Coronary sinus and great cardiac vein electroanatomic mapping predicts the activation delay of the coronary sinus branches.

BACKGROUND: Implantation of left ventricular (LV) lead in segments with delayed electrical activation may improve response to cardiac resynchronization therapy (CRT). The search for the latest LV electrical delay (LVED) site can be time-consuming. OBJECTIVE: To assess if electrical mapping of coronary sinus (CS) and magna cardiac vein can help to identify the latest activated CS branch. METHODS: We retrospectively evaluated 48 consecutive patients who underwent electroanatomic mapping system-guided (EAMS)-CRT device implantation with ≥2 mapped CS branches. The activation mapping of the CS and relative branches were performed using an insulated guide wire. LVED was defined as the interval between the beginning of the QRS complex on the surface electrocardiogram and the local electrogram and expressed in milliseconds (ms). RESULTS: Thirty-two (67%) patients showed left bundle branch block (LBBB) and 16 (33%) non-LBBB electrocardiographic patterns. A total of 116 CS branches (mean, 2.4/patient; range, 2-5) were mapped. In the left oblique view, most patients (N = 39, 81%) showed the latest CS-LVED in lateral segments while nine (19%) showed the latest CS-LVED in anterior or posterior segments. Specifically, 94% of patients with LBBB showed the latest CS-LVED in lateral segments while CS activation among non-LBBB patients was heterogeneous. In all patients, the CS branch that demonstrated the highest LVED originated from the latest activated segment of the CS. CONCLUSION: Electrical mapping of CS allows identifying the latest activated branches. This finding may contribute to simplify CRT device implantation compared to activation mapping of all the branches.

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.

Clinical impact, safety, and accuracy of the remotely monitored implantable loop recorder Medtronic Reveal LINQTM.

Aims: Implantable loop recorders (ILR) are indicated in a variety of clinical situations when extended cardiac rhythm monitoring is needed. We aimed to assess the clinical impact, safety, and accuracy of the new Medtronic Reveal LINQTM ILR that can be inserted outside the electrophysiology (EP) laboratory and remotely monitored. Methods and results: All 154 consecutive patients (100 males, 63 ± 15 year-old) who received the Reveal LINQTM ILR during the period July 2014-June 2016 were enrolled. The device was implanted in a procedure room and all patients where provided with the MyCareLinkTM remote monitoring system. Data were reviewed every working day via the Carelink® web system by a specialist nurse who, in case of significant events, consulted an electrophysiologist. During a mean follow-up of 12.1 (6.7-18.4) months (range 2-24 months), a diagnosis was made in 99 (64%) patients and in 60 (39%) ≥1 therapeutic interventions were established following recording of arrhythmias. In 26 of these 60 patients, remote monitoring prompted therapeutic interventions following asymptomatic arrhythmic events 3.8 months before the next theoretical scheduled in-office data download. False bradycardia detection for undersensing occurred in 44 (29%) patients and false tachycardia detection for oversensing in 4 (3%). One patient experienced skin erosion requiring explantation and none suffered from infection. Conclusion: The remote monitoring feature of the Reveal LINQTM allowed earlier diagnosis of asymptomatic but serious arrhythmias in a significant proportion of patients. Implantation of the device outside the EP laboratory appeared safe. However, R-wave undersensing and consequent false recognition of bradyarrhythmias remains a clinically important technical issue.

Pulmonary Vein Isolation with the Cryoballoon Technique: Feasibility, Procedural Outcomes, and Adoption in the Real World: Data from One Shot Technologies TO Pulmonary Vein Isolation (1STOP) Project.

BACKGROUND: Catheter ablation (CA) is recommended for patients with drug refractory symptomatic atrial fibrillation (AF). "One Shot" catheters have been introduced to simplify CA and cryoballoon ablation (CBA) is spreading rapidly. Few real-world data are available on standard clinical practice, mainly from single-center experience. We aimed to evaluate clinical settings, demographics, and acute procedural outcomes in a large cohort of patients treated with CBA. METHODS: A total of 903 patients (73% male, mean age 59 ± 11) underwent pulmonary vein CBA. Correlations between the patient's inclusion time and clinical characteristics, procedure duration, acute success rate, and intraprocedural complications were evaluated. RESULTS: Seventy-seven percent of patients were affected by paroxysmal AF and 23% by persistent AF. Overall, acute success rate was 97.9% and periprocedural complications were observed in 35 (3.9%) patients, 13 (1.4%) of which were classified as major complications. With respect to the patient's inclusion time analysis, an increase in treatment of persistent AF was observed, a significant decrease in CBA times (procedure, ablation, and fluoroscopy: 136.0 ± 46.5 minutes, 28.8 ± 19.6 minutes, and 34.3 ± 15.4 minutes, respectively) was observed, with comparable acute success rate and intraprocedural complications over time. The rate of major complications was extremely low (1.4%); no death, atrioesophageal fistula, stroke, or other major periinterventional or late complications occurred. CONCLUSION: This series represents the largest experience of CBA in the treatment of AF that also describes the adoption curve of this relatively recent technology. CBA showed an excellent safety profile when performed in a large real-world clinical setting, with satisfactory acute success rate and, on average, short procedural times. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov (NCT01007474).

Reduction of inappropriate anti-tachycardia pacing therapies and shocks by a novel suite of detection algorithms in heart failure patients with cardiac resynchronization therapy defibrillators: a historical comparison of a prospective database.

AIMS: Implantable cardioverter defibrillators improve survival of patients at risk for ventricular arrhythmias, but inappropriate shocks occur in up to 30% of patients and have been associated with worse quality of life and prognosis. In heart failure patients with cardiac resynchronization therapy defibrillators (CRT-Ds), we evaluated whether a new generation of detection and discrimination algorithms reduces inappropriate shocks. METHODS AND RESULTS: We analysed 1983 Medtronic CRT-D patients (80% male, 67 ± 10 years), 1368 with standard devices (Control CRT-D) and 615 with new generation devices (New CRT-D). Expert electrophysiologists reviewed and classified the electrograms of all device-detected ventricular tachycardia/fibrillation episodes. Total follow-up was 3751 patients-years. Incidence of inappropriate shocks at 1 year was 2.8% [95% confidence interval (CI) = 2.0-3.5] in Control CRT-D and 0.9% (CI = 0.4-2.2) in New CRT-D (hazard ratio = 0.37, CI = 0.21-0.66, P < 0.001). In New CRT-D, inappropriate shocks were reduced by 77% [incidence rate ratio (IRR) = 0.23, CI = 0.16-0.35, P < 0.001] and inappropriate anti-tachycardia pacing by 81% (IRR = 0.19, CI = 0.11-0.335, P < 0.001). Annual rate per 100 patient-years for appropriate VF detections was 3.0 (CI = 2.1-4.2) in New CRT-D and 3.2 (CI = 2.1-5.0) in Control CRT-D (P = 0.68), for syncope was 0.4 (CI = 0.2-0.9) in New CRT-D and 0.7 (CI = 0.5-1.0) in Control CRT-D (P = 0.266), and for death was 1.0 (CI = 0.6-1.6) in New CRT-D and 3.5 (CI = 3.0-4.1) in Control CRT-D (P < 0.001). CONCLUSION: Detection and discrimination algorithms used in new generation CRT-D significantly reduced inappropriate shocks when compared with standard CRT-D. This result, with no compromise on VF sensitivity or risk of syncope, has important implications for patients' quality of life and prognosis.

Spontaneous and adenosine-induced pulmonary vein reconnection after cryoballoon ablation with the second-generation device.

INTRODUCTION: Longer observational time and adenosine challenge have proven to be able to detect pulmonary vein (PV) reconnections. The aim of this study was to assess incidence of spontaneous and adenosine-induced PV reconnection after ablation with second-generation cryoballoon (CB-Adv). METHODS AND RESULTS: Fifty consecutive patients (76% male, mean age 60.5 ± 11.9 years) having undergone PV isolation (PVI) using the CB-Adv were enrolled. After isolation, reconnections were evaluated using the Achieve catheter over 30 minutes observation and adenosine administration during isoproterenol infusion (adenosine challenge). Among 200 PVs, isolation was achieved in 190 (95%) during the first application. Lower nadir temperature and longer rewarming time were associated with successful PVI (P = 0.02 and 0.04). Spontaneous (4 veins) and adenosine-induced (4 veins) PV reconnections occurred in the 4% of initially isolated veins (8 veins) in 6 patients (12%). At receiver-operator curve analysis, nadir temperature <-51 °C and rewarming time >28 seconds identified absence of reconnections (sensitivity 100% and 87%, area under the curve 0.75 and 0.72). Patients with right-sided early branching frequently experienced reconnections (P < 0.01). After a mean follow-up of 7.0 ± 1.7 months, 86% of patients were free from atrial fibrillation. None of those with PV reconnections experienced recurrences. CONCLUSIONS: The incidence of spontaneous and adenosine-induced PV reconnection following ablation with the novel CB-Adv is very low occurring in 4% of initially isolated veins. Nadir temperature <-51 °C and rewarming time >28 seconds identified absence of acute reconnections, thus avoiding prolonged waiting time and adenosine challenge in such cases.

Improving atrial fibrillation detection in patients with implantable cardiac devices by means of a remote monitoring and management application.

BACKGROUND: Atrial fibrillation (AF) is common in patients with cardiac implantable electronic devices (CIED) and has been associated with an increased stroke risk. The aim of our project was to assess the clinical value of a web-based application, Discovery Link AFinder, in improving AF detection in CIED patients. METHODS AND RESULTS: Seven Italian hospitals performed an observational study consisting of four phases. During phase 1, expert nurses and cardiologists prospectively followed-up CIED patients via in-hospital examinations and remote monitoring, and classified clinically relevant events, particularly AF occurrence. During phase 2, Discovery Link AFinder was exploited to identify patients who had suffered AF in the previous 12 months through the systematic scanning of device data remote transmissions. Phases 3 and 4 were repetitions of phases 1 and 2, respectively, and were implemented 6 months after the previous phases. A total of 472 consecutive patients were included in phase 1; AF occurred in 170 patients, 61 of whom were identified as new AF patients. Evidence of AF during this phase prompted prescription of oral anticoagulation (OAC) therapy in 30 patients. In phase 2, AFinder uncovered new AF, unidentified in phase 1, in 54 patients and prompted implementation of OAC therapy in 11 patients. During phase 3, 30 new AF patients were identified by means of remote monitoring, while during phase 4, a further three AF patients were identified by AFinder only. CONCLUSIONS: The AFinder web-based software, applied on top of standard in-hospital and remote monitoring, improved AF detection and enabled OAC treatment to be undertaken.

Transvenous lead extraction of lumenless 3830 pacing lead in conduction system pacing: a single-center experience.

BACKGROUND: The Medtronic SelectSecure Model 3830 lumenless lead (Medtronic, Inc., Minneapolis, MN) is commonly used for conduction system pacing (CSP). However, with this increased use, the potential need for transvenous lead extraction (TLE) also will increase. While extraction of endocardial 3830 leads is rather well described especially in pediatric and adult congenital heart disease population, there is very limited data on extraction of CSP leads. In the present study, we reported our preliminary experience on TLE of CSP leads and provided technical considerations. METHODS: The study population comprised 6 consecutive patients (67% male; mean age 70 ± 22 years) with CSP leads (3830 leads), including left bundle branch pacing (LBBP) lead (n = 3) and His pacing lead (n = 3) undergoing TLE. Overall target leads were 17. The mean implant duration time of CSP leads was 97 ± 90 months [range 8-193). RESULTS: Manual traction was successful in 2 cases and mechanical extraction tools were required in the remaining cases. Sixteen leads (94%) were completely extracted, whereas incomplete removal was observed in one lead (6%) among 1 patient. Of note, in the only lead incompletely removed, we observed retention of < 1-cm remnant of lead material consisting of the screw of 3830 LBBP lead into the interventricular septum. No failure of lead extraction was reported and no major complications occurred. CONCLUSIONS: Our findings demonstrated that at an experienced center the success of TLE of chronically implanted CSP leads is high in the absence of major complications also when mechanical extraction tools are needed.

Personalized computational electro-mechanics simulations to optimize cardiac resynchronization therapy.

In this study, we present a computational framework designed to evaluate virtual scenarios of cardiac resynchronization therapy (CRT) and compare their effectiveness based on relevant clinical biomarkers. Our approach involves electro-mechanical numerical simulations personalized, for patients with left bundle branch block, by means of a calibration obtained using data from Electro-Anatomical Mapping System (EAMS) measures acquired by cardiologists during the CRT procedure, as well as ventricular pressures and volumes, both obtained pre-implantation. We validate the calibration by using EAMS data coming from right pacing conditions. Three patients with fibrosis and three without are considered to explore various conditions. Our virtual scenarios consist of personalized numerical experiments, incorporating different positions of the left electrode along reconstructed epicardial veins; different locations of the right electrode; different ventriculo-ventricular delays. The aim is to offer a comprehensive tool capable of optimizing CRT efficiency for individual patients. We provide preliminary answers on optimal electrode placement and delay, by computing some relevant biomarkers such as d P / d t max , ejection fraction, stroke work. From our numerical experiments, we found that the latest activated segment during sinus rhythm is an effective choice for the non-fibrotic cases for the location of the left electrode. Also, our results showed that the activation of the right electrode before the left one seems to improve the CRT performance for the non-fibrotic cases. Last, we found that the CRT performance seems to improve by positioning the right electrode halfway between the base and the apex. This work is on the line of computational works for the study of CRT and introduces new features in the field, such as the presence of the epicardial veins and the movement of the right electrode. All these studies from the different research groups can in future synergistically flow together in the development of a tool which clinicians could use during the procedure to have quantitative information about the patient's propagation in different scenarios.

Permanent His-bundle pacing maintains long-term ventricular synchrony and left ventricular performance, unlike conventional right ventricular apical pacing.

AIMS: Right ventricular apical pacing (RVAP) may be deleterious, determining abnormal left ventricular (LV) electrical activation and progressive LV dysfunction. Permanent His-bundle pacing (HBP) has been proposed to prevent this detrimental effect. The aim of our study was to compare the long-term effects of HBP on LV synchrony and systolic performance with those of RVAP in the same group of patients. METHODS: Our analysis included 26 patients who received both an HBP lead and an RVAP lead, as backup, in our electrophysiology laboratory between 2004 and 2007. After implantation, all devices were programmed to obtain HBP. An intra-patient comparison of the effects of HBP and RVAP on LV dyssynchrony and function was performed at the last available follow-up examination. RESULTS: After a mean of 34.6 ± 11 months, the pacing modality was temporarily switched to RVAP. During RVAP, LV ejection fraction significantly decreased (50.1 ± 8.8% vs. 57.3 ± 8.5%, P < 0.001), mitral regurgitation significantly increased (22.5 ± 10.9% vs.16.3 ± 12.4%; P = 0.018), and inter-ventricular delay significantly worsened (33.4 ± 19.5 ms vs. 7.1 ± 4.7 ms, P = 0.003) in comparison with HBP. However, the myocardial performance index was not statistically different between the two pacing modalities (P = 0.779). No asynchrony was revealed by tissue Doppler imaging during HBP, while during RVAP the asynchrony index was significantly higher in both the four-chamber (125.8 ± 63.9 ms; P = 0.035 vs. HBP) and two-chamber (126 ± 86.5 ms; P = 0.037 vs. HBP) apical views. CONCLUSION: His-bundle pacing has long-term positive effects on inter- and intra-ventricular synchrony and ventricular contractile performance in comparison with RVAP. It prevents asynchronous pacing-induced LV ejection fraction depression and mitral regurgitation.

Usefulness of Contrast Intracardiac Echocardiography in Performing Pulmonary Vein Balloon Occlusion during Cryo-ablation for Atrial Fibrillation.

BACKGROUND: Cryoballoon ablation (CBA) has been proven to be very effective for pulmonary vein (PV) isolation (PVI) if complete occlusion is achieved and conventionally assessed by angiographic injection of contrast within PV lumen. The aim of our study was to assess the usefulness of saline contrast intracardiac echocardiography in guiding CBA with respect to PV angiography. METHODS: Thirty consecutive patients with paroxysmal atrial fibrillation were randomly assigned fluoroscopy plus color-flow Doppler (n = 15; group 1: an iodinated medium as both angiographic and echographic contrast) or contrast intracardiac echocardiography plus color-flow Doppler (n = 15; group 2: saline contrast) for guidance of CBA. RESULTS: We evaluated 338 occlusions of 107 PVs. The intracardiac echocontrastography-guided assessment of occlusion, defined as loss of echocontrastographic back-flow to the left atrium after saline injection regardless of the visualization of PV antrum, showed a high level of agreement with the angiographic diagnosis of occlusion. PVI rate was similar in both groups and effectively guided by intracardiac echocontrastography (PVI using ≤ 2 double cryofreezes: 89% of PVs in group 1 vs. 91% in group 2; p=n.s.). Group 2 patients had significantly shorter procedure (127 ± 16 vs. 152 ± 19 minutes; p<0.05) and fluoroscopy times (30 ± 12 vs. 43 ± 9 minutes, p<0.05) and used a lower iodinated contrast (88 ± 26 vs. 190 ± 47 mL, p<0.05). CONCLUSIONS: PV occlusion and PVI during cryoablation can be effectively predicted by intracardiac saline echocontrastography. This technique reduces procedural time, radiological exposure and iodinated contrast use.

Computational electrophysiology of the coronary sinus branches based on electro-anatomical mapping for the prediction of the latest activated region.

This work dealt with the assessment of a computational tool to estimate the electrical activation in the left ventricle focusing on the latest electrically activated segment (LEAS) in patients with left bundle branch block and possible myocardial fibrosis. We considered the Eikonal-diffusion equation and to recover the electrical activation maps in the myocardium. The model was calibrated by using activation times acquired in the coronary sinus (CS) branches or in the CS solely with an electroanatomic mapping system (EAMS) during cardiac resynchronization therapy (CRT). We applied our computational tool to ten patients founding an excellent accordance with EAMS measures; in particular, the error for LEAS location was less than 4 mm. We also calibrated our model using only information in the CS, still obtaining an excellent agreement with the measured LEAS. The proposed tool was able to accurately reproduce the electrical activation maps and in particular LEAS location in the CS branches, with an almost real-time computational effort, regardless of the presence of myocardial fibrosis, even when information only at CS was used to calibrate the model. This could be useful in the clinical practice since LEAS is often used as a target site for the left lead placement during CRT. Overall picture of the computational pipeline for the estimation of LEAS.

Heart Team for Left Appendage Occlusion without the Use of Antithrombotic Therapy: The Epicardial Perspective.

BACKGROUND: Left atrial appendage occlusion is an increasingly proposed treatment for patients with atrial fibrillation and poor tolerance to anticoagulants. All endovascular devices require antithrombotic therapy. Anatomical and clinical variables predisposing to device-related thrombosis, as well as post-procedural peri-device leaks, could mandate the continuation or reintroduction of aggressive antithrombotic treatment. Because of the absence of foreign material inside the heart, epicardial appendage closure possibly does not necessitate antithrombotic therapy, but data of large series are missing. METHODS: Multidisciplinary team evaluation for standalone totally thoracoscopic epicardial appendage closure was done in 180 consecutive patients with atrial fibrillation and poor tolerance to antithrombotic therapy. One hundred and fifty-two patients consented (male 66.1%, mean age 76.1 ± 7.4, CHA2DS2VASc mean 5.3 ± 1.6, HASBLED mean 3.8 ± 1.1). Indications were cerebral hemorrhage (48%), gastro-intestinal bleeding (33.3%), and other bleeding (20.7%). No antithrombotic therapy was prescribed from the day of surgery to the latest follow up. RESULTS: Procedural success was 98.7%. At a mean follow up of 38.2 ± 18.8 months, cardioembolic and bleeding events were 1.3% and 0.6%, respectively. Among patients with a history of blood transfusions (41.1%), none needed further transfusions or treatment post procedure. CONCLUSION: Epicardial appendage occlusion without any antithrombotic therapy appears to be safe and effective. This strategy could be advised when minimization of bleeding risk concomitant to stroke prevention is needed.

Intrathoracic impedance and ultrasound lung comets in heart failure deterioration monitoring.

PURPOSE: Echographic examination of the lung surface may reveal multiple ultrasound lung comets (ULCs) originating from water-thickened interlobular septa. These images were demonstrated to be useful for noninvasive assessment of interstitial pulmonary edema. Similarly, the correlation between implantable defibrillator-measured intrathoracic impedance and pulmonary capillary wedge pressure (PCWP) was demonstrated in heart failure (HF) patients. The aims of this analysis were to assess the agreement between defibrillator-detected impedance decrease and the presence of ULCs, as well as to compare the performance of the impedance-detection algorithm and the ULCs assessment in predicting HF worsening. METHODS AND RESULTS: We studied 23 HF patients implanted with a defibrillator capable of intrathoracic impedance measurement and alerting for fluid accumulation diagnosis. At regular follow-up and at visits for HF decompensation or device alert, clinical status was assessed, chest ultrasound was performed, and PCWP was noninvasively estimated with Doppler echocardiography. During 23 ± 11 months of follow-up, 45 paired assessments of defibrillator-measured intrathoracic impedance and ULCs were performed. The number of ULCs resulted significantly correlated to the paired PCWP estimations (r = 0.917, P < 0.001) and to the impedance fluid index (r = 0.669, P < 0.001). During follow-up, 12 episodes of HF decompensation were reported in 12 patients. The impedance alert detected clinical HF deterioration with 92% sensitivity and 69% positive predictive value. The presence of ≥5 ULCs showed 83% sensitivity and 91% positive predictive value. CONCLUSIONS: These data demonstrate the correlation between intrathoracic impedance and the number of ULCs at chest ultrasound, and a good agreement between the defibrillator warning for fluid index and the detection of multiple ULCs.

Safety and performance of a system specifically designed for selective site pacing.

INTRODUCTION: In the right ventricle, selective site pacing (SSP) has been shown to avoid detrimental hemodynamic effects induced by right ventricular apical pacing and, in the right atrium, to prevent the onset of atrial fibrillation and to slow down disease progression. The purpose of our multicenter observational study was to describe the use of a transvenous 4-French catheter-delivered lead for SSP in the clinical practice of a large number of centers. METHODS: We enrolled 574 patients in whom an implantable device was indicated. In all patients, SSP was achieved by using the Select Secure System™ (Medtronic Inc., Minneapolis, MN, USA). RESULTS: In 570 patients, the lead was successfully implanted. In 125 patients, atrial SSP was performed: in 75 (60%) the lead was placed in the interatrial septum, in 31 (25%) in the coronary sinus ostium, and in 19 (15%) in the Bachman bundle. Ventricular SSP was undertaken in 138 patients: in 105 (76%) the high septal right ventricular outflow tract (RVOT) position was paced, in seven (5%) the high free-wall RVOT, in 25 (18%) the low septal RVOT, and in one (1%) the low free-wall RVOT. In the remaining 307 patients, the His zone was paced: in 87 (28%) patients, direct His-bundle pacing and in 220 (72%) patients para-hisian pacing was achieved. Adequate pacing parameters and a lead-related complication rate of 2.6% were recorded during a follow-up of 20 ± 10 months. CONCLUSIONS: Our results demonstrated that many sites, in the right atrium, in the right ventricle, and in His-bundle region, can be paced using the Select Secure System™.

Endocavitary electrophysiological study by percutaneous antecubital vein and without X-ray for risk stratification of asymptomatic ventricular pre-excitation in young athletes.

Athletes with asymptomatic ventricular pre-excitation (VP) should undergo electrophysiological study for risk stratification. We aimed to evaluate the feasibility, efficacy, safety and tolerability of an electrophysiological study using a percutaneous antecubital vein access and without the use of X-ray (ESnoXr). Methods: We collected data from all young athletes < 18 year-old with AVP, who underwent ESnoXr from January 2000 to September 2020 for evaluation of accessory pathway refractoriness and arrhythmia inducibility using an antecubital percutaneous venous access. Endocavitary signals were used to advance the catheter in the right atrium and ventricle. Results: We included 63 consecutive young athletes (mean age 14.6 ± 1.9 years, 46% male). Feasibility of the ESnoXr technique was 87% while in 13% fluoroscopy and/or a femoral approach were needed. Specifically, fluoroscopy was used in 7 cases to position the catheter inside the heart cavities with an average exposure of 43 ± 38 s while in 2 femoral venous access was needed. The mean procedural time was 35 ± 11 min. The exam was diagnostic in all patients, there were no procedural complications and tolerability was excellent. 53% of the patients had an accessory pathway with high refractoriness and no inducible atrio-ventricular reentry tachycardia: this subgroup was considered eligible to competitive sports and no event was observed during long-term follow-up (13.6 ± 5.2 years) without drug use. The others underwent catheter ablation. Conclusion. ESnoXr has been shown to be a feasible, effective, safe and well-tolerated procedure for the assessment of arrhythmic risk in a population of young athletes with asymptomatic VP.

Scheduled versus alert transmissions for remote follow-up of cardiac implantable electronic devices: Clinical relevance and resource consumption.

BACKGROUND: The remote follow-up of pacemakers and implantable cardiac defibrillators (ICDs) usually includes scheduled checks and alert transmissions. However, this results in a high volume of remote data reviews to be managed. We measured the relative contribution of scheduled and alert transmissions to the detection of relevant conditions, and the workload generated by their management. METHODS: At our center, the frequency of remote scheduled transmissions is 4/year. Moreover, all system-integrity and clinical alerts are turned on for wireless notification. We calculated the number of transmissions received from January to December 2020, and identified transmissions that necessitated in-hospital access for further assessment and transmissions that required clinical discussion with the physician. For all alert transmissions, we identified whether the alert was clinically meaningful (i.e. center was not previously aware of the condition and no action had yet been taken to treat it). RESULTS: Of 8545 transmissions received from 1697 pacemakers and ICDs, 5766 (67%) were scheduled and 2779 (33%) were alert transmissions received from 764 patients (45%); 499 (9%) scheduled transmissions required clinical discussion with the physician, but only 2 of these necessitated in-hospital visits for further assessment. Of the alert transmissions, 664 (24%) required clinical discussion, and 75 (3%) necessitated in-hospital visits. The proportion of alerts judged clinically meaningful was 7%. CONCLUSION: Scheduled transmissions generate 67% of remote data reviews for pacemakers and ICDs, but their ability to detect clinically relevant events is very low. A strategy that relies exclusively on alert transmissions could ensure continuity of patient monitoring while reducing the workload at the center.

First-line therapy: insights from a real-world analysis of cryoablation in patients with atrial fibrillation.

AIMS: Pulmonary vein isolation (PVI) using cryoballoon ablation (CBA) is mainly reserved for patients with drug-refractory or drug-intolerant symptomatic atrial fibrillation. We evaluated a large cohort of patients treated in a real-world setting and examined the safety and efficacy profile of CBA when applied as a first-line treatment for atrial fibrillation. METHODS: In total, 249 patients (23% women; 56 ±â€Š13 years; mean left atrial diameter 41 ±â€Š7 mm; 73.5% paroxysmal atrial fibrillation; and 26.5% persistent atrial fibrillation) underwent an index PVI by CBA. Data were collected prospectively in the framework of the 1STOP ClinicalService project, involving 26 Italian cardiology centers. RESULTS: Median procedure and fluoroscopy times were 90.0 and 21.0 min, respectively. Acute procedural success was 99.8%. Acute/periprocedural complications were observed in seven patients (2.8%), including: four transient diaphragmatic paralyses, one pericardial effusion (not requiring any intervention), one transient ischemic attack, and one minor vascular complication. The Kaplan--Meier freedom from atrial fibrillation recurrence was 86.3% at 12 months and 76% at 24 months. Seventeen patients (6.8%) had a repeat catheter ablation procedure during the follow-up period. At last follow-up, 10% of patients were on an anticoagulation therapy, whereas 6.8% were on an antiarrhythmic drug. CONCLUSION: In our multicenter real-world experience, PVI by CBA in a first-line atrial fibrillation patient population was well tolerated, effective, and promising. CBA with a PVI strategy can be used to treat patients with paroxysmal and persistent atrial fibrillation with good acute procedural success, short procedure times, and acceptable safety. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov (NCT01007474).

Intrathoracic impedance and pulmonary wedge pressure for the detection of heart failure deterioration.

AIMS: The aims of this analysis were to assess the agreement between implantable defibrillator (ICD)-measured intrathoracic impedance and pulmonary capillary wedge pressure (PCWP) collected during long-term follow-up, as well as to evaluate whether PCWP measures may improve the performance of the impedance detection algorithm in predicting heart failure (HF) worsening. METHODS AND RESULTS: We studied 23 HF patients implanted with an ICD capable of intrathoracic impedance measurement and alerting for fluid accumulation diagnosis. At regular follow-up and at visits for HF decompensation or device alert, clinical status was assessed and PCWP was non-invasively estimated with a validated echo-Doppler method. During 23 +/- 11 months, 45 paired assessments of impedance and PCWP were performed. The Kappa analysis revealed good agreement between impedance and PCWP (k = 0.701, SE 0.113, P < 0.001). Moreover, PCWP estimations and the paired values of the impedance fluid index resulted significantly correlated (r = 0.677, P < 0.001). The impedance-alert detected clinical HF deterioration with 92% sensitivity and 69% positive predictive value. The combined finding of decreased impedance and increased PCWP resulted in enhanced positive predictive value (92%) and no change in sensitivity (92%). CONCLUSION: These data confirm the inverse correlation between impedance and PCWP at long-term follow-up and suggest the potential clinical value of a combined impedance and pressure assessment for the improved detection of HF deterioration.