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.

Impact of monitoring on detection of arrhythmia recurrences in the ESC-EHRA EORP atrial fibrillation ablation long-term registry.

AIMS: Monitoring of patients after ablation had wide variations in the ESC-EHRA atrial fibrillation ablation long-term (AFA-LT) registry. We aimed to compare four different monitoring strategies after catheter AF ablation. METHODS AND RESULTS: The ESC-EHRA AFA-LT registry included 3593 patients who underwent ablation. Arrhythmia monitoring during follow-up was performed by 12-lead electrocardiogram (ECG), Holter ECG, trans-telephonic ECG monitoring (TTMON), or an implanted cardiac monitoring (ICM) system. Patients were selected to a given monitoring group according to the most extensive ECG tool used in each of them. Comparison of the probability of freedom from recurrences was performed by censored log-rank test and presented by Kaplan-Meier curves. The rhythm monitoring methods were used among 2658 patients: ECG (N = 578), Holter ECG (N = 1874), TTMON (N = 101), and ICM (N = 105). A total of 767 of 2658 patients (28.9%) had AF recurrences during follow-up. Censored log-rank test discovered a lower probability of freedom from relapses, which was detected with ICM compared to TTMON, ECG, and Holter ECG (P < 0.001). The rate of freedom from AF recurrences was 50.5% among patients using the ICM while it was 65.4%, 70.6%, and 72.8% using the TTMON, ECG, and Holter ECG, respectively. CONCLUSION: Comparing all main electrocardiographic monitoring methods in a large patient sample, our results suggest that post-ablation recurrences of AF are significantly underreported by TTMON, ECG, and Holter ECG. The ICM estimates AF ablation recurrences most reliably and should be a preferred mode of monitoring for trials evaluating novel AF ablation techniques.

Updated national multicenter registry on procedural safety of catheter ablation for atrial fibrillation.

INTRODUCTION: Despite catheter ablation (CA) becoming an accepted treatment option for symptomatic, drug-resistant atrial fibrillation (AF), safety of this procedure continues to be cause for concern. Aim of the present multicenter registry was to assess the incidence of early CA complications and detect their predictors in a contemporary, unselected AF population METHODS AND RESULTS: From January 1, 2011 to December 31, 2011, data from 2,323 consecutive patients who underwent CA (median age 60 [52-67]; 72.3% male) for AF in 29 Italian centers were collected. All major complications occurring to the patient from admission to 30th postprocedural day were recorded. No procedure-related death was observed. Major complications occurred in 94 patients (4.0%): 50 patients (2.2%) suffered vascular access complications; 12 patients (0.5%) developed cardiac tamponade; 14 patients (0.6%) presented with pericarditis; 5 patients (0.2%) had transient ischemic attack; 4 patients had stroke; 3 patients (0.1%) had phrenic nerve paralysis; 3 patients (0.1%) had hemothorax. Other isolated but serious adverse events were documented in 3 patients (0.1%). Female gender (OR 2.643; 95% CI 1.686-4.143; P < 0.0001) and longer procedural duration (OR 2.195; 95% CI 1.388-3.473; P < 0.001) independently predicted a higher risk of complications. CONCLUSION: Major complications occurred in 4.0% of the CA procedures for AF, with vascular access complications being the most frequent events.

Stereotactic Arrhythmia Radioablation Treatment of Ventricular Tachycardia: Current Technology and Evolving Indications.

Ventricular tachycardia in patients with structural heart disease is a significant cause of morbidity and mortality. According to current guidelines, cardioverter defibrillator implantation, antiarrhythmic drugs, and catheter ablation are established therapies in the management of ventricular arrhythmias but their efficacy is limited in some cases. Sustained ventricular tachycardia can be terminated by cardioverter-defibrillator therapies although shocks in particular have been demonstrated to increase mortality and worsen patients' quality of life. Antiarrhythmic drugs have important side effects and relatively low efficacy, while catheter ablation, even if it is actually an established treatment, is an invasive procedure with intrinsic procedural risks and is frequently affected by patients' hemodynamic instability. Stereotactic arrhythmia radioablation for ventricular arrhythmias was developed as bail-out therapy in patients unresponsive to traditional treatments. Radiotherapy has been mainly applied in the oncological field, but new current perspectives have developed in the field of ventricular arrhythmias. Stereotactic arrhythmia radioablation provides an alternative non-invasive and painless therapeutic strategy for the treatment of previously detected cardiac arrhythmic substrate by three-dimensional intracardiac mapping or different tools. Since preliminary experiences have been reported, several retrospective studies, registries, and case reports have been published in the literature. Although, for now, stereotactic arrhythmia radioablation is considered an alternative palliative treatment for patients with refractory ventricular tachycardia and no other therapeutic options, this research field is currently extremely promising.

Subcutaneous ICD Implantation and Catheter Ablation: A Step-Planned Approach for Ventricular Tachycardia Management in ARVC.

Secondary prevention of sudden cardiac death in the young patient with arrhythmogenic right ventricular cardiomyopathy and hemodynamically tolerated ventricular tachycardia is still a challenging field. We present a combined approach, including subcutaneous implantable cardioverter-defibrillator (ICD) and catheter ablation, as a promising treatment to prevent both ventricular tachycardia recurrences and ICD shocks. (Level of Difficulty: Intermediate.).

Atrial fibrillation ablation: is common practice far from guidelines' world? The Italian experience from a national survey.

PURPOSE: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, occurring in 1-2% of the general population. Catheter ablation has become an important treatment modality for patients with symptomatic drug-refractory AF. We report data regarding the AF ablation approaches and modalities in the Italian "real world." METHODS: The survey was set-up to collect data on ablation procedure across Italy. All centers performing AF ablation were invited, regardless of the number of annual procedures, to complete a questionnaire regarding their ablation approaches. All centers reported data regarding procedures performed during the year 2017. RESULTS: A total of 3260 procedures were reported from 49 participating hospitals. Most of Italian regions were included in the study. The majority of the centers performed "Always" pulmonary vein isolation (PVI) in paroxysmal and persistent AF catheter ablation, while adjunctive lesions in persistent AF ablation were planned in most of them but not all, and 16% never performed lesions other than PVI. During ablation procedure, vitamin k inhibitors were uninterrupted in 55% of centers, while direct oral anticoagulant in 44% of centers was used uninterruptedly. No relationship was observed between patient data and the number of procedures performed at each center. CONCLUSIONS: This survey suggests that the adherence of Italian centers to the most recent European Society of Cardiology guidelines for AF ablation is reasonably high.

Diagnosis and Treatment of Idiopathic Premature Ventricular Contractions: A Stepwise Approach Based on the Site of Origin.

Premature ventricular contractions in the absence of structural heart disease are among the most common arrhythmias in clinical practice, with well-defined sites of origin in the right and left ventricle. In this review, starting from the electrocardiographic localization of premature ventricular contractions, we investigated the mechanisms, prevalence in the general population, diagnostic work-up, prognosis and treatment of premature ventricular contractions, according to current scientific evidence.

Adherence to guidelines for atrial fibrillation management of patients referred to cardiology departments: Studio Italiano multicentrico sul Trattamento della Fibrillazione Atriale (SITAF).

AIMS: The purpose of this study was to evaluate adherence to national guidelines on the non-pharmacologic (ablative) treatment of atrial fibrillation (AF). METHODS AND RESULTS: This prospective, observational, transversal study enrolled 1256 consecutive in- and outpatients referred to 43 cardiology departments between 1 and 31 October 2008 for the management of AF as a primary diagnosis. A rhythm-control strategy (cardioversion, antiarrhythmic medication, pace-maker implantation, substrate ablation, alone or in combination) was prescribed in 865 (69%) of the patients and a rate-control strategy [drugs, atrioventricular junction ablation and pace-maker implantation (Ablate and Pace)] in 285 (23%). Specifically, substrate catheter ablation was indicated by the attending cardiologist in 187 (14.9%) patients and Ablate and Pace in 29 (2.3%). According to guideline indications, substrate catheter ablation would have been indicated in 183 (14.6%) patients, but only 105 (57%) of these were correctly identified by the attending cardiologist (K statistics for agreement for indications 0.49). Atrioventricular junction ablation and pace-maker implantation would have been indicated in 108 (8.6%) patients, but only 29 (27%) of these were correctly identified by the attending cardiologist (K statistics for agreement for indications 0.06). CONCLUSION: About a quarter of patients referred to cardiology departments for AF management have potential indications for non-pharmacological treatment according to the guidelines. Substrate catheter ablation was offered by the attending cardiologist in a percentage similar to that expected, but concordance with guideline indications was moderate. Atrioventricular junction ablation and pace-maker implantation was largely underused.

Proportion of patients needing an implantable cardioverter defibrillator on the basis of current guidelines: impact on healthcare resources in Italy and the USA. Data from the ALPHA study registry.

AIMS: Implantable cardioverter defibrillators (ICD) improve survival in selected patients with left ventricular dysfunction or heart failure (HF). The objective is to estimate the number of ICD candidates and to assess the potential impact on public health expenditure in Italy and the USA. METHODS AND RESULTS: Data from 3513 consecutive patients (ALPHA study registry) were screened. A model based on international guidelines inclusion criteria and epidemiological data was used to estimate the number of eligible patients. A comparison with current ICD implant rate was done to estimate the necessary incremental rate to treat eligible patients within 5 years. Up to 54% of HF patients are estimated to be eligible for ICD implantation. An implantation policy based on guidelines would significantly increase the ICD number to 2671 implants per million inhabitants in Italy and to 4261 in the USA. An annual increment of prophylactic ICD implants of 20% in the USA and 68% in Italy would be necessary to treat all indicated patients in a 5-year timeframe. CONCLUSION: Implantable cardioverter defibrillator implantation policy based on current evidence may have significant impact on public health expenditure. Effective risk stratification may be useful in order to maximize benefit of ICD therapy and its cost-effectiveness in primary prevention.

An unusual case of iatrogenic Twiddler's syndrome.

: Twiddler's syndrome is an uncommon cause of cardiac implantable electronic device malfunction, usually due to manipulation of the pulse generator. A few spontaneous cases have already been described. We present the unique case of a 77-year-old woman who experienced iatrogenic Twiddler's syndrome.

Atrial fibrillation ablation long-term ESC-EHRA EORP AFA LT registry: in-hospital and 1-year follow-up findings in Italy.

AIM: To report the Italian data deriving from the European Society of Cardiology-EURObservational Research Program atrial fibrillation ablation long-term registry. METHODS AND RESULTS: Ten Italian centers enrolled up to 50 consecutive patients undergoing atrial fibrillation ablation. Of the 318 patients included, 5 (1.6%) did not undergo catheter ablation, 1 had ablation partially done and 62 were lost at 1-year follow-up. Women were less represented (23.6%) and the median age was 60.0 years. A total of 195 patients (62.3%) suffered paroxysmal atrial fibrillation, whereas only 9 (2.9%) had long-standing persistent atrial fibrillation. Most Italian patients (92.3%) were symptomatic but suffering fewer symptomatic events than patients enrolled in other countries (median of two events in the month preceding the ablation vs. three, respectively; P < 0.0001). The main finding of the study is that the success rate at 1 year, with and without antiarrhythmic drugs, was 76.4%, consistently with other participating countries (73.4%). This result was obtained however, with a significantly lower prevalence of 1-year adverse events (7.3 vs. 16.6%, P < 0.0001). Procedure duration and fluoroscopy total time resulted as being shorter in Italy (145 vs. 160, P = 0.0005 and 16.9 vs. 20.0 min, P = 0.0018, respectively); however, the radiation dose per BSA was greater (37.5 vs. 26.0 mGy/cm, P = 0.0022). CONCLUSION: The demographic characteristics of patients undergoing atrial fibrillation ablation are similar to those reported in other countries. The success rate in Italy is consistent with those in other countries, whereas the complications rate is lower.

Predictors of mortality and hospitalization for cardiac causes in patients with heart failure and nonischemic heart disease: a subanalysis of the ALPHA study.

BACKGROUND: Several studies have searched for predictors of clinical outcome in patients with heart failure (HF). However, since they were collected in clinical trials, most data were subject to selection biases and do not specifically apply to patients with nonischemic heart disease. This study examined the impact of several variables on combined all-cause mortality and hospitalization for cardiac causes, in consecutive ambulatory patients with HF included in the ALPHA registry. METHODS AND RESULTS: This analysis included 446 patients with HF and nonischemic heart disease, in New York Heart Association functional class II or III, and a left ventricular (LV) ejection fraction below 40%. In 126 patients (73%) the disease was idiopathic dilated cardiomyopathy, in 72 (16%) hypertensive, in nine (2%) valvular, and in 39 (9%) of other etiologies. The median age was 61 years (range 51-69 years) and 349 (78%) patients were men. Over a median follow-up of 31 months (range 23-40), 82 patients (18%) died or were hospitalized for cardiac causes. In a proportional hazard (Cox) regression model, maximal oxygen consumption (HR 0.9, P = 0.001), LV end-diastolic diameter (HR 1.07, P < 0.001), resting systolic blood pressure (HR 0.97, P < 0.005), and hemoglobin (HR 0.86, P < 0.05) were independent predictors of the combined study endpoint. CONCLUSIONS: In an unselected population of patients with HF and nonischemic heart disease, a reduced exercise capacity, large LV end-diastolic diameter, low systolic blood pressure, and hemoglobin were correlated with long-term all-cause mortality or hospitalization for cardiac causes. These observations may help stratifying and tailoring the treatment of patients with HF and nonischemic heart disease.

Right ventricular free-wall scar: an exceptional source of post-infarction ventricular tachycardia. A case report.

BACKGROUND: In patients with coronary artery disease, ventricular tachycardia (VT) is usually related to left ventricular (LV) post-infarction scars. CASE SUMMARY: A case of a 78-year-old man with post-infarction VT originating from the right ventricular (RV) free wall is described. Following recurrent episodes of VT with left bundle branch block morphology and left superior axis deviation, a patient with prior myocardial infarction was submitted to catheter ablation. Two areas of abnormal bipolar electrograms were observed at 3D electroanatomical mapping: one located at the basal aspect of the posterior and postero-septal LV, and the other one extending from the antero-lateral to the posterior mid-basal RV free wall. Ventricular late potentials (LPs) were recorded within both scars, but only pacing from those located in the RV resulted in long stimulus-to-QRS latency and optimal pace-mapping. Accordingly, this substrate was deemed the culprit of the clinical VT. Radiofrequency catheter ablation aimed at eliminating all LPs recorded from both scars was effective in preventing VT recurrences at follow-up. DISCUSSION: A post-infarction RV free-wall scar may exceptionally be responsible of VT occurrence. Right ventricular mapping should be considered in selected cases based on 12-lead electrocardiogram VT morphology and prior RV infarct.

Cardiac autonomic regulation in patients undergoing pulmonary vein isolation for atrial fibrillation.

AIMS: Ablation procedures for the treatment of atrial fibrillation lead to changes in autonomic heart control; however, there are insufficient data on the possible association of these changes with atrial fibrillation recurrence. The study aim was to assess the effects of pulmonary vein isolation (PVI) on cardiac autonomic modulation and atrial fibrillation recurrence. METHODS: We screened 52 patients with atrial fibrillation referred for PVI, of whom 20 patients met inclusion and exclusion criteria, and were enrolled in the study and followed over 6 months. Beat-to-beat blood pressure monitoring was performed 1-2 days before PVI, 1 and 6 months after PVI. We estimated pulse interval variability and spontaneous baroreflex sensitivity (BRS) both in the time and frequency domains, and performed the Valsalva manoeuvre assessing the Valsalva ratio. RESULTS: During 6 months after PVI, atrial fibrillation recurrence was observed in six patients. One month after PVI, pulse interval variability and BRS (sequence method) significantly decreased in all patients, returning to preintervention values by 6 months. Patients without atrial fibrillation recurrence at 1 month showed a transient reduction in pulse interval variability (frequency domain) and in BRS (both methods) in contrast to those with atrial fibrillation recurrence. A significant decrease in the Valsalva ratio observed at 1 month was maintained at 6 months after PVI in both groups. CONCLUSION: Successful PVI may lead to transient autonomic alterations reflected by a reduction in pulse interval variability and BRS, with more prolonged changes in the Valsalva ratio. The efficacy of PVI in preventing atrial fibrillation recurrence seems to be related to transient parasympathetic atrial denervation.

Ablation of atrioventricular nodal "slow pathway" for simultaneous treatment of coexisting atrioventricular and nodal reciprocating tachycardias.

INTRODUCTION: We report the case of a 49-year-old male patient with recurrent palpitations and two different supraventricular reciprocating tachycardias due to atrioventricular (AV) nodal reentry and orthodromic AV reentry sustained by a left-sided, concealed AV accessory pathway (AP). METHODS AND RESULTS: During the baseline electrophysiological study, dual AV nodal conduction (90 ms jump) and non-decremental, eccentric, ventriculo-atrial conduction due to a left-sided, unidirectional, postero-septal AP were documented. Both typical AV nodal reentrant and orthodromic AV reentrant tachycardias were induced by programmed electrical stimulation. In both cases, shift and sustained conduction over the AV "slow pathway" were required for tachycardia induction and maintenance, respectively. Accordingly, catheter ablation was performed by targeting the AV nodal "slow pathway" first with radiofrequency current applications delivered at the inferior portion of the Koch's triangle. Irritative, slow-rate junctional rhythm was observed during ablation. Afterward, programmed electrical stimulation demonstrated a continuous AV nodal conduction curve, persistent conduction over the AP, and only single orthodromic AV echo beat inducible under baseline condition and pharmacological stress (atropine 0.02 mg/kg i.v. bolus and continuous isoprenaline i.v. administration). Sustained reentrant tachycardias were not inducible any more. For these reasons, the procedure was stopped without any attempt to ablate the AP. After a 4 years follow-up the patient is still asymptomatic without antiarrhythmic drug usage. CONCLUSION: AV nodal "slow pathway" ablation may abolish both typical AV nodal reentry tachycardia and orthodromic AV reentry tachycardia induction when the latter arrhythmia is dependent from AV nodal "slow pathway" conduction for induction and maintenance. This ablation strategy could be considered, under some instances (e.g. right antero-septal accessory pathways, older patients, etc), in order to reduce the procedure risks due to multiple arrhythmia substrate ablations.

Successful treatment of anteroseptal accessory pathways by transvenous cryomapping and cryoablation.

Radiofrequency is the most commonly used energy source for the treatment of cardiac arrhythmias. Despite its high success rate, radiofrequency energy may sometimes present limitations, especially in case of anteroseptal atrioventricular accessory pathways. In these patients, inadvertent atrioventricular block may occur during or after the procedure and a high recurrence rate of conduction over the accessory pathway is observed. Since the late 1970s, cryosurgery has been an integral part of the management of cardiac arrhythmias, and recently, animal and clinical studies demonstrated the feasibility and safety of applying percutaneous catheter cryoablation technology. These studies also showed that reversible cryomapping of high-risk arrhythmogenic sites can be performed before creating permanent lesions. In this preliminary report, we describe the successful use of percutaneous cryoablation for the permanent interruption of conduction over anteroseptal accessory pathways.

The ALPHA study (T-wave alternans in patients with heart failure): rationale, design and endpoints.

BACKGROUND: Sudden death and pump failure are the main causes of death in patients with heart failure. Patients with ischemic and non-ischemic cardiomyopathy are at similar risk of arrhythmic mortality; however, standard non-invasive and invasive tests are not routinely available for non-ischemic patients. T-wave alternans (TWA) has been proposed as a potential marker of susceptibility to ventricular tachycardia-fibrillation in several groups of patients. METHODS: The ALPHA study was designed to evaluate the independent predictive value of the measurement of microvolt TWA on the combined occurrence, after 18 months of follow-up, of cardiac death and life-threatening arrhythmias in a population of patients with non-ischemic dilated cardiomyopathy and NYHA class II and III. This is a multicenter prospective observational study. A total of 370 patients, with measurable TWA, will be enrolled during routine follow-up for heart failure treatment; a logbook will be used to collect basic information on the whole screened population. Patients will be enrolled during a 2-year period and will be followed up for 18 months. The primary endpoint of the study will be the combined incidence of cardiac death and life-threatening ventricular arrhythmias. The study will complete recruitment by mid 2004 and report in 2006.