become extremely complicated, whatever technique is used.

Funding Acknowledgements Type of funding sources: None. Introduction Patients undergoing transvenous lead extraction (TLE) usually receive general anesthesia, although in our experience local anesthesia is a frequent alternative. Purpose We sought to verify safety and effectiveness of local anesthesia in patients undergoing tranvenous lead extraction (TLE). Methods A retrospective analysis of patients who underwent to TLE in our center was performed. 1293 patients were divided in three groups depending on EROS class and comparisons were made in each group depending on type of anesthesia. Lead extraction was performed by manual traction or mechanical dilatation and use of transjugular approach was evaluated on case-by-case. Results In the EROS 1 group (726 pts.) 559 (77%) receive local anesthesia, in the EROS 2 (367 pts.) 252 (69%) and in the EROS 3 (200 pts.) 73 (36%). There was no differences in total complications (EROS 1 3.76% vs 2.99%, p=0.814, EROS 2 4.76% vs 5.21%, p=0.851, EROS 3 5.48% vs 11.81%, p=0.210) and clinical success (EROS 1 98.75% vs 99.40%, p=0.689, EROS 2 98.41% vs 94.78%, p=0.077, EROS 3 80.82% vs 85.04%, p=0.439) between local and general anesthesia throughout the groups; use of internal jugular approach was significantly higher in EROS 2 patients undergoing general anesthesia (4.76% vs 11.30%, p=0.021), while in EROS 1 and 3 patients this difference was not statistically significant (EROS 1 5.01% vs 8.38%, p= 0.101, EROS 3 8,22% vs 18,11%, p=0.056). Conclusion These results suggest that local anesthesia in patients undergoing transvenous lead extraction does not affect procedural outcomes and safety. Complex procedures with the need for internal jugular approach may drive this choice with preference for general anesthesia.

Funding Acknowledgements Type of funding sources: None. Purpose Early detection of cardiac arrhythmias is a major opportunity for mobile health, as portable devices nowadays available can detect multiple-lead electrocardiogram (ECG). The study aims to validate the in-ear region as a new anatomical site for ECG signal detection in patients (pts) affected by atrial tachyarrhythmias. Methods We performed the ECG using KardiaMobile 6L device on 20 patients affected by tachyarrhythmias and admitted to our hospital for electrical cardioversion. All the digital ECGs were detected in a modified modality or using the left in-ear region instead of the right hand. All the recorded ECGs were analyzed by the device and the results checked by two cardiologists. Results We successfully collected all 20 modified digital ECGs performed on the group of 20 pts (age 68.4 ± 9.2 years; male 60%; 14pts in atrial fibrillation (AF); 6pts in atrial flutter (AFl); medium HR 94±28.4bpm; 65% affected by hypertension; 5% affected by diabetes mellitus; 95% in NOACs). In case of AF, the KardiaMobile 6L diagnosis of the ECG detected by this modified modality was correct in 100% of cases. In the 6 pts affected by AFl the KardiaMobile 6L diagnosis was "normal" in 3 cases and "not classified" in the other 3. For that reason, in these 6 pts, we performed a new digital ECG using the KardiaMobile 6L in the standard modality, and the diagnosis for each patients was the same. Conclusion The in-ear region could be a reliable novel anatomical site for ECG signal detection in patients affected by atrial fibrillation. Further studies are needed to overcome the misdiagnosis of digital ECG in case of patients affected by atrial flutter. These data support the development of new portable ECG devices using the left in ear region and so leaving at least one hand free.

Funding Acknowledgements Type of funding sources: None. Introduction Transcatheter atrial fibrillation (AF) ablation is still carried out with continuous invasive radial arterial blood pressure (BP) monitoring in many centers. Continuous noninvasive blood pressure (CNBP) measurement using the volume-clamp method is a non invasive alternative method used in ICU. No data on CNBP reliability are available in the electrophysiology lab during AF ablation, where rhythm variations are common. Purpose The objective of the present study was to compare continuous noninvasive arterial pressure measured with the ClearSight device with invasive radial artery pressure, used as the reference method during AF ablation. Methods We prospectively enrolled 55 consecutive patients (age 62±11 years, 79% male) undergoing transcatheter AF ablation (62% paroxysmal, 38% persistent) at our center. Standard of care invasive BP monitoring via a radial cannula and a contro-lateral non-invasive finger volume-clamp continuous BP measurement device were positioned simultaneously in all patients for the entire procedure. Bland-Altman analysis was used to analyze agreement between the two techniques. Results A total of 1219 paired measurements for systolic, diastolic, and mean arterial pressure were obtained in 55 subjects, with a mean (SD) of 22 (9) measurements per patient. Mean bias (SD) was -12,97 (13,89) mmHg for systolic pressure (level of agreement -14,24–40,20; correlation coefficient 0,84), -1,85 (8,52) mmHg for diastolic pressure (level of agreement -18,54–14,84; correlation coefficient 0,77) and 2,31 (8,75) mmHg for mean pressure (level of agreement -14,84–19,46; correlation coefficient 0,85). Conclusion In patients undergoing AF ablation, non-invasive finger volume-clamp continuous BP monitoring with the ClearSight device showed acceptable agreement with standard of care invasive BP monitoring. Larger studies are needed to confirm potential clinical implications of a continuous non-invasive BP monitoring during AF ablation.

Funding Acknowledgements Type of funding sources: None. Background Infections and malfunction are major indications to transvenous lead extraction. Managing extracted patients represents a clinical and interventional challenge, since this population may be at higher risk for mechanical, vascular or infective complications. The use of leadless pacing systems has been described as a potentially useful technology that could tackle the obstacles that affect this peculiar population. The study aimed to investigate feasibility and long-term outcomes of M-TPS implant in a specific patient population, like post transvenous lead extraction patients, which represent a challenge for conventional cardiac pacing. Methods Between May 2014 and November 2021, 155 patients (120 males, 77.42%, mean age 78 ± 9 y) underwent M-TPS implantation in our Center, targeting a non-apical site of delivery when feasible. A subgroup of 48 patients (39 males, 81.25%) had undergone transvenous lead extraction. All patients fulfilled standard criteria for pacemaker implantation with specific indication to receive VVI pacing. The outcome evaluation included electrical performance (capture threshold, pacing impedance, R wave amplitude) before hospital discharge and then followed at 1, 6, and 12 months and then annually. Major complications were defined as life-threatening events, required surgical intervention or any event causing significant hemodynamic instability or resulting in death. High pacing threshold (HPT) was defined as 1.0 V/0.24 ms. Results In 48/155 cases (39 males, 81,25%) M-TPS was implanted after successful transvenous lead extraction. There were no statistically significant differences between groups for demographics characteristics, and PM implant indications. The implant procedure was successful in all cases and no device-related events were registered during follow-up. In particular, no device infection and/or malfunction were reported. Patients were followed-up for an average of 24 months (median 18 months). No differences were observed between groups in procedure duration, single device delivery (group 1 vs group 2: 63.21% vs 73.91%, p=0.20), fluoroscopy time (group 1 vs group 2: 11.79 ± 7.53 vs 10.49 ± 6.19 minutes, p=0.64), electrical performance at implant (group 1 vs group 2: pacing threshold 0.54 ± 0.35 V/0.24 ms vs 0.62 ± 0.32 V/0.24 ms, p=0.09; impedance 758.02 ± 227.89 Ohm vs 724.26 ± 178.14 Ohm, p=0.36; R wave amplitude 10.1 ± 4.73 mV vs 9.59 ± 5.30 mV, p=0.50) and at 18 month F-U (group 1 vs group 2: pacing threshold 0.50 ± 0.10 V/0.24 ms vs 0.85 ± 0.9 V/0.24 ms, p=0.45; impedance 559.58 ± 94.43 Ohm vs 543.34 ± 64.39 Ohm, p=0.69; R wave amplitude 12.00 ± 5.06 mV vs 13.42 ± 5.77 mV, p=0.55). Conclusions Leadless pacemaker implant is a feasible, safe and effective option for patients treated with transvenous lead extraction, with electrical performance and outcomes comparable to a cohort of naïve patients at long-term follow up.

Funding Acknowledgements Type of funding sources: None. Introduction The ELECTRa Registry Outcome Score (EROS) was developed to identify patients at increased transvenous lead extraction (TLE) risk Purpose Aim of the study is to explore the efficiency of EROS for stratifying patients undergoing TLE. Methods We performed a retrospective analysis of 1293 patients who underwent to TLE in our center. We performed extraction procedures with manual traction or mechanical dilatation. We calculated EROS, and we divided patients into 3 groups depending on the EROS class. For this purpose, we made statistical analysis and comparison between EROS 1+2 vs. EROS 3 groups. We used an X2 for among-group comparisons or Fisher’s exact test if the expected cell count was less than five. Results Our analysis included 1293 patients. EROS-1 counted 726 patients (56,1%), EROS-2 367 (28,4%) patients and EROS-3 200 (15,5%) patients. There was no statistical difference in peri-procedural death between EROS-1+2 and EROS-3 (0.18% vs 1.50%, p=0.134). Major complications (0.82% vs. 3.00%, p=0.014), minor complications (3.11% vs. 6.50%, p=0.019) and use of internal jugular approach (6.13% vs. 14.50%, p Conclusion EROS effectively separates patients at higher risk of complications. Use of internal jugular approach was significantly higher in EROS 3 patients.

Funding Acknowledgements Type of funding sources: None. Introduction Data on left atrial/left atrial appendage (LA/LAA) thrombus resolution after non–vitamin K antagonist (VKA) oral anticoagulant treatment (OAT) are scarce. Purpose The aim of this study was to explore retrospectively the resolution of LA/LAA spontaneous echo-contrast or thrombus in patients with nonvalvular atrial fibrillation (AF) or atrial flutter (AFL) after OAT in a real-world single center practice. Methods A single center retrospective analysis of patients with AF/AFL who underwent a transesophageal echocardiography (TEE) for an electrical cardioversion and/or atrial fibrillation ablation was performed. Patients showing LA/LAA echo-contrast or thrombus and with at least one TEE follow up to detect the resolution of LA/LAA echo-contrast/thrombus were included and analyzed. Results Among 277 TEE performed, 73 cases (26%) of LA/LAA echo-contrast or thrombus were detected in our hospital. Among them, a total of 53 patients showed LAA/LA echo-contrast (19%) and 20 (7%) patients showed a thrombus. Patients with echo-contrast or thrombus were usually male (78% vs 72%, p=0.05) with more comorbidities, as hypertension (90% vs 72%, p=0.03) and congestive heart failure (36% vs 17%, p=0.007) and with an overall higher CHA2DS2-Vasc score (3.5±1.5 vs 3±1, p=0.0001). All they were under chronic anticoagulation with a VKA (65%) or with a NOAC (35%), without differences between groups. (p=NS). At the TTE/TEE analysis, they showed a comparable ejection fraction (55±11 vs 55±22%, p=NS), a trend for an increased LA dilatation (27±8 vs 26±6 cm2, p=0.07) and a low LAA peak velocity (94% vs 19%, p=0.0001). The Echo-contrast Group maintained the same OAT strategy in 49 patients (93%), switching from VKA to NOAC in 3 cases (6%) and from NOAC to NOAC in 1 (1%). The Thrombus Group kept the same OAT strategy with a NOAC in 6 cases (30%) and changed the strategy in 14 patients (70%). Particularly, they titrated NOAC dose in 1 (5%) and the VKA dose in 4 (20%), switched from NOAC to VKA in 5 (25%), from VKA to NOAC in 3(15%) and from NOAC to NOAC in 1 (5%). Smoke resolution was observed in LA/LAA smoke group in 1/10 cases (10%) after a median time of 52 days (20-135) and LA/LAA thrombus resolution 8/15 (53%) after a median time of 45 days (25-180). Patients with the thrombus resolution had a lower CHA2DS2-Vasc score (3.5±2 vs 4±1, p=0.05), and showed a trend for a more frequent use of a NOAC (37.5 vs 28%, p=0.07) and a longer overall anticoagulation time (7.5 vs 4 months, p=0.08). At one-year follow-up, 1 ischemic stroke (1.9%) and 2 deaths (3.8%) were observed only in the Echo-contrast group. Conclusion(s) In OAT patients with an LA/LAA thrombus changing the OAT strategy is associated with thrombus resolution in more than 50% of cases, after an appropriate anticoagulation period and in lower CHAD2S2Vasc patients. Chronic OAT strategy confirmation, also with NOAC, is rarely effective, also in case of echo-contrast resolution.

Introduction High-power short-duration (HPSD) is an increasingly used ablation strategy for pulmonary vein isolation (PVI) procedures, but Lesion Index (LSI)-guided HPSD radio-frequency (RF) application has not been described in this clinical setting. Purpose We evaluated the procedural efficiency and safety of an LSI-guided HPSD strategy for atrial fibrillation (AF) ablation. Methods Paroxysmal and persistent AF patients scheduled for AF ablation were prospectively enrolled and divided in two groups, according to the ablation power used. The LSI-HP Group included patients ablated with a RF power of 50 Watts and the LSI-LP Group included patients ablated with 35 Watts. All patients underwent only PVI under LSI guidance (LSI between 5.5 and 6 anteriorly; LSI between 4.5 and 5 posteriorly) with a point by point strategy and an inter-lesion distance Results Forty-six patients with AF (60% paroxysmal) were prospectively enrolled, 25 in the LSI-HP Group and 21 in the LSI-LP Group. They were usually male (78%) with a low-intermediate CHA2DS2-Vasc score (1.8±1.1), a preserved ejection fraction (60±6%) and moderate left atrial dilatation (45±6 mm). Baseline clinical characteristics resulted comparable between groups (p=NS). PVI was successful in all patients. RF time (30.22±9.04 vs 47.85±11.87 min, p Conclusions LSI-HP AF ablation significantly improves procedural efficiency, reducing ablation time, total procedural duration and fluoroscopy use, while maintaining a comparable safety profile as lower powers. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Introduction Mapping and ablation of atypical atrial flutter (AFL) continue to be a challenge for clinical electrophysiologists. The advent of high-density (HD) mapping has allowed the generation of electro-anatomic maps with a very high resolution level. Purpose In this single center retrospective analysis, we evaluated the clinical impact of the ultra HD activation sequence mapping compared with the standard low density (LD) ablation catheter mapping technique in the treatment of AFLs. Methods We performed a 7 years-single center retrospective analysis of patients undergoing radiofrequency ablations (RFA) for right and left atypical AFL. We evaluated procedural and clinical outcomes of patients approached with a Low Density (LD) electro-anatomical (EAM) strategy compared with patients mapped with new automatic multipolar HD Mapping (HD Group). Results Seventy-five patients were included. Patients were almost male (60%), relatively old (65±8 years), with a moderate CHA2DS2Vasc score (2.3±1.3), a preserved ejection fraction (58±6) and moderate atrial dilatation (44±7 mm). Baseline clinical characteristics were comparable between groups (p=NS). Among 88 AFLs, 10 (11%) were located in the right and 78 (89%) in the left atrium, including 22 (28%) roof dependent and 37 (47%) mitral dependent (p=NS). Regarding procedural outcomes, Sinus rhythm restoration during ablation was more frequently observed in the HD Group (79% vs 56%, p=0.037), even if no differences in mapping time, procedural time and radiological dose were observed (p=NS). Freedom from AFL/atrial fibrillation (AF) at 1-year was lower in the HD Group (83% vs 45%, p=0.009) with an increased trend for AF recurrences during long term follow-up (17% vs 23% at 1 and 3-years respectively, p=0.059). At the multivariate analysis, HD map (OR 0,17; 95% CI 0,04–0,66) and younger age (OR 1,09; 95% CI 1,01–1,19) were identified as independent predictors of ablation success at 1 year. Conclusions Acute procedural success of ablation of atypical atrial flutter is higher in case of HD mapping strategy. Patient age and HD strategy resulted independent predictors of overall atrial arrhythmias recurrences. During follow-up, AFL recurrences are rare beyond 12 months, differently from AF which continues to show increasing trends. Funding Acknowledgement Type of funding sources: None. Procedural outcomesAtypical atrial flutter HD map

Funding Acknowledgements Type of funding sources: None. Background A high incidence of pulmonary vein (PV) reconnection has been reported in patients with clinical recurrences of AF. Detailed characterization of PV gaps in terms of local impedance (LI) is still lacking. Purpose to characterize PV gaps with a novel local impedance algorithm during redo PV ablation in AF patients (pts). Methods Consecutive pts undergoing repeated AF ablation from the CHARISMA registry with complete characterization of PV gaps through local impedance at 6 Italian centers were included. A complete map of the left atrium and PVs was performed prior and after ablation through the Rhythmia mapping system. A novel RF ablation catheter with dedicated algorithm (DirectSense) was used to measure LI at the distal electrode of this catheter. Each gap was characterized in terms of LI and its variations during ablation procedure according to different ablation sites around the PVs. 7 sites around the left and right pair of PV for LI evaluation during ablation were defined: 2 for posterior sites (PS) (posterior inferior and posterior superior), 2 for anterior sites (AN) (anterior inferior and anterior superior), 1 for interior site (INF), 1 for superior site (SUP) and 1 for the carina (CAR). Ablation endpoint was PVI as assessed by entrance and exit block. Results Eighteen cases of redo AF ablation were analyzed (9 after prior RF ablation, 9 after prior cryoablation). A total of 41 PV gaps were detected (20 after RF ablation, 21 after cryoablation; mean number of gaps per pt = 2.3 ± 1.1): one gap was identified In five (27.8%) pts, 2 gaps were present in 7 (38.9%) pts, 3 gaps were detected in 2 (11.1%) pts and 4 gaps were identified in the remaining 4 (22.2%) pts. PV gaps were most common at AN sites (17, 41.5%), followed by PS sites (12, 29.3%) and CAR sites (11, 28.6%). The mean LI at gap sites was 113.9 ± 15Ω prior to ablation: it was significantly higher than LI at scar tissue closer to gap (99.7 ± 8Ω, p Conclusion In our preliminary experience, PV gaps after failed PVI were most common at anterior, followed by posterior and carina sites. LI characteristics at PV gaps significantly differ from both scar and healthy tissue and could be used to target ablation deliveries.

Background Ablation Index (AI) is a proprietary lesion quality marker that combines power, contact force and time. Recent studies showed that radiofrequency (RF) pulmonary vein isolation (PVI) using AI can deliver high arrhythmia-free survival rates at mid-term follow-up in patients with paroxysmal atrial fibrillation. Purpose The aim of this multicenter study was to compare the outcome of three different strategies of PVI using AI (group 1 and 2) or VISITAG module with average force and strict criteria of stability as target parameters (group 3). Methods We enrolled 132 consecutive naive patients (97 males, mean age 61,03±9,42) affected by paroxysmal atrial fibrillation who underwent PVI at two high volume centres between January 2017 and February 2019. AI target was set at ≥380 at the posterior wall and ≥500 at the anterior wall. A strict stability criteria (VISITALY criteria: 3 mm for a time of 15 s and a FOT >5 g for 60% of the time) was set for Group 1 procedures (65 patients), whereas Group 2 procedures (67 patients) were carried out with standard stability criteria (VISTAX criteria: 3 mm for a time of 3 s and FOT >3 g for 25% of the time). We then compared those strategies with a historical cohort of 72 patients (40 males, mean age 60,74±8,53) treated at our centres with RF PVI using the VISITAG module with average force and strict stability criteria as target parameters. An interlesion distance ≤6 mm was a target parameter for all procedures. Recurrence was defined as any AF, atrial tachycardia (AT) or atrial flutter (AFL) during the 12 months after ablation, excluding a blanking period of 90 days. Results There were no significant differences in terms of age (Group 1 59,2±8,97; Group 2 62,81±9,58; Group 3 60,74±8,53 years) and left atrial area (Group 1 24,16±20,46; Group 2 22,55±12,32; Group 3 20,74±3,84 cm2). Group 1 showed a slightly higher number of males (Group 1 78,46%; Group 2 68,66%; Group 3 55,56%; p=0,004). Procedure duration was significantly lower in Group 2 compared to Groups 1 and 3 (176,67±50,88 vs 224,05±47,21 min, p Conclusion A strategy of PVI using AI with standard stability criteria performed the best in terms of procedure efficiency, with a significant benefit in terms of procedure duration, delivering a 12 months arrhythmia-free survival rate comparable with other strategies. Combination of AI with strict stability criteria provided no benefit, at a cost of a higher fluoroscopy time and longer procedure duration. Funding Acknowledgement Type of funding source: None

Background Contact force catheter ablation is the gold standard for treatment of atrial fibrillation (AF). Local tissue impedance (LI) evaluation has been recently studied to evaluate lesion formation during radiofrequency ablation. Purpose Aim of the study was to assess the outcomes of an irrigated catether with LI alghorithm compared to contact force (CF)-sensing catheters in the treatment of symptomatic AF. Methods A prospective, single-center, nonrandomized study was conducted, to compare outcomes between CF-AF ablation (Group 1) and LI-AF ablation (Group 2). For Group 1 ablation was performed using the Carto 3© System with the SmartTouch SF catheter and, as ablation target, an ablation index value of 500 anterior and 400 posterior. For Group 2, ablation was performed using the Rhythmia™ System with novel ablation catheter with a dedicated algorithm (DirectSense) used to measure LI at the distal electrode of this catheter. An absolute impedance drop greater than 20Ω was used at each targeted. According to the Close Protocol, ablation included a point by point pulmonary vein isolation (PVI) with an Inter-lesion space ≤5 mm in both Groups. Procedural endpoint was PVI, with confirmed bidirectional block. Results A total of 116 patients were enrolled, 59 patients in Group 1 (CF) and 57 in Group 2 (LI), 65 (63%) with a paroxismal AF and 36 (37%) with a persistent AF. Baseline patients features were not different between groups (P=ns). LI-Group showed a comparable procedural time (180±89 vs 180±56, P=0.59) but with a longer fluoroscopy time (20±12 vs 13±9 min, P=0.002). Wide antral isolation was more often observed in CF-Group (95% vs 80%, P=0.022), while LI-Group 2 required frequently additional right or left carina ablation (28% vs 14%, P=0.013). The mean LI was 106±14Ω prior to ablation and 92.5±11Ω after ablation (mean LI drop of 13.5±8Ω) during a median RF time of 26 [19–34] sec for each ablation spot. No steam pops or complications during the procedures were reported. The acute procedural success was 100%, with all PVs successfully isolated in all study patients. Regarding safety, only minor vascular complications were observed (5%), without differences between groups (p=0.97). During follow up, 9-month freedom from atrial fibrillation/atrial flutter/atrial tachycardia recurrence was 86% in Group 1 and 75% in Group 2 (P=0.2). Conclusions An LI-guided PV ablation strategy seems to be safe and effective, with acute and mid-term outcomes comparable to the current contact force strategy. LI monitoring could be a promising complementary parameter to evaluate not only wall contact but also lesion formation during power delivery. Procedural Outcomes Funding Acknowledgement Type of funding source: None

Background Managing elderly patients with infection or malfunction deriving from a cardiac implantable electronic device (CIED) may be challenging. The aim of this study was to evaluate safety and efficacy of mechanical transvenous lead extraction (TLE) in elderly patients. Methods Patients who had undergone TLE in single tertiary referral center were divided in two groups (Group 1: ≥80 years; group 2: Results Our analysis included 1316 patients (group 1: 202, group 2: 1114 patients), with a total of 2513 leads extracted. Group 1 presented more comorbidities and more pacemakers, whereas the dwelling time of the oldest lead was similar, irrespectively of patient's age. In group 1 the radiological success rate for lead was higher (99.0% vs 95.9%; P Conclusions Mechanical TLE in elderly patients is a safe and effective procedure. In the over-80s, a comparable incidence of major complications with younger patients was observed, with at least a similar efficacy of the procedure and no procedural-related deaths. Funding Acknowledgement Type of funding source: None

Introduction the management of patients with infection or malfunction of a cardiac implantable electronic device (CIED) may be challenging. Purpose The aim of the study is to evaluate the safety and efficacy of transvenous lead extraction (TLE) in elderly patients. Methods a retrospective analysis of patients who underwent to TLE in our center was performed. Patients were divided in two groups: 1) patients 80 years of age or older, 2) patients younger than 80 years. All patients were treated with manual traction or mechanical dilatation. Results our analysis included 1316 patients, with a total of 2513 leads extracted. Group 1 (≥80 years) counted 202 patients and group 2 ( Conclusion TLE in elderly patients is a safe and effective procedure. In patients older than 80 years there are not more major complications than in younger patients, and the efficacy of the procedure seems to be superior. Abstract Figure 1

Background A high incidence of pulmonary vein (PV) reconnection has been reported in patients (pts) with clinical recurrences of AF. Low-voltage activity beyond PVs (e.g. antral activity) may contribute to ablation failures in the long term. Detailed characterization of PV antra through high density mapping (HDM) and automated algorithm is still lacking. Purpose to characterize PV gaps and the low-voltage activity in tissue such as the PV antra during and after ablation of PVs in AF pts. Methods Consecutive pts undergoing AF ablation from the CHARISMA registry with complete characterization of residual PV antral activity were included. A complete map of the left atrium and PVs was performed prior and after ablation through the Rhythmia HDM system. A novel map analysis tool (Lumipoint - LM -) that automatically identifies split potentials and continuous activation was used sequentially on each PV component, in order to assess the presence of gaps (PVG) and residual potential within the antral scar (RAP, defined as any low voltage high frequency fractionated signal propagating within the antral scar without conduction into the vein) and characterize electrical propagation. After ablation we reassessed with repeat voltage and propagation maps that electrical quiescence was achieved. Ablation endpoint was PV isolation. Results Thirty-six cases of AF ablation were analyzed (11 de novo, 25 redo). A total of 36 PVG in 13 (36%) patients were detected after remap (1 case of de novo) or initial map of redo patients (12 cases). A total of 34 RAP in 20 cases (56%) were found: 4 (36%) cases of de novo (all after ablation and remap) and 16 (64%) cases of redo (all after initial map). In 7 (19%) cases we found at least one RAP in pts with complete absence of PV conduction. 100% of PVG (n = 36) and 89% of RAP (n = 29) were fully detected though a first pass automated annotation. In 5 RAPs (11%) an additional temporal consistency of low-voltage signal relative to neighboring activation was needed due to the very low voltage EGM (≤0.1 mV). PVGs were more common at right PV sites (n = 26, 72%) and anterior PV sites (n = 20, 55.6%) whereas RAPs were detected more frequently at left PV sites (n = 20, 59%) and anterior PV sites (n = 21, 62%). RAP showed a lower median voltage compared with PVG (0.22[0.2-0.3]mV for RAP vs 0.97[0.6-1.3]mV for PVG, p Conclusion In our preliminary experience, local vulnerabilities in antral lesion sets were commonly discernible using HDM system both in de novo or redo patients when no PV conduction was present. The applied workflow seemed to be useful to quickly pinpoint and accelerate the search of local PV activity or concealed low-voltage activity.

Background Leadless cardiac pacing is a promising technology in terms of efficacy and safety. Purpose The aim of the study was to compare the long-term clinical and electrical performance of Micra leadless pacemaker with ventricular single-chamber transvenous pacemaker (VVI TV-PM) in a high-volume centre for transvenous lead extraction (TLE). Methods Between May 2014 and April 2019, 100 patients (group 1) underwent Micra implant at our centre. We identified 100 patients (group 2) who underwent VVI TV-PM implant in the same period for a 1:1 comparison matched by age, sex, left ventricular systolic ejection fraction and previous TLE. Results The implant procedure was successful in all patients. In group 1, the procedure duration was lower than in group 2 (43.86 ± 22.38 vs 58.38 ± 17.85 min, p < 0.001), while the fluoroscopy time was longer (12.25 ± 6.84 vs 5.32 ± 4.42 min, p < 0.001). There was no difference about the rate of septal deployment at the right ventricle (group 1 vs group 2: 76% vs 86%, p = 0.10). Patients were followed-up for a median of 12 months. We did not observe any acute and chronic procedure-related complications in group 1, while we reported acute complications in seven patients (0 vs 7%, p = 0.02) and long-term complications in three patients (0 vs 3%, p = 0.24), needing for a system revisions in 6 cases (0 vs 6%, p = 0.038) in group 2. One systemic infection occurred during follow-up in a patient with VVI TV-PM. Electrical measurements were stable during follow-up in both groups, with a longer estimated battery life in group 1 (mean delivered energy at implant group 1 vs group 2: 0.14 ± 0.21 vs 0.26 ± 0.22 μJ, p < 0.001). Conclusion Micra pacemaker implant is a safe and effective procedure, with a lower rate of acute complications and system revisions and a longer estimated battery life compared to VVI TV-PM, even in a real life setting including patients who underwent TLE.

BACKGROUND Leadless pacemakers have been introduced into the clinical practice as a breakthrough technology that could tackle most of the major sources of complication of traditional pacemakers (PM). The excellent safety profile and optimal electrical performance of Micra have been already largely described, nevertheless the impact on QRS duration has not been investigated so far. We aimed to compare changes in QRS duration after septal Micra implant in comparison to patients who received transvenous right ventricular leads in the same position. METHODS We enrolled all patients who underwent Micra implantation (group 1) at our Center from April 2017 to March 2019. A septal placement was attempted in all cases. Duration of spontaneous and paced QRS and their difference (delta QRS) were measured using a polygraph. To provide a comparison group, we analyzed the QRS duration in a matched group of patients (group 2) who received a traditional single chamber pacing system with a transvenously implanted lead at septal position in the same period. Confounding variables that were used to provide the control group were age, sex, left ventricle ejection fraction, and rhythm at implant. High pacing threshold was defined as ≥1.0 V at pulse duration of 0.24 ms. RESULTS Twenty-eight consecutive patients (mean age 78 ± 3 years; 71.43% males) who underwent successful Micra implant were enrolled. A septal position was achieved in all cases with a single device delivery in 17/28 patients (60.7%). Mean pacing threshold at implant was 0.56 ± 0.34V/0.24 ms with only 3/28 patients (10.7%) presenting a high pacing threshold. No significant differences in demographic, clinical characteristics and ventricular pacing site were observed between groups. QRS duration was slightly longer in group 1 compared to group 2 before implant (median 123 ms (IQR 104-146.5 ms) vs median 116 ms (IQR 90-125 ms); p = 0.09). Nevertheless, there was a significantly lower delta QRS after implant in Micra compared to the traditional pacing group (15.82 ± 31.77 ms vs 35.82 ± 22.13 ms, p = 0.008). CONCLUSION Right ventricular stimulation induces ventricular dyssynchrony, which is correlated with the amount of QRS enlargement after pacing. Micra implant, in a non-apical position, produces significantly smaller changes on the QRS duration in comparison with transvenous lead implanted at the same site, although larger studies are necessary to confirm these results.

Early detection of cardiac arrhythmias is a major opportunity for mobile health, as wearable devices nowadays available can detect single-lead electrocardiogram (ECG). The study aims to validate the in-ear region as a new anatomical site for ECG signal detection and looks towards designing innovative ECG wearable devices. We performed ECG using KardiaMobile device (AliveCor®) on 35 healthy volunteers. First, ECG was detected by standard modality using both hands. Then, ECG was detected using the left in-ear region instead of the right hand. All the recorded ECGs were analyzed by the device and by two cardiologists in blind testing. We successfully collected 70 ECGs performed on 35 volunteers (male 54%, age 39.1 ± 10.7 years; BMI 22.9 ± 2.89 kg/m2) with no differences observed by KardiaMobile in ECG reports detected in the two different modalities. All the ECGs were reported as normal by the device and the two cardiologists. Moreover, linear regression analysis showed good correlation between the amplitude (mV) of P (r = 0.76; r2 = 0.57; p

Introduction Transvenous lead extraction is a safe and effective procedure. The dwell time of the leads, with other factors, is associated with poor outcome of the procedure. However, a precise estimation of the success of the procedure is not available. Purpose The aim of this study is to identify a lead's age threshold able to predict the success of the transvenous lead extraction (TLE) procedure. Methods All patients who underwent TLE in our center from January 2009 to December 2017 were retrospectively analyzed. The primary endpoint was the clinical success of the procedure. The optimal cut-off threshold was determined by the analysis of Receiver-Operating Characteristics (ROC) curves, using the Youden index. Results We analyzed 1210 consecutive patients that required transvenous removal of 2343 leads (686 ICD leads, 1657 pacemaker leads, 322 coronary sinus leads). Clinical success was achieved in 1168 patients (96.5%). Dwelling time median of the oldest lead for a patient was 66 months (interquartile range 27.0–115.0). The oldest lead completely removed was 32 years old. ROC curve analysis showed a dwell time threshold of 107 months – 8,92 years - for clinical success (Positive Predictive Value: 99.5%; Negative Predictive Value: 7.8%) and the area under the curve (AUC) was 0.879. Comparison of ROC for dwelling time and the 0.5 curve was assessed as statistically significative (p Conclusions Transvenous lead extraction is an effective procedure. The best cut-off threshold to predict a very high clinical success is 107 months.

Introduction Cardiac computerized tomography (CT) is commonly used to study left atrial (LA) and pulmonary veins (PVs) anatomy before atrial fibrillation (AF) ablation. However, it remains unclear whether pre-procedural imaging actually is associated with an improvement of efficiency, efficacy, and safety. Purpose Aim of the the study was to determine the impact of pre-procedural imaging using CT with 3-D reconstruction on procedural outcomes and radiological exposure in patients who undergo radiofrequency catheter ablation (RFA) to eliminate AF. Methods In this registry, 493 consecutive patients (age 62±8 years, 70% male) with paroxysmal (316) or persistent (177) AF who underwent RFA were included. A CT scan was obtained in 324 (66%) patients (CT Group) prior to RFA, while 169 (34%) didn't have any pre-procedural imaging (No-CT Group). Antral PVs isolation was performed in all patients along using an open-irrigation-tip catheter with a 3-D electroanatomical navigation system. Additional ablation applications were targeted if required. Procedural outcome, including radiological exposure, and clinical outcomes were compared among patients who underwent RFA with (CT-Group) and without (No CT-Group) pre-procedural imaging. Results Acute PV isolation was obtained in all patients. Additional ablation targets were targeted along the CTI (71/324 [22%] vs. 40/169 [24%], P=NS), the roof line (74/324 [23%] vs. 40/169 [24%], P=NS), the mitral isthmus (33/324 [10%] vs. 12/169 [7%], P=NS) and CFAEs (28/324 [8.6%] vs. 12/169 [7.1%], P=NS), without significant differences among groups. Complication rate were comparable between CT and No CT patients (4.3% vs 3%, P=0.7). In one Redo procedure of the No-CT Group, for the impossibility of identifying left PVs, a 3D LA fluoro-angiography was performed, which confirmed a left PVs occlusion. (Figure) No differences were observed about mean duration of the procedure (231±60 vs 233±58 min, P=0.7) and fluoroscopy time (13±10 vs 13±8 min, P=0.6) between groups. Cumulative radiation dose resulted significantly higher in the CT-Group (8.9±24 vs 4.8±15 mSV, P=0.02). Compared to paroxistical AF, persistent AF patients showed a comparable procedural-ED (6.6±26 vs 6±19, P=0.8) but with an higher CT-ED (1.7±2.9 vs 1.1±1.9, P=0.01).At 1 year, 227/324 (70%) and 119/169 (70%) of the patients who did and did not have pre-procedural imaging were free from AF (P = NS). Figure 1 Conclusions Pre-procedural CT does not improve safety and efficacy of AF ablation, increasing significantly the cumulative radiological exposure. Considering that patients candidate to AF ablation are often young, the cumulative radiation dose per life span and radiation dose reduction strategies should remain a matter of concern for doctors. Acknowledgement/Funding None

The dissemination of correct information about seismic hazard is an ethical duty of scientific community worldwide. A proper assessment of a earthquake severity and impact should not ignore the evaluation of its intensity, taking into account both the effects on humans, man-made structures, as well as on the natural evironment. We illustrate the new macroseismic scale that measures the intensity taking into account the effects of earthquakes on the environment: the ESI 2007 (Environmental Seismic Intensity) scale (Michetti et al., 2007), ratified by the INQUA (International Union for Quaternary Research) during the XVII Congress in Cairns (Australia). The ESI scale integrates and completes the traditional macroseismic scales, of which it represents the evolution, allowing to assess the intensity parameter also where buildings are absent or damage-based diagnostic elements saturate. Each degree reflects the corresponding strength of an earthquake and the role of ground effects, evaluating the Intensity on the basis of the characteristics and size of primary (e.g. surface faulting and tectonic uplift/subsidence) and secondary effects (e.g. ground cracks, slope movements, liquefaction phenomena, hydrological changes, anomalous waves, tsunamis, trees shaking, dust clouds and jumping stones). This approach can be considered "ethical" because helps to define the real scenario of an earthquake, regardless of the country's socio-economic conditions and level of development. Here lies the value and the relevance of macroseismic scales even today, one hundred years after the death of Giuseppe Mercalli, who conceived the homonymous scale for the evaluation of earthquake intensity. For an appropriate mitigation strategy in seismic areas, it is fundamental to consider the role played by seismically induced effects on ground, such as active faults (size in length and displacement) and secondary effects (the total area affecting). With these perspectives two different cases studies have been reviewed: the destructive 1976 February 4 Guatemala, earthquake (M 7.5) and the 1743 February 20 Nardò, historical earthquake (Salento, Southern Italy). The re-analysis of both earthquakes contributes to define more realistic seismic scenarios in terms of intensities assessment and consequent regional seismic hazards.

In quest articolo è analizzato il comportamento di edifici ecclesiastici in muratura per effetto di azioni sismiche. A questo scopo, sono state analizzate dieci chiese a pianta basilicale impiegando una procedura a “due passi”. Durante il primo step, il modello 3D agli elementi finiti di ogni edificio è analizzato in campo lineare al fine di determinarne le caratteristiche dinamiche e di valutare la richiesta sismica. Successivamente, gli edifici sono scomposti in singoli macroelementi, ciascuno dei quali è stato analizzato in campo non lineare fino al collasso al fine di determinarne la capacità portante a carichi orizzontali. I risultati del primo step(richiesta sismica) e del secondo(capacità) sono quindi stati confrontati per avere una stima del livello di sicurezza/vulnerabilità del singolo macroelemento e della struttura a livello globale.

In this paper the behaviour of masonry church buildings under seismic actions is examined and discussed. For this purpose, ten basilica churches are analyzed using a “two steps” procedure. In the first step, each building is analyzed in the linear range with 3D finite element models, in order to determine static and dynamic properties, and to evaluate the elastic strength demands. Afterwards, the 3D complex is sub-structured in its constituting macro-elements, and each macro-element is analyzed in the non-linear range up to collapse, in order to determine its horizontal capacity. The results from the first step (strength demand) and second step (strength capacity) are then compared with the purpose of assessing the level of safety/vulnerability of each macro-element and of the global structure.

Atti del seminario conclusivo del progetto di ricerca DPC-ReLUIS 2005-2008. Napoli, 4-5 dicembre 2008

Previous studies have shown that whereas exogenous GM1 ganglioside co-administration leads to an increase of haloperidol-induced behavioral supersensitivity, GM1 significantly attenuates the behavioral parameters of dopaminergic supersensitivity when administered after abrupt haloperidol withdrawal. In the present study, the effects of GM1 and haloperidol co-administration (5 mg/kg GM1 i.p. and 1 mg/kg haloperidol i.p., twice daily, for 30 days) as well as the effects of a 3 day treatment with GM1 were investigated in rats withdrawn from haloperidol administration by measuring striatal D2 dopamine receptor binding and dopamine turnover. The results showed that under these two experimental conditions GM1 modified neither the haloperidol-induced striatal D2 dopamine receptor up regulation nor the decrease in dopamine turnover produced by haloperidol withdrawal. These results suggest that the effects of GM1 on behavioral supersensitivity are not related to modifications in dopamine receptor number or affinity and in the synaptic availability of this catecholamine.