Electrocardiographic and clinical predictors of permanent pacemaker insertion following Perceval sutureless aortic valve implantation.

BACKGROUND: Sutureless aortic valve replacement surgery (AVR) is a reasonable alternative surgical approach in those patients with aortic stenosis who would benefit from reduced cross clamp time, such as elderly and high-risk patients. We sought to evaluate the incidence of pacemaker (PM) implantation following sutureless AVR and to analyse possible pre-operative electrocardiographic and clinical predictors of PM implantation. METHODS AND RESULTS: Between November 2013 and March 2015, 58 patients (male 43%, age 77.9 ±â€¯4.9 years) having undergone sutureless AVR with a Perceval prosthesis (Sorin Biomedica Cardio Srl, Saluggia, Italy) were taken into consideration for our analysis. During a mean follow up of 13.8 ±â€¯5.0 months (median 13 months), 14 patients (24.1%) underwent pacemaker (PM) implantation following sutureless AVR procedure. Among these patients, 12 (86%) presented III degree atrioventricular (AV) block, 1 (7%) presented II degree AV block, and remaining one (7%) severe symptomatic bradycardia. The comparison of pre-operative characteristics between PM group and no PM group highlighted that QRS duration, EuroSCORE II index and chronic renal dysfunction were significantly associated with the development of AV conduction abnormalities/symptomatic bradycardia requiring PM implantation (respectively, p = 0.01, p = 0.02 and p = 0.03). CONCLUSIONS: The incidence of PM implantation after sutureless AVR was 24.1% in the present study. The EuroSCORE II, QRS duration and renal dysfunction were significantly associated with higher risk of AV conduction abnormalities/symptomatic bradycardia requiring PM placement.

Early repolarization pattern as a predictor of atrial fibrillation recurrence following radiofrequency pulmonary vein isolation.

BACKGROUND: Early repolarization patterns (ERP) have been found to be associated with poor cardiovascular end points. We aimed to evaluate the ERP prevalence among patients with structurally normal hearts undergoing radiofrequency (RF) pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF) ablation and its association with the AF recurrence. METHODS: All consecutive patients who underwent RF-PVI as index procedure for paroxysmal AF in our center were evaluated. EXCLUSION CRITERIA: structural heart disease, ongoing use of Class I/III antiarrhythmics, complete-bundle-branch-block. Lateral (I, aVL, V5 -V6 ), inferior (II, III, aVF), or infero-lateral (both) ERP were defined in baseline ECG as horizontal/downsloping J-point elevation ≥1 mm in two consecutive leads with QRS slurring/notching. Documented episodes of AF lasting ≥30 s were considered recurrence. RESULTS: Of 701 cases, 434 patients (305 males, 58 ± 11 years) were included for analysis. ERP observed in 67 patients (15.4%) (Infero-lateral n = 26, inferior n = 23, lateral n = 18) which were significantly younger, demonstrating longer PR-interval and lower heart rates. At a mean follow-up of 22.1 ± 9.7 months, AF recurrences were found in 107 patients (24.6%). In middle-aged patients (≥40-<60 years; n = 206, 79% male), those with an infero-lateral ERP had higher recurrence compared with the ones without (56.3% vs. 19%; p = 0.002). Infero-lateral ERP was significantly predicting recurrence (HR 2.42, 95% CI 1.21-4.82; p = 0.01). CONCLUSION: Early repolarization patterns was more prevalent in our AF population than in the general population. Infero-lateral ERP in baseline ECG might predict AF recurrence in the follow-up after RF-PVI in middle-aged patients.

Leadless pacing in a young patient with cardioinhibitory vasovagal syncope.

Vasovagal syncope is characterized by vasodilatation and/or bradycardia and thereby a fall in arterial BP and global cerebral perfusion in response to a trigger. Although it is a benign condition, patients with frequent and traumatic episodes need treatment in order to improve quality of life. We describe the case of a 17-years-old boy suffering from cardioinhibitory syncope. At the end of a complete negative cardiac and neurological examination, a loop recorder was implanted. During the subsequent follow-up the ILR documented a 9-s pause. To improve the patient's compliance, and considering cardioinhibitory syncope as a temporary condition, a leadless pacemaker was eventually implanted.

Second generation cryoballoon ablation for atrial fibrillation in young adults: midterm outcome in patients under 40 years of age.

Aims: Pulmonary vein isolation (PVI) has been demonstrated more effective in young patients, in which the substrate for atrial fibrillation (AF) is probably more confined to pulmonary vein potentials. The present study sought to focus on the midterm outcomes in patients under 40 years having undergone PVI with the Cryoballoon Advance because of drug resistant AF. Methods and results: Between June 2012 and December 2015, 57 patients having undergone Cryoballoon ablation (CB-A) below 40 years of age for AF in our centre were retrospectively analysed and considered for our analysis. All patients underwent this procedure with the 28 mm Cryoballon Advance. All 227 veins were successfully isolated without the need for additional focal tip ablation. Median follow-up was 18 ±10 months. The freedom from AF after a blanking period of 3 months was 88% in our cohort of patients younger than 40 years old. The most frequent periprocedural complication was related to the groin puncture and occurred in 2 patients. After a single procedure, the only univariate predictor of clinical recurrence was the diagnosis of hypertrophic cardiomyopathy. Conclusion: Young patients affected by AF can be effectively and safely treated with CB-A that grants freedom from AF in 88% of the patients at 18 months follow-up following a 3-month blanking period. All veins could be isolated with the large 28 mm Cryoballoon Advance only.

Long-term outcome of pulmonary vein isolation in patients with paroxysmal atrial fibrillation and Brugada syndrome.

Aims: The therapeutical management of atrial fibrillation (AF) in the setting of Brugada syndrome (BS) might be challenging as many antiarrhythmic drugs (AADs) with sodium channel blocking properties might lead to to the development of ventricular arrhythmias. This study sought to evaluate the clinical outcome in a consecutive series of patients with BS having undergone pulmonary vein (PV) isolation by means of radiofrequency (RF) or cryoballoon (CB) ablation and the efficacy of catheter ablation for preventing inappropriate interventions delivered by implantable cardioverter defibrillators (ICD) on a 3-year follow up. Methods and results: Twenty-three consecutive patients with BS (13 males; mean age was 47 ± 18 years) having undergone PV isolation for drug-resistant paroxysmal AF were enrolled. Eleven patients (48%) had an ICD implanted of whom four had inappropriate shocks secondary to rapid AF. Over a mean follow-up period of 35.0 ± 25.4 months (median 36 months) the freedom from AF recurrence after the index PV isolation procedure was 74% without AADs. Patients with inappropriate ICD interventions for AF did not present futher ICD shocks after AF ablation. No major complications occurred. Conclusion: Catheter ablation is a valid therapeutic choice for patients with BS and paroxysmal AF considering the high success rates, the limitations of the AADs and the safety of the procedure, and it should be taken into consideration especially in those patients presenting inappropriate ICD shocks due to rapid AF.

Role of the burden of premature atrial contractions during the blanking period following second-generation cryoballoon ablation in predicting late recurrences of atrial arrhythmias.

PURPOSE: Recent data suggests that high burden of premature atrial complexes after pulmonary vein isolation predicts recurrences of atrial arrhythmias. The present study sought to assess the role of premature atrial complexes burden in predicting atrial arrhythmias recurrences in patients with atrial fibrillation (AF) who have undergone second-generation cryoballoon ablation (CB-Adv). METHODS: Consecutive patients with drug-resistant paroxysmal atrial fibrillation who underwent pulmonary vein isolation using CB-Adv technology as the index procedure were retrospectively included. Twenty-four-hour Holter recordings were performed for every patient. Based on previously published data, a burden of more than 76 premature atrial complexes per day was considered as being high. RESULTS: One hundred and seven patients were included in the analysis. The recurrence rate among the group of patients with more than 76 premature atrial complexes per day was significantly higher compared with the group with a lower burden of premature atrial complexes (47.5 vs 11.9%, respectively; p < 0.001). In the multivariate analysis, the documentation of more than 76 premature atrial complexes per day registered at 1 month and at the end of the blanking period, predicted late recurrence of atrial arrhythmias. CONCLUSIONS: Frequent premature atrial complexes in the early stages after CB-Adv ablation strongly predict late recurrences of atrial arrhythmias.

Single freeze strategy with the second- generation cryballoon for atrial fibrillation: a multicenter international retrospective analysis in a large cohort of patients.

PURPOSE: The second-generation cryoballoon (CB-A, Arctic Front Advance, Medtronic, Minneapolis, MN, USA) has proven to be highly effective in achieving freedom from atrial fibrillation; nonetheless, the ideal number and duration of freezing cycles is still a matter of debate. We investigated the acute success, procedural complications, and clinical outcome of a single freeze strategy using the CB-A in a large, retrospective, international multicenter study. METHODS: Between January 2013 and September 2015, 818 consecutive patients (58 ± 12 years, 68% males) with drug-resistant atrial fibrillation (AF) who underwent a CB-A using a single freeze strategy were taken into consideration for our analysis. RESULTS: Paroxysmal AF was documented in 74.1% of the patients, while 25.9% presented with persistent AF. Additional freezes were needed in a mean 1.4 veins per patient. 0.2% of the patients experienced persistent PNP that was still documented at the last follow-up. After a median follow-up of 14 ± 8 months, taking into consideration a blanking period (BP) of 3 months, 692 patients (84.6%) were free from arrhythmia recurrence. After a single procedure, AF recurrence during BP and persistent AF were identified as predictors of clinical recurrence after BP. CONCLUSIONS: Single freeze CB-A ablation is effective in treating drug-resistant AF and affords freedom from arrhythmia recurrences in 84.6% of patients during a 14-month follow-up. Persistent AF and recurrence during BP are predictors of arrhythmia recurrences.

Efficacy and safety of the second generation cryoballoon ablation for the treatment of paroxysmal atrial fibrillation in patients over 75 years: a comparison with a younger cohort.

AIMS: In this double centre, retrospective study, we aimed to analyse the 1-year efficacy and safety of cryoballoon ablation (CB-A) in patients older than 75 years compared with those younger than 75-years old. METHODS AND RESULTS: Fifty-three consecutive patients aged 75 years or older with drug-resistant paroxysmal AF (PAF) who underwent pulmonary vein isolation (PVI) by the means of second generation CB-A, were compared with 106 patients aged <75 years. The mean age in the study group (>75 years) was 78.19 ± 2.7 years and 58.97 ± 8.5 in the control group. At 1-year follow-up the global success rate was 83.6% and did not significantly differ between older (10/53) and younger patients (16/106) (81.1 vs. 84.9%, P = 0.54). Transient phrenic nerve palsy was the most common complication which occurred in eight patients in the younger group and in three in the older group (7.5 vs. 5.7%, respectively, P = 0.66). CONCLUSIONS: The results of our study showed that CB-A for the treatment of PAF is a feasible and safe procedure in elderly patients, with similar success and complications rates when compared with a younger population.

Long-term outcome after second-generation cryoballoon ablation for paroxysmal atrial fibrillation - a 3-years follow-up.

BACKGROUND: The second-generation cryoballoon (cryoballoon Advance; CB-A) offers excellent outcomes on the mid-term follow-up. To the best of our knowledge, little is known regarding the long-term outcome after CB-A ablation for paroxysmal atrial fibrillation (AF). OBJECTIVE: The aim of the study was to evaluate the freedom from recurrence of AF during a 3-year follow-up period, among consecutive patients having undergone pulmonary vein isolation (PVI) with the CB-A for paroxysmal AF (PAF). METHODS: Consecutive patients with drug-resistant PAF who underwent PVI using CB-A as an index procedure formed the study group. Patients were evaluated with holter ECG recordings at 1, 3, 6 and 12 months and subsequent follow-up was biannual or based on the clinical status and at the physician discretion. RESULTS: Seventy-six consecutive patients were enrolled. Of these patients, 6 were excluded because of lack of long-term follow-up. A total of 70 patients [44 male (63%); mean age 57.9 ± 14.5 years] with a mean follow-up of 38.0 ± 7.4 months were finally included. In total, 278 PVs were depicted on the pre-procedural CT scan. All PVs (100%) could be isolated with the CB-A only. The freedom from AF without antiarrhythmic drug (AADs) after a single procedure was 71.5% of patients at a mean 38.0 ± 7.4 months follow-up. If including repeat procedures, 80% of the patients were free from AF recurrence after 1.11 ± 0.32 procedures without AADs. CONCLUSION: The second-generation cryoballoon offers long-term freedom from PAF in 71.5% of treated patients with a single procedure without AADs on a 3-year follow-up period.

Repeat procedures using the second-generation cryoballoon for recurrence of atrial fibrillation after initial ablation with conventional radiofrequency.

PURPOSE: Pulmonary vein isolation is now widely accepted for the treatment of symptomatic atrial fibrillation refractory to antiarrhythmic drugs. However, multiple procedures are often required to significantly reduce atrial fibrillation (AF) recurrence. In the present study, we analyzed the acute results and the midterm clinical outcome of a second-generation cryoballoon ablation (CB-A) performed during repeat procedures for recurrence of AF after an initial procedure performed with conventional radiofrequency (RF). METHODS: Consecutive patients with paroxysmal and persistent AF who underwent pulmonary vein isolation by CB-A from June 2012 in our hospital as a redo procedure after a previous pulmonary vein isolation with RF were retrospectively included in this analysis. RESULTS: Forty-seven patients having undergone CB-A as a redo procedure were considered for our analysis. Pulmonary vein potentials were documented in 83 pulmonary veins (PV) that were all successfully re-isolated using the CB-A. Transient phrenic nerve palsy was the only complication occurring in our study cohort. After a mean follow-up of 15 ± 8 months, 76.6% of patients were free from recurrence of atrial fibrillation. If taking into consideration a 3-month blanking period, 83% of patients were free from recurrence. The success rate in patients affected by paroxysmal AF was 87% at final follow-up following the blanking period. CONCLUSIONS: The second-generation CB is effective in treating recurrence of AF after a previous ablation performed with conventional RF. Considering a 3-month blanking period, 83% of the patients were free from any atrial tachycardia recurrence during a 15-month follow-up. This approach proved particularly successful in patients affected by paroxysmal AF.

Femoral venous pressure waveform as indicator of phrenic nerve injury in the setting of second-generation cryoballoon ablation.

AIMS: Femoral venous pressure waveform (VPW) analysis has been recently described as a novel method to assess phrenic nerve function during atrial fibrillation ablation procedures by means of the cryoballoon technique. In this study, we sought to evaluate the feasibility and effectiveness of this technique, with respect to the incidence of phrenic nerve injury (PNI), in comparison with the traditional abdominal palpation technique alone. METHODS: Consecutive patients undergoing second-generation cryoballoon ablation (CB-A) from June 2014 to June 2015 were retrospectively analyzed. Diagnosis of PNI was made if any reduced motility or paralysis of the hemidiaphragm was detected on fluoroscopy. RESULTS: During the study period, a total of 350 consecutive patients (man 67%, age 57.2 ±â€Š12.9 years) were enrolled (200 using traditional phrenic nerve assessment and 150 using VPW monitoring). The incidence of PNI in the overall population was 8.0% (28/350); of these, eight were impending PNI (2.3%), 14 transient (4.0%), and six persistent (1.7%). Patients having undergone CB-A with traditional assessment experienced 18 phrenic nerve palsies (9.0%) vs two in 'VPW monitoring' group (1.3%; P = 0.002). Specifically, the former presented 12 transient (6.0%) and six persistent (3.0%) phrenic nerve palsies, and the latter exhibited two transient (1.3%; P = 0.03) and no persistent (0%; P = 0.04) phrenic nerve palsies. CONCLUSION: In conclusion, this novel method assessing the VPW for predicting PNI is inexpensive, easily available, with reproducible measurements, and appears to be more effective than traditional assessment methods.

Learning curve using the second-generation cryoballoon ablation.

AIMS: To study the learning curve with the second-generation cryoballoon technology focusing on safety, efficacy and procedural characteristics. METHODS: We included 300 patients (men 64.6%, mean age 58.3 ±â€Š12.4 years), 240 of whom were treated by four operators without prior experience in atrial fibrillation ablation and compared them with 60 consecutive patients treated by senior operator. To study the learning curves, we divided the study period into two trimesters and analyzed procedure duration, fluoroscopy times, complications, characteristics of the freeze-thaw cycles and midterm outcomes. RESULTS: Hands-on help from senior operators to achieve pulmonary vein isolation was needed only in the first study trimester (24.1%), most commonly to achieve right inferior pulmonary vein isolation (55.2%). The mean procedure duration shortened from 76.7 ±â€Š17.4 to 65.1 ±â€Š11.4 min (P < 0.0001), and fluoroscopy time decreased from 18.5 ±â€Š7.3 to 12.1 ±â€Š4.3 min (P < 0.0001) for first and second trimester, respectively, and approached senior operator's results (58.2 ±â€Š12.8 and 8.7 ±â€Š4.5 min). Most of the major complications (one stroke, four pseudoaneurysms and one retroperitoneal hematoma) occurred during the first study trimester. Most characteristics of the freeze cycles remained unchanged in both study periods. Compared with junior operators, the senior operator achieved lower nadir temperatures in both inferior veins. However, there was no significant difference in midterm outcomes between junior and senior operators (79.5 vs 83.3%, P = 0.589). CONCLUSION: The learning curve with the second-generation cryoballoon is steep. Inexperienced operators, trained in high-volume centers, can achieve pulmonary vein isolation safely and efficiently with short procedure and fluoroscopy times after having performed 20-30 cases.

Cryoballoon ablation during atrial fibrillation is associated with faster temperature drop and lower freezing temperatures.

PURPOSE: Our aim was to analyse the temperature behaviour during second-generation cryoballoon ablation (CB-A) in patients with ongoing atrial fibrillation (AF) compared with those in sinus rhythm (SR). METHODS: Consecutive patients with drug-resistant AF who underwent pulmonary vein (PV) isolation by CB-A from April 2014 to May 2015 were analysed. The exclusion criteria were any contraindication for the procedure including the presence of an intracavitary thrombus, uncontrolled heart failure, contraindications to general anaesthesia and cardioversion to SR during the ablation procedure. RESULTS: A total amount of 323 consecutive patients having undergone PV isolation by means of CB-A (male 66 %, age 56.1 ± 13.4 years) was enrolled. During ablation in the left-sided PVs, time needed to reach -20°, -30° and -40° was significantly shorter in patients with AF than those in SR. During ablation in the right superior pulmonary vein (RSPV), time to reach -30° and -40° was also significantly longer in patients with AF; during ablation in the right inferior pulmonary vein (RIPV), although the temperature drop was faster in the AF group, times needed to reach -20°, -30° and -40° were not significantly prolonged compared with those in the SR group. Temperatures attained at 60 s, and minimal temperatures were also significantly lower in the AF group during all PV ablations except RIPV. CONCLUSIONS: The temperature drop during AF cryoablation was significantly faster and attained significantly lower freezing degrees in patients with ongoing AF during the procedure compared with those in SR. This finding resulted markedly significant during each PV isolation except for RIPV cryoablation.

Repeat procedures after second-generation cryoballoon ablation as an index procedure for persistent atrial fibrillation: one-year follow-up.

PURPOSE: Data indicate that the second-generation cryoballoon (Arctic Front Advance, Medtronic, Minnesota, USA) could be effective for persistent atrial fibrillation. However, electrophysiological findings and the midterm clinical outcome of repeat procedures following second-generation cryoballoon ablation are lacking. METHODS: Consecutive patients with drug-resistant persistent atrial fibrillation who underwent a repeat ablation due to arrhythmia recurrence following an index procedure with second-generation cryoballoon were retrospectively included in our analysis. A total of 24 patients were included. Twenty underwent repeat procedures because of atrial fibrillation or left atrial arrhythmias and four because of typical atrial flutter. Mean time to recurrence of atrial tachyarrhythmias was 6.6 ± 3 months. Mean redo procedural time was 122 ± 23 min. RESULTS: At a mean follow-up of 11.8 ± 6.5 months, 15 patients (75 %) did not experience recurrence of atrial arrhythmias. Of the five patients (25 %) who had recurrence of atrial tachyarrhythmia, four presented with persistent atrial fibrillation and one with a mitral isthmus-dependent flutter. Of note is that the four patients with typical flutter were free from atrial tachycardia recurrence after the redo procedure. Two patients (9 %) underwent a third procedure. Mean time to recurrence of atrial arrhythmias from the repeat procedure was 9 ± 1 months. CONCLUSIONS: Our findings show that repeat ablation procedures following a second-generation cryoballoon ablation for persistent atrial fibrillation result in 75 % of freedom from any atrial tachycardia at 12 months follow-up. Of the recurrences, 63 % were due to new onset of atrial fibrillation and 37 % to organized tachycardias.

Second-Generation Cryoballoon Ablation in the Setting of Lone Paroxysmal Atrial Fibrillation: Single Procedural Outcome at 12 Months.

BACKGROUND: Lone atrial fibrillation (LAF) develops in younger individuals without cardiovascular or pulmonary disease. As pulmonary vein isolation has been recognized as an optimal treatment for drug-resistant atrial fibrillation, cryoballoon ablation with second-generation balloon (CB-A) may be an ideal solution for LAF patients. OBJECTIVE: The aim of this study was to investigate acute success, periprocedural complications and outcome over a 12-month follow-up period in a cohort of patients having undergone PV isolation (PVI) for LAF using CB-A technology. METHODS: A total of 75 consecutive patients (50 male, mean age 47 ± 12 years) with a diagnosis of lone paroxysmal atrial fibrillation who underwent pulmonary vein isolation (PVI) by CB-A from June 2012 were included. All patients underwent this procedure with the 28 mm CB-A. A total of 299 PVs (100%) could be isolated with CB-A alone. RESULTS: The freedom from AF recurrence after a single procedure was 92% of patients during the entire 13-month follow-up. When considering a blanking period (BP) of 3 months, success rate was 93.3%. Transient phrenic nerve palsy (PNP) was the most frequent complication, occurring in 5.3% of individuals (4 patients); complete recovery was documented for all of these patients prior to hospital discharge. CONCLUSIONS: CB-A is extremely effective in achieving PVI and affords freedom from AF at 13-month follow-up in 93% of young patients affected by drug-resistant LPAF following a 3-month BP. The most frequent complication observed was PNP, which reverted prior to discharge in all patients.

Incidence of real-time recordings of pulmonary vein potentials using the third-generation short-tip cryoballoon.

AIMS: The third-generation Cryoballoon Advance Short-tip (CB-ST) has been designed with a 40% shortened tip length compared with the former second-generation CB Advance device. Ideally, a shorter tip should permit an improved visualization of real-time (RT) recordings in the pulmonary vein (PV) due to a more proximal positioning of the inner lumen mapping catheter. In the present study, we sought to analyse the rate of visualization of RT recordings in our first series of patients with the CB-ST device. METHODS AND RESULTS: All consecutive patients having undergone CB ablation using CB-ST technology were analysed. Exclusion criteria were the presence of an intracavitary thrombus, uncontrolled heart failure, moderate or severe valvular disease, and contraindications to general anaesthesia. A total of 60 consecutive patients (60.5 ± 11.2 years, 62% males) were evaluated. Real-time recordings were detected in 209 of 240 PVs (87.1%). Specifically, RT recordings could be visualized in 55 left superior PVs (91.7%), 51 left inferior PVs (85.0%), 53 right superior PVs (88.3%), and 50 right inferior PVs (83.3). CONCLUSION: The rate of visualization of RT recordings is significantly high during third-generation CB-ST ablation. Real-time recordings can be visualized in ∼87.1% of veins with this novel cryoballoon.

Improved visualisation of real-time recordings during third generation cryoballoon ablation: a comparison between the novel short-tip and the second generation device.

BACKGROUND: The third-generation Cryoballoon Advance Short-tip (CB-ST) has been designed with a 40 % shortened tip length compared with the former second generation CB advance device (CB-A). Ideally, a shorter tip should permit an improved visualisation of real-time recordings in the pulmonary vein (PV) due to a more proximal positioning of the inner lumen mapping catheter. We sought to compare the incidence of visualisation of real-time recordings in patients having undergone ablation with the CB-ST with patients having received CB-A ablation. METHODS: All patients having undergone CB ablation using CB-ST technology and the last 500 consecutive patients having undergone CB-A ablation were analysed. Exclusion criteria were the presence of an intracavitary thrombus, uncontrolled heart failure, moderate or severe valvular disease, and contraindications to general anaesthesia. RESULTS: A total of 600 consecutive patients (58.1 ± 12.9 years, 64 % males) were evaluated (100 CB-ST and 500 CB-A ablations). Real-time recordings were significantly more prevalent in the CB-ST population compared with CB-A group (85.7 vs 67.2 %, p < 0.0001). Real-time recordings could be more frequently visualised in the CB-ST group in all types of veins (LSPV 89 vs 73.4 %, p = 0.0005; LIPV 84 vs 65.6 %, p = 0.0002; RSPV 87 vs 67.4 %, p < 0.0001; RIPV 83 vs 62.4 %, p < 0.0001). CONCLUSION: The rate of visualisation of real-time recordings is significantly higher during third-generation CB-ST ablation if compared to the second-generation CB-A device. Real-time recordings can be visualised in approximately 85.7 % of veins with this novel cryoballoon.

Second-generation cryoballoon ablation for paroxysmal atrial fibrillation: Predictive role of atrial arrhythmias occurring in the blanking period on the incidence of late recurrences.

BACKGROUND: Although consensus documents on catheter and surgical ablation of atrial fibrillation (AF) suggest a uniform "blanking period" of 3 months, recent evidence suggested that early recurrences of atrial tachyarrhythmias (ERATs) are strongly associated with late recurrences (LRs), especially if ERATs occurred in the last part of the "blanking period". OBJECTIVE: The present study sought to assess the role of ERATs in predicting LRs in a large cohort of patients with paroxysmal AF who have undergone second-generation cryoballoon ablation. METHODS: Consecutive patients with drug-resistant paroxysmal AF who underwent pulmonary vein isolation using CB-A technology as the index procedure were retrospectively included in our analysis. The exclusion criteria were any contraindications for the procedure, including the presence of an intracavitary thrombus, uncontrolled heart failure, contraindications to general anesthesia, and persistent AF. RESULTS: A total of 331 consecutive patients (104 women [31%]; mean age 56.7 ± 13.3 years) were enrolled. Atrial tachyarrhythmias/AF recurrences were detected in 57 patients (17.2%). The highest prevalence of ERATs was observed in the first 2 weeks (55%) after pulmonary vein isolation. Of note, all the ERATs occurring 1.5 months after AF ablation relapsed after 3 months and were confirmed as definitive recurrences. Late recurrence of AF and atrial tachycardia occurred in 20 of 29 patients with ERATs (69.0%) and 28 of 302 patients without ERATs (9.3%) (P < .0001). A multivariate Cox regression analysis showed that the early recurrence within the blanking period was significantly and independently associated with an increased risk of developing a late recurrence (hazard ratio 6.79; 95% confidence interval 3.52-10.14; P < .0001). CONCLUSION: Our findings reveal that ERATs are strongly associated with an LR after paroxysmal AF ablation using CB-A technology (hazard ratio 6.79; 95% confidence interval 3.52-10.14; P < .0001). Of note, when ERATs occurred later than 1.5 months, patients systematically experienced an LR.

Modern antiplatelet agents in coronary artery disease.

Dual antiplatelet therapy is well recognized in the prevention of thrombotic complications of acute coronary syndrome and percutaneous coronary interventions. Despite clinical benefits of aspirin and clopidogrel therapy, a number of limitations curtail their efficacy: slow onset of action, variability in platelet inhibitory response and potential drug-drug interactions. Furthermore, the single platelet-activation pathway targeted by these agents allows continued platelet activation via other pathways, ensuring incomplete protection against ischemic events, thus, underscoring the need for alternate antiplatelet treatment strategies. A number of novel antiplatelet agents are currently in advance development and many have established superior effects on platelet inhibition, clinical outcomes and safety profile than clopidogrel in high-risk patients. The aim of this review is to provide an overview of the current status of P2Y12 receptor inhibition and PAR-1 antagonists in determining a future strategy for individualized antiplatelet therapy.