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Background: Numerous studies propose a tailored ablation strategy based on the identification of low-voltage zones (LVZs) for the treatment of persistent atrial fibrillation (PsAF). Objective: We evaluated a systematic approach of a tailored PsAF ablation strategy (SATA) using an orthogonal mapping catheter. Method: This is a single center observational study comparing 36-month patient outcome of the SATA strategy with the outcome of a matching Control Group (CG) treated with wide antral circumferential ablation technique (WACA) and additional linear lesions . SATA consists of different phases. Firstly, during ongoing AF temporal stable and regular rotational activities get identified and treated together with isolation of pulmonary veins performed with WACA. Secondly during sinus rhythm PVI will be confirmed, and any gaps will be isolated together with treatment of LVZs compatible with non-compact atrial fibrosis. Results: WACA was the only treatment performed in 80.6% of the SATA patients versus 30.5% of the CG (p= 0.001). During the follow-up a lower mean number of AF recurrences per patient were observed in the SATA patients compared to CG. The Kaplan-Meier curve show significantly less first recurrence of AF in the SATA patients (log rank test 0.031). The analysis of all recurrences by means of the Incidence Rate and the Rate Ratio show that the risk per unit of time of having AF recurrence in the SATA patients is less than half compared to the CG (p=0.009). The performance analysis expressed by the success of all ablation procedures, demonstrated that in the SATA patients the risk of having a double procedure is less than one fifth compared to the CG (p=0.009). Conclusions: In our experience the SATA strategy was more effective than rigorous PVI and additional linear lesions.

BACKGROUND Palpitations in athletes are usually benign, but the presence of major cardiac arrhythmias should be ruled out despite the infrequent appraisal of symptoms. External loop recorders (ELR) are promising to identify arrhythmias in these circumstances, but experiences in athletes are lacking. We aimed to investigate the feasibility and diagnostic yield of an ELR in athletes with unexplained palpitations in a cohort study. METHODS 122 consecutive subjects (61 athletes and 61 sedentary controls) with sporadic palpitations and inconclusive diagnosis were enrolled and equipped with an ELR. Findings were categorized as major and minor arrhythmic findings, non-arrhythmic findings or negative monitoring. RESULTS Long-term ELR monitoring was feasible in all subjects, with median duration of 12 (11; 15) days. Major arrhythmic events during palpitations were found in 9 (14.8%) athletes: 7 experienced sustained paroxysmal supraventricular tachycardia, and 2 had non sustained ventricular tachycardia. Minor arrhythmic events (premature supraventricular or ventricular beats) were observed in 13 athletes (21.3%). Non-arrhythmic findings (i.e., sinus rhythm or sinus tachycardia) were recorded in 28 athletes (45.9%), whereas 11 (18%) had negative monitoring. In the sedentary group, arrhythmic events were similar for types and frequency to athletes. The diagnostic yield of loop monitoring was 82.8% in the overall population and 82.0% in the athlete's group. CONCLUSIONS In the management of an athlete symptomatic with unexplained palpitations after 24-hour ECG monitoring and stress test, ELR is an efficient tool to identify major arrhythmic events, which can be present in up to 10% of symptomatic athletes during practice and competition.

The Mediterranean diet has a lot of health benefits but especially because it lowers the incidence of cardiovascular diseases. It has been shown that food components, certain nutrients and the pattern of the diet lowers the risk of several diseases such as diabetes, certain cancers, obesity, respiratory disorders, mental health and cognitive decline, bone diseases (osteoarthritis), healthy aging and quality of life among more others. It has been concluded from studying the mechanism responsible for lowering these risks that food combinations, food nutrients, presence of non-nutritive substances, lifestyles habits and the cooking techniques all together make the Mediterranean dietary pattern into a tool that can not only prevent but can also be used as a way of treatment for these medical ailments. As part of the essential dietary fat, consumption of extra virgin olive oil is the main feature of Mediterranean diet. Olive oil is noted to have anti-bacterial characteristics, involved in improving the endothelial function in young females, and is hypothesized to have epigenetic effects interplay offering protection from cancers due to the presence of beneficial monounsaturated fats. The presence of antioxidants contributes to the inflammation protecting properties of the olive oil. Olive oil has high quantities of antioxidants and offers numerous benefits for cardiovascular health, such as protection of LDL from oxidation and lowering of the high blood pressure as well as offers protection from diabetes mellitus. The Mediterranean diet and the Olive oil consumption also have a fundamental impact in secondary prevention, such as in patients with atrial fibrillation that underwent catheter ablation.

Sports are a double-edged sword. On the one hand, cardiovascular benefits from sports activity are well-known, and on the other hand, sports may increase the risk of sudden cardiac death (SCD) in subjects with known or unknown cardiovascular diseases. SCD is rare but has a very strong emotional issue. There are many examples involving famous professional athletes, but this is only scratching the surface of a widespread phenomenon that also involves amateur athletes. The importance of safely performing physical activity appears clear in both professional and amateur athletes. In particular, the former undergo a pre-participation screening for SCD primary prevention with different recommendations in each country. On the other hand, a medical examination is not mandatory for non-professional athletes and, therefore, for people who practice sports as an amateur. Widespread distribution of automatic external defibrillators and people trained for cardiopulmonary resuscitation are necessary to promote secondary prevention of SCD. We briefly report a case series of athletes with aborted SCD during sports activity in order to underline and discuss in this review the previously highlighted issues.

Molecular genetic testing is an increasingly available test to support the clinical diagnosis of inherited cardiovascular diseases through identification of pathogenic gene variants and to make a preclinical genetic diagnosis among proband's family members (so-called "cascade family screening"). In athletes, the added value of molecular genetic testing is to assist in discriminating between physiological adaptive changes of the athlete's heart and inherited cardiovascular diseases, in the presence of overlapping phenotypic features such as ECG changes, imaging abnormalities or arrhythmias ("grey zone"). Additional benefits of molecular genetic testing in the athlete include the potential impact on the disease risk stratification and the implications for eligibility to competitive sports. This position statement of the Italian Society of Sports Cardiology aims to guide general sports medical physicians and sports cardiologists on clinical decision as why and when to perform a molecular genetic testing in the athlete, highlighting strengths and weaknesses for each inherited cardiovascular disease at-risk of sudden cardiac death during sport. The importance of early (preclinical) diagnosis to prevent the negative effects of exercise on phenotypic expression, disease progression and worsening of the arrhythmogenic substrate is also addressed.

Aims Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an electrical genetic disease characterized by induction of malignant ventricular arrhythmias during adrenergic stress in structurally normal hearts. CPVT is correlated to syncope or sudden cardiac death (SCD). Usually, it is caused by an autosomal dominant mutation in the cardiac ryanodine receptor (RyR2), an essential gene for Ca2+ homeostasis. Methods and results Our case series refers to: a man (59 years) who came to our attention for a clinical check-up 4 years after implanting bicameral pacemaker at the age of 55 years for complete AV block; and his three sons (E. female 27 years; D. male 25 years; and B. female 17 years) who had evidence of polymorphic non-sustained ventricular tachycardia (NSVT) with increasing effort during stress test. The three sons performed cardiac MRI and underwent genetic test. All three were found to be carriers of the same microdeletion of the RYR 2 gene (1q43- extended for about 49 kb) at the genetic test. They also have non-compacted myocardium at cardiac MRI. The father was also found to be a carrier of the same genetic microdeletion, while the mother was negative to the genetic test. The man was diagnosed to be a carrier of the mutation 4 years after pacemaker implantation. Conclusions Mutation of the RyR2 may have different phenotypic expressions and can be correlated to various clinical manifestations. CPVT is the most common one, and its prompt identification is crucial to prevent subjects from sport-related risks and to plan an efficient therapy. Our case series provides evidence for a careful consideration of such a genetic disorder even in presence of a major AV conduction disease in a relatively young subject. In the present case series, no major adverse events occurred. However, we can, in the aftermath, speculate that if a genetic disorder had been suspected when AV block occurred, a timely diagnosis could have been made earlier also for the sons.

Please let me know if it is necessary…we are working on a reply to a previous work

The importance of physical activity is worldwide known, not only for healthy subjects but also for patients with heart disease. In particular, an accurate balance between risks and benefits of physical activity is necessary for patients with implantable defibrillator (ICD). The guidelines do not offer strict indications regarding the indications and limitations in sports for ICD patients, but it is of pivotal importance to guarantee their safety: an adequate preimplantation assessment also with device selection and tailored programming can avoid potential adverse events (like inappropriate shocks, lead fracture or dislocation, undersensing of ventricular arrhythmias). The use of improving technology, caution, common sense, and open discussion with single patients can help physicians to make the best decisions.

Background. Atrial Fibrillation ablation in older patients represents a challenge to be addressed to ensure the improvement of the quality of life and survival of these patients. New mapping system tools can help to treat older patients because of its ability to simplify and reduce procedural risks. The new NavX EnSite “Live view” tool allows dynamic “beat to beat” activation and voltage mapping visualization in order to instantly recognize vein disconnection and minimize RF deliveries. Methods. An 81-year old patient with paroxysmal AF and well-documented firing focus trigger underwent pulmonary veins isolation using NavX EnSite Precision, HD Grid multipolar catheter, and the new “Live view” tool. Results. All pulmonary veins were successfully isolated with no procedural complications. “Live view” tool allows to perform shorter and safer procedure (total procedural time: 90 minutes, left atrium dwell time: 60 minutes, total RF delivery number: 78). Conclusion. “Live view tool” allows dynamic activation and voltage mapping in order to perform a safe and tailored approach to ablation, especially in older patients.

Since 1989, SIC Sport and a FMSI, in partnership with leading Italian Cardiological Scientific Associations (ANCE, ANMCO and SIC) have produced Cardiological Guidelines for Completive Sports Eligibility for athletes with heart disease (COCIS -- 1989, 1995, 2003, 2009 and 2017). The English version of the Italian Cardiological Guidelines for Competitive Sports Eligibility for athletes with heart disease was published in 2013 in this Journal. This publication is an update with respect to the document previously published in English in 2013. It includes the principal innovations that have emerged over recent years, and is divided into five main chapters: arrhythmias, ion channel disorders, congenital heart diseases, acquired valve diseases, cardiomyopathies, myocarditis and pericarditis and ischemic heart disease. Wherever no new data have been introduced with respect to the 2013 publication, please refer to the previous version. This document is intended to complement recent European and American guidelines but an important difference should be noted. The European and American guidelines indicate good practice for people engaging in physical activity at various levels, not only at the competitive level. In contrast, the COCIS guidelines refer specifically to competitive athletes in various sports including those with high cardiovascular stress. This explains why Italian guidelines are more restrictive than European and USA ones. COCIS guidelines address 'sports doctors' who, in Italy, must certify fitness to participate in competitive sports. In Italy, this certificate is essential for participating in any competition.

Purpose: Electroanatomical mapping (EAM) could increase cardiac magnetic resonance imaging (CMR) sensitivity in detecting ventricular scar. Possible bias may be scar over-estimation due to inadequate tissue contact. Aim of the study is to evaluate contact-force monitoring influence during EAM, in patients with idiopathic right ventricular arrhythmias. Methods: 20 pts (13 M; 43 ± 12 y) with idiopathic right ventricular outflow tract (RVOT) arrhythmias and no structural abnormalities were submitted to Smarttouch catheter Carto3 EAM. Native maps included points collected without considering contact-force. EAM scar was defined as area ≥1 cm2 including at least 3 adjacent points with signal amplitude (bipolar

Background: Third-generation cryoballoon (CB3) is characterized by a 40% shorter distal tip designed to increase the rate of pulmonary veins real-time signal recording in order to measure time necessary to isolate veins, the “Time to effect” (TTE). Few data are currently available on clinical follow up of CB3 treated patients. Methods: Sixtyeight consecutive patients (mean age 57.8 ± 9.6 years, 48 male) with paroxysmal or persistent atrial fibrillation (AF) were enrolled. Thirthyfour (25 paroxysmal AF) underwent to a 28 mmCB3 pulmonary veins isolation and were compared to 34 treated (21 paroxysmal AF) with 28 mmCB2. Results: CB3 use was correlated to significant increase of the possibility to measure TTE in every treated veins (left superior 82,35% vs 23,53%, left inferior 70,59% vs 38,24%, right superior 58,82% vs 14,71%, right inferior 52,94% vs 17,65%). When it is measured, TTE wasn't different between two groups. Higher nadir temperature was observed in CB3 patients (−39.4 ± 5.2 °C vs −43.0 ± 7.2 °C, p = 0.03). CB3 procedures were shorter (91.4 ± 21.7 vs 110.9 ± 31.8 min, p = 0.018), with a significant reduction in cryoenergy delivery time (24.2 ± 8.5 vs 20.3 ± 6.7 min, p

Complex fractionated atrial electrograms (CFAEs) are related to atrial fibrosis, but their ablation has not yet shown superiority. The aim of the study was to compare, in terms of clinical outcome, two strategies of paroxysmal atrial fibrillation (AF) ablation in patients with type 1 diabetes mellitus (DM): pulmonary vein isolation (PVI) vs. PVI + CFAEs. Compared to an historical population of patient with paroxysmal AF and without DM, a higher percentage of patients with DM showed more than 25% of atrial area interested by CFAEs (study population, 58% vs historical group, 15%; p 7.5% (30% vs 22%; p = not significant), but a greater AF burden was observed in patients with HbA1c > 7.5% (6 ± 2 vs 1 ± 2; p 7.5% (hazard ratio, 1.28; p 7.5%), long diabetes mellitus history and high AF burden, benefit from PVI+ CFAEs approach.

The study of atrial fibrillation (AF) pathophysiology represents a challenge that is not yet completely understood.

Background The Amigo® Remote Catheter System is a relatively new robotic system for catheter navigation. This study compared feasibility and safety using Amigo (RCM) versus manual catheter manipulation (MCM) to treat paroxysmal atrial fibrillation (PAF). Contact force (CF) and force-time integral (FTI) values obtained during pulmonary vein isolation (PVI) ablation were compared. Methods Forty patients were randomly selected for either RCM (20) or MCM (20). All were studied with the Thermocool® SmartTouch® force-sensing catheter (STc). Contact Force (CF), Force Time Integral (FTI) and procedure-related data, were measured/stored in the CARTO®3. Results All cases achieved complete PVI without major complications. Mean CF was significantly higher in the RCM group (13.3 ± 7.7 g in RCM vs. 12.04 ± 7.42 g in MCM p

A case of a 31 years old woman volleyball player highly symptomatic for arrhythmic palpitations is reported. The woman was disqualified from competitive sport and referred to our centre for atrial fibrillation (AF) ablation. During symptoms surface ECG had documented irregular supraventricular tachyarrhythmia interpreted as AF. Electrophysiological study could reveal double-His conduction as the true arrhythmia mechanism and the patient was successfully treated with nodal slow pathway ablation. Patient was totally asymptomatic at a 12 months follow up and he was readmitted to competitive sport. The case further underlines the concept that young subjects with suspected lone AF should undergo to a careful clinical evaluation in order to reconstruct the exact electrophysiological mechanism to plan a safe and effective therapy.

Ghosts are new mass lesions in the right cardiac chamber after leads extraction, whose clinical significance is not clear. Because we do not know the true origin of ghosts, prolonged hospitalization and antibiotic therapy are considered necessary. Sixteen patients scheduled for leads removal