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Although cryoablation (CA) of septally located accessory pathways (APs) is an established treatment for Wolff-Parkinson-White syndrome, its major limitation is the lack of data regarding long-term follow-up (FU). The present study sought to investigate long-term outcomes of a specific CA protocol targeting para-Hisian (P-H) and mid-septal (M-S) APs.26 patients who previously underwent CA of PH or MS APs from 2004 to 2014, were prospectively considered to receive a follow-up (FU) during 2021. All subjects received an outpatient control visit, performing an exercise stress test and a 24-h ECG Holter monitoring.Acute success was achieved in 22 patients (85%). One case of recurrence was reported at short-term FU. Long-term FU, performed after a mean time of 150 ± 37 months, did not show ventricular preexcitation recurrences, with a success rate of 81%, and without late adverse events. Symptoms reduction (12% vs. 96%, plt;.001) and lower rates of antiarrhythmic drug use (12% vs. 62%, plt;.001) were observed at long term-FU with respect to baseline. This clinical outcome was detected also among patients who underwent unsuccessful CA at baseline.Our CA protocol confirmed remarkable safety and efficacy throughout a longterm FU. Significant clinical improvement in terms of antiarrhythmic therapy discontinuation and symptoms reduction was also shown among patients who experienced acute failure of CA.

Atypical atrial flutters are complex supraventricular arrhythmias that share different pathophysiological aspects in common. In most cases, the arrhythmogenic substrate is essentially embodied by slow-conducting areas eliciting re-entrant circuits. Although atrial scarring seems to promote slow conduction, these arrhythmias may occur even in the absence of structural heart disease. To set out the ablation strategy in this setting, three-dimensional mapping systems have proved invaluable over the last decades, helping the cardiac electrophysiologist understand the electrophysiological complexity of these circuits and easily identify critical areas amenable to effective catheter ablation.

Ablation of typical atrial flutter has a high safety and efficacy profile, but hidden pitfalls may be encountered. In some cases, a longer cycle length with isoelectric lines is associated with a different or more complex arrhythmogenic substrate, which may be missed if conduction block of the cavotricuspid isthmus is performed in the absence of the clinical arrhythmia. Prior surgery may have consistently modified the atrial substrate and complex or multiple arrhythmias associated with an isthmus-dependent circuit can be encountered. In these cases, electroanatomic mapping is useful to guide the procedure and plan an appropriate ablation strategy.

Complex atrial tachyarrhythmias (CATs) are commonly observed in patients with prior catheter ablation or cardiac surgery. These arrhythmias are challenging to map and ablate. Historically, entrainment mapping was utilized to characterize CAT. With the advent of high-definition mapping (HDM), full visualization of the CAT circuit is possible which may obviate the need for entrainment mapping.We sought to investigate the outcomes of catheter ablation of CAT guided only by HDM. Consecutive patients who underwent CAT ablation from 2017 to 2021 were included in our study (excluding right atrial tachyarrhythmias). Patients were sorted by the type of mapping performed. Group I consisted of patients where HDM alone was utilized with no attempt of entrainment. Group II consisted of patients where both entrainment and HDM were utilized.A total of 67 patients were included in our study, with 40 patients in HDM group (I) and 27 patients in entrainment group (II). No statistically significant difference regarding 1-year freedom from atrial arrhythmias was found between the two groups (80% vs 77.8%, p = 0.819). Four CATs were terminated by entrainment during procedure versus none in the HDM-only group (p = 0.011).CAT ablation with HDM alone yielded similar 1-year freedom from atrial arrhythmias compared to ablation with HDM and entrainment. Entrainment combined with HDM was associated with higher undesired CAT interruption rate. Further validation is needed with randomized control trials.

Background. Nowadays, it is still not possible to clinically distinguish whether an increase in high-sensitivity cardiac troponin (hs-cTn) values is due to myocardial injury or an acute coronary syndrome (ACS). Moreover, predictive data regarding hs-cTnT in an emergency room (ER) setting are scarce. This monocentric retrospective study aimed to improve the knowledge and interpretation of this cardiac biomarker in daily clinical practice. Methods. Consecutive adult patients presenting at the ER and hospitalized with a first abnormal hs-cTnT value (≥14 ng/L) were enrolled for 6 months. The baseline hs-cTnT value and the ensuing changes and variations were correlated with the clinical presentation and the type of diagnosis. Subsequently, multivariable models were built to assess which clinical/laboratory variables most influenced hospital admissions in the investigated population analyzed according to the final reason for hospitalization: (1) cardiovascular vs. non-cardiovascular diagnosis, and (2) ACS vs. non-ACS one. Results. A total of 4660 patients were considered, and, after a first screening, 4149 patients were enrolled. Out of 4129 patients, 1555 (37.5%) had a first hs-cTnT ≥14 ng/L, and 1007 (65%) were hospitalized with the following types of diagnosis: ACS (182; 18%), non-ACS cardiovascular disease (337; 34%) and non-cardiovascular disease (487; 48%). Higher hs-cTnT values and significant hs-cTnT variations were found in the ACS group (p < 0.01). The mean percentage of variation was higher in patients with ACS, intermediate in those with non-ACS cardiovascular disease, and low in those with non-cardiovascular disease (407.5%, 270.6% and 12.4%, respectively). Only syncope and CRP (OR: 0.08, 95% CI: 0.02–0.39, p < 0.01 and OR: 0.9988, 95% CI: 0.9979–0.9998, p = 0.02, respectively) or CRP (OR: 0.9948, 95% CI: 0.9908–0.9989, p = 0.01) and NT-proBNP (OR: 1.0002, 95% CI: 1.0000–1.0004, p = 0.02) were independent predictors of a cardiovascular disease diagnosis. On the other hand, only chest pain (OR: 22.91, 95% CI: 3.97–132.32, p < 0.01) and eGFR (OR: 1.04, 95% CI: 1.004–1.083, p = 0.03) were associated with the ACS diagnosis. Conclusions. Differently from the investigated biomarkers, in this study, only clinical variables predicted hospitalizations in different patients’ subgroups.

Atypical atrial flutters (AAFL) are difficult-to-manage atrial arrhythmias, yet potentially amenable to effective radiofrequency catheter ablation (CA). However, data on CA feasibility are only sparingly reported in the literature in different clinical settings, such as AAFL related to surgical correction of congenital heart disease. The aim of this review was to provide an overview of the clinical settings in which AAFL may occur to help the cardiac electrophysiologist in the prediction of the tachycardia circuit location before CA. Moreover, the role and proper implementation of cutting-edge technologies in this setting were investigated as well as which procedural and clinical factors are associated with long-term failure to maintain sinus rhythm (SR) to find out which patients may, or may not, benefit from this procedure. Not only different surgical and non-surgical scenarios are associated with peculiar anatomical location of AAFL, but we also found that CA of AAFL is generally feasible. The success rate may be as low as 50% in surgically corrected congenital heart disease (CHD) patients but up to about 90% on average after pulmonary vein isolation (PVI) or in patients without structural heart disease. Over the years, the progressive implementation of three-dimensional mapping systems and high-density mapping tools has also proved helpful for ablation of these macro-reentrant circuits. However, the long-term maintenance of SR may still be suboptimal due to the progressive electroanatomic atrial remodeling occurring after cardiac surgery or other interventional procedures, thus limiting the likelihood of successful ablation in specific clinical settings.

Background The Coronavirus Disease 19 (COVID-19) pandemic brought significant disruption to in-hospital medical training. Virtual reality simulating the clinical environment has the potential to overcome this issue and can be particularly useful to supplement the traditional in-hospital medical training during the COVID-19 pandemic, when hospital access is banned for medical students. The aim of this study was to assess medical students’ perception on fully online training including simulated clinical scenarios during COVID-19 pandemic. Methods From May to July 2020 when in-hospital training was not possible, 122 students attending the sixth year of the course of Medicine and Surgery underwent online training sessions including an online platform with simulated clinical scenarios (Body Interact™) of 21 patient-based cases. Each session focused on one case, lasted 2 h and was divided into three different parts: introduction, virtual patient-based training, and debriefing. In the same period, adjunctive online training with formal presentation and discussion of clinical cases was also given. At the completion of training, a survey was performed, and students filled in a 12-item anonymous questionnaire on a voluntary basis to rate the training quality. Results were reported as percentages or with numeric ratings from 1 to 4. Due to the study design, no sample size was calculated. Results One hundred and fifteen students (94%) completed the questionnaire: 104 (90%) gave positive evaluation to virtual reality training and 107 (93%) appreciated the format in which online training was structured. The majority of participants considered the platform of virtual reality training realistic for the initial clinical assessment (77%), diagnostic activity (94%), and treatment options (81%). Furthermore, 97 (84%) considered the future use of this virtual reality training useful in addition to the apprenticeship at patient’s bedside. Finally, 32 (28%) participants found the online access difficult due to technical issues. Conclusions During the COVID-19 pandemic, online medical training including simulated clinical scenarios avoided training interruption and the majority of participant students gave a positive response on the perceived quality of this training modality. During this time frame, a non-negligible proportion of students experienced difficulties in online access to this virtual reality platform.

The remarkable scientific progress in the treatment of patients with heart failure (HF) and reduced ejection fraction (HFrEF) has more than halved the risk of sudden cardiac death (SCD) in this setting. However, SCD remains one of the major causes of death in this patient population. Beyond the acknowledged role of beta blockers and inhibitors of the renin-angiotensin-aldosterone system (RAAS), a new class of drugs, the angiotensin receptor neprilysin inhibitors (ARNI), proved to reduce the overall cardiovascular mortality and, more specifically, the risk of SCD in HFrEF patients. The mechanism by which ARNI may reduce the mortality connected with harmful ventricular arrhythmias is not utterly clear. A variety of direct and indirect mechanisms have been suggested, but a favorable left ventricular reverse remodeling seems to play a key role in this setting. Furthermore, the well-known protective effect of implantable cardioverter-defibrillator (ICD) has been debated in HFrEF patients with non-ischemic cardiomyopathy (NICM) arguing against the role of primary prevention ICD in this setting, particularly when ARNI therapy is considered. The purpose of this review was to provide insights into the SCD mechanisms involved in HFrEF patients together with the current role of electrical therapies and new drug agents in this setting. [Figure not available: see fulltext.].

Aims There are several studies that describes a possible use of periodical infusions of Levosimendan in patients with advance heart failure (AHF). In these studies, Levosimendan was administered in ambulatory settings (LevoRep, LION-HEART) or during 24 h of hospital stay (LAICA) and for a maximum of 12 months. Currently there is no strong evidence about the feasibility and safety of performing the infusions in an out of hospital setting. Aim of our study was to analyse the feasibility and safety of periodical Levosimendan infusions in AHF patients, in an out of hospital setting for palliative use. Methods and results Aretrospective study was conducted from June 2016 to September 2021 on AHF patients, followed by our centre for periodic infusion of Levosimendan. All patients were previously implanted with an ICD, were ineligible for heart transplant or for ventricular assist devices. All patients on each cycle underwent a cardiological evaluation, a blood sample (complete blood count, biochemical profile, coagulation profile, and NTproBNP), and Levosimendan was administrated with a wearable infusion pump (CADD-Legacy®; Smiths Medical). The patient went home and came back the day after, to return the pump and for reassessment. We collected data on the different infusion regimen, adapted for every patient, and on adverse events during infusions. We enrolled 11 patients with AHF, 9 (82%) of which of ischaemic origin, 2 (18%) were female, median age 72 years (IQR: 64–75), 10 with NYHA class III, 1 with a NYHA class IV, for a total of 231 infusions, with a median Follow-up of 459 days (IQR 132; 783). A total dose of 6.25 mg was administered at 0.05 μg/kg/min in 24 h. In five patients the infusion was of 12.5 mg at 0.1 μg/kg/min rate in 24 h and in other three patients at 0.05 μg/kg/min in 48 h. The median interval between administrations was 21 days (IQR: 14–24.5). Mild adverse events (i.e. that did not contraindicate successive cycles) were 7 on 231 infusions (3.0%): symptomatic hypotension (four cases, 1.7%), loss of consciousness (two cases 0.9%), bleeding for vein access misplacement (one case, 0.4%). No serious adverse event such as sustained or malignant arrhythmia, allergic reaction, or need for hospital admission were recorded. Conclusions The administration of Levosimendan at home with a wearable iv pump is safe and well tolerated. This practice allows to reduce infusion costs of day hospital regime and to lengthen the time available for drug infusion, thus reducing the events caused by a too rapid infusion.

Aims Subcutaneous air has been reported as uncommon cause of early device malfunction after implantation of subcutaneous implantable cardioverter defibrillator (S-ICD). Methods and results A 43-year-old man was admitted to our hospital due to syncopal episodes. During a brain computed tomography (CT), he was resuscitated from cardiac arrest due to ventricular fibrillation. Further investigations excluded ischaemic heart disease and cardiac magnetic resonance showed signs of prior myocarditis. After successful screening, an S-ICD was inserted for secondary prevention using the standard technique. The chest X-ray excluded acute post-procedural complications. Three days after implantation, he experienced two inappropriate shocks while conscious. Device interrogation revealed frequent high-amplitude signals followed by two shocks (Figure 1A and B) that could be interpreted as oversensing. During provocative maneuvers on the generator case, minimal and intermittent noise only on the secondary sensing vector was observed. Lateral and antero-posterior chest X-ray excluded subcutaneous air. However, the general agreement based on previous reports was that oversensing as observed in Figures 1A and B was typical for noise due to micro-air bubbles in the connection between the lead and the generator case. As a consequence, the sensing vector was successfully changed and no other inappropriate shocks were observed during follow-up. Conclusions Entrapped micro-air bubbles in the connection between the leads and the generator case can cause inappropriate shocks in the early period after S-ICD implantation. Timely recognition of this complication is important to prevent inappropriate shocks. It can occur shortly after the procedure even if the intra-procedural parameters were normal and chest X-ray excluded acute complications. As demonstrated in our case, the device can be reprogrammed using another sensing vector to solve these oversensing problems.

Aims Post-operative atrial fibrillation (POP AF) is frequent in patients who undergo cardiac surgery. However, its prognostic impact in the long-term remains unclear. Methods and results We followed for an average of 10 ± 3 years 1386 patients who underwent a variety of cardiac surgical procedures (cardiac transplantation and surgery for heart failure included) while they were in sinus rhythm. Among 1178 patents without a history of AF, 726 (62%) did not develop AF during the entire duration of the study and 452 (38%) developed new-onset POP AF during the first 30 peri-operative days after heart surgery. Other 125 patients with a positive history of paroxysmal or persistent AF were in sinus rhythm at the time of surgery and 87 of them (70%) developed POP AF. Finally, 83 patients had permanent AF when they underwent surgery. All-cause mortality was the primary outcome of the study. We tested the associations of potential determinants with all-cause mortality using univariable and multivariable statistical analyses by means of Cox proportional hazard models. Overall, 473 patients (34%) died during a long-term follow-up. Compared with patients who never developed AF, neither the patients with new-onset POP AF [adjusted HR = 1.31 (95% CI: 0.90–1.89); P = 0.1609], nor those with history of AF at the time of surgery (adjusted HR = 1.33, 95% CI: 0.71–2.49; P = 0.3736) showed a significantly increased risk of mortality (Figure 1). In new-onset POP AF patients, oral anticoagulation was not associated with mortality [adjusted HR = 1.13 (95% CI: 0.83–1.54), P = 0.4299]. Conclusions In this huge prospective cohort of patients who underwent different types of heart surgery, POP AF was not associated with an increased risk of mortality. In this setting, the role of long-term anticoagulation remains unclear.

Aims During 2020, Italy was hit by the pandemic of the ‘Coronavirus disease 2019’ (COVID-19) with an incidence/100 000 citizens characterized by two peaks. An increase in out-of-hospital cardiac arrest (OHCA) mortality during the first pandemic peak has already been described, but there are few data on the whole year. The goal of our study is to evaluate the impact of the pandemic on post-OHCA mortality. Methods We considered patients with OHCA in Varese territory from January to December 2020 with medical aetiology according with Utstein 2014 classification. The primary endpoint of the study was the assessment of acute post-arrest mortality and which parameters influence this outcome. In particular, both the role of pandemic peaks (‘first peak’ from 11 March 2020 to 23rd May 2020 and ‘second peak’ from 7 October 2020 to 31 December 2020) and the average rescue times, i.e.: (i) interval between OHCA and call for first aid (delay in activation of assistance); (ii) the interval between the call and the arrival of the rescue vehicles (delay in the arrival of the first aid) and finally; (iii) the time between the arrival of the rescue vehicles and the end of Cardiopulmonary Resuscitation (CPR), interrupted due to death or Recovery of Spontaneous Circulation (ROSC). Finally, we performed a multivariate analysis to assess which of the variables considered had the greatest impact on the outcome. Results We analysed 708 patients (mean age 76 + 14.09 years; 40% women). Overall mortality was 89%. During the peaks there was an increase in mortality compared to the pre-pandemic period (first peak 96% vs. 83%, OR 4.49; second peak 92% vs. 83%, OR 2.45) (Figure 1). The time between the collapse and the call for help was significantly higher during the first pandemic peak compared to the second peak and the pre-pandemic period (P = 0.003); the time between the call and the arrival on the patient was significantly longer during both pandemic peaks than in the previous period (P = 0.002) and there was no significant difference in CPR duration time between the periods analysed. In a multivariate model, the only time associated with an increase in mortality is the period between the call for help and the arrival on the patient, regardless of the COVID-19 pandemic. Conclusions During the COVID-19 pandemic there has been an increase in mortality of patients with OHCA. Among the variables considered, the increase in mortality is mainly associated with the delay in the arrival of emergency vehicles on site. This delay, although decreasing, was also maintained during the second peak of the pandemic.

Aims The long-term clinical effects of Levosimendan in patients (pts) with heart failure and reduced ejection fraction (HFrEF) are mainly mediated by its long-acting metabolite, OR-1896, whose half-life is much longer (81 h vs. 1–1.5 h), although with similar inotropic and vasodilatory effect. Echocardiographic data are still lacking, expecially in the chronic setting. Global longitudinal strain (GLS) and left ventricular myocardial work index (LVMWI) are novel non-invasive methods for left ventricle (LV) function evaluation that consider myocardial deformation and afterloads using LV strain combined with the non-invasive estimation of LV pressure. The aim of this study was to perform an echocardiographic assessment in pts with advanced HFrEF before and after infusion of Levosimendan in a chronic setting, using GLS and LVMWI. Methods and results 6 pts with ischaemic HFrEF were prospectively enrolled in the study. Echo-data were collected from all patients using a Vivid E95 system (GE Healthcare), before and after the end of infusion (24–48 h). Moreover, 4 pts underwent another echo evaluation 96 h after the infusion to assess the long term effect of OR-1896. Although mean end-diastolic volume decreased after 24–48 h, increased after 96 h, as reported in Table 1. As to the Ejection Fraction (EF), strain-parameters and stroke volume (SV) remain unchanged before and after the infusion. Similarly LVMWI-derived parameters also remain overall unchanged (Table 1). Conclusions In pts with ischaemic HFrEF undergoing periodical infusion of Levosimendan, we very preliminary observed a reduction of LV size short after the infusion, which interestingly do not persist after 96 h. The other considered echocardiographic parameters (EF, SV, strain-derived parameters) did not show significant differences before and after the infusion. An explanation is that Levosimendan improves LV congestion but not the contractile force in pts with advanced HFrEF, whose myocardial performance is too compromised. Therefore the haemodynamic benefits observed chronically in pts with Levosimendan might be due to the initial decongestion and its vasodilatory effect, and it may not persist in mid-term, depending on basal myocardial conditions. Larger studies should be conducted to conferm these findings.

Aims Severe pulmonary complications are well described in the coronavirus disease 2019 (COVID-19) and cardiovascular diseases (CVDs) have been documented as well. Most patients (pts) recover quickly; nevertheless, the potential long-term cardiovascular sequalae of COVID-19 remain currently unknown. The aim was to report cases of acute coronary syndromes (ACS) after healing from COVID-19 and their features at coronary angiography; secondary purpose was to hypothesize the underlying mechanisms. Methods and results A retrospective study was performed by acquiring data from the electronic medical record. From January to June 2021, four hypertensive pts (64 ± 17 years old; three males) with no history of CVDs and previous symptomatic SARS-CoV-2 infection (mean interval from first positive molecular swab 47 ± 32 days; all recovered after 15 days with double negative swab) were admitted to the emergency department for ST-elevation myocardial infarction (3 anterior and one inferior). At admission, the SARS-CoV-2 molecular swab tested negative, left ventricle ejection fraction was 42 ± 12%, troponin T and Nt-proBNP values were 47 ± 24 ng/l and 1180 ± 978 ng/l, respectively. Emergency coronary angiography showed single-vessel acute thrombotic occlusion (in three cases of the anterior descending artery and in one case of the right coronary artery), with no evidence of atherosclerotic disease. Because of the high thrombotic burden, in all cases a mechanical thrombus aspiration system was used, tirofiban infusion started and no balloon angioplasty or drug-eluting stent implantation was necessary (Figures A–D). After 72 h, a second SARS-CoV-2 molecular swab tested also negative. In the following days, the pts gradually recovered and they were discharged home. Conclusions These cases deserve specific considerations both on the pathophysiologic mechanisms of the ACS possibly related to SARS-CoV-2 and on the subsequent long-term sequelae. Among various pathophysiologic mechanisms proposed, the high affinity of the spike protein for the angiotensin converting enzyme two receptor (expressed by both cardiac and endothelial cells) could explain direct cardiac viral infection and vasculitis with possible development of thrombosis. The latter could contribute both to acute and long-term cardiac sequelae, even months after the acute infection, configuring a sort of ‘cardiac post-Covid syndrome’. Whether and how long this status persists, making COVID-19 a risk factor for subsequent CVDs, is still an unresolved question. In this regard, continuous monitoring of these pts and larger future studies will be essential.

Aims Wolff–Parkinson–White (WPW) is a cardiac conduction system disorder characterized by abnormal accessory conduction pathways between the atria and the ventricles. Palpitations, presyncope, or syncope that result from supraventricular tachycardia represent classic symptoms; however, especially in young athletes, the syndrome can occur with sudden cardiac death. As result, the presence of an accessory pathway (AP) and tachycardia induced by physical activity contraindicates agonist physical activity and represents an indication to perform an electrophysiology (EP) study to stratify the arrhythmic risk, also allowing an eventual transcatheter ablation (TCA) of the AP. Methods and results An agonist football player, known since the age of 6 years for Wolff–Parkinson–White syndrome from an intermittent right midseptal parahissian AP, underwent a transesophageal EP study and subsequently ineffective TCA with radiofrequency when he was 13 years old. For evidence of intermittent ventricular preexcitation (VPE), at the age of 15 he underwent a further endocavitary EP study with documentation of poor conductive abilities of the AP. Subsequently, at the age of 17, he had a resumption of palpitation and lipotimie during effort; during another sport medical examination with an exercise stress test (EST), a persistent VPE with the start of an orthodromic atrioventricular reentrant tachycardia during the recovery phase was documented. A new EP study with isoprenaline infusion confermed the precence of the parahissian AP and the inducibility of an orthodromic atrioventricular reentrant tachycardia (Picture 1-2B); therefore, after mapping the arrhythmia, a cryoablation of AP was performed (Picture 1c-1d). Nevertheless, 12 h after the procedure, there was still evidence of intermittent VPE. The patient was then discharged and, after a month, he repeated the EST with documentation of persistent VPE which suddenly disappeared at the peak of the exercise and reappeared during the recovery phase. At the 1-year follow-up, no arrhythmic recurrence but persistence of VPE was reported and a successive EST confirmed abrupt interruption of VPE at the peak of the exercise. Due to the low arrhythmic risk, sport activity was not more restricted. Conclusions This represents an original clinical case, as it raises the question of what practical criteria should be defined as an effective TCA of AP in a competitive athlete with unfavorable anatomy. The current guidelines (Sport Cardiology and Exercise 2020) provide useful indications in linear and common cases, but may be a source of doubts in particular cases. Therefore, only the experience and the careful evaluation of the individual patient can provide the key to a correct management of the cases like this.

Background: subclinical pulmonary and peripheral congestion is an emerging concept in heart failure, correlated with a worse prognosis. Very few studies have evaluated its prognostic impact in an outpatient setting and its relationship with right-ventricular dysfunction. The study aims to investigate subclinical congestion in chronic heart failure outpatients, exploring the close relationship between the right heart-pulmonary unit and peripheral congestion. Materials and methods: in this observational study, 104 chronic HF outpatients were enrolled. The degree of congestion and signs of elevated filling pressures of the right ventricle were evaluated by physical examination and a transthoracic ultrasound to define multiparametric right ventricular dysfunction, estimate the right atrial pressure and the pulmonary artery systolic pressure. Outcome data were obtained by scheduled visits and phone calls. Results: ultrasound signs of congestion were found in 26% of patients and, among this cohort, half of them presented as subclinical, affecting their prognosis, revealing a linear correlation between right ventricular/arterial coupling, the right-chambers size and ultrasound congestion. Right ventricular dysfunction, TAPSE/PAPS ratio, clinical and ultrasound signs of congestion have been confirmed to be useful predictors of outcome. Conclusions: subclinical congestion is widespread in the heart failure outpatient population, significantly affecting prognosis, especially when right ventricular dysfunction also occurs, suggesting a strict correlation between the heart-pulmonary unit and volume overload.

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Late‐onset migration of pacing leads in the left hemithorax is a rare but potentially life‐threatening complication. Radiological examinations are required to detect any involvement of either left ventricle or lung parenchyma, prompting immediate surgical extraction in this setting. Identification of high‐risk patients is mandatory to prevent this complex iatrogenic complication., Lead migration in the left hemithorax is a dreadful complication. Computed tomography of the thorax is the diagnostic cornerstone and should prompt off‐pump surgical extraction. High‐risk patients liable to develop this complication should be recognized before device implantation, and less traumatic, passive‐fixation leads might be used in this setting.

Atrial fibrillation has been associated with stroke, heart failure and cardiovascular mortality. Although several studies have recently put forward a connection between atrial fibrillation and sudden cardiac death, whether the arrhythmia should be regarded as an independent predictor of potentially harmful ventricular tachycardias is not utterly clear. Nor have the underlying mechanisms been thoroughly investigated yet. A cause-effect relationship seems to be involved in some cases. In other clinical scenarios, however, atrial fibrillation could be a mere expression of the severity of the underlying structural or electrical heart disease, therefore playing an unremarkable pathophysiologic role in this setting. Moreover, despite some exceptions, current guidelines do not provide a straightforward approach to identify which patients with atrial fibrillation bear a greater risk of sudden cardiac death. The aim of this review is to discuss the available clinical evidence in this field, suggesting a pathophysiologic sequence and a patient-tailored approach for an effective risk stratification and management of patients with atrial fibrillation.

Background Primary cardiac tumors (PCT) are rare lesions but have the potential to cause significant morbidity if not timely treated. We reviewed our single‐center experience in the surgical treatment of PCT with a focus on the long‐term outcome. Methods From 2001 to 2020, 57 consecutive patients underwent surgical resection of PCT at our Institution. Data including the demographic characteristics, tumor histology, surgical procedure, and postoperative outcomes were collected and analyzed. Results Mean age at presentation was 63.6 ± 11.2 years, and 33 (57.9%) of the patients were female. A total of 55 (96.5%) subjects were diagnosed with benign cardiac tumor, while the remaining had malignant tumors. The most common histopathological type was myxoma. All patients survived to hospital discharge. Main postoperative complications were: acute kidney injury (n = 3), sepsis (n = 3), and stroke (n = 2). Mean follow‐up time was 9 ± 5.9 years. Long‐term mortality was 22.8% (13/57). No tumor recurrence was observed among survivors. There was a significant relationship between mortality and pathological characteristics of the tumor, and myxomas had higher survival rates. Conclusion Surgical treatment of PCT is a safe and highly effective strategy associated with excellent short‐term outcomes. Long‐term survival remains poor for primary malignant tumors of the heart.

Introduction In the treatment of patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI), it is unclear which combination of antithrombotic drugs is preferable and which is the optimal duration of treatment. Areas covered The authors review the available evidence in this area resulting from single studies and meta-analyses. In the absence of direct head-to-head comparisons between different non-vitamin K oral anticoagulants (NOAC), the authors review the available studies with NOACS in these patients and derived indirect comparisons. Expert opinion In patients with AF who undergo PCI, a dual antithrombotic strategy which includes a NOAC plus single antiplatelet therapy with a P2Y12 inhibitor (preferably clopidogrel) should be considered as the preferred treatment option in most cases. Oral anticoagulation associated with dual antiplatelet therapy (triple antithrombotic therapy) should be offered for no longer than 30 days to patients with very high thrombotic and low hemorrhagic risk. It is unclear whether the dual antithrombotic strategy should be continued beyond 12 months in patients at high risk of thrombotic events. Additional data from adequately powered controlled studies are needed to support the long-term efficacy of this strategy and to establish the best patient-tailored approach in this complex scenario.

Implantable loop recorders allow prolonged and continuous single-lead electrocardiogram recording, with the pivotal addition of remote monitoring. They have significantly shortened time to electrocardiographic diagnosis and appropriate therapy of many bradyarrhythmias/tachyarrhythmias and proved helpful in arrhythmia burden definition, offering invaluable information in the diagnostic workup for syncope and atrial fibrillation. Advanced cardiac signal recording is also possible by transesophageal catheters. They have been used to orient diagnosis during wide and narrow QRS complex tachycardias and also to perform minimally invasive pacing. Intracardiac electrophysiologic study remains, however, essential for diagnosis of several arrhythmias in the perspective of curative catheter ablation.

Polymorphic wide QRS complex tachycardia is defined as a tachyarrhythmia showing variable and frequently alternating morphologies of the QRS complex with irregular R-R intervals. It may present with a specific and reproducible pattern including torsade de pointes and bidirectional ventricular tachycardia or with a nonspecific and very irregular pattern, different from ventricular fibrillation. Polymorphic ventricular tachycardia is a challenging diagnosis and is associated with a high risk for sudden cardiac death. Although rare, preexcited atrial fibrillation over multiple accessory pathways can also generate a polymorphic wide QRS complex tachycardia mimicking polymorphic ventricular tachycardia.

Aims heart failure (HF) and coronary artery disease (CAD) are independent predictors of death in patients with COVID-19. The adverse prognostic impact of the combination of HF and CAD in these patients is unclear. Methods and results we analysed data from 954 consecutive patients hospitalized for SARS-CoV-2 in five Italian Hospitals from February 23 to May 22, 2020. The study was a systematic prospective data collection according to a pre-specified protocol. All-cause mortality during hospitalization was the outcome measure. Mean duration of hospitalization was 33 days. Mortality was 11% in the total population and 7.4% in the group without evidence of HF or CAD (reference group). Mortality was 11.6% in the group with CAD and without HF (odds ratio [OR]: 1.6, p = 0.120), 15.5% in the group with HF and without CAD (OR: 2.3, p = 0.032), and 35.6% in the group with CAD and HF (OR: 6.9, p, Graphical abstract Image, graphical abstract

Background: Post-operative (POP) atrial fibrillation (AF) is frequent in patients who undergo cardiac surgery. However, its prognostic impact in the long term remains unclear. Methods: We followed 1386 patients who underwent cardiac surgery for an average of 10 ± 3 years. According to clinical history of AF before and after surgery, four subgroups were identified: (1) patients with no history of AF and without episodes of AF during the first 30 days after surgery (control or Group 1, n = 726), (2) patients with no history of AF before surgery in whom new-onset POP AF was detected during the first 30 days after surgery (new-onset POP AF or Group 2, n = 452), (3) patients with a history of paroxysmal/persistent AF before cardiac surgery (Group 3, n = 125, including 87 POP AF patients and 38 who did not develop POP AF), and (4) patients with permanent AF at the time of cardiac surgery (Group 4, n = 83). All-cause mortality was the primary outcome of the study. We tested the associations of potential determinants with all-cause mortality using univariable and multivariable statistical analyses. Results: Overall, 473 patients (34%) died during follow-up. After adjustment for multiple confounders, new-onset POP AF (hazard ratio (HR) = 1.31, 95% confidence interval (CI): 0.90–1.89; p = 0.1609), history of paroxysmal/persistent AF before cardiac surgery (HR = 1.33, 95% CI: 0.71–2.49; p = 0.3736), and permanent AF (Group 4) (HR = 1.55, 95% CI 0.82–2.95; p = 0.1803) were not associated with a significantly increased risk of mortality when compared with Group 1 (patients with no history of AF and without episodes of AF during the first 30 days after surgery). In new-onset POP AF patients, oral anticoagulation was not associated with mortality (HR = 1.13, 95% CI: 0.83–1.54; p = 0.4299). Conclusions: In this cohort of patients who underwent different types of heart surgery, POP AF was not associated with an increased risk of mortality. In this setting, the role of long-term anticoagulation remains unclear.

Although catheter ablation of accessory pathways is deemed highly safe and effective, peculiar location of these pathways might lead to complex and potentially hazardous procedures requiring ablation in anatomic regions such as para-Hisian area, coronary sinus, and epicardial surface. The electrophysiologist should know these possible scenarios to plan the best strategy for safe and effective ablation of these uncommon accessory pathways.

Highlights • We evaluated ECG features of patients hospitalized for COVID-19 pneumonia. • New ECG abnormalities reflected a wide spectrum of cardiovascular complications. • The most common manifestations were signs of pericarditis and atrial fibrillation. • ECG abnormalities showed a late onset from hospitalization. • ECG abnormalities seem to follow a separate course from the respiratory infection., Background . The electrocardiographic (ECG) changes which may occur during hospitalization for COVID-19 have not yet been comprehensively assessed. Patients and methods . We examined 50 patients admitted to hospital with proven COVID-19 pneumonia. At entry, all patients underwent a detailed clinical examination, 12-lead ECG, laboratory tests and arterial blood gas test. ECG was also recorded at discharge and in case of worsening clinical conditions. Results . Mean age of patients was 64 years and 72% were men. At baseline, 30% of patients had ST-T abnormalities, and 33% had left ventricular hypertrophy. During hospitalization, 26% of patients developed new ECG abnormalities which included atrial fibrillation, ST-T changes, tachy-brady syndrome, and changes consistent with acute pericarditis. One patient was transferred to intensive care unit for massive pulmonary embolism with right bundle branch block, and another for non-ST segment elevation myocardial infarction. Patients free of ECG changes during hospitalization were more likely to be treated with antiretrovirals (68% vs 15%, p = 0.001) and hydroxychloroquine (89% vs 62%, p = 0.026) versus those who developed ECG abnormalities after admission. Most measurable ECG features at discharge did not show significant changes from baseline (all p>0.05) except for a slightly decrease in Cornell voltages (13±6 vs 11±5 mm; p = 0.0001) and a modest increase in the PR interval. The majority (54%) of patients with ECG abnormalities had 2 prior consecutive negative nasopharyngeal swabs. ECG abnormalities were first detected after an average of about 30 days from symptoms’ onset (range 12–51 days). Conclusions . ECG abnormalities during hospitalization for COVID-19 pneumonia reflect a wide spectrum of cardiovascular complications, exhibit a late onset, do not progress in parallel with pulmonary abnormalities and may occur after negative nasopharyngeal swabs.

In some cases, atrioventricular reentrant arrhythmias are sustained by accessory pathways with peculiar electrophysiologic properties related to their specific anatomy. Most of these fibers, which may be responsible for variants of ventricular preexcitation, show decremental conduction properties due to a nodelike aspect or a peculiar tortuous anatomic route across the atrioventricular groove. Moreover, some fibers do not actively sustain any reentrant circuit and can be only involved as bystander in other arrhythmias. Although rare, these accessory pathway variants should be properly diagnosed using noninvasive and invasive methods to guide catheter ablation procedures when needed.

In rare cases, atrioventricular reentrant arrhythmias are sustained by accessory pathways with peculiar electrophysiologic features that may be related to their specific anatomy. Most of these bundles show decremental nodelike conduction properties and sustain peculiar forms of arrhythmias that require careful differential diagnosis. On the other hand, some pathways do not actively sustain any reentrant circuit and should nevertheless be promptly recognized to avoid unnecessary ablation attempts. Although rare, these variants of accessory pathway should be known to warrant a safe and effective catheter ablation procedure.

Objectives The purpose of this study was to evaluate the safety and efficacy of uninterrupted and interrupted direct oral anticoagulant (DOAC) administration in patients undergoing pulmonary vein isolation (PVI). Background The optimal periprocedural management of DOACs in patients undergoing PVI is not well defined, and different strategies are used. Methods A systematic search of PubMed/MEDLINE, Ovid/MEDLINE, and EMBASE was performed. Three strategies for periprocedural DOAC administration were considered: uninterrupted, mildly interrupted ( Results The analysis included 43 studies for a total of 8,362 patients. DOACs showed similar safety and efficacy in the 3 subgroups. The WMI of MB was 1.02%, 1.49%, and 1.17% for the uninterrupted, mildly interrupted, and interrupted strategy, respectively; the WMI of TE complications was 0.16%, 0.46%, and 0.49% for the uninterrupted, mildly interrupted, and interrupted strategy, respectively, with no heterogeneity. OB appeared to be higher in uninterrupted (6.33%) and mildly interrupted (8.62%) groups compared with the interrupted (3.53%), with substantial heterogeneity among studies. No interaction was found between the incidence of MB and TE complications and different DOACs. Conclusions In patients undergoing PVI, these 3 anticoagulation strategies may have similar safety and efficacy in terms of MB and TE complications. OB appears to be higher in uninterrupted and mildly interrupted strategies compared with the interrupted strategy. No substantial differences were observed among DOACs regarding the incidence of MB and TE complications.

Wide complex tachycardia may represent a challenge for correct interpretation of standard electrocardiogram, which is crucial for proper patient management. For this reason, algorithms based on electrocardiographic criteria have been developed to guide interpretation in a step-by-step approach. Despite their greater accuracy, some cases of wide QRS complex tachycardia are a challenge. Some peculiar forms of ventricular tachycardia, and complex supraventricular substrate or particular clinical condition, may originate a challenging electrocardiographic pattern. In this article, a series of peculiar cases of wide QRS complex tachycardia is presented as paradigm of how important a comprehensive clinical approach is in these patients.

Several arrhythmogenic substrates may generate narrow QRS complex tachycardia, frequently encountered in clinical practice. Some narrow QRS complex tachycardias, however, are sustained by an uncommon arrhythmogenic mechanism. Although rare, these forms should be taken into account in the differential diagnosis to avoid misdiagnosis and improper patient management. Dual atrioventricular node physiology can be responsible for different uncommon forms of narrow QRS complex tachycardia, also nonreentrant in mechanism. A ventricular origin also is possible, if the tachycardia site is located in the upper ventricular septum with fast ventricular propagation to the specific conduction system and narrowing of the QRS complex.

Radiofrequency (RF) catheter ablation of para-Hisian (P-H) and mid-septal (M-S) accessory pathways (APs) is a potentially harmful procedure due to their close location to the A-V node. Conversely, cryoablation (CA) appears safer in this setting. The aim of this study was to assess the efficacy and safety of CA of these APs using a specific protocol. Fifty-three patients undergoing CA for P-H (45) or M-S (8) APs were included. CA was performed with a 4-mm catheter at − 75 °C for 480 s in the site where conduction block over the AP was obtained by a specific cryomapping protocol. Optimal catheter-tissue contact was achieved by inferior or superior vena cava approach. In case of failure, a 6-mm catheter and/or trans-septal catheterization (TSC) were considered. Normal AV conduction was monitored throughout CA, which was interrupted in case of its inadvertent modifications. In 46 patients (87%), CA was successful. Reasons for failure were as follows: lack of AP interruption (3 patients), intraprocedure AP conduction resumption (3), or transient A-H interval prolongation (1). Failure was associated with more aggressive approach including multiple procedures, greater use of 6-mm catheters, TSC, and longer CA applications. No major complications were observed. Three out of 46 patients (6.5%) experienced relapse of AP conduction during follow-up and were successfully re-treated by CA. CA of P-H and M-S APs is highly safe and effective and a specific protocol for cryomapping and CA could lead to a low recurrence rate at follow-up.

The management of asymptomatic patients with ventricular pre-excitation diagnosed occasionally is controversial. In fact, the lack of clinical arrhythmias does not necessarily define a benign condition: it could be possibly due to poor conduction over the accessory pathway or, conversely, to peculiar and individual conditions, which, even if the accessory pathway is capable of fast conduction, can prevent the onset of arrhythmias. These can occur unexpectedly during follow-up and may include malignant ventricular arrhythmias, although sudden death is very rare in this clinical scenario. An aggressive strategy aiming at extensive ablation in all cases with asymptomatic ventricular pre-excitation is not justified, as well as the "wait-and-see" approach. Clinically, it is important to accurately define the individual risk of any arrhythmia related to the accessory pathway, which may require treatment. For decades, the management of asymptomatic ventricular pre-excitation has been quite inhomogeneous among centers and in some cases it is still very different. Recently, a consensus document proposed the combined use of non-invasive and invasive diagnostic tools for accurate screening of these patients. If non-invasive methodologies are unable to demonstrate poor conduction over the accessory pathway, then an invasive approach is justified for arrhythmia risk definition and, if necessary, adequate therapy.

The purpose of this study was to evaluate the safety and efficacy of uninterrupted and interrupted direct oral anticoagulant (DOAC) administration in patients undergoing pulmonary vein isolation (PVI).The optimal periprocedural management of DOACs in patients undergoing PVI is not well defined, and different strategies are used.A systematic search of PubMed/MEDLINE, Ovid/MEDLINE, and EMBASE was performed. Three strategies for periprocedural DOAC administration were considered: uninterrupted, mildly interrupted (12 h), and interrupted (≥12 h). Primary endpoints were major bleeding (MB) and thromboembolic (TE) complications; pooled weighted mean incidence (WMI) was calculated using a random-effects model. A secondary endpoint was the WMI of overall bleeding (OB).The analysis included 43 studies for a total of 8,362 patients. DOACs showed similar safety and efficacy in the 3 subgroups. The WMI of MB was 1.02%, 1.49%, and 1.17% for the uninterrupted, mildly interrupted, and interrupted strategy, respectively; the WMI of TE complications was 0.16%, 0.46%, and 0.49% for the uninterrupted, mildly interrupted, and interrupted strategy, respectively, with no heterogeneity. OB appeared to be higher in uninterrupted (6.33%) and mildly interrupted (8.62%) groups compared with the interrupted (3.53%), with substantial heterogeneity among studies. No interaction was found between the incidence of MB and TE complications and different DOACs.In patients undergoing PVI, these 3 anticoagulation strategies may have similar safety and efficacy in terms of MB and TE complications. OB appears to be higher in uninterrupted and mildly interrupted strategies compared with the interrupted strategy. No substantial differences were observed among DOACs regarding the incidence of MB and TE complications.

The sick sinus syndrome includes symptoms and signs related to sinus node dysfunction. This can be caused by intrinsic abnormal impulse formation and/or propagation from the sinus node or, in some cases, by extrinsic reversible causes. Careful evaluation of symptoms and of the electrocardiogram is of crucial importance, because diagnosis is mainly based on these 2 elements. In some cases, the pathophysiologic mechanism that induces sinus node dysfunction also favors the onset of atrial arrhythmias, which results in a more complex clinical condition, known as "bradycardia-tachycardia syndrome."

Aims During pulmonary vein isolation (PVI), even if operators are aware of the contact force (CF), its values may greatly vary and the impact of cardiac rhythm has not been thoroughly investigated yet. This study aims at assessing the actual values of CF, the applications with suboptimal CF, and the impact of cardiac rhythm on CF during PVI. Methods and results Twenty patients undergoing point-by-point PVI with a CF-sensing catheter were considered. CF target was between 6 and 40 g. The mean CF per application (mCF) was evaluated and considered suboptimal if ≤5 g. The real-time graphic of CF was also evaluated and classified as pulsatile if regular variations synchronous with the atrial rate were seen; otherwise it was irregular. To achieve PVI, 1458 applications were delivered; 287 (19.68%) had suboptimal mCF. A great variability of mCF was seen according to anatomy, operators and patients. Compared to applications in atrial fibrillation (AF), those in sinus rhythm (SR) showed a higher median value of mCF (11 vs. 9 g; P = 0.0099) and a lower percentage of suboptimal mCF (17.95% vs. 25.15%; P = 0.0051). Compared to the irregular, the pulsatile pattern, almost exclusively observed in SR, was associated with higher mCF (14.69 ± 8.77 vs. 10.79 ± 7.89 g; P