Does Timing of Ventricular Tachycardia Ablation Affect Prognosis in Patients With an Implantable Cardioverter Defibrillator? Results From the Multicenter Randomized PARTITA Trial.

BACKGROUND: Optimal timing for catheter ablation of ventricular tachycardia is an important unresolved issue. There are no randomized trials evaluating the benefit of ablation after the first implantable cardioverter defibrillator (ICD) shock. METHODS: We conducted a 2-phase, prospective, multicenter, randomized clinical trial. Patients with ischemic or nonischemic dilated cardiomyopathy and primary or secondary prevention indication for ICD were enrolled in an initial observational phase until first appropriate shock (phase A). After reconsenting, patients were randomly assigned 1:1 in phase B to immediate ablation (within 2 months from shock delivery) or continuation of standard therapy. The primary end point was a composite of death from any cause or hospitalization for worsening heart failure. Amiodarone intake was not allowed except for documented atrial tachyarrhythmias. On July 23, 2021, phase B of the trial was interrupted as a result of the first interim analysis on the basis of the Bayesian adaptive design. RESULTS: Of the 517 patients enrolled in phase A, 154 (30%) had ventricular tachycardia, 56 (11%) received an appropriate shock over a median follow-up of 2.4 years (interquartile range, 1.4-4.4), and 47 of 56 (84%) agreed to participate in phase B. After 24.2 (8.5-24.4) months, the primary end point occurred in 1 of 23 (4%) patients in the ablation group and 10 of 24 (42%) patients in the control group (hazard ratio, 0.11 [95% CI, 0.01-0.85]; P=0.034). The results met the prespecified termination criterion of >99% Bayesian posterior probability of superiority of treatment over standard therapy. No deaths were observed in the ablation group versus 8 deaths (33%) in the control group (P=0.004); there was 1 worsening heart failure hospitalization in the ablation group (4%) versus 4 in the control group (17%; P=0.159). ICD shocks were less frequent in the ablation group (9%) than in the control group (42%; P=0.039). CONCLUSIONS: Ventricular tachycardia ablation after first appropriate shock was associated with a reduced risk of the combined death or worsening heart failure hospitalization end point, lower mortality, and fewer ICD shocks. These findings provide support for considering ventricular tachycardia ablation after the first ICD shock. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT01547208.

Pacing maneuvers from the aortic cusps: A useful technique during ablation of focal arrhythmias arising from the aortic root.

BACKGROUND: The ablation of arrhythmias arising near the His-bundle region in the non-coronary aortic cusp (NCAC) is challenging. Among the aortic sinuses of Valsalva, the NCAC is located between the right atrium and the left atrium. For this reason, pacing from the NCAC should result in atrial capture while pacing from the right and left coronary cusps (LCC) may result in ventricular capture. The objective of this study is to prove that atrial capture during pacing from the sinuses of Valsalva may be used to confirm a correct position in the non-coronary cusp. METHODS: A total of 30 patients with structurally normal heart undergoing left sided ablation procedures, underwent electrophysiological study of the aortic cusps. Each of the aortic valve cusps was paced with increasing outputs and analyzed offline to determine their unique electrocardiographic characteristics. RESULTS: In the NCAC, we obtained an atrial capture in 29 out of 30 patients (96.6%). The atrial capture was highly specific for a position in the NCAC (p < .001). The median output required to capture from the cusp was 10 mA (range 5-25 mA) at a pulse width of 2 ms. In the right coronary cusp (RCC) and LCC, we obtained ventricular capture in all patients (100%). The median output required to capture from the cusp was 10 mA (range 10-25 mA) in RCC and 25 mA (range 10-25 mA) in LCC at a pulse width of 2 ms. CONCLUSIONS: Atrial capture during a pacemapping from the aortic cusps can be considered proof of a correct position in NCAC.

Safety, efficacy, and reproducibility of cavotricuspid isthmus ablation guided by the ablation index: acute results of the FLAI study.

AIMS: Ablation index (AI) is a marker of lesion quality during catheter ablation that incorporates contact force, time, and power in a weighted formula. This index was originally developed for pulmonary vein isolation as well as other left atrial procedures. The aim of our study is to evaluate the feasibility and efficacy of the AI for the ablation of the cavotricuspid isthmus (CTI) in patients presenting with typical atrial flutter (AFL). METHODS AND RESULTS: This prospective multicentre non-randomized study enrolled 412 consecutive patients with typical AFL undergoing AI-guided cavotricuspid isthmus ablation. The procedure was performed targeting an AI of 500 and an inter-lesion distance measurement of ≤6 mm. The primary endpoints were CTI 'first-pass' block and persistent block after a 20-min waiting time. Secondary endpoints included procedural and radiofrequency duration and fluoroscopic time. A total of 412 consecutive patients were enrolled in 31 centres (mean age 64.9 ± 9.8; 72.1% males and 27.7% with structural heart disease). The CTI bidirectional 'first-pass' block was reached in 355 patients (88.3%), whereas CTI block at the end of the waiting time was achieved in 405 patients (98.3%). Mean procedural, radiofrequency, and fluoroscopic time were 56.5 ± 28.1, 7.8 ± 4.8, and 1.9 ± 4.8 min, respectively. There were no major procedural complications. There was no significant inter-operator variability in the ability to achieve any of the primary endpoints. CONCLUSION: AI-guided ablation with an inter-lesion distance ≤6 mm represents an effective, safe, and highly reproducible strategy to achieve bidirectional block in the treatment of typical AFL.

A comparison of acute procedural outcomes within four generations of cryoballoon catheters utilized in the real-world multicenter experience of 1STOP.

INTRODUCTION: Four generations of the cryoballoon (CB) catheter were retrospectively evaluated in a real-world examination of patients with atrial fibrillation (AF). METHODS AND RESULTS: Four hundred eighty patients (27% female and 60 ± 10 years) suffering from AF, underwent pulmonary vein (PV) ablation with one-of-four generations of the CB catheter. The total cohort was divided into four groups of patients: 120 with first-generation (CB-1); 120 with second-generation (CB-2); 120 with third-generation (CB-3); and 120 with fourth-generation (CB-4). Equal group sizes were achieved by examining the last 120 patients treated in each cohort, attempting to minimize the effect of a learning curve between the generations of CB catheter. Baseline clinical and patient characteristics were similar between the four cohorts, excepting age and the number of tested antiarrhythmic drugs. Procedure, fluoroscopy, and left atrial dwell times were significantly lower in the CB-4 cohort compared to previous generations of the CB catheters, while the acute procedural success rate was comparable across all catheter groups (>99%). Total acute procedural complications were low (2.5%), and acute complications were comparable within the CB-2, CB-3, and CB-4 groups (0.8% reported in each cohort). The rate of time-to-isolation (TTI) visualization increased with later generations of the CB catheters. CONCLUSIONS: The novel CB-4 achieved significantly faster procedural ablation times in comparison to the previous generations, while still maintaining a low rate of acute complications. Also, the rate of TTI visualization was observed to be higher with the CB-4 catheter. Further long-term evaluation is necessary, including an assessment of AF recurrence and PV reconnection(s).

Cryoballoon or radiofrequency ablation? Alternating technique for repeat procedures in patients with atrial fibrillation.

BACKGROUND: Which technique is better for repeat ablation in patients with atrial fibrillation (AF) remains unclear. The aim of the study was to compare long-term efficacy of repeat ablation using the alternative technique for the first redo ablation procedure: (a) cryoballoon (CB) re-ablation after a failed index pulmonary vein isolation (PVI) with radiofrequency (RF) ablation, RF-then-CB group or (b) RF repeat ablation following a failed CB ablation, CB-then-RF group. METHODS: Within the 1STOP Italian Project, consecutive patients undergoing repeat ablation with a different technique from the index procedure were included. RESULTS: We studied 474 patients, 349 in RF-then-CB and 125 in CB-then-RF group. Less women (21% vs 30%; P = .041), more persistent AF (33% vs 22%; P = .015), longer duration of AF (60 vs 31 months; P < .001), and more hypertension (50% vs 36%; P = .007) were observed in the RF-then-CB cohort as compared with the CB-then-RF group. The number of reconnected PVs was 3.7 ± 0.7 and 1.4 + 1.3 in RF-then-CB and CB-then-RF group, respectively (P < .001). During the follow-up, significantly less AF recurrence occurred in the CB-then-RF group (22% vs 8%, HR = 0.46; 95% CI: 0.24-0.92; P = .025). Cohort designation was the only independent predictor of AF recurrence. CONCLUSION: Alternation of energy source for repeat ablation was safe and effective, regardless the energy used first. However, patients initially treated with CB PVI undergoing repeat ablation with RF current had less AF recurrence at long-term follow-up as compared with those originally treated by RF ablation receiving a CB repeat ablation.

Management of untreatable ventricular arrhythmias during pharmacologic challenges with sodium channel blockers for suspected Brugada syndrome.

Pharmacologic challenge with sodium channel blockers is part of the diagnostic workout in patients with suspected Brugada syndrome. The test is overall considered safe but both ajmaline and flecainide detain well known pro-arrhythmic properties. Moreover, the treatment of patients with life-threatening arrhythmias during these diagnostic procedures is not well defined. Current consensus guidelines suggest to adopt cautious protocols interrupting the sodium channel blockers as soon as any ECG alteration appears. Nevertheless, the risk of life-threatening arrhythmias persists, even adopting a safe and cautious protocol and in absence of major arrhythmic risk factors. The authors revise the main published case studies of sodium channel blockers challenge in adults and in children, and summarize three cases of untreatable ventricular arrhythmias discussing their management. In particular, the role of advanced cardiopulmonary resuscitation with extra-corporeal membrane oxygenation is stressed as it can reveal to be the only reliable lifesaving facility in prolonged cardiac arrest.

Contiguity Between Ablation Lesions and Strict Catheter Stability Settings Assessed by VISITAGTM Module Improve Clinical Outcomes of Paroxysmal Atrial Fibrillation Ablation　- Results From the VISITALY Study.

BACKGROUND: Our aim was to evaluate the clinical outcome of paroxysmal atrial fibrillation (AF) ablation with contact force technology, using an automated lesion tagging system (VISITAGTM module) with strict criteria of catheter stability.Methods and Results:We enrolled 200 consecutive patients who underwent pulmonary vein isolation (PVI) in 11 centers and were followed up for 12 months. The stability setting was within 3 mm for ≥10 s and for ≥15 s in 47% and 53% of patients, respectively. A mean of 67.2±21.9 VISITAGs was acquired. Freedom from atrial tachyarrhythmias at follow-up was 77.5% (155/200), and the contiguity between lesions was associated with a higher chronic success rate (96% vs. 77.1%; log-rank P=0.036). Radiofrequency (RF), fluoroscopy times, and recurrence rates at the 12-month follow-up were significantly lower than in a comparison group of 80 patients without VISITAGTM module (42.7±14.5 vs. 50.9±23.6 min; P=0.032; 11.6±7.8 vs. 18.4±12.8 min; P=0.003 and 22.5% vs. 41.2%; P=0.02). Two major complications (1 cardiac tamponade and 1 minor stroke) were observed only in the control group. CONCLUSIONS: Paroxysmal AF ablation with contact force technology and strict criteria of stability using the VISITAG module was a safe procedure, associated with an improvement in efficiency and a reduction of atrial tachyarrhythmia recurrence at the 12-month follow-up compared with manual annotation. Contiguity between lesions seemed to enhance effectiveness outcomes.

Low incidence of permanent complications during catheter ablation for atrial fibrillation using open-irrigated catheters: a multicentre registry.

AIMS: Despite catheter ablation (CA) has become an accepted treatment option for symptomatic, drug-resistant atrial fibrillation (AF), the safety of this procedure continues to be cause for concern. The aim of the present study was to assess the incidence of complications with permanent sequelae of CA for AF using open-irrigated catheters in a contemporary, unselected population of consecutive patients. METHODS AND RESULTS: From 1 January 2011 to 31 December 2011, data from 2167 consecutive patients who underwent CA for AF using an open-irrigated catheter in 29 Italian centres were collected. All the complications occurring to the patient from admission to the 30th post-procedural day were recorded. No procedure-related death was observed. Complications occurred in 81 patients (3.7%): 46 patients (2.1%) suffered vascular access complications; 13 patients (0.6%) cardiac tamponade, successfully drained in all the cases; six patients (0.3%) arterial thromboembolism (four transient ischaemic attack and two ischaemic strokes); five (0.2%) patients conservatively treated pericardial effusion; three patients (0.1%) phrenic nerve paralysis; three patients (0.1%) pericarditis; three patients (0.1%) haemothorax, and two patients (0.1%) other isolated adverse events. At multivariate analysis, only female sex [odds ratio (OR) 2.5, confidence interval (CI): 1.5-3.7, P < 001] and the operator experience (OR 0.5, CI: 0.4-0.7, P < 001) related to the complications. Only five (0.2%) patients developed permanent sequelae from their complications. CONCLUSION: Catheter ablation for AF with the use of open-irrigated catheters is currently affected by a very low rate of complications leading to permanent sequelae.

Risk stratification in individuals with the Brugada type 1 ECG pattern without previous cardiac arrest: usefulness of a combined clinical and electrophysiologic approach.

AIMS: Risk stratification in individuals with type 1 Brugada electrocardiogram (ECG) pattern (type 1 ECG) for primary prevention of sudden death (SD). METHODS AND RESULTS: Three hundred and twenty patients (258 males, median age 43 years) with type 1 ECG were enrolled. No patient had previous cardiac arrest. Fifty-four per cent of patients had a spontaneous and 46% a drug-induced type 1 ECG. One-third had syncope, two-thirds were asymptomatic. Two hundred and forty-five patients underwent electrophysiologic study (EPS) and 110 patients received an implantable cardiac defibrillator (ICD). During follow-up [median length 40 months (IQ20-67)], 17 patients had major arrhythmic events (MAE) (14 resuscitated ventricular fibrillation (VF) and three SD). Both a spontaneous type 1 ECG and syncope significantly increased the risk (2.6 and 3.0% event rate per year vs. 0.4 and 0.8%). Major arrhythmic events occurred in 14% of subjects with positive EPS, in no subjects with negative EPS and in 5.3% of subjects without EPS. All MAE occurred in subjects who had at least two potential risk factors (syncope, family history of SD, and positive EPS). Among these patients, those with spontaneous type 1 ECG had a 30% event rate. CONCLUSION: (1) In subjects with the Brugada type 1 ECG, no single clinical risk factor, nor EPS alone, is able to identify subjects at highest risk; (2) a multiparametric approach (including syncope, family history of SD, and positive EPS) helps to identify populations at highest risk; (3) subjects at highest risk are those with a spontaneous type 1 ECG and at least two risk factors; (4) the remainder are at low risk.

Oral procainamide as pharmacological treatment of recurrent and refractory ventricular tachyarrhythmias: A single-center experience.

BACKGROUND: Antiarrhythmic therapy for recurrent ventricular arrhythmias in patients who have undergone catheter ablation, and in whom amiodarone and/or beta-blockers were ineffective or contraindicated, is a controversial issue. OBJECTIVE: The present study sought to evaluate the efficacy and tolerability of oral procainamide in patients with recurrent ventricular arrhythmias when the standard therapy strategy had failed. METHODS: All patients treated with procainamide for recurrent ventricular tachycardia (VT) or ventricular fibrillation (VF) in our institution between January 2010 and May 2019 were enrolled. The primary endpoint was the total number of implantable cardioverter-defibrillator (ICD) interventions after the beginning of procainamide therapy. Secondary endpoints were the total number of VTs and VFs recorded on the ICDs' controls and discontinuation of therapy. The events occurring during procainamide treatment were compared with a matched-duration period before the initiation of therapy with procainamide. Patients therefore served as self-controls. RESULTS: A total of 34 consecutive patients (32 male, 94.1%; mean age 74.4 ± 9.7 years) were included in the retrospective analysis. The mean time of procainamide treatment was 12.9 ± 13.7 months (median 9 [2-20] months). The mean dose of procainamide was 1207 ± 487 mg/day. Procainamide therapy significantly decreased ICD interventions (median 5 [0-22.5] vs 15.5 [3-32.25], P < .05). Procainamide also decreased the total number of VT/VF episodes (median 5.5 [0.75-30] vs 19 [7.5-30], P < .05). Only 3 patients (8.8%) presented severe side effects (dyspnea or hypotension), requiring discontinuation of therapy. CONCLUSION: Oral procainamide was associated with a significant decrease in ICD therapies and ventricular arrhythmias, showing an acceptable profile of tolerability.

[The Pacemaker and Implantable Cardioverter-Defibrillator Registry of the Italian Association of Arrhythmology and Cardiac Pacing - Annual report 2019]. / Registro Italiano Pacemaker e Defibrillatori - Bollettino Periodico 2019. Associazione Italiana di Aritmologia e Cardiostimolazione.

BACKGROUND: The pacemaker (PM) and implantable cardioverter-defibrillator (ICD) Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) monitors the main epidemiological data in real-world practice. The survey for the 2019 activity collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the Italian collaborating centers. METHODS: The Registry collects prospectively national PM and ICD implantation activity on the basis of European cards. RESULTS: PM Registry: data about 22 889 PM implantations were collected (19 621 first implants and 3268 replacements). The number of collaborating centers was 173. Median age of treated patients was 81 years (75 quartile I; 87 quartile III). ECG indications included atrioventricular conduction disorders in 33.3% of first PM implants, sick sinus syndrome in 16.4%, atrial fibrillation plus bradycardia in 11.6%, other in 38.7%. Among atrioventricular conduction defects, third-degree atrioventricular block was the most common type (18.3% of first implants). Use of single-chamber PMs was reported in 25.5% of first implants, of dual-chamber PMs in 67.1%, of PMs with cardiac resynchronization therapy (CRT) in 1.5%, and of single lead atrial-synchronized ventricular stimulation (VDD/R PMs) in 5.8%. ICD Registry: data about 17 328 ICD implantations were collected (12 129 first implants and 5199 replacements). The number of collaborating centers was 425. Median age of treated patients was 71 years (62 quartile I; 77 quartile III). Primary prevention indication was reported in 83.1% of first implants, secondary prevention in 16.9% (cardiac arrest in 5.9%). A single-chamber ICD was used in 26.1% of first implants, dual-chamber ICD in 28.0% and biventricular ICD in 45.9%. CONCLUSIONS: The PM and ICD Registry appears fundamental for monitoring PM and ICD utilization on a large national scale with rigorous examination of demographics and clinical indications. The PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The use of CRT-PM regards a very limited number of patients. The ICD Registry documented a large use of prophylactic and biventricular ICD, reflecting a favorable adherence to trials and guidelines in clinical practice. In order to increase and optimize the cooperation of Italian implanting centers, online data entry (https://www.aiac.it/riprid) should be adopted at large scale.

Trend of the main clinical characteristics and pacing modality in patients treated by pacemaker: data from the Italian Pacemaker Registry for the quinquennium 2003-07.

AIMS: To assess the impact on clinical practice of the major published studies, we report the information collected by the Italian Pacemaker Registry (IPR) in the quinquennium 2003-07. METHODS AND RESULTS: The IPR collected prospectively main epidemiological, clinical, and electrocardiographic data of patients treated by pacemaker (PM) in Italy on the basis of European PM Card. The number of reported PMs in Italy was 30,820 in 2003, 32,047 in 2004, 31,870 in 2005, 31,813 in 2006, and 31,146 in 2007, respectively. The median age was 79 years in all 5 years. Among the atrio-ventricular (AV) conduction defects, third-degree AV block was the most common occurrence. Of the sick sinus syndrome (SSS), sinus node dysfunction involved the majority of cases followed by bradycardia-tachycardia syndrome. Year-over-year percentages among the different indications remained stable. Syncope and dizzy spells were by far the most common symptoms. Dual-chamber pacing showed an increasing utilization in all the examined years. CONCLUSION: Italian PM Registry data for the study period reveal a stable pattern of PM utilization and indications. A higher use of dual-chamber pacing in comparison to single-chamber pacing was reported for all indications, despite inconclusive data of the major randomized trials.

Left Atrial Appendage Thrombosis and Persistent Atrial Fibrillation: combined Treatment with a Totally Thoracoscopic Approach.

Minimally invasive surgical ablation is generally contraindicated in patients with atrial fibrillation and thrombosis of the left atrial appendage. We have treated three of these patients using an innovative technique based on a bilateral video-thoracoscopic approach, performing a continuous encircling lesion at the pulmonary veins outflow with radio-frequency ablation, simultaneously excluding the left atrial appendage. The postoperative course was uneventful, without neurologic events and all patients maintained a stable sinus rhythm at 1-year follow-up. This procedure represents a new mini-invasive method to treat persistent atrial fibrillation when partial thrombosis of the left atrial appendage contraindicates other ablation techniques.

[The Pacemaker and Implantable Cardioverter-Defibrillator Registry of the Italian Association of Arrhythmology and Cardiac Pacing - Annual report 2018]. / Registro Italiano Pacemaker e Defibrillatori - Bollettino Periodico 2018. Associazione Italiana di Aritmologia e Cardiostimolazione.

BACKGROUND: The pacemaker (PM) and implantable cardioverter-defibrillator (ICD) Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) monitors the main epidemiological data in real-world practice. The survey for the 2018 activity collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the Italian collaborating centers. METHODS: The Registry collects prospectively national PM and ICD implantation activity on the basis of European cards. RESULTS: PM Registry: data about 23 912 PM implantations were collected (20 084 first implants and 3828 replacements). The number of collaborating centers was 180. Median age of treated patients was 81 years (75 quartile I; 86 quartile III). ECG indications included atrioventricular conduction disorders in 34.5% of first PM implants, sick sinus syndrome in 18.3%, atrial fibrillation plus bradycardia in 13.0%, other in 34.2%. Among atrioventricular conduction defects, third-degree atrioventricular block was the most common type (19.2% of first implants). Use of single-chamber PMs was reported in 24.9% of first implants, of dual-chamber PMs in 67.6%, of PMs with cardiac resynchronization therapy (CRT) in 1.6%, and of single lead atrial-synchronized ventricular stimulation (VDD/R PMs) in 5.9%. ICD Registry: data about 18 353 ICD implantations were collected (13 944 first implants and 4359 replacements). The number of collaborating centers was 433. Median age of treated patients was 71 years (63 quartile I; 78 quartile III). Primary prevention indication was reported in 84.3% of first implants, secondary prevention in 15.7% (cardiac arrest in 5.3%). A single-chamber ICD was used in 27.9% of first implants, dual-chamber ICD in 31.9% and biventricular ICD in 40.2%. CONCLUSIONS: The PM and ICD Registry appears fundamental for monitoring PM and ICD utilization on a large national scale with rigorous examination of demographics and clinical indications. The PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The use of CRT-PM regards a very limited number of patients. The ICD Registry documented a large use of prophylactic and biventricular ICD, reflecting a favorable adherence to trials and guidelines in clinical practice. In order to increase and optimize the cooperation of Italian implanting centers, online data entry (http://www.aiac.it/riprid) should be adopted at large scale.

Impact of the main implantable cardioverter-defibrillator trials in clinical practice: data from the Italian ICD Registry for the years 2005-07.

AIMS: Several studies have demonstrated the life-saving role of implantable cardioverter-defibrillator (ICD) therapy. In order to evaluate the effects of major trials in clinical practice, we report the clinical data of patients enrolled in the Italian ICD Registry for the years 2005-07. METHODS AND RESULTS: The Registry collects prospectively national ICD implantation activity on the basis of EURID Card. The number of ICDs per million of inhabitants was 180.6 in the year 2005, 192.5 in the year 2006, and 220.6 in the year 2007 (P = 0.02). The median age was 69 years for all 3 years considered. Implantable cardioverter-defibrillator implantation for primary prevention concerned 4692 patients in 2005 (44.2%), 5938 patients in 2006 (52.2%), 7324 patients in 2007 (55.7%) and for secondary prevention 5921 patients in 2005 (55.8%), 5447 patients in 2006 (47.8%), and 5828 patients in 2007 (44.3%). Single-chamber ICDs were implanted in 30.9, 31.0, and 28.5% of patients, dual chamber ICDs in 31.9, 31.5, and 31.7%, and biventricular ICDs in 37.2, 37.5, and 39.8%, respectively. CONCLUSION: The ICD implantation rate in Italy increased significantly in the period 2005-07. The registry showed a significant increase in prophylactic and biventricular ICD use, reflecting a favourable adherence to trials and guidelines in the clinical practice.

Use of implantable cardioverter-defibrillator in inherited arrhythmogenic diseases: data from Italian ICD Registry for the years 2001-6.

BACKGROUND: Previous studies have demonstrated the lifesaving role of an implantable cardioverter-defibrillator (ICD) in high-risk patients with genetic arrhythmogenic diseases. AIM: To evaluate the clinical data of patients with hypertrophic cardiomyopathy (HCM), arrhythmogenic right ventricular cardiomyopathy (ARVD/C), idiopathic ventricular arrhythmia (IDIO-VA) including Brugada syndrome, short QT syndrome, and long QT syndrome (LQT) enrolled in the Italian ICD Registry in the years 2001-6. METHODS: The survey collected prospectively clinical data and technical characteristics of ICD implants on the basis of EURID form. RESULTS: The number of patients was 1,274 in the HCM group, 520 in the ARVD/C group, 460 in the IDIO-VA group, and 245 in the LQT group. Primary prevention involved 29.5% of patients in the HCM group, 15.9% in the ARVD/C group, 16.9% in the IDIO-VA group, and 16.6% in the LQT group, respectively. Ventricular tachycardia and ventricular fibrillation were reported in 49.0% and 24.8% in the HCM group, 72.9% and 20.0% in the ARVD/C group, 48.2% and 42.9% in the IDIO-VA group, and 21.2% and 61.6% in the LQT group, respectively. Single-, dual-, and triple-chamber ICDs were implanted in 41.5%, 47.6%, and 10.9% in the HCM group; 57.9%, 36.7%, and 5.4% in the ARVD/C group; 55.0%, 45.0%, and 0% in the IDIO-VA group; and 57.4%, 42.6%, and 0% in LQT group, respectively. CONCLUSION: ICD therapies in the years 2001-6 for patients with inherited arrhythmia syndromes were utilized in Italy in a still-limited number of patients. Secondary prevention represented the major indication for ICD implant and the majority of patients were treated by single-chamber ICDs.

[The Pacemaker and Implantable Cardioverter-Defibrillator Registry of the Italian Association of Arrhythmology and Cardiac Pacing - Annual report 2017]. / Registro Italiano Pacemaker e Defibrillatori Bollettino Periodico 2017 Associazione Italiana di Aritmologia e Cardiostimolazione.

BACKGROUND: The pacemaker (PM) and implantable cardioverter-defibrillator (ICD) Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) monitors the main epidemiological data in real-world practice. The survey for the 2017 activity collects information about demographics, clinical characteristics, main indications for PM/ICD therapy and device types from the Italian collaborating centers. METHODS: The Registry collects prospectively national PM and ICD implantation activity on the basis of European cards. RESULTS: PM Registry: data about 23 457 PM implantations were collected (19 378 first implant and 4079 replacements). The number of collaborating centers was 185. Median age of treated patients was 81 years (75 quartile I; 86 quartile III). ECG indications included atrioventricular conduction disorders in 37.1% of first PM implants, sick sinus syndrome in 19.5%, atrial fibrillation plus bradycardia in 13.2%, other in 30.2%. Among atrioventricular conduction defects, third-degree atrioventricular block was the most common type (21.0% of first implants). Use of single-chamber PMs was reported in 25.6% of first implants, of dual-chamber PMs in 66.7%, of PMs with cardiac resynchronization therapy (CRT) in 1.4%, and of single lead atrial-synchronized ventricular stimulation (VDD/R PMs) in 6.3%. ICD Registry: data about 19 023 ICD implantations were collected (13 898 first implants and 5125 replacements). The number of collaborating centers was 437. Median age of treated patients was 71 years (63 quartile I; 78 quartile III). Primary prevention indication was reported in 81.8% of first implants, secondary prevention in 18.2% (cardiac arrest in 6.4%). A single-chamber ICD was used in 27.0% of first implants, dual-chamber in 33.6% and biventricular in 39.3%. CONCLUSIONS: The PM and ICD Registry appears fundamental for monitoring PM and ICD utilization on a large national scale with rigorous examination of demographics and clinical indications. The PM Registry showed stable electrocardiographic and symptom indications, with an important prevalence of dual-chamber pacing. The use of CRT-PM regards a very limited number of patients. The ICD Registry documented a large use of prophylactic and biventricular ICD, reflecting a favorable adherence to trials and guidelines in clinical practice. In order to increase and optimize the cooperation of Italian implanting centers, online data entry (http://www.aiac.it/riprid) should be adopted at large scale.

Prognostic role of non-sustained ventricular tachycardia detected with remote interrogation in a pacemaker population.

BACKGROUND: Non-sustained ventricular tachycardia (NSVT) can occur asymptomatically and can be incidentally detected in the internal records of pacemakers (PM). The clinical value of NSVT in the population of PM patients is still uncertain.Our aim was to assess the prevalence of NSVT detected by remote PM control, to describe the clinical and demographic characteristics of patients with NSVT, and to assess the prognostic significance of NSVT in terms of both overall and cardiovascular mortality. METHODS: Consecutive patients followed with PM remote interrogations from September 2010 to December 2015 were included. The transmissions pertaining to the first 12 months of remote control were analysed and the patients were divided by those presenting NSVT and those without NSVT. The two groups were compared in terms of total mortality and cardiovascular mortality based on the administrative data provided by the regional administration of the Italian National Health System. RESULTS: The prevalence of NSVT in 408 patients (62% males, mean age 75.6; SD 10.6 years old) was 21% in a year. During a mean follow-up duration of 44 months, NSVT did not emerge as independently associated with overall mortality, but was associated with cardiovascular mortality in a competing risk regression model with older age, male gender, diabetes, chronic renal insufficiency, ischemic cardiomyopathy and chronic obstructive pulmonary disease. CONCLUSIONS: We show that NSVT episodes recorded by remote control in a PM population are independently associated with cardiovascular mortality with possible implications for risk stratification and therapeutic options.

Radiofrequency ablation of drug-refractory atrial fibrillation: an observational study comparing 'ablate and pace' with pulmonary vein isolation.

AIMS: To compare clinical characteristics, procedure complexity, acute and long-term outcome of 'ablate and pace' (A&P) with pulmonary vein isolation (PVI) in patients with drug-refractory atrial fibrillation (AF). So far, only few small studies have compared the two procedures. METHODS AND RESULTS: We analysed retrospectively a cohort of symptomatic consecutive patients with drug-refractory AF. Group 1 included 100 patients treated with A&P and Group 2 included 144 patients treated with PVI. Group 1 patients were older (74 +/- 8 vs. 56 +/- 9 years; P < 0.0001), had lower left ventricular ejection fraction (50 +/- 13% vs. 59 +/- 7%; P < 0.05), and a lower prevalence of paroxysmal AF (46% vs. 65%; P < 0.05). Acute success was not statistically different (98% vs. 92.3%, P = ns). Group 1 patients had shorter procedure time and lower radiation exposure with respect to Group 2 patients (70 +/- 15 vs. 204 +/- 58 min, and 8 +/- 4 vs. 57 +/- 22 min; P < 0.0001, respectively). After a median follow-up of 29 months (I, III quartile; 15, 40 months) vs. 25 months (I, III quartile; 8, 36 months) (P = ns), all the patients in Group 1 were free of symptomatic AF, while 113 patients (79%) of Group 2 were in stable sinus rhythm (P < 0.0001). Persistent or permanent AF has been documented in 58 patients (58%) of Group 1 vs. 11 (8%) of Group 2 (P < 0.0001). CONCLUSION: In this series (i) patients treated with A&P and PVI for drug-refractory AF showed significant differences in clinical profile; (ii) A&P is a shorter and less complex procedure, but is associated with a higher rate of persistent AF; (iii) symptomatic recurrences of paroxysmal AF were more frequent in PVI group. Randomized studies appear necessary to identify the best strategy in selected cases.