Cardiac implantable electronic devices and bloodstream infections: management and outcomes.

BACKGROUND AND AIMS: Bloodstream infection (BSI) of any cause may lead to device infection in cardiac implantable electronic device (CIED) patients. Aiming for a better understanding of the diagnostic approach, treatment, and outcome, patients with an implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy and defibrillator (CRT-D) hospitalized with BSI were investigated. METHODS: This is a single-centre, retrospective, cohort analysis including consecutive ICD/CRT-D patients implanted between 2012 and 2021. These patients were screened against a list of all hospitalized patients having positive blood cultures consistent with diagnosed infection in any department of a local public hospital. RESULTS: The total cohort consisted of 515 patients. Over a median follow-up of 59 months (interquartile range 31-87 months), there were 47 BSI episodes in 36 patients. The majority of patients with BSI (92%) was admitted to non-cardiology units, and in 25 episodes (53%), no cardiac imaging was performed. Nearly all patients (85%) were treated with short-term antibiotics, whereas chronic antibiotic suppression therapy (n = 4) and system extraction (n = 3) were less frequent. Patients with BSI had a nearly seven-fold higher rate (hazard ratio 6.7, 95% confidence interval 3.9-11.2; P < .001) of all-cause mortality. CONCLUSIONS: Diagnostic workup of defibrillator patients with BSI admitted to a non-cardiology unit is often insufficient to characterize lead-related endocarditis. The high mortality rate in these patients with BSI may relate to underdiagnosis and consequently late/absence of system removal. Efforts to increase an interdisciplinary approach and greater use of cardiac imaging are necessary for timely diagnosis and adequate treatment.

Cyclic and Linear Tetrablock Copolymers Synthesized at Speed and Scale by Lewis Pair Polymerization of a One-Pot (Meth)acrylic Mixture and Characterized at Multiple Levels.

Cyclic block copolymers (cBCP) are fundamentally intriguing materials, but their synthetic challenges that demand precision in controlling both the monomer sequence and polymer topology limit access to AB and ABC block architectures. Here, we show that cyclic ABAB tetra-BCPs (cABAB) and their linear counterpart (lABAB) can be readily obtained at a speed and scale from one-pot (meth)acrylic monomer mixtures, through coupling the Lewis pair polymerization's unique compounded-sequence control with its precision in topology control. This approach achieves fast (<15 min) and quantitative (>99%) conversion to tetra-BCPs of predesignated linear or cyclic topology at scale (40 g) in a one-pot procedure, precluding the needs for repeated chain extensions, stoichiometric addition steps, dilute conditions, and postsynthetic modifications, and/or postsynthetic ring-closure steps. The resulting lABAB and cABAB have essentially identical molecular weights (Mn = 165-168 kg mol-1) and block degrees/symmetry, allowing for direct behavioral comparisons in solution (hydrodynamic volume, intrinsic viscosity, elution time, and refractive indices), bulk (thermal transitions), and film (thermomechanical and rheometric properties and X-ray scattering patterns) states. To further the morphological characterizations, allylic side-chain functionality is exploited via the thiol-ene click chemistry to install crystalline octadecane side chains and promote phase separation between the A and B blocks, allowing visualization of microdomain formation.

Installing Controlled Stereo-Defects Yields Semicrystalline and Biodegradable Poly(3-Hydroxybutyrate) with High Toughness and Optical Clarity.

Stereo-defects present in stereo-regular polymers often diminish thermal and mechanical properties, and hence suppressing or eliminating them is a major aspirational goal for achieving polymers with optimal or enhanced properties. Here, we accomplish the opposite by introducing controlled stereo-defects to semicrystalline biodegradable poly(3-hydroxybutyrate) (P3HB), which offers an attractive biodegradable alternative to semicrystalline isotactic polypropylene but is brittle and opaque. We enhance the specific properties and mechanical performance of P3HB by drastically toughening it and also rendering it with the desired optical clarity while maintaining its biodegradability and crystallinity. This toughening strategy of stereo-microstructural engineering without changing the chemical compositions also departs from the conventional approach of toughening P3HB through copolymerization that increases chemical complexity, suppresses crystallization in the resulting copolymers, and is thus undesirable in the context of polymer recycling and performance. More specifically, syndio-rich P3HB (sr-P3HB), readily synthesized from the eight-membered meso-dimethyl diolide, has a unique set of stereo-microstructures comprising enriched syndiotactic [rr] and no isotactic [mm] triads but abundant stereo-defects randomly distributed along the chain. This sr-P3HB material is characterized by high toughness (UT = 96 MJ/m3) as a result of its high elongation at break (>400%) and tensile strength (34 MPa), crystallinity (Tm = 114 °C), optical clarity (due to its submicron spherulites), and good barrier properties, while it still biodegrades in freshwater and soil.

Fewer Worsening Heart Failure Events With HeartLogic on top of Standard Care: a Propensity-Matched Cohort Analysis.

BACKGROUND: The implantable cardiac defibrillator-based HeartLogic algorithm aims to detect impending fluid retention in patients with heart failure (HF). Studies show that HeartLogic is safe to integrate into clinical practice. The current study investigates whether HeartLogic provides clinical benefit on top of standard care and device telemonitoring in patients with HF. METHODS: A multicenter, retrospective, propensity-matched cohort analysis was performed in patients with HF and implantable cardiac defibrillators, and it compared HeartLogic to conventional telemonitoring. The primary endpoint was the number of worsening HF events. Hospitalizations and ambulatory visits due to HF were also evaluated. RESULTS: Propensity score matching yielded 127 pairs (median age 68 years, 80% male). Worsening HF events occurred more frequently in the control group (2; IQR 0-4) compared to the HeartLogic group (1; IQR 0-3; P = 0.004). The number of HF hospitalization days was higher in controls than in the HeartLogic group (8; IQR 5-12 vs 5; IQR 2-7; P = 0.023), and ambulatory visits for diuretic escalation were more frequent in the control group than in the HeartLogic group (2; IQR 0-3 vs 1; IQR 0-2; P = 0.0001). CONCLUSION: Integrating the HeartLogic algorithm in a well-equipped HF care path on top of standard care is associated with fewer worsening HF events and shorter duration of fluid retention-related hospitalizations.

Tailoring the Nucleation and Crystallization Rate of Polyhydroxybutyrate by Copolymerization.

In the polyester family, the biopolymer with the greatest industrial potential could be poly(3-hydroxybutyrate) (PHB), which can be produced nowadays biologically or chemically. The scarce commercial use of PHB derives from its poor mechanical properties, which can be improved by incorporating a flexible aliphatic polyester with good mechanical performance, such as poly(ε-caprolactone) (PCL), while retaining its biodegradability. This work studies the structural, thermal, and morphological properties of block and random copolymers of PHB and PCL. The presence of a comonomer influences the thermal parameters following nonisothermal crystallization and the kinetics of isothermal crystallization. Specifically, the copolymers exhibit lower melting and crystallization temperatures and present lower overall crystallization kinetics than neat homopolymers. The nucleation rates of the PHB components are greatly enhanced in the copolymers, reducing spherulitic sizes and promoting transparency with respect to neat PHB. However, their spherulitic growth rates are depressed so much that superstructural growth becomes the dominating factor that reduces the overall crystallization kinetics of the PHB component in the copolymers. The block and random copolymers analyzed here also display important differences in the structure, morphology, and crystallization that were examined in detail. Our results show that copolymerization can tailor the thermal properties, morphology (spherulitic size), and crystallization kinetics of PHB, potentially improving the processing, optical, and mechanical properties of PHB.

Synthesis, Morphology, and Crystallization Kinetics of Polyheptalactone (PHL).

Aliphatic polyesters are widely studied due to their excellent properties and low-cost production and also because, in many cases, they are biodegradable and/or recyclable. Therefore, expanding the range of available aliphatic polyesters is highly desirable. This paper reports the synthesis, morphology, and crystallization kinetics of a scarcely studied polyester, polyheptalactone (PHL). First, we synthesized the η-heptalactone monomer by the Baeyer-Villiger oxidation of cycloheptanone before several polyheptalactones of different molecular weights (in the range between 2 and 12 kDa), and low dispersities were prepared by ring-opening polymerization (ROP). The influence of molecular weight on primary nucleation rate, spherulitic growth rate, and overall crystallization rate was studied for the first time. All of these rates increased with PHL molecular weight, and they approached a plateau for the highest molecular weight samples employed here. Single crystals of PHLs were prepared for the first time, and hexagonal-shaped flat single crystals were obtained. The study of the crystallization and morphology of PHL revealed strong similarities with PCL, making PHLs very promising materials, considering their potential biodegradable character.

Electromechanical factors associated with favourable outcome in cardiac resynchronization therapy.

AIMS: Electromechanical coupling in patients receiving cardiac resynchronization therapy (CRT) is not fully understood. Our aim was to determine the best combination of electrical and mechanical substrates associated with effective CRT. METHODS AND RESULTS: Sixty-two patients were prospectively enrolled from two centres. Patients underwent 12-lead electrocardiogram (ECG), cardiovascular magnetic resonance (CMR), echocardiography, and anatomo-electromechanical mapping (AEMM). Remodelling was measured as the end-systolic volume (ΔESV) decrease at 6 months. CRT was defined effective with ΔESV ≤ -15%. QRS duration (QRSd) was measured from ECG. Area strain was obtained from AEMM and used to derive systolic stretch index (SSI) and total left-ventricular mechanical time. Total left-ventricular activation time (TLVAT) and transeptal time (TST) were derived from AEMM and ECG. Scar was measured from CMR. Significant correlations were observed between ΔESV and TST [rho = 0.42; responder: 50 (20-58) vs. non-responder: 33 (8-44) ms], TLVAT [-0.68; 81 (73-97) vs. 112 (96-127) ms], scar [-0.27; 0.0 (0.0-1.2) vs. 8.7 (0.0-19.1)%], and SSI [0.41; 10.7 (7.1-16.8) vs. 4.2 (2.9-5.5)], but not QRSd [-0.13; 155 (140-176) vs. 167 (155-177) ms]. TLVAT and SSI were highly accurate in identifying CRT response [area under the curve (AUC) > 0.80], followed by scar (AUC > 0.70). Total left-ventricular activation time (odds ratio = 0.91), scar (0.94), and SSI (1.29) were independent factors associated with effective CRT. Subjects with SSI >7.9% and TLVAT <91 ms all responded to CRT with a median ΔESV ≈ -50%, while low SSI and prolonged TLVAT were more common in non-responders (ΔESV ≈ -5%). CONCLUSION: Electromechanical measurements are better associated with CRT response than conventional ECG variables. The absence of scar combined with high SSI and low TLVAT ensures effectiveness of CRT.

Role of genetic testing in young patients with idiopathic atrioventricular conduction disease.

AIMS: To investigate the role of genetic testing in patients with idiopathic atrioventricular conduction disease requiring pacemaker (PM) implantation before the age of 50 years. METHODS AND RESULTS: All consecutive PM implantations in Southern Switzerland between 2010 and 2019 were evaluated. Inclusion criteria were: (i) age at the time of PM implantation: < 50 years; (ii) atrioventricular block (AVB) of unknown aetiology. Study population was investigated by ajmaline challenge and echocardiographic assessment over time. Genetic testing was performed using next-generation sequencing panel, containing 174 genes associated to inherited cardiac diseases, and Sanger sequencing confirmation of suspected variants with clinical implication. Of 2510 patients who underwent PM implantation, 15 (0.6%) were young adults (median age: 44 years, male predominance) presenting with advanced AVB of unknown origin. The average incidence of idiopathic AVB computed over the 2010-2019 time window was 0.7 per 100 000 persons per year (95% CI 0.4-1.2). Most of patients (67%) presented with specific genetic findings (pathogenic variant) or variants of uncertain significance (VUS). A pathogenic variant of PKP2 gene was found in one patient (6.7%) with no overt structural cardiac abnormalities. A VUS of TRPM4, MYBPC3, SCN5A, KCNE1, LMNA, GJA5 genes was found in other nine cases (60%). Of these, three unrelated patients (20%) presented the same heterozygous missense variant c.2531G > A p.(Gly844Asp) in TRPM4 gene. Diagnostic re-assessment over time led to a diagnosis of Brugada syndrome and long-QT syndrome in two patients (13%). No cardiac events occurred during a median follow-up of 72 months. CONCLUSION: Idiopathic AVB in adults younger than 50 years is a very rare condition with an incidence of 0.7 per 100 000 persons/year. Systematic investigations, including genetic testing and ajmaline challenge, can lead to the achievement of a specific diagnosis in up to 20% of patients. Heterozygous missense variant c.2531G > A p.(Gly844Asp) in TRPM4 gene was found in an additional 20% of unrelated patients, suggesting possible association of the variant with the disease.

Efficacy and Safety of Leadless Pacemaker Implantation in Octogenarians.

INTRODUCTION: Long-term complication rates in standard transvenous pacemakers are reported around 4-12% with a higher incidence in the elderly population. We report our experience in octogenarians undergoing leadless pacemaker implantation in two large-volume centers in Switzerland. METHODS: Consecutive patients undergoing leadless pacemaker implantation at two Swiss large volume centers (University Hospital Zurich, Zurich and Cardiocentro Ticino Institute, Lugano) between October 2015 and March 2020 were included in this retrospective analysis. Demographic information, clinical data, and procedural characteristics were recorded at the day of implantation and during follow-up. RESULTS: Two hundred and twenty patients (mean age 80.6 ± 7.7 years, male 66%) were included. The main indication for pacemaker implantation was slow ventricular rate atrial fibrillation (111 of 220 patients, 50.4%). Out of the 220 patients, 124 (56.3%) were ≥80 years. Overall successful implantation rate was 98.6%. In the octogenarian population, the median procedure time (45 ± 20.2 min vs. 40 ± 19.6 min, p = 0.03) and radiation duration (6.1 ± 8.2 min vs. 5.0 ± 7.2 min, p = 0.03) were longer compared to patients <80 years. Major complications (2.7%, n = 6) and device measurements during follow-up were similar between patients ≥80 and <80 years. CONCLUSION: Implantation of a leadless pacemaker device in octogenarians is safe and effective with a similarly low complication rate compared to non-octogenarians.

A Variant in TBCD Associated with Motoneuronopathy and Corpus Callosum Hypoplasia: A Case Report.

Mutations in the tubulin-specific chaperon D (TBCD) gene, involved in the assembly and disassembly of the α/ß-tubulin heterodimers, have been reported in early-onset progressive neurodevelopment regression, with epilepsy and mental retardation. We describe a rare homozygous variant in TBCD, namely c.881G>A/p.Arg294Gln, in a young woman with a phenotype dominated by distal motorneuronopathy and mild mental retardation, with neuroimaging evidence of corpus callosum hypoplasia. The peculiar phenotype is discussed in light of the molecular interpretation, enriching the literature data on tubulinopathies generated from TBCD mutations.

Toughening Brittle Bio-P3HB with Synthetic P3HB of Engineered Stereomicrostructures.

Poly(3-hydroxybutyrate) (P3HB), a biologically produced, biodegradable natural polyester, exhibits excellent thermal and barrier properties but suffers from mechanical brittleness, largely limiting its applications. Here we report a mono-material product design strategy to toughen stereoperfect, brittle bio or synthetic P3HB by blending it with stereomicrostructurally engineered P3HB. Through tacticity ([mm] from 0 to 100 %) and molecular weight (Mn to 788 kDa) tuning, high-performance synthetic P3HB materials with tensile strength to ≈30 MPa, fracture strain to ≈800 %, and toughness to 126 MJ m-3 (>110× tougher than bio-P3HB) have been produced. Physical blending of the brittle P3HB with such P3HB in 10 to 90 wt % dramatically enhances its ductility from ≈5 % to 95-450 % and optical clarity from 19 % to 85 % visible light transmittance while maintaining desirably high elastic modulus (>1 GPa), tensile strength (>35 MPa), and melting temperature (160-170 °C). This P3HB-toughening-P3HB methodology departs from the traditional approach of incorporating chemically distinct components to toughen P3HB, which hinders chemical or mechanical recycling, highlighting the potential of the mono-material product design solely based on biodegradable P3HB to deliver P3HB materials with diverse performance properties.

Effect of Chain Stereoconfiguration on Poly(3-hydroxybutyrate) Crystallization Kinetics.

Poly(3-hydroxybutyrate) (PHB) is naturally accumulated by bacteria but can also be synthesized chemically. Its processability is limited, as it tends to degrade at temperatures above its melting temperature; hence, investigation into crystallization kinetics and morphology of PHB materials of both natural and synthetic origins is of great need and interest to get a better understanding of structure-property relationship. Accordingly, this contribution reports a first study of the crystallization and morphology of synthetic PHB materials of different molecular weights. These synthetic PHBs are racemic mixtures (50/50 mol %) of R and S chain configurations and are compared with an enantiopure bacterial R-PHB. Nonisothermal and isothermal crystallization studies show that R and S chains of PHB can cocrystallize in the same unit cell as the R-PHB. Most significantly, the results show that the presence of S chains decreases the overall crystallization rate, which could enhance the processability and industrialization of PHB-based materials.

Impact of SMART Pass filter in patients with ajmaline-induced Brugada syndrome and subcutaneous implantable cardioverter-defibrillator eligibility failure: results from a prospective multicentre study.

AIMS: Ajmaline challenge can unmask subcutaneous implantable cardioverter-defibrillator (S-ICD) screening failure in patients with Brugada syndrome (BrS) and non-diagnostic baseline electrocardiogram (ECG). The efficacy of the SMART Pass (SP) filter, a high-pass filter designed to reduce cardiac oversensing (while maintaining an appropriate sensing margin), has not yet been assessed in patients with BrS. The aim of this prospective multicentre study was to investigate the effect of the SP filter on dynamic Brugada ECG changes evoked by ajmaline and to assess its value in reducing S-ICD screening failure in patients with drug-induced Brugada ECGs. METHODS AND RESULTS: The S-ICD screening with conventional automated screening tool (AST) was performed during ajmaline challenge in subjects with suspected BrS. The S-ICD recordings were obtained before, during and after ajmaline administration and evaluated by the means of a simulation model that emulates the AST behaviour with and without SP filter. A patient was considered suitable for S-ICD if at least one sensing vector was acceptable in all tested postures. A sensing vector was considered acceptable in the presence of QRS amplitude >0.5 mV, QRS/T-wave ratio >3.5, and sense vector score >100. Of the 126 subjects (mean age: 42 ± 14 years, males: 61%, sensing vectors: 6786), 46 (36%) presented with an ajmaline-induced Brugada type 1 ECG. Up to 30% of subjects and 40% of vectors failed the screening during the appearance of Brugada type 1 ECG evoked by ajmaline. The S-ICD screening failure rate was not significantly reduced in patients with Brugada ECGs when SP filter was enabled (30% vs. 24%). Similarly, there was only a trend in reduction of vector-failure rate attributable to the SP filter (from 40% to 36%). The most frequent reason for screening failure was low QRS amplitude or low QRS/T-wave ratio. None of these patients was implanted with an S-ICD. CONCLUSION: Patients who pass the sensing screening during ajmaline can be considered good candidates for S-ICD implantation, while those who fail might be susceptible to sensing issues. Although there was a trend towards reduction of vector sensing failure rate when SP filter was enabled, the reduction in S-ICD screening failure in patients with Brugada ECGs did not reach statistical significance. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov Unique Identifier NCT04504591.

Duplication of exons 15 and 16 in Matrin-3: a phenotype bridging amyotrophic lateral sclerosis and immune-mediated disorders.

Mutations in Matrin-3 (MATR3) gene have been described in ALS, suggesting a role for this gene in the disease pathogenesis. While most of MATR3 mutations are point mutations, here we report the first case of ALS associated with duplication in exons 15 and 16. The patient presented with limb-onset ALS and a complex past medical history because of Sjögren syndrome, antiphospholipid antibodies positivity, polyallergies, endometriosis, aldosterone-secreting adrenal cortical adenoma, congenital vesicoureteral reflux, and right breast hypoplasia. We discuss MATR3 effect in ALS and the role of this previously undescribed mutation in this peculiar ALS phenotype associated with systemic autoimmunity involvement.

Reconstruction of three-dimensional biventricular activation based on the 12-lead electrocardiogram via patient-specific modelling.

AIMS: Non-invasive imaging of electrical activation requires high-density body surface potential mapping. The nine electrodes of the 12-lead electrocardiogram (ECG) are insufficient for a reliable reconstruction with standard inverse methods. Patient-specific modelling may offer an alternative route to physiologically constraint the reconstruction. The aim of the study was to assess the feasibility of reconstructing the fully 3D electrical activation map of the ventricles from the 12-lead ECG and cardiovascular magnetic resonance (CMR). METHODS AND RESULTS: Ventricular activation was estimated by iteratively optimizing the parameters (conduction velocity and sites of earliest activation) of a patient-specific model to fit the simulated to the recorded ECG. Chest and cardiac anatomy of 11 patients (QRS duration 126-180 ms, documented scar in two) were segmented from CMR images. Scar presence was assessed by magnetic resonance (MR) contrast enhancement. Activation sequences were modelled with a physiologically based propagation model and ECGs with lead field theory. Validation was performed by comparing reconstructed activation maps with those acquired by invasive electroanatomical mapping of coronary sinus/veins (CS) and right ventricular (RV) and left ventricular (LV) endocardium. The QRS complex was correctly reproduced by the model (Pearson's correlation r = 0.923). Reconstructions accurately located the earliest and latest activated LV regions (median barycentre distance 8.2 mm, IQR 8.8 mm). Correlation of simulated with recorded activation time was very good at LV endocardium (r = 0.83) and good at CS (r = 0.68) and RV endocardium (r = 0.58). CONCLUSION: Non-invasive assessment of biventricular 3D activation using the 12-lead ECG and MR imaging is feasible. Potential applications include patient-specific modelling and pre-/per-procedural evaluation of ventricular activation.

Long-term outcome of catheter ablation for atrial fibrillation in patients with severe left atrial enlargement and reduced left ventricular ejection fraction.

AIMS: Data regarding the efficacy of catheter ablation in heart failure patients with severely dilated left atrium and reduced left ventricular ejection fraction (LVEF) are scanty. We sought to assess the efficacy of catheter ablation in patients with reduced LVEF and severe left atrial (LA) enlargement, and to compare it to those patients with preserved left ventricular function and equally dilated left atrium. METHODS AND RESULTS: Three patient groups with paroxysmal or persistent atrial fibrillation (AF) undergoing a first pulmonary vein isolation (PVI) were considered: Group 1 included patients with normal or mildly abnormal LA volume (≤41 mL/m2) and normal LVEF; Group 2 included patients with severe LA enlargement (>48 mL/m2) and normal LVEF; and Group 3 included patients with severe LA enlargement and reduced LVEF. Time to event analysis was used to investigate AF recurrences. The study cohort includes 439 patients; Group 3 had a higher prevalence of cardiovascular risk factors. LA enlargement was associated with a two-fold in risk of AF recurrence, on the contrary only a smaller non-significant increase of 30% was shown with the further addition of LVEF reduction. CONCLUSIONS: The long-term outcome of patients with severe LA dilatation and reduced LVEF is comparable to those with severe LA enlargement but preserved LVEF. Long-term efficacy of PVI is certainly affected by the enlargement of the left atrium, but less so by the addition of a reduced LVEF. CA remains the best strategy for rhythm control both in paroxysmal and persistent AF in this subgroup of patients.

Evidence of Preferential Flow Activation in the Vadose Zone via Geophysical Monitoring.

Preferential pathways allow rapid and non-uniform water movement in the subsurface due to strong heterogeneity of texture, composition, and hydraulic properties. Understanding the importance of preferential pathways is crucial, because they have strong impact on flow and transport hydrodynamics in the unsaturated zone. Particularly, improving knowledge of the water dynamics is essential for estimating travel time through soil to quantify hazards for groundwater, assess aquifer recharge rates, improve agricultural water management, and prevent surface stormflow and flooding hazards. Small scale field heterogeneities cannot be always captured by the limited number of point scale measurements collected. In order to overcome these limitations, noninvasive geophysical techniques have been widely used in the last decade to predict hydrodynamic processes, due to their capability to spatialize hydrogeophysical properties with high resolution. In the test site located in Bari, Southern Italy, the geophysical approach, based on electrical resistivity tomography (ERT) monitoring, has been implemented to detect preferential pathways triggered by an artificial rainfall event. ERT-derived soil moisture estimations were obtained in order to quantitatively predict the water storage (m3m-3), water velocity (ms-1), and spread (m2) through preferential pathways by using spatial moments analysis.

High-density mapping in patients undergoing ablation of atrial fibrillation with the fourth-generation cryoballoon and the new spiral mapping catheter.

AIMS: To assess the value of high-density mapping (HDM) in revealing undetected incomplete pulmonary vein isolation (PVI) after the fourth-generation cryoballoon (CB4G) ablation compared to the previous cryoballoon's versions. METHODS AND RESULTS: Consecutive patients with paroxysmal or early-persistent atrial fibrillation (AF) undergoing CB ablation as the index procedure, assisted by HDM, were retrospectively included in this study. A total of 68 patients (52 males; mean age: 60 ± 12 years, 58 paroxysmal AF) were included, and a total of 272 veins were mapped. Fourth-generation cryoballoon with the new spiral mapping catheter (SMC) was used in 35 patients (51%). Time to PVI was determined in 102/132 (77%) and in 112/140 (80%) veins during second-generation cryoballoon/third-generation cryoballoon (CB2G/CB3G) and CB4G ablation, respectively (P = 0.66). There was a statistically significant difference in terms of discrepancy rate between the SMC and the mini-basket catheter in PV detection after CB4G and CB2G/CB3G ablation(1.4% vs. 7.6%; P = 0.01). A total of 57 patients (84%) remained free of symptomatic AF during a mean follow-up of 9.8 ± 4.6 months. CONCLUSION: High-density mapping after cryoballoon ablation using CB4G and the new SMC identifies incomplete PVI, not detected by the new SMC, in a significantly lower proportion of veins compared to HDM performed after the other generation CB ablation.

The influence of scar on the spatio-temporal relationship between electrical and mechanical activation in heart failure patients.

AIMS: The aim of this study was to determine the relationship between electrical and mechanical activation in heart failure (HF) patients and whether electromechanical coupling is affected by scar. METHODS AND RESULTS: Seventy HF patients referred for cardiac resynchronization therapy or biological therapy underwent endocardial anatomo-electromechanical mapping (AEMM) and delayed-enhancement magnetic resonance (CMR) scans. Area strain and activation times were derived from AEMM data, allowing to correlate mechanical and electrical activation in time and space with unprecedented accuracy. Special attention was paid to the effect of presence of CMR-evidenced scar. Patients were divided into a scar (n = 43) and a non-scar group (n-27). Correlation between time of electrical and mechanical activation was stronger in the non-scar compared to the scar group [R = 0.84 (0.72-0.89) vs. 0.74 (0.52-0.88), respectively; P = 0.01]. The overlap between latest electrical and mechanical activation areas was larger in the absence than in presence of scar [72% (54-81) vs. 56% (36-73), respectively; P = 0.02], with smaller distance between the centroids of the two regions [10.7 (4.9-17.4) vs. 20.3 (6.9-29.4) % of left ventricular radius, P = 0.02]. CONCLUSION: Scar decreases the association between electrical and mechanical activation, even when scar is remote from late activated regions.

A Bayesian spatiotemporal statistical analysis of out-of-hospital cardiac arrests.

We propose a Bayesian spatiotemporal statistical model for predicting out-of-hospital cardiac arrests (OHCAs). Risk maps for Ticino, adjusted for demographic covariates, are built for explaining and forecasting the spatial distribution of OHCAs and their temporal dynamics. The occurrence intensity of the OHCA event in each area of interest, and the cardiac risk-based clustering of municipalities are efficiently estimated, through a statistical model that decomposes OHCA intensity into overall intensity, demographic fixed effects, spatially structured and unstructured random effects, time polynomial dependence, and spatiotemporal random effect. In the studied geography, time evolution and dependence on demographic features are robust over different categories of OHCAs, but with variability in their spatial and spatiotemporal structure. Two main OHCA incidence-based clusters of municipalities are identified.