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Since the first description of Brugada syndrome (BrS), several studies were carried out aimed at diagnosis, arrhythmic risk stratification, and available strategies for sudden death prevention. In high-risk patients, the use of an implantable cardiac defibrillator was an evident option since the first description of the syndrome. Nevertheless, this strategy, while proven, as expected, to be effective in sudden death prevention, does not prevent arrhythmias and may not be an adequate or accepted solution for all patients. The need of a non-pharmacological therapy as a potential solution based on the electrophysiological mechanisms underlying the syndrome, led to search for substrate as target for catheter ablation. Advances in the tools, technology, and technical approach enabled to launch studies aimed at mapping the epicardium of patients with BrS in order to identify and ablate the substrate. As described in previous work and in our experience, an anatomically identifiable electrical substrate, which correspond to the typical ECG, is the ablation target. Complete substrate is better identified in a larger area with sodium-channel-blockers. Ablation of all abnormal electrical potentials is able to normalize the ECG and prevent arrhythmias induction. Encouraging preliminary data, if confirmed by longer follow-up and by multicentre randomized study, could change the whole therapeutic management in BrS patients.

Background Since 2014, European Guidelines have recommended using a novel clinical risk prediction model, called the HCM Risk-SCD, to identify which patients with hypertrophic cardiomyopathy (HCM) who are at higher risk for sudden cardiac death (SCD) and would benefit most from having a prophylactic cardioverter defibrillator (ICD) implantable. In recent years, evidence has called into question the effectiveness of this model in patient selection. Material and Methods Data from consecutive patients with HCM and ICD who were followed at our Cardiology Department from January 2000 to January 2022 were retrospectively collected. Results Among 702 HCM patients, 52 (7%) received an ICD (female, 31%; mean age at implantation, 49 ± 20; S-ICD, 13%; single-chamber ICD, 50%). Of them, 7 (13%) patients were implanted for secondary prevention while 45 (87%) for primary prevention. Out of the 45 primary prevention patients, 7 (16%) experienced 8 appropriate shocks (AS) while 10 (22%) had 15 inappropriate shocks (IS), during a mean follow up of 8 ± 5 years. Overall, mean HCM Risk-SCD score was 6.8 ± 4.7. Patients with AS showed a non-significant higher risk score when compared to non-AS subjects (7.1 ± 5.4 vs 4.8 ± 5.1, p=0.27). By stratifying study population according to pre-established and clinically adopted HCM Risk-SCD score cut-off (such as < 4 vs. > or = 4), we failed to highlight any significant difference in term of AS between groups. Indeed, out of 10 (22%) patients with HCM Risk-SCD score < 4, 3 (7%) experienced AS, while among 35 (78%) patients with HCM Risk-SCD score > or = 4, 4 (9%) had AS (30% vs. 11%, p=0.17). Conclusions The HCM Risk-SCD score does not seem to be able to predict the occurrence of life-threatening ventricular arrhythmias and AS in HCM patients. Our data highlight the need to elaborate a new score in order to improve SCD risk stratification and better select patients for ICD implantation.

Background Subcutaneous ICD (S-ICD) is a safe and effective tool in preventing sudden cardiac death (SCD) and it has the potential to overcome the limitations of transvenous ICDs. Because of increased left ventricular mass and unpredictable electrical substrate, concerns regarding the safety and efficacy of S-ICD in hypertrophic cardiomyopathy (HCM) patients have been raised. Material and Methods We retrospectively collected clinical data from consecutive HCM patients who underwent ICD implantation and were followed at our Cardiology Department from January 2000 to January 2022. Results Among 702 HCM patients, 52 (7.4%) received an ICD (female, 30.7%; mean age at implantation, 49 ± 20; primary prevention, 86.5%; S-ICD, 13%; single-chamber ICD, 50%). During a mean follow up of 8 ± 5 years, 27 shocks occurred in 20 (38%) patients of which 11 appropriate shocks (AS) in 9 (17%) patients and 16 inappropriate shocks (IS) in 11 (21%) patients, respectively after 4.3 ± 3 and 5 ± 4 years. AS were due to ventricular tachycardia (7) and ventricular fibrillation (4) and occurred in 9 patients with transvenous ICD vs. 0 in S-ICD patients (100% vs. 0%, p=0.32). IS were due to AF (8), PSVT (3), sinus tachycardia (2), and oversensing (3), with a non-significant trend towards a higher rate in patients with transvenous ICD compared to those with S-ICD (33% vs 14%, p=0.41). Device-related complications (DC) were recorded in 14 (27%) patients and were secondary to lead fracture (6), pocket hematoma (3), pneumothorax (1), device malfunctioning (1), endocarditis (2), and venous thrombosis (1). Compared to S-ICD, transvenous ICD was associated with a non-significant higher risk of DC (31% vs. 0%, p=0.17). Conclusions In HCM patients at high risk of SCD, when compared to transvenous ICD, S-ICD is related to a non-significant lower rate of IS and DC, with similar rate of AS. Further randomized studies as well as large prospective registries are needed to confirm these findings.

Data regarding the age-specific outcomes of VT ablation in patients with structural heart disease (SHD) are scarce. We performed a systematic review and meta-analysis to evaluate the outcomes of VT ablation in elderly vs. younger patients with SHD. MEDLINE/PubMed, Cochrane, and Google Scholar and references comparing VT ablation in elderly vs. younger patients were screened and studies included if matching inclusion and exclusion criteria. Five retrospective studies enrolling 2778 SHD patients (868 elderly vs. 1910 younger) were included. Compared to younger subjects, the elderly showed similar results in terms of acute ablation success (OR 0.78, 95% CI 0.54–1.13, p = 0.189) and minor complications (OR 1.74, 95% CI 0.74–4.09, p = 0.205), a trend toward a higher risk of major complications (OR 2.30, 95% CI 0.83–6.40, p = 0.110) and significantly higher rates of all complications (OR 2.67, 95% CI 1.51–4.71, p = 0.001) and periprocedural mortality (OR 1.93, 95% CI 1.24–3.01, p = 0.004). At a mean follow-up of 18 months, elderly patients showed similar long-term VT recurrence rate (OR 1.02, 95% CI 0.85–1.22, p = 0.861) and higher all-cause mortality (OR 2.00, 95% CI 1.40–2.86, p

Despite the availability of effective lipid-lowering drugs, only few high-risk patients attain their LDL cholesterol (LDL-C) guideline-recommended risk-based goal because of underprescription of combination therapy. We present an 18-month experience with variation of prescription protocols after publication of the 2019 ESC/EAS guidelines for the management of dyslipidemias.Overall, 621 consecutive patients hospitalized for acute coronary syndrome at Mauriziano Hospital in Turin, Italy, between January 2020 and June 2021 were enrolled. Lipid-lowering therapy recommended at discharge was registered to evaluate how many patients received statin monotherapy, statin plus ezetimibe combination or triple therapy with high-intensity statin plus ezetimibe and proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i). At 6-month follow-up, the reduction in LDL-C, adverse events, compliance and cardiovascular recurrences was analyzed.Of 621 patients enrolled, 7 died during hospitalization. During the entire study period, 33% of patients received statin monotherapy, 50% were discharged on statin-ezetimibe combination, and PCSK9i (evolocumab) was prescribed to 17% of patients. Between April 2020 and June 2021, when new recommendations were introduced into clinical practice, 20% of patients received evolocumab, 56% combination therapy and only 24% were discharged on statin monotherapy. At the beginning of observation, evolocumab was prescribed to 3% of patients hospitalized for acute coronary syndrome, while at the end of the study period 27% of patients were discharged on PCSK9i, with an increase of the prescription rate by 759%; in the same period, prescription of statin monotherapy decreased by 75%. At 6-month follow-up, LDL-C reduction was 77% in patients treated with PCSK9i vs 48% in patients taking statin-ezetimibe combination therapy (p0.001). All patients on evolocumab reached the guideline-directed goals and a low rate of adverse events was reported, mainly represented by local injection site reactions. Six patients experienced acute coronary syndrome recurrence; only one of them was treated with evolocumab.Prescription of intensive lipid-lowering therapy after acute coronary syndrome, eventually with introduction of PCSK9i during hospitalization or at discharge, leads to attainment of guideline-recommended goals for all patients, with a low incidence of adverse events and optimal compliance.

Background During the COVID‐19 pandemic in‐person visits for patients with cardiac implantable electronic devices should be replaced by remote monitoring (RM), in order to prevent viral transmission. A direct home‐delivery service of the RM communicator has been implemented at 49 Italian arrhythmia centers. Methods According to individual patient preference or the organizational decision of the center, patients were assigned to the home‐delivery group or the standard in‐clinic delivery group. In the former case, patients received telephone training on the activation process and use of the communicator. In June 2020, the centers were asked to reply to an ad hoc questionnaire to describe and evaluate their experience in the previous 3 months. Results RM was activated in 1324 patients: 821 (62%) received the communicator at home and the communicator was activated remotely. Activation required one additional call in 49% of cases, and the median time needed to complete the activation process was 15 min [25th‐75th percentile: 10–20]. 753 (92%) patients were able to complete the correct activation of the system. At the time when the questionnaire was completed, 743 (90%) communicators were regularly transmitting data. The service was generally deemed useful (96% of respondents) in facilitating the activation of RM during the COVID‐19 pandemic and possibly beyond. Conclusions Home delivery of the communicator proved to be a successful approach to system activation, and received positive feedback from clinicians. The increased use of a RM protocol will reduce risks for both providers and patients, while maintaining high‐quality care.

Aims During the COVID-19 pandemic in-person visits for patients with cardiac implantable electronic devices should be replaced by remote monitoring (RM), in order to prevent viral transmission. A direct home-delivery service of the RM communicator has been implemented at 49 Italian arrhythmia centres. Methods and results According to individual patient preference or the organizational decision of the centre, patients were assigned to the home-delivery group or the standard in-clinic delivery group. In the former case, patients received telephone training on the activation process and use of the communicator. In June 2020, the centres were asked to reply to an ad hoc questionnaire to describe and evaluate their experience in the previous 3 months. RM was activated in 1324 patients: 821 (62%) received the communicator at home and the communicator was activated remotely. Activation required one additional call in 49% of cases, and the median time needed to complete the activation process was 15 min (25th–75th percentile: 10–20). 753 (92%) patients were able to complete the correct activation of the system. At the time when the questionnaire was completed, 743 (90%) communicators were regularly transmitting data. The service was generally deemed useful (96% of respondents) in facilitating the activation of RM during the COVID-19 pandemic and possibly beyond. Conclusions Home delivery of the communicator proved to be a successful approach to system activation, and received positive feedback from clinicians. The increased use of a RM protocol will reduce risks for both providers and patients, while maintaining high-quality care.

Background and Aims COVID-19 has heterogeneous clinical manifestations. SARS-CoV-2 related AKI and hypercoagulability are negative prognostic factors. The incidence of thromboembolic events is about 30%, of AKI up to 20%. We report a patient with severe AKI who required hemodialysis (HD) and developed a massive DVT developing from the femoral CVC, and belatedly testing positive for SARS-CoV-2 in the absence of typical pulmonary involvement. Method A 53-year-old male with a clinical history of hypertension, type II diabetes mellitus, in therapy with metformin and ace-inhibitor, was admitted to our E.R. with diarrhea, nausea and vomiting for about 2 days. Main signs: ideomotor slowdown, mild hypohydration and reduced urine output (unrelevant sediment). Initial blood tests showed severe AKI with hyperkalemic metabolic acidosis and hyponatremia (sCreatinine 18.76 mg/dl, BUN 161 mg/dl, K+ 7.8 mmol/l, Na+ 128 mmol/L, HCO3- 9.8 mmol/l). Mild neutrophilic leukocytosis with lymphopenia was detected, with slightly increased inflammation indices (CRP 1.05 mg / dl, D-dimer 720 ng / ml). CT scan: absence of typical SARS-CoV-2 signs, normal kidneys, no dilation of urinary tract. SARS-CoV-2 rapid antigen test and the first molecular swab test were negative. After femoral CVC insertion, HD was needed for a few sessions. Broad range antibiotic therapy was also set. On Day 3: a second SARS-CoV-2 PCR swab test resulted negative. He never manifested fever or dyspnea. On Day 6, despite an improvement of renal function (sCr 2.7 mg/dl), the patient, although he walked, presented right leg pain with signs of DVT. Ultrasound and angio-CT scan documented peri-catheter DVT extended to the common femoral and external iliac vein and superficial femoral vein involvement, without pulmonary embolism. I.v. therapy with sodium heparin was therefore started with quite a difficulty in reaching the expected range. On day 8, massive flittene appeared, the CVC was removed and a caval filter was placed; marked neutrophilic leucocytosis and increased inflammatory indices (CRP 11.50 mg/dl) was documented. Nevertheless, thrombosis has progressed to the entire venous axis and the inferior cava. Through a tibial vein introducer local i.v. alteplase was also started. Just after, copious bleeding from the site of the removed CVC followed by haemorrhagic shock occurred and the patient was transferred to the ICU (D-dimer 219800 ng/ml). The same day a third swab for SARS-CoV-2 resulted positive while a further CT-scan did not show signs of virus-like interstitial pneumonia. On the following day (day 9) the patient underwent thrombus aspiration (Aspirex®S device) and fasciotomy of the right leg for a compartment syndrome. Results Despite the continuation of heparin, PTT ratio was never >1.5, with an extension of DVT and also involvement of the contralateral iliac vein, as well as a worsening of the clinical-laboratory picture and patient’s death on day 14. Serum complement, autoantibodies (ANA, ANCA, ENA, ANTI-dsDNA, anti-cardiolipin, AMA, anti-B-glycoprotein) and factor V Leiden test were normal. All blood cultures were found to be sterile. Conclusion Our case confirms the heterogenicity of COVID-19 manifestations, often without pulmonary involvement. According to our experience from the onset of the pandemic, SARS-CoV-2 can also be found later in patients with already advanced organ damage. In this case, in the absence of other possible factors, AKI and intestinal involvement may have been early signs of COVID-19, with a virus initially not detectable in the nasopharyngeal mucosa. Furthermore, the increased thromboembolic risk of COVID-19 should not be underestimated in the presence of risk factors as external devices, also given the difficult management of anticoagulation target. Anticoagulant prophylaxis in cases with doubtful symptomatology and CVC must be considered even in non-bedridden patients, due to the current risk of SARS-CoV-2 infection.

Meniscal injuries are a common challenge in orthopaedic surgery. Depending on their location and the patient’s age and functional needs, they can be treated either conservatively or surgically. A surgical approach can consist of arthroscopic meniscectomy or meniscal suture. The latter is the treatment of choice in case of lesions involving the red-red or red-white areas of the meniscus, especially for young high-demanding patients. We report here our experience with the repair of longitudinal meniscal tears using the all-inside technique with the Fast-Fix™ 360 Meniscal Repair System (Smith & Nephew Endoscopy, Andover, MA). We retrospectively evaluated 20 consecutive cases of longitudinal meniscal tears. In 4 cases, concomitant ACL rupture was diagnosed and treated alongside the meniscal repair. All patients underwent periodic clinical evaluations. At the latest check-up, their functional outcomes were rated according to the Tegner-Lysholm Knee and KOOS scoring scales. The mean Tegner-Lysholm Knee score was 84.85 (44-100) and the mean KOOS score was 88.58. No failure or major complications were observed. Furthermore, a negative statistical association was observed between age at surgery and the post-operative Tegner-Lysholm Knee score (coef. = -1.01189 [-1.942073,-0.0817063], p = 0.035). This relation, independent of gender, meniscus involved, eventual associated ACL reconstruction, and chondral injury, suggests that functional outcomes worsen with increasing patient age. Our results suggest that the arthroscopic all-inside suture is both safe and effective in cases of longitudinal meniscal tear, considering the good post-operative functionality and low rates of local complications and surgical failures.

PURPOSE Ventricular tachycardia (VT) ablation is a complex procedure that requires remarkable catheter manipulation skill, great mapping accuracy and catheter stability, and can expose patients to serious complications. Magnetic navigation system (RMN)-guided ablation and contact force-sensing (CFS) catheters have the potential to overcome these obstacles. We performed a systematic review and updated meta-analysis of all available studies evaluating the outcomes of VT ablation by using RMN-guided compared to manual navigation (MAN)-guided, with and without CFS catheters. METHODS MEDLINE/PubMed, Cochrane, and Google Scholar were searched for randomized controlled trials (RCT) or observational studies with multivariate adjustment comparing RMN-guided versus MAN-guided VT ablation. RESULTS Thirteen studies enrolling 1348 patients (656 RMN-guided vs. 692 MAN-guided) were included. CFS catheter were used in 14% of MAN-guided patients. In comparison to MAN-guided and CFS-guided, RMN-guided VT ablation was associated with a significant higher acute ablation success (OR 2.32, 1.66-3.23 and OR 2.91, 1.29-6.53, respectively) but similar results in term of long-term VT recurrence (OR 0.75, 0.56-1.01 and OR 0.79, 0.27-2.36, respectively). RMN-guided showed a better safety profile (for all complications, OR 0.52, 0.34-0.81) and allowed a significant x-ray reduction compared to MAN-guided (OR 0.21, 0.14-0.32) and CFS-guided VT ablation (OR 0.23, 0.11-0.52, all 95% CI). CONCLUSIONS RMN-guided was superior to MAN-guided and CFS-guided VT ablation in term of acute ablation success, all complications endpoint, and reduction of fluoroscopy exposure, but did not reduce long-term VT recurrence. Large prospective multicenter randomized trials are needed to confirm these findings.

This report presents the authors’ experience with surgical wound-healing using a negative-pressure wound therapy (NPWT) device in a population of oncological orthopedic patients. Two groups of 26 oncological patients each underwent surgical excision. After surgery, the control group received standard dressings and the closed incisional NPWT (ciNPWT) group was treated with a ciNPWT system on the sutured wound area for 14 days. As a primary endpoint, the percentage of post-surgery wound-site complications using ciNPWT devices was compared to that with standard patch dressings. Overall, 30.7% of the control group and 7.7% of the ciNPWT group manifested wound-site complications within 2 weeks after surgery. As a secondary endpoint, final wound healing was compared between the groups: delayed wound healing was observed in 4 (15.4%) patients in the control group and in none (0%) of those in the ciNPWT group. Finally, the length of stay (LOS) was 6.3 days in the control group and 5.1 days in the ciNPWT group. These results suggest that the ciNPWT device could be beneficial in minimizing the incidence of short-term surgical-site complications and decreasing length of stay in high-risk patients, such as those undergoing oncological orthopedic surgery.

Epicardial right ventricular outflow tract (RVOT) ablation has been described for the treatement of Brugada syndrome (BrS) high risk patients. Purpose Success evaluation of epicardial ablation for BrS. Methods Type 1 ECG was defined as spontaneous if recorded in absence of drugs and/or specific conditions. BrS patients were scheduled for ablation if presented at least one of: spontaneous type 1 ECG, syncope, ventricular arrhythmias (VA). Programmed electrical stimulation (PES) was performed (2 extrastimuli, 2 sites) in basal conditions and after ajmaline infusion. Epicardial subxifoid access and electroanatomical endo-epicardial maps were obtained during sinus rhythm. Delayed fragmented/low-frequency, low-voltage electrograms (EGM) were targeted: substrate area measured in basal conditions and after ajmaline. Epicardial ablation Radiofrequency (RF) was delivered (50 W power control mode) till complete elimination of targeted EGM and BrS-ECG pattern after ajmaline. Eventually PES repeated: if positive a repeated PES scheduled at follow-up (fu). Success was defined as absence of type 1 ECG either spontaneous or with ajmaline challenge at 3 month. Recurrences were scheduled to redo ablation. Results 55 patients were submitted to 58 ablation procedures. 38 spontaneous type 1 ECG: 18 symptomatic for syncope/polimorphic VT/VF or appropriate ICD shock; 13 had VA induction at PES. 4 patients with ajmaline-type 1 ECG had VA induction. 36% of the symptomatic patients and 26% of asymptomatic had PES-VA induction. In all patients abnormal EGM area (cm2) was detected in epicardial RVOT (table 1). Acute success: No patient had ECG type 1 with ajmaline. 5 patients had PES induction of VA. Complications: 1 cardiac tamponade, 16 mild pericarditis. At FU of 1,1±0,6 yrs no patient had spontaneous ECG type 1 nor arrhythmic events. 50 had negative ajmaline challenge (90% success rate after single procedure), 3 underwent redo: 2 had negative ajmaline challenge at FU, 1 had persistence type 1-ajmaline induction; 2 are scheduled for redo. No patient had VT induction at PES. Multivariate analysis: Single procedure success was not related either to history (symptoms, VA, type 1 ECG) or to procedural findings (PES results, substrate area). Conclusion Epicardial substrate ablation was safe end effective in BrS. No clinical or procedural findings were related to success Funding Acknowledgement Type of funding source: None

Background This meta-analysis aims to assess the impact of a voltage-guided substrate modification by targeting low-voltage area (LVA) in addition to pulmonary vein isolation (PVI) in patients undergoing catheter ablation for atrial fibrillation (AF). Methods MEDLINE/PubMed, Cochrane Library, and references reporting AF ablation and “voltage* OR substrate* OR fibrosis OR fibrotic area*” were screened and studies included if matching inclusion and exclusion criteria. Results Six studies were included. Patients enrolled were 885 (517 in the study group and 368 in the control group). Median age was 60 years; 92% had nonparoxysmal AF. At a mean follow-up of 17 months, 70% of patients in the study group vs. 43% in the control group were free from AF/atrial tachycardia (AT) recurrences (odds ratio [OR] = 3.41, 95% confidence interval [CI] 2.22–5.24). LVA ablation in addition to PVI was more effective than PVI alone and PVI + conventional wide empirical ablation (70% vs. 43%, OR = 3.41, 95% CI 2.22–5.24), without increasing the adverse event rate (2.5% vs. 6%, OR = 0.43, 95% CI 0.15–1.26). Compared to PVI + conventional wide empirical ablation, LVA ablation reduced the occurrence of postablation AT (14% vs. 46%, OR = 0.16, 95% CI 0.07–0.37), procedure time (176 min vs. 220 min, OR = 0.36, 95% CI 0.24–0.56), fluoroscopy time (25 min vs. 31 min, OR = 0.22, 95% CI 0.12–0.39), and radiofrequency time (55 min vs. 90 min, OR = 0.49, 95% CI 0.27–0.90). Conclusions A voltage-guided substrate modification by targeting LVA in addition to PVI is more effective, safer, and holds a lower proarrhythmic potential than conventional ablation approaches. Further randomized studies are necessary to confirm these findings.

Background: Anisotropy in conduction velocity (CV) is a key substrate abnormality influencing atrial arrhythmias. In skeletal muscle fibers, CV and frequency content of the surface electromyogram signal are directly related. We hypothesized that in human atria the frequency content of the bipolar signal, recorded on the endocardial surface, is directly related to the local CV. Methods: In 15 patients submitted to ablation of supraventricular arrhythmias, incremental pacing was performed through an octapolar catheter inserted into the coronary sinus (CS), alternatively from both extremities in two different sequences: CS bipole 1-2 as the pacing site and CS bipole 7-8 as the detection site in the first, and vice versa in the second. The pacing cycle length (PCL) was stepwise decreased from 600 ms to 500 ms, 400 ms, 300 ms, until 250 ms. Estimation of the CV was performed as the ratio between the distance traveled by the propagating pulse and the propagation time. The frequency distribution of the signal energy was estimated using the fast Fourier transform, and the characteristic frequency (CF) was estimated as the barycenter of the frequency spectrum. Results: A total of 2,496 bipolar signals were analyzed; CV and CF were estimated and compared. The single patient and group data analysis showed a significant direct correlation between CV and CF of the local bipolar signal. Conclusions: Comparing the degree of spectral compression among signals registered in different points of the endocardial cardiac surface in response to decreasing PCL enables to map local differences in CV, a useful arrhythmogenic substrate index.

Aims Atrial fibrillation recurrences after pulmonary vein isolation (PVI) are not uncommon and are frequently related to pulmonary vein reconnection. Adenosine/ATP can reveal dormant pulmonary vein conduction after PVI. Previous studies revealed that adenosine-guided Additional ablation could improve arrhythmia-free survival. We performed a meta-analysis to assess the impact of additional ablation to eliminate adenosine-induced transient pulmonary vein reconnection in terms of atrial fibrillation recurrence at follow-up. Methods MEDLINE/PubMed, Cochrane Library and references reporting atrial fibrillation ablation and adenosine/ATP-following PVI were screened, and studies were included if they matched inclusion and exclusion criteria. Results A total of 3524 patients were enrolled with a median follow-up of 13 (6-20) months. Overall, 70% (60-85) of patients in ATP-guided ablation vs. 63% (48-79) in no ATP-guided ablation were free of atrial fibrillation at follow-up. Pooled results revealed that ATP-guided ablation reduced the risk of atrial fibrillation recurrence of 42% [odds ratio (OR) 0.58, 0.41-0.81], but this result was primary because of the contribution of retrospective over-randomized studies [OR 0.48 (0.35-0.65) vs. 0.76 (0.42-1.40), respectively]. 3.2% of patients experienced an adverse event. ATP-guided ablation is related to a nonsignificant increase in fluoroscopy time (OR 1.71, 0.98-2.96) and to a significant increase in procedure time (OR 2.84, 1.32-6.09). Conclusion Additional ablation aiming to eliminate adenosine-induced transient pulmonary vein reconnection failed to reduce the risk of atrial fibrillation recurrence at follow-up. Moreover, although adenosine-guided PVI is not affected by an augmented risk of adverse events, it is associated with a NS increased fluoroscopy exposure and significantly longer procedure duration. Further studies are required to identify the actual role of adenosine in PVI.

Apixaban, a direct factor Xa inhibitor recently approved for thromboembolic prophylaxis in patients with nonvalvular atrial fibrillation (AF), is increasingly used in patients undergoing catheter ablation of AF. However, large randomized studies supporting its use in the ablation context are still lacking. We undertook the present meta-analysis to assess the impact of apixaban in terms of thromboembolic and bleeding events in patients undergoing AF ablation as compared to warfarin.MEDLINE/PubMed, Cochrane Library, and references reporting AF ablation and apixaban were screened and studies included if matching inclusion and exclusion criteria.One randomized and five nonrandomized studies were included in the analysis. Patients enrolled were 1691 patients (668 on apixaban and 1023 on warfarin). There was no heterogeneity in all the outcome comparisons. No deaths were reported. We did not observe any difference between apixaban and warfarin with respect to thromboembolic events (OR = 1.10, 95 % CI 0.24-5.16), major bleedings (OR = 1.56, 95 % CI 0.59-4.13), cardiac tamponade (OR 1.69, 95 % CI 0.52-5.54), minor bleedings (OR 0.96, 95 % CI 0.58-1.59), and the composite endpoint of death, thromboembolic events, and bleedings (OR 1.03, 95 % CI 0.65-1.64).The rates of death, thromboembolic events, major bleedings including cardiac tamponade, and minor bleedings in patients on apixaban undergoing AF ablation are very low and similar to that seen in patients treated with uninterrupted warfarin. Although primary driven by nonrandomized studies, these results support apixaban as periprocedural anticoagulation during AF ablation procedures.

Atrial fibrillation increases thromboembolic risk. Oral anticoagulation with antivitamin K (AVK) reduces thromboembolic event rate, but increases hemorrhagic risk.The aim of the present study was to describe long-term cerebral thromboembolic/hemorrhagic event rates in atrial fibrillation patients managed by rhythm control, pursued by atrial fibrillation transcatheter ablation (AFTCA), and rate control strategy.One thousand and five hundred consecutive patients referring to three medical care centers for atrial fibrillation were retrospectively divided into three groups: AFTCA maintaining AVK (group A); AFTCA discontinuing AVK (group B); and rate control strategy and AVK (group C). Thromboembolic and hemorrhagic events were recorded in 60 ± 28 months of follow-up. Thromboembolic events did not differ between the groups (5/500, 1% group A; 7/500, 1.4% group B; 11/500, 2.2% group C; P = 0.45), and hemorrhagic events were greater in group A (9/500, 1.8%) and C (12/500, 2.4%) than in group B (no events; P = 0.003). Among patients with CHA2DS2 VASc score 2 or less, thromboembolic events did not differ in the group discontinuing AVK (group B, 4/388, 1%) or not (group A, 1/319, 0.3%; P = 0.38), whereas hemorrhagic events were more common in patients on AVK (5/319, 1.5% group A and 3/175, 1.7% group C; P = 0.02) compared with those discontinuing AVK (0/388, group B). Following AFTCA (groups A and B), 299/1000 experienced atrial fibrillation relapses; all thromboembolic events (12/299, 4%) occurred within these patients (P 0.001).Considering this multicenter design study, AVK continuation following AFTCA, especially within patients with low-to-intermediate thromboembolic risk, confers a hemorrhagic risk greater to the thromboembolic protective effect. All thromboembolic events following AFTCA occur within patients experiencing atrial fibrillation relapses; therefore, in patients with high thromboembolic risk routine rhythm monitoring is essential after AVK discontinuation.

Focusing on the issue. Channelopathies are a group of inherited arrhythmic syndromes caused by mutations of genes encoding for proteins that regulate ion currents in patients without structural heart disease and expose to atrial and ventricular arrhythmias and sudden death. What physicians working in ED should know. All patients with a known or suspected channelopathy who refer for arrhythmic suggestive symptoms should be ECG-monitored and a cardiologic evaluation sought. Most of inherited arrhythmic disorders could be diagnosed on the basis of a standard 12-lead ECG. Polymorphic ventricular tachycardia is the typical life-threatening arrhythmia of patients with channelopathies and its occurrence in the absence of structural heart disease suggests the presence of an inherited arrhythmia syndrome. What cardiologists should know. Cardiology evaluation should seek for the following : (1) rule out structural heart disease and secondary causes that mimic channelopathies, (2) define diagnosis, and (3) provide risk stratification in order to plan long-term management. Indications for hospitalization, follow-up, and referral. Following the arrhythmic index event, channelopathy patient should be reevaluated for risk stratification and prevention of recurrences. Expert centers with a focus on inherited arrhythmias should be involved in complex cases.

Focusing the issue. Arrhythmias and sudden death are frequent late complications of congenital heart disease (CHD) patients. Arrhythmia substrate and consequent management is peculiar for any CHD, but some general principles can be identified and recently international scientific boards have provided evidence-based recommendations on best practice.

Objective Cryoenergy is a new valuable treatment option to perform ablation close to the atrioventricular (AV) node in the cure of supraventricular tachycardias because of its favourable properties, such as the possibility of creating reversible lesions. The aim of this study was to report our experience on the effectiveness and safety of catheter cryoablation performed in "critical areas" to treat a large cohort of patients with supraventricular arrhythmias. Methods One hundred and thirty-one patients suffering from supraventricular tachycardias underwent catheter cryoablation using a 7F catheter. Eighty-seven patients presented with AV nodal re-entrant tachycardia (AVNRT), 39 had accessory pathways (APs) either manifest or concealed (15 midseptal, 24 parahissian), three had ectopic right atrial tachycardia (AT), and two patients had a permanent junctional reciprocating tachycardia (PJRT). When the optimal parameters were recorded, ice mapping at -30 degrees C was performed for 80 s to validate the ablation site. If the expected result occurred, cryoablation was carried out by lowering the temperature to -75 degrees C for 4 min. Results In two patients cryoablation was not performed because of technical reasons. Cryoablation was acutely successful in 84 out of 85 patients with AVNRT, in 37 of 39 with APs and in all patients with AT and PJRT. No complications occurred in any patient. Transient AV conduction impairment occurred in seven patients with midseptal APs and in two patients with AVNRT. In particular, in these patients no late permanent AV block was observed at follow-up. At a mean follow-up of 27 +/- 12.9 months, clinical success rate was 87%. Conclusions Cryoablation is a safe and effective technique with a high success rate in the long term. It may be particularly useful when performing ablation close to the AV node or His bundle owing to the possibility of validating the ablation site with ice mapping, which creates only a reversible lesion, mainly in the midseptal APs.

Background— A prolonged QT interval is associated with a risk for life-threatening events. However, little is known about prognostic implications of the reverse—a short QT interval. Several members of 2 different families were referred for syncope, palpitations, and resuscitated cardiac arrest in the presence of a positive family history for sudden cardiac death. Autopsy did not reveal any structural heart disease. All patients had a constantly and uniformly short QT interval at ECG. Methods and Results— Six patients from both families were submitted to extensive noninvasive and invasive work-up, including serial resting ECGs, echocardiogram, cardiac MRI, exercise testing, Holter ECG, and signal-averaged ECG. Four of 6 patients underwent electrophysiological evaluation including programmed ventricular stimulation. In all subjects, a structural heart disease was excluded. At baseline ECG, all patients exhibited a QT interval ≤280 ms (QTc ≤300 ms). During electrophysiological study, short atrial and ventricular refractory periods were documented in all and increased ventricular vulnerability to fibrillation in 3 of 4 patients. Conclusions— The short QT syndrome is characterized by familial sudden death, short refractory periods, and inducible ventricular fibrillation. It is important to recognize this ECG pattern because it is related to a high risk of sudden death in young, otherwise healthy subjects.

AF Ablation and Impaired Left Ventricular Function. Introduction: Long-term outcome of AF ablation in patients with impaired LVEF is unknown. The aim of this study is to evaluate sinus rhythm (SR) maintenance, clinical status, and echocardiographic parameters over a long-term period following atrial fibrillation (AF) transcatheter ablation in patients with left ventricular ejection fraction (LVEF)

Aims Morphology discrimination (MD) is an algorithm based on QRS morphology analysis, that can be used alone or in various combinations with other discriminators in order to diagnose ventricular tachycardia (VT) [the implantable cardioverter-defibrillator (ICD) may be set to diagnose VT if ‘Any’ or ‘All’ the discriminators indicate VT)]. Methods and results We evaluated the contribution of MD in terms of Specificity (SP) and Sensitivity (SE) of rhythm discrimination in slow and fast VT zones (rates

Methods were developed to facilitate the use of subzonal insemination to achieve fertilization in vitro. A clinical trial was undertaken in those patients having previously failed to achieve fertilization by in vitro fertilization, and in those presenting with severe oligospermia/oligoasthenospermia. From 85 patients, 585 oocytes were obtained. Of these, 0.3% had been "activated" parthenogenetically in vivo, 369 (72%) at metaphase II underwent subzonal insemination, 15% were fertilized, and 0.5% had three pronuclei. Thirty-eight percent of the patients had fertilization with 36% having a replacement. One conceptus was replaced in 19 patients, two conceptus in 8 patients, and three in 4 patients. A twin and two singleton pregnancies were established.

Introduction: Catheter ablation has become a routine treatment for patients with Wolff-Parkinson-White syndrome because of its low risk and high efficacy; however, radiofrequency ablation in the septum close to the AV node or His bundle still carries a definite risk for AV block. Cryoenergy catheter ablation has recently become available. This technique has specific features, such as the ability to create reversible loss of function to predict the effects of ablation (ice mapping) and the adherence of the catheter tip to the endocardium with freezing, which avoids the risk for dislodgment. Both of these characteristics may minimize the risk of complications. The aim of this study was to analyze the effectiveness and safety of catheter cryoablation in 20 patients with para-Hisian or midseptal accessory pathways (AP). Methods and Results: Eleven patients with para-Hisian and 9 patients with midseptal AP underwent catheter cryoablation. Ice mapping at −30°C was performed to ascertain the disappearance of AP conduction and the absence of impairment of AV nodal conduction. If the expected result was obtained, cryoablation was performed by lowering the temperature to −75°C for 4 minutes in order to create a permanent lesion. Cryoablation was successful in all patients using a mean of 1.2 ± 0.4 applications. Recurrences occurred in 4 patients (20%) who underwent a second successful cryoablation session. No complications were observed. Conclusion: Cryoablation appears to be a safe and effective technique for ablation of APs close to the AV node or His bundle because of the ability to predict the acute effects of ablation with ice mapping before creation of an irreversible lesion. (J Cardiovasc Electrophysiol, Vol. 14, pp. 825-829, August 2003)

Radiofrequency catheter ablation is nowadays a widely used technique for the treatment of arrhythmias; however, due to the possible complications such as atrioventricular block when radiofrequency is delivered in the septal area, this type of energy is not optimal. In contrast, cryoenergy has several positive features; first of all, it allows for the creation of reversible lesions and hence to test the effects of the ablation while the lesion is still forming thus reducing the number of ineffective and useless lesions. In addition, it also allows for the evaluation of the acute effects on the structures adjacent to the ablation site. The aim of the present study was to analyze the effectiveness and safety of catheter cryoablation in the treatment of atrioventricular nodal reentrant tachycardia (AVNRT).Thirty-two patients presenting with AVNRT underwent catheter cryoablation using a 7F catheter. When the optimal parameters were recorded, "ice mapping" at -30 degrees C was performed for 80 s to validate the ablation site by means of a reversible lesion. If the expected result was achieved, the cryoablation was carried out lowering the temperature to -75 degrees C for 4 min thus creating a permanent lesion.Slow pathway ablation guided by a slow pathway potential was successfully performed in 31 out of the 32 patients with a mean of 2.6 +/- 1.0 cryoapplications. No complications occurred in any patients. Transient AH prolongation was observed in 2 patients in a midseptal site during the ice mapping phase of AVNRT ablation.Cryoablation is a safe and effective technique for AVNRT ablation. It may be useful particularly when the ablation must be performed close to the atrioventricular node or His bundle, due to the possibility of validating the site of ablation by means of ice mapping that creates only a reversible lesion.

Atrial fibrillation (AF) is the most common supraventricular arrhythmia: the prevalence is 1% over the age of 60 years and above 5% over the age of 70 [1]. In the past 10 years various studies have suggested a worse outcome in patients affected by AF. From the analysis of the Framingham study population, AF seems related to excessive mortality, irrespective of underlying structural heart disease, age, diabetes, smoking, hypertension, or stroke, with an odds ratio of 1.5 in men and of 1.9 in women [2]. Other studies have shown an increased risk of death in patients with AF, between 1.3 and 2.6 with respect to those in sinus rhythm [3,4]. In patients with dilated cardiomyopathy AF has been shown as an independent predictor of sudden death when the ejection fraction is less than 50% [5]. AF is thought to increase the risk of death mainly through thromboembolic complications and their hemodynamic consequences. The risk of cerebral thromboembolism in patients with nonvalvular AF is increased by a factor of 5-7, with a probability of ischemic stroke of 5% per year; the risk increases in presence of hypertension, diabetes, previous ischemic events, recent heart failure, and age over 65 years (in the 50% of cases cerebral events occur in patients older than 75 years). Even in patients with lone AF the risk of stroke is increased four times compared to age-matched controls in sinus rhythm [6]; counting transient ischemic attacks and asymptomatic stroke, the incidence rises to 7% per year [7,8]. The hemodynamic consequences of AF are related to the rapid and irregular ventricular response and to the lack of atrial contribution to ventricular filling. They are more evident in patients with reduced left ventricular function, and the loss of atrial kick may reduce cardiac output by up to 20% in patients with impaired diastolic function [9]. The persistence of a rapid ventricular rate for more than 6 months may induce the development of a reversible form of tachy-cardiomyopathy [10]. However, the real impact of AF on prognosis has been questioned more recently, and critical attention must be paid to the actual role of AF in Divisione di Cardiologia, Ospedale Mauriziano Umberto I, Turin, Italy the clinical outcome of affected patients. Its hemodynamic and thromboembolic consequences can be limited by the use of anticoagulant therapy and drugs that slow the heart rate. Does the prognostic value of AF go beyond that? Even in patients at high risk, such as those with heart failure, the proposition that AF has independent prognostic significance is controversial, following from some studies but not from others.

Heart failure (HF) represents the natural evolution of many cardiovascular diseases. The prevalence of HF varies between 1% and 3% in the general population, being even more frequent in the elderly [1]. Atrial fibrillation (AF) on the other hand, is the most frequent arrhythmia, with a prevalence of 0.5%-1% in the general population and up to 10% in octogenarians [2]. These two diseases often have common causes and they are frequently associated. HF predisposes to AF, which is present in from 10% of patients in NYHA class II and up to 40%-50% of patients in NYHA class IV, with an average of 15%-30% in the whole group of patients with HF [3-6]. AF worsens the outcome of patients with HF. A rapid and irregular ventricular response and the lack of the atrial kick during AF may further reduce cardiac output [7].

Introduction: Permanent junctional reciprocating tachycardia (PJRT) is an infrequent form of reciprocating tachycardia, almost incessant from childhood and usually refractory to drug therapy. Radiofrequency catheter ablation currently is the first-line therapy for PJRT, but its application in the septal region may be associated with complications. In contrast, cryoenergy has several advantages, such as the ability to test the effects of ablation while the lesion is still forming, thus reducing the number of ineffective, useless, and potentially harmful lesions. The aim of this study was to investigate the potential clinical utility of percutaneous cryoenergy catheter ablation for treatment of pediatric patients with PJRT. Methods and Results: Four patients (age 14 ± 5 years; mean ± SD) with a clinical diagnosis of PJRT underwent catheter cryoablation. The ablation was successfully accomplished in 4 (100%) of 4 patients. The mean ± SD number of cryoapplications was 1.8 ± 0.8, and from 1 to 6 cryomappings were performed for each permanent cryolesion. The successful site was in the mid-septal region (2 patients), at the coronary sinus orifice (1 patient), and in the middle cardiac vein (1 patient). No complications with cryoablation were reported, nor was there prolongation of the AH interval during cryomapping or cryoablation. No pain was reported by patients during the cryoenergy catheter ablation procedure. PJRT recurrence occurred in 1 patient who underwent a second successful cryoablation procedure. Conclusion: The outcomes of cryoenergy catheter ablation in these 4 patients treated for PJRT suggest that cryoablation is a safe, effective, and pain-free technique for treating pediatric patients with PJRT. (J Cardiovasc Electrophysiol, Vol. 15, pp. 263-268, March 2004)