A comparison of contact force and remote magnetic navigation on lesion formation for the ablation of atrial fibrillation.

RATIONALE: Pulmonary vein isolation (PVI) is the method of choice for the treatment of drug-resistant atrial fibrillation (AF). However, arrhythmia recurrences are frequent due to suboptimal lesions formation and pulmonary vein reconnection. Contact force (CF)- and remote magnetic navigation (RMN)-guided catheters are both capable of improving contact and energy transfer to the tissue, possibly improving PVI outcome. OBJECTIVE: The objective of our study was to compare CF- and RMN-guided PVI in patients with paroxysmal AF in terms of surrogate parameters of the dimension and quality of the lesions. METHODS AND RESULTS: Between March 2014 and March 2016, 44 patients affected by paroxysmal AF underwent a circumferential PVI procedure, 22 with a CF catheter and 22 with a RMN catheter. Signals were recorded before and after 30 seconds of radiofrequency point-by-point delivery. For each location, signal energy attenuation and impedance drop were evaluated as lesion dimension surrogates and signal fragmentation and shrinkage were estimated as lesion quality surrogates. Statistical analysis shows that CF catheter achieves higher attenuation and impedance drop than RMN-guided catheter, which instead performs better in terms of shrinkage and fragmentation. There were no differences in terms of PVI rate and sinus rhythm maintenance 1 year after the procedure (77.2% in both groups). CONCLUSIONS: CF-guided catheters produce lesions that are larger but less homogeneous than those produced by RMN-guided catheters in terms of surrogate parameters. These two features could possibly offset each other, resulting in identical acute and long-term outcomes.

Left Atrial Substrate Modification Targeting Low-Voltage Areas for Catheter Ablation of Atrial Fibrillation: A Systematic Review and Meta-Analysis.

BACKGROUND: This meta-analysis aims to assess the impact of a voltage-guided substrate modification by targeting low-voltage area (LVA) in addition to pulmonary vein isolation (PVI) in patients undergoing catheter ablation for atrial fibrillation (AF). METHODS: MEDLINE/PubMed, Cochrane Library, and references reporting AF ablation and "voltage* OR substrate* OR fibrosis OR fibrotic area*" were screened and studies included if matching inclusion and exclusion criteria. RESULTS: Six studies were included. Patients enrolled were 885 (517 in the study group and 368 in the control group). Median age was 60 years; 92% had nonparoxysmal AF. At a mean follow-up of 17 months, 70% of patients in the study group vs. 43% in the control group were free from AF/atrial tachycardia (AT) recurrences (odds ratio [OR] = 3.41, 95% confidence interval [CI] 2.22-5.24). LVA ablation in addition to PVI was more effective than PVI alone and PVI + conventional wide empirical ablation (70% vs. 43%, OR = 3.41, 95% CI 2.22-5.24), without increasing the adverse event rate (2.5% vs. 6%, OR = 0.43, 95% CI 0.15-1.26). Compared to PVI + conventional wide empirical ablation, LVA ablation reduced the occurrence of postablation AT (14% vs. 46%, OR = 0.16, 95% CI 0.07-0.37), procedure time (176 min vs. 220 min, OR = 0.36, 95% CI 0.24-0.56), fluoroscopy time (25 min vs. 31 min, OR = 0.22, 95% CI 0.12-0.39), and radiofrequency time (55 min vs. 90 min, OR = 0.49, 95% CI 0.27-0.90). CONCLUSIONS: A voltage-guided substrate modification by targeting LVA in addition to PVI is more effective, safer, and holds a lower proarrhythmic potential than conventional ablation approaches. Further randomized studies are necessary to confirm these findings.

Atrial Conduction Velocity Correlates with Frequency Content of Bipolar Signal.

BACKGROUND: Anisotropy in conduction velocity (CV) is a key substrate abnormality influencing atrial arrhythmias. In skeletal muscle fibers, CV and frequency content of the surface electromyogram signal are directly related. We hypothesized that in human atria the frequency content of the bipolar signal, recorded on the endocardial surface, is directly related to the local CV. METHODS: In 15 patients submitted to ablation of supraventricular arrhythmias, incremental pacing was performed through an octapolar catheter inserted into the coronary sinus (CS), alternatively from both extremities in two different sequences: CS bipole 1-2 as the pacing site and CS bipole 7-8 as the detection site in the first, and vice versa in the second. The pacing cycle length (PCL) was stepwise decreased from 600 ms to 500 ms, 400 ms, 300 ms, until 250 ms. Estimation of the CV was performed as the ratio between the distance traveled by the propagating pulse and the propagation time. The frequency distribution of the signal energy was estimated using the fast Fourier transform, and the characteristic frequency (CF) was estimated as the barycenter of the frequency spectrum. RESULTS: A total of 2,496 bipolar signals were analyzed; CV and CF were estimated and compared. The single patient and group data analysis showed a significant direct correlation between CV and CF of the local bipolar signal. CONCLUSIONS: Comparing the degree of spectral compression among signals registered in different points of the endocardial cardiac surface in response to decreasing PCL enables to map local differences in CV, a useful arrhythmogenic substrate index.

Electrocardiographic evolution in patients with hypertrophic cardiomyopathy who develop a left ventricular apical aneurysm.

INTRODUCTION: Hypertrophic cardiomyopathy (HCM) patients with apical aneurysm have a largely unfavourable clinical course, and are often unrecognised because echocardiography is limited in the assessment of the left ventricular (LV) apex. The aim of this study is the identification of electrocardiographic (ECG) abnormalities associated with the development of apical aneurysm in HCM patients. MATERIALS AND METHODS: Electrocardiographic features were assessed in 14 HCM patients who had a good-quality baseline ECG recorded before and after the diagnosis of apical aneurysm. RESULTS: During follow-up (8.8±7.5years), the following ECG changes were observed: increase in QRS-complex duration (87±12ms to 118±34ms, p=0.006), QRS-complex fragmentation, decrease in QRS-complex amplitude (SV1+RV5-6, from 41±18mm to 26±11mm, p=0.015), ST-segment elevation in V4-V6 (J-point in V5, from -0.9±1.3mm to +0.7±1.3, p=0.003), positivisation of negative T waves in V3-V6 (T-wave depth in V5, from -3.4±6.6 to +3.1±4.1, p=0.005). CONCLUSIONS: HCM patients who develop LV apical aneurysm exhibit distinctive ECG changes along with apical remodelling. Suggestive ECGs should lead the physician to study LV apex by nonstandard echocardiographic views, and perform MRI.

Clinical outcomes following percutaneous coronary intervention with drug-eluting stents versus bare metal stents in patients on chronic hemodialysis.

BACKGROUND: Patients on chronic hemodialysis (HD) are recognized as a high-risk group for adverse events after percutaneous coronary intervention, and whether drug-eluting stents (DES) are associated with improved outcomes over bare metal stents (BMS) is still uncertain. The purpose of this study was to assess the efficacy of DES compared with BMS at short- and long-term follow-up (FU) in an unselected sample of HD patients. METHODS AND RESULTS: In the time period 2005-2010, consecutive patients on chronic HD treated with percutaneous coronary intervention (PCI) and stent implantation were retrospectively selected and analyzed. A total of 169 patients were selected, 77 treated exclusively with BMS and 92 exclusively with DES. Baseline clinical characteristics were similar in the 2 groups as well as the number of treated vessels, treated lesions, and the stent per patient ratio. At longest available FU, no difference between the 2 study groups was found in terms of cardiac death (18.2% vs 16.3%, P=0.83), myocardial infarction (2.5% vs 8.6%, P=0.09), cerebrovascular accidents (0% vs 1.1%, P=0.98), and target vessel revascularization (TVR) (9.1% vs 16.3%, P=0.17). Major adverse cardiac and cerebrovascular events-free survival at 1,500 days in the BMS and DES groups was 57.6% and 50.9% (P=0.11), respectively. CONCLUSIONS: PCI in patients on chronic HD treatment is associated with a high incidence of adverse events at FU, mainly represented by death. In our study, the use of DES was not associated with a reduction of target lesion revascularization (TLR) and TVR.

Late gadolinium enhancement on cardiac magnetic resonance and phenotypic expression in hypertrophic cardiomyopathy.

BACKGROUND: Cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE) can identify areas of myocardial fibrosis in vivo in patients with hypertrophic cardiomyopathy (HCM). The aim of this study was to examine the association between clinical-morphological variables, risk factor for sudden death, and LGE findings in a consecutive, unselected population of HCM patients. METHODS: From January 2005 to August 2009, 124 HCM patients (53 ± 17 years, 86 men) were prospectively evaluated with CMR examination, assessing left ventricular (LV) hypertrophy, function, and LGE. RESULTS: In univariate analysis, patients were divided into tertiles according to the number of segments positive for LGE (first tertile, 0.3 ± 0.4; second tertile, 2.2 ± 0.4; third tertile, 5.2 ± 1.9 segments). Male gender (P = .05), maximum LV wall thickness (P = .002), nonsustained ventricular tachycardia (P = .001), ejection fraction <50% (P = .02), LV mass (P = .02), left atrium dilation (P = .04), perfusion defects (P ≤ .001), and telesystolic volume (P = .04) were all positively related with the number of segments of LGE. In multivariable analysis, male gender (P = .007), maximum LV wall thickness (P = .006), LV mass (P = .031), and perfusion alterations (P = .017) were independent predictors of LGE extent. CONCLUSIONS: Our study shows an independent association, even at multivariate analysis, between the entity of LGE and maximum LV wall thickness, mass, and perfusion defects in patients with HCM. Whether the presence and the extent of LGE translates into clinical events later on awaits further long-term follow-up studies.

Cardiogenic shock complicating acute myocardial infarction in the elderly: predictors of long-term survival.

BACKGROUND: Cardiogenic shock (CS) is a severe complication of acute myocardial infarction (AMI), associated with a high mortality. A significant improvement in survival has been reported with immediate coronary revascularization. However, there is no clear evidence of such an improvement amongst older patients. The aim of our work was to evaluate in-hospital and long-term outcomes in the group of elderly AMI patients with CS (≥75 years old). METHODS: We collected data of 157 consecutive AMI patients with CS who underwent percutaneous coronary intervention (PCI) and compared clinical and procedural characteristics and in-hospital and long-term outcomes between patients <75 years and patients ≥75 years old. RESULTS: There were 58 patients (36.9%) with age ≥75 years and 99 patients (63.1%) with age <75 years. Patients were followed up for an average period of 34 months (range 5-69). In-hospital and long-term mortality was significantly higher in the older group (55 vs. 25%, P < 0.0001; and 62.1 vs. 37.3%, P = 0.005, respectively). Multivariate predictors of in-hospital mortality were age ≥75 years (hazard ratio 1.81, 95% CI 1.006-3.27, P = 0.04) and PCI failure (hazard ratio 2.67, 95% CI 1.34-5.307, P = 0.005), whereas, the only multivariate predictor of long-term mortality was PCI failure (hazard ratio 2.88, 95% CI 1.52-5.46, P = 0.001). Age ≥75 years showed only a trend toward statistical significance (hazard ratio 1.62, 95% CI 0.96-2.76, P = 0.07). CONCLUSIONS: In elderly AMI patients with CS, PCI can be performed with an acceptable risk that seems lower than that reported in most previous studies.

Early angio-guided complete revascularization versus culprit vessel PCI followed by ischemia-guided staged PCI in STEMI patients with multivessel disease.

BACKGROUND: Optimal management of multivessel disease (MVD) in ST-segment elevation myocardial infarction (STEMI) patients treated by primary percutaneous coronary intervention (PCI) is still unclear. OBJECTIVES: To compare short- and long-term clinical outcomes of early-staged, angio-guided approach and delayed, ischemia-guided treatment of non-infarct-related arteries (IRAs). METHODS: Consecutive patients with STEMI and MVD treated with primary PCI in 6 tertiary care centers were retrospectively selected and analyzed. Major adverse cardiac events (MACE) were defined as the composite end-point of death, MI, and repeat revascularization. All the events were adjudicated according to the Academic Research Consortium (ARC) definitions. RESULTS: In the time period 2004-2008, 800 primary PCIs in STEMI patients with MVD were performed. Four hundred and seventeen were addressed to early-staged, angio-guided PCI of non-IRAs (CR group) and 383 to an incomplete revascularization (IncR group). During the hospital stay, no difference in terms of death and repeat revascularization was found between groups but the incidence of periprocedural MI/reinfarction and MACE was significantly higher in the CR group (13.9% vs. 3.1%, P = 0.01 and 14.1% vs. 9.1%, P = 0.017, respectively). At a mean follow-up of 642 ± 545 days, no difference in terms of death and MI was found between the CR and IncR group. The MACE-free survival was significantly higher in the IncR group (73.8% vs. 57%, log rank 0.05), mainly driven by the lower incidence of re-PCI. CONCLUSIONS: Early complete revascularization based only on angiographic findings in patients with STEMI and MVD is associated with an excess of periprocedural/re-MI and with a significantly higher incidence of MACE at follow-up.

Syncope and risk of sudden death in hypertrophic cardiomyopathy.

BACKGROUND: The prognostic significance of syncope has not been investigated systematically in hypertrophic cardiomyopathy, and treatment strategies have been based largely on intuition and experience. METHODS AND RESULTS: We assessed the relationship between syncope and sudden death in 1511 consecutive patients with hypertrophic cardiomyopathy. Unexplained (n=153) or neurally mediated (n=52) syncope occurred in 205 patients (14%). Over a 5.6+/-5.2-year follow-up, 74 patients died suddenly. Relative risk of sudden death was 1.78 (95% confidence interval 0.88 to 3.51, P=0.08) in patients with unexplained syncope and 0.91 (95% confidence interval 0.00 to 3.83, P=1.0) in those with neurally mediated syncope compared with patients without syncope. In multivariable analysis, the temporal proximity of unexplained syncope to initial patient evaluation was independently associated with risk of sudden death (P=0.006). Patients with unexplained syncope within 6 months before the initial evaluation showed a 5-fold increase in risk compared with patients without syncope (adjusted hazard ratio 4.89, 95% confidence interval 2.19 to 10.94), a relationship that was maintained throughout all age groups (<18, 18 to 39, and > or =40 years). Older patients (> or =40 years of age) with remote episodes of syncope (>5 years before initial evaluation) did not show an increased risk of sudden death (adjusted hazard ratio 0.38, 95% confidence interval 0.05 to 2.74). CONCLUSIONS: In the present large cohort of patients with hypertrophic cardiomyopathy, unexplained syncope was a risk factor for sudden death. Patients with syncopal events that occurred in close temporal proximity to the initial evaluation showed a substantially higher risk of sudden death than patients without syncope. Older patients with remote syncopal events did not show an increased risk.

Relation of QRS duration to mortality in a community-based cohort with hypertrophic cardiomyopathy.

A prolonged QRS duration on the standard electrocardiogram is associated with an increased risk of cardiovascular death in cardiomyopathies of different origin. However, the relation between QRS duration and prognosis in hypertrophic cardiomyopathy (HC) remains undefined. We assessed the relation between QRS duration and cardiovascular death in 241 consecutive patients with HC. The study cohort was divided into 2 groups according to QRS duration: <120 and > or =120 ms. Of the 241 patients, 191 (79%) had a QRS duration <120 ms and 50 (21%) a QRS duration > or =120 ms. During a mean follow-up of 7.9 +/- 5.1 years, 35 patients died of cardiovascular causes related to HC. Of these 35 patients, 13 (6%) had a QRS duration <120 ms and 22 (43%) had a QRS duration > or =120 ms (p <0.01). Risk of cardiovascular death was significantly higher in patients with a QRS duration > or =120 ms than in those with a QRS duration <120 ms (relative risk 5.2, p <0.0001). At 8-year follow-up, cumulative risks of HC-related death were 7.1% in patients with a QRS duration <120 ms and 55% in those with a QRS duration > or =120 ms. Multivariate analysis confirmed that a QRS duration > or =120 ms was independently associated with an increased risk of cardiovascular death (hazard ratio 3.2, p = 0.007). New York Heart Association functional class III/IV was the only other clinical variable significantly and independently associated with an increased risk of cardiovascular death. In conclusion, in patients with HC, QRS duration on standard electrocardiogram is directly related to cardiovascular mortality, and a QRS duration > or =120 ms is a strong and independent predictor of prognosis.

Usefulness and safety of transcatheter ablation of atrial fibrillation in patients with hypertrophic cardiomyopathy.

Atrial fibrillation (AF) is common in patients with hypertrophic cardiomyopathy (HC) and predicts adverse outcome. Radiofrequency catheter ablation (RFCA) represents a potentially advantageous alternative to lifelong pharmacologic treatment. However, its efficacy in patients with HC is not established. In the present study, the feasibility, safety, and efficacy of RFCA of AF in patients with HC were evaluated. Twenty-six patients with HC with paroxysmal (n = 13) or permanent (n = 13) AF refractory to antiarrhythmic therapy (age 58 +/- 11 years, time from AF onset 7.3 +/- 6.2 years, left atrial volume 170 +/- 48 ml) underwent RFCA. A schema with pulmonary vein isolation plus linear lesions was used. No major periprocedural complication occurred. One patient died from a hemorrhagic stroke 4 weeks after RFCA while in sinus rhythm. During a 19 +/- 10-month follow-up, 9 of the remaining 25 patients (36%) experienced recurrence of AF (despite repeated RFCA in 3) and were considered failures, whereas 16 remained in sinus rhythm (i.e., 64% overall success rate). Ten of these 16 patients were off antiarrhythmic drug therapy at final evaluation. RFCA was highly successful in patients with paroxysmal AF (77% success rate compared with 50% in the subgroup with permanent AF). Patients with restoration of sinus rhythm showed marked symptomatic improvement (final New York Heart Association functional class 1.2 +/- 0.5 vs 1.7 +/- 0.7 before the procedure, p = 0.003). Conversely, patients for whom RFCA failed showed no change (final functional class 1.9 +/- 0.8 vs 1.7 +/- 0.9 before the procedure, p = 0.59). In conclusion, in most studied patients with HC, RFCA proved a safe and effective therapeutic option for AF, improved functional status, and was able to reduce or postpone the need for long-term pharmacologic treatment.

Targeted Cancer Therapies and QT Interval Prolongation: Unveiling the Mechanisms Underlying Arrhythmic Complications and the Need for Risk Stratification Strategies.

The care and treatment of cancer patients has significantly changed in the last decade with a remarkable shift towards novel targeted therapies. These promising new drugs may represent effective and potentially life-saving therapeutic options in cancer patients, but are also emerging in the cardiotoxicity scenario for their arrhythmogenic potential due to their QT-prolonging activity. In this article we review the mechanisms underlying drug-induced QT interval prolongation and the classes of anticancer-targeted therapies most frequently responsible for this adverse event, with a particular focus on tyrosine kinase-targeting molecules. Since up to 49 % of serious adverse drug reactions (ADRs) and 58 % of potentially fatal ADRs may not appear on initial drug safety labels, we also review and discuss data from the post-marketing VigiBase® safety reporting system, the World Health Organization's global database of ADRs. Finally, we discuss arrhythmic risk stratification and prevention strategies in the complex multiple-risk setting of cancer patients, paying particular attention to drug-drug interactions with common antimicrobial, psychotropic and antiemetic supportive care, and we also provide an electrocardiographic QT monitoring algorithm for patients who are candidates for targeted cancer therapies.

Impact of targeting adenosine-induced transient venous reconnection in patients undergoing pulmonary vein isolation for atrial fibrillation: a meta-analysis of 3524 patients.

AIMS: Atrial fibrillation recurrences after pulmonary vein isolation (PVI) are not uncommon and are frequently related to pulmonary vein reconnection. Adenosine/ATP can reveal dormant pulmonary vein conduction after PVI. Previous studies revealed that adenosine-guided Additional ablation could improve arrhythmia-free survival. We performed a meta-analysis to assess the impact of additional ablation to eliminate adenosine-induced transient pulmonary vein reconnection in terms of atrial fibrillation recurrence at follow-up. METHODS: MEDLINE/PubMed, Cochrane Library and references reporting atrial fibrillation ablation and adenosine/ATP-following PVI were screened, and studies were included if they matched inclusion and exclusion criteria. RESULTS: A total of 3524 patients were enrolled with a median follow-up of 13 (6-20) months. Overall, 70% (60-85) of patients in ATP-guided ablation vs. 63% (48-79) in no ATP-guided ablation were free of atrial fibrillation at follow-up. Pooled results revealed that ATP-guided ablation reduced the risk of atrial fibrillation recurrence of 42% [odds ratio (OR) 0.58, 0.41-0.81], but this result was primary because of the contribution of retrospective over-randomized studies [OR 0.48 (0.35-0.65) vs. 0.76 (0.42-1.40), respectively]. 3.2% of patients experienced an adverse event. ATP-guided ablation is related to a nonsignificant increase in fluoroscopy time (OR 1.71, 0.98-2.96) and to a significant increase in procedure time (OR 2.84, 1.32-6.09). CONCLUSION: Additional ablation aiming to eliminate adenosine-induced transient pulmonary vein reconnection failed to reduce the risk of atrial fibrillation recurrence at follow-up. Moreover, although adenosine-guided PVI is not affected by an augmented risk of adverse events, it is associated with a NS increased fluoroscopy exposure and significantly longer procedure duration. Further studies are required to identify the actual role of adenosine in PVI.

Prognostic significance of left atrial size in patients with hypertrophic cardiomyopathy (from the Italian Registry for Hypertrophic Cardiomyopathy).

This study assessed left atrial (LA) dimension as a potential predictor of outcome in hypertrophic cardiomyopathy (HC). From the Italian Registry for Hypertrophic Cardiomyopathy, 1,491 patients (mean age 47 +/- 17 years; 61% men; 19% obstructive), followed for 9.4 +/- 7.4 years after the initial echocardiographic evaluation, constituted the study group. The mean LA transverse dimension was 43 +/- 9 mm and was larger in patients with severe symptoms (48 +/- 9 mm for New York Heart Association classes III and IV vs 42 +/- 9 mm for classes I and II, p <0.001), atrial fibrillation (47 +/- 9 vs 42 +/- 8 mm in sinus rhythm, p <0.001), and left ventricular outflow obstruction (46 +/- 9 mm for >or=30 mm Hg at rest vs 42 +/- 9 mm for <30 mm Hg at rest, p <0.001). On univariate analysis, each 5-mm increase in LA size was associated with a hazard ratio (HR) of 1.2 for all-cause mortality (p <0.0001). On multivariate analysis, a LA dimension >48 mm (the 75th percentile) had a HR of 1.9 for all-cause mortality (p = 0.008), 2.0 for cardiovascular death (p = 0.014), and 3.1 for death related to heart failure (p = 0.008) but was unassociated with sudden death (p = 0.81). Similar results were obtained after the exclusion of patients with atrial fibrillation (HR 1.7, p = 0.008) or outflow obstruction (HR 1.8, p = 0.003). The predictive power of LA dimension >48 mm was also validated in an independent HC cohort from the United States, with similar HRs (1.8 for all-cause mortality, p = 0.019). In conclusion, in a large cohort of patients with HC from a nationwide registry, a marked increase in LA dimension were predictive of long-term outcome, independent of co-existent atrial fibrillation or outflow obstruction. LA dimension is a novel and independent marker of prognosis in HC, particularly relevant to the identification of patients at risk for death related to heart failure.

Apixaban for periprocedural anticoagulation during catheter ablation of atrial fibrillation: a systematic review and meta-analysis of 1691 patients.

PURPOSE: Apixaban, a direct factor Xa inhibitor recently approved for thromboembolic prophylaxis in patients with nonvalvular atrial fibrillation (AF), is increasingly used in patients undergoing catheter ablation of AF. However, large randomized studies supporting its use in the ablation context are still lacking. We undertook the present meta-analysis to assess the impact of apixaban in terms of thromboembolic and bleeding events in patients undergoing AF ablation as compared to warfarin. METHODS: MEDLINE/PubMed, Cochrane Library, and references reporting AF ablation and apixaban were screened and studies included if matching inclusion and exclusion criteria. RESULTS: One randomized and five nonrandomized studies were included in the analysis. Patients enrolled were 1691 patients (668 on apixaban and 1023 on warfarin). There was no heterogeneity in all the outcome comparisons. No deaths were reported. We did not observe any difference between apixaban and warfarin with respect to thromboembolic events (OR = 1.10, 95 % CI 0.24-5.16), major bleedings (OR = 1.56, 95 % CI 0.59-4.13), cardiac tamponade (OR 1.69, 95 % CI 0.52-5.54), minor bleedings (OR 0.96, 95 % CI 0.58-1.59), and the composite endpoint of death, thromboembolic events, and bleedings (OR 1.03, 95 % CI 0.65-1.64). CONCLUSIONS: The rates of death, thromboembolic events, major bleedings including cardiac tamponade, and minor bleedings in patients on apixaban undergoing AF ablation are very low and similar to that seen in patients treated with uninterrupted warfarin. Although primary driven by nonrandomized studies, these results support apixaban as periprocedural anticoagulation during AF ablation procedures.

Scar Detection by Pulse-Cancellation Echocardiography: Validation by CMR in Patients With Recent STEMI.

OBJECTIVES: This study sought to assess an echocardiographic approach (scar imaging echocardiography with ultrasound multipulse scheme [eSCAR]), based on existing multipulse ultrasound scheme, as a marker of myocardial scar in humans, compared with cardiac magnetic resonance assessing late gadolinium enhancement (CMR-LGE). BACKGROUND: The detection of myocardial scar impacts patient prognosis and management in coronary artery disease and other types of cardiac disease. The clinical experience with echocardiography suggests that the reflected ultrasound signal is often significantly enhanced in infarcted myocardial segments. METHODS: Twenty patients with a recent ST-segment elevation myocardial infarction (STEMI) (cases) and 15 patients with absent CMR-LGE (negative controls) were imaged with both the eSCAR pulse-cancellation echocardiography and CMR-LGE to assess their potential association. RESULTS: Scar was detectable at CMR-LGE in 19 of 20 STEMI patients (91%), whereas all (100%) demonstrated eSCAR at echocardiography. In the 19 STEMI patients in whom CMR-LGE was detected, regional matching between eSCAR and CMR-LGE was total, although the segmental extent of detected scar was not always superimposable, particularly in the most apical segments, a region in which eSCAR demonstrated undersensitivity for the true extent of scar. CONCLUSIONS: A 2-dimensional multipulse echocardiography allows detection of myocardial scar, reliably matching the presence and site of CMR-LGE at 30 days after STEMI, or its absence in negative controls.

Temporal changes in the current practice of primary angioplasty: a real life experience of a single high-volume center.

BACKGROUND: In the last years, new techniques, drugs and devices have been introduced in the current practice of primary angioplasty (PPCI) and validated by pivotal studies The objective of our study was to evaluate if these studies have led to significant changes on the current practice of primary PCI in our center. METHODS: From March 2003 to December 2013 1980 patients with ST-segment elevation myocardial infarction underwent PPCI within 12-hours of onset of symptoms. We considered 2 periods of our activity: from 2003 to 2009 (P1) with 1078 patients and from 2010 to 2013 (P2) with 902 patients, and compared them in terms of pharmacological and arterial access strategies and of devices utilization. RESULTS: In P2 there was a significant increase of radial access (34.1% vs. 1.5, p<0.001), as well as of the use of bivalirudin (22.7% vs. 0.5%, p<0.001) and of new antiplatelet drugs (prasugrel or ticagrelor) (18.3% vs. 0%, p<0.001) whereas the use of GP IIb-IIIa and of intraaortic balloon pump significantly decreased (from 82.3% to 52%, p<0.001 and from 17% to 7.5%, p<0.001 respectively). In the P2 there was a significant increase of the procedural efficacy (97.2% vs. 95.1%, p=0.01) that persisted after the logistic regression adjustment (OR 2.09, CI 95%, 1.04-4.21). CONCLUSIONS: Our study shows that in the last years, in a high-PCI center, after the publication of pivotal randomized trial and nationwide registries, there were significant changes in the PPCI current practice that could have had an impact on procedural efficacy.

Biolimus-Eluting StenT For de-novo coRonary artery dIsease in patiENts with Diabetes mellituS: the BESTFRIENDS multicentre registry.

AIMS: Coronary inflammation and healing influence outcomes of diabetic patients treated with Percutaneous coronary revascularization (PCI). Stents covered with biodegradable polymers (bp) may offer advantages over nonerodible polymer ones, because polymer reabsorption extinguish coronary inflammation and favours healing. Aim of our study was to assess the safety and efficacy of bp-biolimus-eluting stent (bp-BES) in a large series of consecutive diabetic patients. METHODS: From 2009 to 2013 we retrospectively enrolled consecutive diabetic patients treated with PCI and bp-BES implantation. Primary end points were target lesion revascularization (TLR) and stent thrombosis rates. RESULTS: Study cohort counted 747 patients. Multivessel disease was present in 48.2% with a mean stent/patient ratio of 1.860.78. During the hospital stay no stent thrombosis occurred. At 3-year follow-up we observed a 1.5% cumulative incidence of cardiac death, 1.1% of myocardial infarction and 6.3% of TLR. Stent thrombosis occurred in 1.1% of patients, all in the first 2 years of follow-up. Kaplan-Meier analysis showed a TLR-free survival at 1 and 3 years of 97.2 and 96.1%, respectively. CONCLUSION: PCI with bp-BES seems to be well tolerated and effective in a large unselected population of diabetic patients. The good results observed were maintained at 3 years of follow-up.

Risk associated with pregnancy in hypertrophic cardiomyopathy.

OBJECTIVES: We sought to assess mortality and morbidity in pregnant women with hypertrophic cardiomyopathy (HCM). BACKGROUND: The risk associated with pregnancy in women with HCM is an important and increasingly frequent clinical issue for which systematic data are not available and a large measure of uncertainty persists. METHODS: Maternal mortality in 91 consecutively evaluated families with HCM was compared with that reported in the general population. The study cohort included 100 women with HCM with one or more live births, for a total of 199 live births. Morbidity related to HCM during pregnancy was investigated in 40 women evaluated within five years of their pregnancy. RESULTS: Two pregnancy-related deaths occurred, both in patients at a particularly high risk. The maternal mortality rate was 10 per 1,000 live births (95% confidence interval [CI] 1.1 to 36.2/1,000) and was in excess of the expected mortality in the general Italian population (relative risk 17.1, 95% CI 2.0 to 61.8). In the 40 patients evaluated within close proximity of their pregnancy, 1 (4%) of the 28 who were previously asymptomatic and 5 (42%) of the 12 with symptoms progressed to functional class III or IV during pregnancy (p < 0.01). One patient had atrial fibrillation and one had syncope, both of whom had already experienced similar and recurrent events before their pregnancy. CONCLUSIONS: Maternal mortality is increased in patients with HCM compared with the general population. However, absolute maternal mortality is low and appears to be principally confined to women at a particularly high risk. In the presence of a favorable clinical profile, the progression of symptoms, atrial fibrillation, and syncope are also uncommon during pregnancy.