Advanced Heart failure (adHF) is the final common pathway of multiple cardiovascular diseases and affects over 64 million people worldwide. Ventricular arrhythmias (VAs), including electrical storm, are part of the natural history of adHF, being associated with morbidity, mortality, and missing of effective therapeutic options. Management often requires intensive care, deep sedation, autonomic modulation, multiple antiarrhythmic drugs, and mechanical circulatory support (MCS), while non-responders have very limited alternatives. Heart transplantation (HTx) remains the gold standard therapy, although its availability is constrained by the lack of donors and strict allocation criteria. VAs are major drivers of urgent HTx listing across allocation systems. In recent years, catheter ablation (CA) has evolved into a disease-modifying therapy for scar-related VAs, with improvements in safety, mapping resolution, and procedural efficacy. Although randomized data in adHF populations remain limited, observational studies and contemporary trials demonstrate that CA can significantly reduce arrhythmic burden, implantable cardioverter-defibrillator shocks, hospitalizations, and the need for urgent HTx, particularly when performed early in the disease course. Advances in substrate-based strategies, functional mapping, multipolar and omnipolar technologies, and integration of cardiac imaging have enhanced procedural precision, while preprocedural risk stratification tools guide the use of MCS to improve safety in high-risk patients. Emerging therapies, including pulsed-field ablation, stereotactic arrhythmia radiotherapy, and autonomic modulation, alongside multimodal imaging, are expanding treatment options for refractory VAs in end-stage cardiomyopathy. This review provides a comprehensive state-of-the-art overview of VA mechanisms, patient selection, ablation strategies, and future directions in the management of severe VAs in adHF, with a focus on patients awaiting HTx.

BACKGROUND:Left atrial appendage closure (LAAC) may be used in atrial fibrillation patients with previous cardioembolic stroke (CS) despite adequate oral anticoagulation (OAC). The aim of this study was to evaluate the safety and efficacy of the hybrid strategy LAAC and OAC in patients with OAC failure. METHODS:In this multicentre study, patients with an ascertained CS while receiving adequate OAC were divided according to the treatment strategy after the index event (LAAC vs medical therapy [MT] group). Other potential embolic sources were excluded and all patients continued OAC after the index event. The primary end point was a composite of all-cause death, CS, and major bleeding. RESULTS:Among the 109 patients included in the study, 44 (40%) formed the LAAC group and 65 (60%) the MT group. At the median follow-up of 48 (interquartile range, 14) months, the LAAC group reported a lower rate of the primary end point (hazard ratio, 0.398; 95% confidence interval, 0.201-0.781; P = 0.008) and CS recurrence (hazard ratio, 0.273; 95% confidence interval, 0.060-0.852; P = 0.041). Congestive Heart Failure, Hypertension, Age (≥75 years), Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age (65-74 years), Sex (Female; CHA2DS2-VASc), NIH Stroke Scale (NIHSS), and acute reperfusion therapy predicted the primary end point whereas CHA2DS2-VASc and NIHSS predicted CS recurrence. Results were confirmed in a propensity score-matching analysis. The calculated annualized rate of CS was 2.0 per 100 patient-years in the LAAC group and 7.8 per 100 patient-years in the MT group. CONCLUSIONS:In patients with CS due to OAC failure, the hybrid strategy LAAC and OAC was associated with better long-term outcomes compared with OAC alone.

Atrial electrical remodeling spans molecular, electrical, and structural alterations that shorten refractoriness, facilitate reentry, and ultimately create the atrial substrate underlying atrial fibrillation (AF). These changes include ion channel dysfunction, calcium-handling abnormalities, oxidative injury, and deranged proteostasis that are tightly intertwined with atrial fibrosis and cardiomyopathy. High-density mapping and advanced imaging now allow in vivo staging of this substrate: left atrial low-voltage areas and functional conduction phenomena identify regions of fibrosis and conduction slowing that are associated with postablation recurrence, although the benefit of low-voltage area-targeted substrate ablation remains uncertain. Building on this pathophysiological framework, this review integrates experimental and clinical evidence to guide decision making in AF therapy, emphasizing early rhythm-control strategies and careful substrate characterization in sinus rhythm. Pulmonary vein (PV) isolation is presented as the cornerstone of ablation, whereas adjunctive substrate-oriented strategies, including low-voltage modification, hybrid surgical-catheter approaches, and vein of Marshall-based techniques, are discussed as investigational options for selected high-risk patients. Finally, the review contrasts PV- and non-PV-dependent forms of AF and appraises emerging artificial intelligence-guided electrogram interpretation within a mechanism-driven framework for personalized management of atrial electrical remodeling.

Accurate identification of the site of origin (SOO) of outflow tract ventricular arrhythmias (OTVAs) is critical for effective ablation planning. Accuracy of the existing algorithms/scores in patients with wide baseline QRS has not been previously described. This study sought to evaluate the performance of available algorithms/scores in predicting the OTVA-SOO in patients with wide baseline QRS due to intraventricular conduction abnormalities or paced rhythm (NCT06602635). Eighty-eight patients with intraventricular conduction disturbances (baseline QRS >110 ms) or a paced rhythm who underwent OTVA ablation in 9 European centers were included. The predictive performance of the existing algorithms/scores was compared using receiver operating characteristic curve analysis, accuracy, sensitivity, and specificity. Median baseline QRS duration was 122ms (114–144), sixty-five (73.9

Background. Pulmonary vein isolation (PVI) represents the cornerstone of paroxysmal (PAF) and persistent atrial fibrillation (PsAF) ablation. Impedance values provide insights on tissue conductive properties. Methods. Consecutive patients undergoing PAF and PsAF ablation were prospectively enrolled. All the patients underwent a preprocedural multidetector computed tomography (MDCT) to evaluate left atrial wall thickness (LAWT). Electroanatomic maps were acquired with the ablation catheter, and impedance values (Ω) and voltage amplitude (mV) of bipolar electrograms were collected. Results. A total of 60 patients (40 with PAF and 20 with PsAF) were included in the study. In all PAF cases, no voltage value lower than 0.5 mV was found at LA mapping; the corresponding mean impedance value was 151.5 ± 5.4 Ω. In PsAF cases, voltage values inferior to 0.05 mV have been reported in 19/20 patients. PsAF patients showed a mean impedance value of 129.1 ± 3.8 Ω. The correlation analysis between bipolar voltage and impedance reported an rs value of 0.4166 (p < 0.001), showing a positive correlation between the two variables. On the contrary, no direct correlation was found between voltage and LAWT and between impedance and LAWT (rsv-t = 0.1838; rsi-t = 0.1133, respectively). Conclusions. This research study suggests a correlation between voltage amplitude and impedance values, so that impedance might be used for arrhythmogenic substrate characterization.

Background: Mitral annular disjunction (MAD) is an anatomical abnormality associated with an increased risk of major arrhythmic events, regardless of the presence of mitral valve prolapse. Cardiac magnetic resonance (CMR) plays a key role in diagnosing MAD and identifying myocardial fibrosis, a marker of arrhythmic vulnerability. Aim: This study reports the experience of the De Gasperis Cardiology Centre at Niguarda Hospital (Milan, Italy) in managing high-risk MAD patients who underwent implantable cardioverter–defibrillator (ICD) implantation and describes their main clinical characteristics. Methods: Between January 2020 and April 2025, five patients with MAD who received ICDs were identified and monitored remotely. Although the small sample size limits generalizability, the objective was to characterize factors associated with arrhythmic susceptibility. Results: Four patients exhibited documented ventricular arrhythmias: two with non-sustained and two with sustained ventricular tachycardia. Notably, CMR did not reveal myocardial fibrosis in two symptomatic cases, suggesting that arrhythmic vulnerability may precede detectable structural abnormalities. The observed coexistence of MAD with arrhythmogenic cardiomyopathies and channelopathies underscores the relevance of comprehensive genetic evaluation in these patients. Conclusions: MAD should be considered a potential arrhythmogenic substrate rather than a benign anatomical variant. A multimodal diagnostic approach and individualized risk stratification—potentially integrating genetic findings—are essential for optimal patient management.

BACKGROUND:The need for transvenous lead extraction (TLE) is increasing worldwide. Since the course of the subclavian vein until the junction with the superior vena cava is a frequent place of lead adherences, we aim to assess the safety and efficacy of a short 13Fr bidirectional rotational mechanical sheath as first choice. METHODS AND RESULTS:In this multicentric study, 202 carriers of a cardiac implantable electronic device (CIED) undergoing TLE using a short 13 Fr bidirectional rotational mechanical sheath were prospectively enrolled. All procedures were performed using a stepwise approach. The indication for TLE were infection (62%), malfunction (32%), and upgrade (6%). Overall, 471 leads were extracted: 65% pacing leads, 20% defibrillator leads, 9% coronary sinus leads, and 6% abandoned leads. Clinical success and complete lead extraction have been achieved in 97% and 95% of cases, respectively. The short sheath was always effective in gaining venous access at the start of the procedure and was sufficient for complete TLE in 67% of cases. Lead dwell time, defibrillator lead, number of leads per patient, and lead malfunction were predicting factors of long bidirectional rotational mechanical sheath use. There were no cases of intraprocedural death, and major complications were reported in 2% of patients. Overall survival was 97% at 1-year follow-up. CONCLUSION:This multicentric experience using a short 13Fr bidirectional rotational mechanical sheath reported high safety and efficacy, demonstrating the utility of routine use of short extraction sheaths of higher caliper as the first choice.

Backgroundwide antral pulmonary vein isolation (PVI) is effective for treating paroxysmal atrial fibrillation (PAF), although time-demanding. We investigated the impact of a standardized ablation protocol by using a bidirectional transeptal steerable sheath, high-density mapping and very high-power-short-duration (vHPSD) catheters on procedure timing, efficacy, and safety.Methodsconsecutive PAF patients free from previous ablations undergoing PVI alone between January 2022 and March 2023 were prospectively enrolled. The standardized workflow included general anesthesia, a single transeptal puncture trough with a bidirectional, steerable visualizable sheath introduced into the left atrium accommodated a high density, penta-spline mapping catheter and a contact force sensor ablation catheter enabled to deliver vHPSD. Procedural data and electrophysiology (EP) laboratory times were systematically collected and analyzed. The primary endpoint was any AF or atrial tachycardia recurrence at 12 and 24 month follow up.Resultsthe study cohort was composed by 138 patients (mean age was 59 ± 11 years, 38% female) and successful PVI was achieved in 100% of cases. Overall, first pass isolation (PFI) was 93%, with a LA dwell time of 32 ± 4 min. Significant complications were reported in 3% of patients. Skin-to-skin time and total EP laboratory time were 58 ± 5 min and 85 ± 7 min, respectively. The primary endpoint was achieved by 9% and 12% of cases at 12 and 24 month follow up, respectively. Upper limit skin-to-skin time and missed FPI resulted predictors of the primary endpoint.ConclusionThis standardized workflow resulted in low procedural times and arrhythmias recurrence without compromising the safety.

Premature ventricular contractions (PVCs) originating from the left ventricular summit (LVS) present a diagnostic and therapeutic challenge due to their complex anatomical location. The LVS includes an epicardial area of the left ventricle bordered by major coronary arteries, which has been increasingly recognized as an arrhythmic focus. Idiopathic ventricular arrhythmias from this area may exhibit specific electrocardiographic characteristics, making accurate localization essential for effective management. Methods: This narrative review explores the primary features of this arrhythmia, emphasizing key diagnostic and therapeutic aspects, including both pharmacological and interventional approaches, considering the recent technological advances in cardiac mapping and ablations. Conclusions: PVCs originating from the left ventricular summit (LVS) exhibit characteristic electrocardiographic features. Prompt recognition of this arrhythmia may facilitate appropriate referral for targeted treatment.

Background: Arrhythmia-induced cardiomyopathy (AIC) is a relatively common yet poorly understood cardiac condition that occurs when arrhythmias cause left ventricular systolic dysfunction, which can be reversed with the resolution of the arrhythmia. Catheter ablation serves as a cornerstone treatment for eliminating the arrhythmic trigger. However, the variability in left ventricular recovery following ablation highlights the need to identify reliable predictors of reverse remodeling. Methods: This review explores key studies on AIC patients undergoing catheter ablation, primarily derived from observational cohorts, to identify significant predictors of left ventricular function recovery. Results: While echocardiography and cardiac magnetic resonance imaging remain the primary diagnostic modalities, additional insights have emerged from electrocardiograms and laboratory biomarkers. Despite these advancements, a comprehensive framework for identifying optimal candidates for ablation remains lacking. Conclusions: By synthesizing existing evidence, this review aims to pinpoint the most robust predictors of systolic recovery in AIC patients following ablation.

Il defibrillatore cardiaco impiantabile (ICD) extravascolare (EV-ICD, Aurora, Medtronic, Minneapolis, MN, USA) è stato recentemente validato come nuovo dispositivo di prevenzione della morte aritmica con l’obiettivo di ridurre le complicanze vascolari e meccaniche dell’ICD transvenoso e di superare i limiti dell’ICD sottocutaneo. La procedura di impianto richiede un programma di apprendimento dedicato e, oltre all’elettrofisiologo, deve essere eseguita con l’ausilio di un anestesista, per l’induzione dell’anestesia generale e, soprattutto nelle prime fasi del training, di un cardiochirurgo, per assistenza durante l’accesso allo spazio retrosternale in cui far alloggiare l’elettrocatetere. L’obiettivo di questa casistica è di descrivere l’esperienza presso il nostro centro ad alto volume dove in un periodo di 8 mesi abbiamo trattato i primi 10 pazienti con il dispositivo EV-ICD.

BACKGROUND:Interleukin-6 (IL-6), a pro-inflammatory cytokine and anti-inflammatory myokine, is involved in immune regulation and metabolic control. Persistent IL-6 activation, particularly via trans-signalling, is implicated in endothelial dysfunction, atherosclerosis, myocardial fibrosis, and adverse remodelling. METHODS:This review summarizes experimental, genetic, and clinical evidence on the role of IL-6 in cardiovascular disease (CVD), focusing on the molecular pathways, prognostic value, and its potential as a therapeutic target. Experimental and genome-wide association studies, as well as clinical trials-including IL-6-targeted interventions-are comprehensively reviewed. RESULTS:While acute activation of IL-6/STAT signalling, that is, before or during myocardial infarction, is protective, chronic activation leads to maladaptive changes in the myocardium. Mechanistically, IL-6 promotes vascular inflammation, monocyte recruitment, coagulation, and fibrosis. Mendelian randomization implies a causal role of IL-6 signalling in coronary artery disease, stroke, and atrial fibrillation. Simultaneously, elevated IL-6 levels predict adverse outcomes in acute coronary syndromes and heart failure. Pharmacological IL-6 inhibition reduces systemic inflammation, with pilot data implying acceptable safety profiles. Large phase III outcome trials are ongoing, shedding light on the impact of IL-6 blockade in high-risk populations, such as those with chronic kidney disease and heart failure with preserved or mildly reduced ejection fraction. CONCLUSIONS:IL-6 plays a dual role-protective versus pathogenic and acute versus chronic. Chronic IL-6 links inflammation and metabolic dysregulation to structural cardiovascular damage. Chronic IL-6 activation requires therapeutic approaches tailored to disease context, timing and signalling mode. The results of ongoing trials will clarify whether IL-6-targeted interventions can be integrated into cardiovascular prevention and management strategies, complementing established therapies and addressing residual inflammatory risk.

BACKGROUND AND OBJECTIVE:Magnetic resonance imaging (MRI) in patients with cardiac implantable electronic devices (CIEDs) is increasingly safe, but workflows requiring pre- and post-scan interrogations are resource-intensive. We aimed to describe MRI mode-switching technologies and assess their impact on workflow efficiency using institutional data. METHODS:We reviewed CIED MRI mode-switching technologies, analyzed all CIED-MRI scans at our center (2017-2024), and modeled workload reductions with broader automation. RESULTS:We identified three technology classes-manual programming, automatic MRI detection within a time-limited window (e.g., AutoMRI, MRI AutoDetect), and always-on 24/7 detection (MRI Guard 24/7)-with stepwise reductions in required interrogations. Among 132,166 scans, 414 (0.3 %) involved CIEDs in our experience: 345 manual, 66 automatic window, and 3 24/7 detection. The total number of scan-related device checks was 756, and automation avoided 72 checks (8.7 %). Scenario modeling assuming 50 % automatic window and 10 % 24/7 adoption predicted ∼25-30 % fewer checks, potentially easing staffing and scheduling constraints. CONCLUSIONS:Automatic MRI mode-switching has the potential to streamline workflows and improve access for CIED patients without compromising safety. Wider adoption, particularly when integrated with remote monitoring, may further enhance efficiency and patient-care outcomes.

BACKGROUND:Patients with non-valvular atrial fibrillation (AF) who experience an ischemic stroke despite oral anticoagulation (OAC) are at particularly high risk of recurrence, with a reported annualized ischemic stroke rate of 5.3%-8.9%. The optimal strategy for secondary prevention in these patients remains unknown. METHODS:We reviewed all percutaneous left atrial appendage closures (LAAC) attempted in AF patients experiencing an ischemic stroke under OAC and who were prospectively collected in four European centers. All index strokes were categorized by an experienced neurologist to exclude patients with non-cardioembolic etiology or insufficient OAC. The primary endpoint was a recurrent ischemic stroke at 2 years after the procedure. Secondary endpoints included procedure-related complications and 2-year death. RESULTS:Of 2234 patients submitted to LAAC procedure, 95 had a cardioembolic breakthrough stroke. LAAC procedures were performed at a mean of 4 months after the breakthrough stroke. The main antithrombotic therapy at discharge (83%) and at the latest follow-up (79%) consisted of OAC. At the median follow-up of 713 days, the primary endpoint occurred in 4 patients (4%). Procedure-related complications were rare (1%) whereas death occurred in 5% of patients. CONCLUSION:LAAC procedures were safe and feasible in patients with cardioembolic breakthrough stroke. Recurrent stroke rates were lower than those reported in previous studies with OAC continuation after breakthrough stroke, suggesting a potential additive protection by LAAC on top of OAC. Results from ongoing randomized trials are required to validate our findings.

BACKGROUND:The long-term natural history of moderate tricuspid regurgitation (TR) patients with preserved left-ventricular ejection fraction (LVEF) and without severe left-sided valvular heart disease (VHD) remains ambiguous. We aimed to assess the outcomes of patients with moderate TR, preserved LVEF and without concomitant severe left-sided VHD. METHODS:We evaluated patients diagnosed with moderate TR in our centers between 2012 and 2020. The primary outcome was all-cause death, the secondary outcome was the composite of all-cause death+heart failure (HF) hospitalization, also accounting for pulmonary artery systolic pressure (PASP) values and concomitant moderate left-sided VHD. RESULTS:Among 1198 moderate TR patients, 53 % had New York Heart Association class ≥II and mean LVEF was 58 ± 5 %. After a median follow-up of 2.9 years, 3-year survival was 69 % (95 % confidence interval [CI]: 66 %-72 %), significantly worse than an age- and gender-matched population (p < 0.001), and 3-year survival free from the secondary composite outcome was 63 % (95 % CI: 60-67 %). At secondary analysis, increasing PASP values were associated with worse adjusted prognosis, and in patients with PASP <35 mmHg 3-year survival free from the primary and secondary outcome was 85 % (95 % CI: 80 %-89 %) and 80 % (95 % CI: 75 %-86 %), respectively. Finally, among patients with concomitant moderate left-sided VHD groups, the group with moderate aortic stenosis+moderate TR presented the worst adjusted prognosis, and patients with isolated moderate TR had a yearly mortality of 8.9 % (95 % CI: 6.0 %-11.0 %). CONCLUSIONS:Our cohort of moderate TR patients, despite having preserved LVEF and no concomitant severe left-sided VHD, presented significant risk of death and of HF hospitalization.

INTRODUCTION:Patients with acute coronary syndrome (ACS) have concomitant ventricular arrhythmic events (VA). Literature data are conflicting regarding short- and long-term prognosis. International guidelines do not recommend defibrillator (ICD) implantation in the first 40 days after a myocardial infarction. However, some patients may have an increased arrhythmic risk and deserve closer monitoring. PURPOSE:The aim of our study was to define the incidence of arrhythmic events in a population of patients admitted for ACS to the Cardiac Intensive Care Unit (CICU) of a tertiary center and to determine the short- and long-term prognosis in patients with arrhythmic onset compared with patients without arrhythmic onset. METHODS:This is a single-center retrospective cohort data analysis of 1587 consecutive patients admitted with a diagnosis of ACS to the CICU of Niguarda Hospital of Milan, from 2014 to 2022. We classified the patients into two groups according to the arrhythmias at presentation: VA (sustained VT or VF) and no-VA. Kaplan-Meier (KM) estimated the probability of remaining event free in the time after ACS and were compared between VA and no-VA groups, using the log-rank test. Cox regression analysis was used to explore the association of specific variables with the occurrence of cardiac events in univariate and multivariate analysis. Statistical analyses were performed with R 42.0 statistical package (R Core Team, Vienna, Austria). RESULTS:Among 1587 ASC patients, 4.6 % had arrhythmic onset (4.0 had a diagnosis of VF and 0.6 % of VT). Patients with VA were significantly younger (63 y. vs 67 y., p = 0.026) and had a lower incidence of cardiovascular risk factors, such as hypertension and dyslipidemia, compared with no-VA group. VA group had a higher risk of arrhythmias during the hospitalization (9.6 % vs 1.3 %, p < 0.001) and had a clinical course characterized by a significantly higher use of mechanical support with intra-aortic balloon pumps (IABP, 35.6 % vs. 6.8 %, p < 0.001) and a greater use of inotropic drugs (34 % vs. 9 %, p < 0.001). We observed in VA group a six-fold increase in-hospital mortality (23 % vs 4 %, p < 0.001), identifying arrhythmic presentation as a marker of worse in-hospital prognosis in patients admitted with ACS. Likewise, mortality at 40 days after the acute event was higher in the VA group than in the no-VA group (22 % vs. 5 %, p < 0.001). Conversely, during a median follow-up of 5.9 years, VA onset did not affect long-term mortality in patients discharged alive. CONCLUSION:In this long-term follow-up retrospective registry involving a large cohort of patients with ACS admitted to the CICU, concomitant VA at admission was found to be linked with an increase in in-hospital arrhythmic complications and in-hospital mortality. The mortality rate at 40 days post-ACS was also notably higher in the VA group. This study underscores the complexity of arrhythmic presentation in ACS patients, emphasizing the critical need for vigilant monitoring throughout their hospitalization and particularly in the initial 6 weeks following the event index. This heightened surveillance is justified by the documented elevated levels of morbidity and mortality during this phase.

BACKGROUND:Performing a left atrial appendage occlusion (LAAO) or catheter ablation with left-sided intracardiac thrombus is considered very-high risk for periinterventional stroke. Cerebral embolic protection (CEP) devices are designed to prevent cardioembolic stroke and have been widely studied in TAVR procedures. However, their role in LAAO and catheter ablation of ventricular tachycardia (VT) or in pulmonary vein isolation (PVI) with cardiac thrombus present remains unknown. PURPOSE:to study utility and safety of CEP devices during LAAO and catheter ablation in patients with left sided intracardiac thrombus in a multicenter setting. METHODS:Two different CEP devices were used according to the physician's discretion: (1) a capture device consisting of two filters for the brachiocephalic and left common carotid arteries placed from a radial artery; or (2) a deflection device covering all three supra-aortic vessels placed over a femoral artery. Periprocedural and safety data from 2019 to 2023 were retrospectively obtained from procedural reports and discharge letters for all patients with left-sided intracardiac thrombus undergoing LAAO, VT ablation, or PVI under protection with a CEP device. Long-term safety data were obtained by clinical follow-up in the respective institutions and telephone consultations. RESULTS:Sixty-five patients were enrolled in five centers in Italy. Fifty-two patients underwent LAA closure, 12 patients underwent VT ablation and one patient underwent PVI. Mean age was 73 ± 10 years and 43 (66%) were male, mean LVEF was 46 ± 13%. The location of the cardiac thrombus was the LAA in all 52 patients (100%) undergoing LAA closure whereas in patients undergoing VT ablation, thrombus was present in the LAA in five cases (42%), left ventricle (n = 6; 50%) and aortic arch (n = 1;8%). One patient developed left atrial thrombus during PVI. The capture device was used in 39 out of 65 (60%) and the deflection device in 26 out of 65 cases (40%). There were no periprocedural strokes or transitory ischemic attacks (TIA). CEP-related complications at the arterial access site were noted in 4 cases (6%) and were minor, not requiring surgery. Other periprocedural events were one transient ST-elevation caused by coronary spasm in a patient undergoing LAA closure, not related to the CEP device. There was one in-hospital death after VT ablation due to cardiogenic shock, not related to the CEP device. At long-term follow-up, one TIA and three non-cardiovascular deaths occurred with a mean follow-up time of 455 days. CONCLUSIONS:This is the first multicentre experience showing that LAA closure or catheter ablation with cerebral protection in patients with cardiac thrombus is feasible without thromboembolic complications. The possibility of safely performing an intervention in this high-risk setting is promising and should be tested in a prospective randomized trial.

The extravascular implantable cardioverter-defibrillator (EV-ICD, Aurora, Medtronic, Minneapolis, MN, USA) has recently been validated as a new device for preventing arrhythmic death with the aim of reducing vascular and mechanical complications of transvenous ICDs and overcoming the limitations of subcutaneous ICDs. A dedicated learning program is required and, in addition to the electrophysiologist, the implantation procedure must be performed with the assistance of an anesthesiologist for general anesthesia induction and, especially in the early stages of training, a cardiothoracic surgeon for assistance during access to the retrosternal space where the lead should be placed. The objective of this case series is to describe the experience at our high-volume hospital where we treated the first 10 patients with the Aurora EV-ICD device over a period of 8 months.

Background: Cardiovascular disease (CVD) in pregnancy is a major cause of maternal morbidity and mortality, accounting for nearly one-third of pregnancy-related deaths worldwide. Physiological adaptations—expanded plasma volume, increased cardiac output, and a prothrombotic state—represent a natural cardiovascular stress test that may precipitate decompensation or unmask subclinical disease. Aim: This review critically examines contemporary evidence and international guidelines on the management of pregnancy-related cardiovascular disorders, focusing on pathophysiological mechanisms, diagnostic challenges, and therapeutic controversies. Content: The discussion centers on three high-impact clinical domains: (1) peripartum and preexisting cardiomyopathies, emphasizing mechanisms, prognosis, and the role of bromocriptine; (2) anticoagulation management in women with mechanical prosthetic valves, balancing maternal safety and fetal protection; and (3) hypertensive disorders of pregnancy, highlighting recent evidence from the CHAP and WILL trials and their implications for long-term cardiovascular prevention. Comparative analysis of ESC 2025 and AHA 2020 recommendations reveals broad consensus but persistent discrepancies in anticoagulation targets, postpartum surveillance, and follow-up strategies. Perspectives: Endothelial dysfunction, angiogenic imbalance, and systemic inflammation emerge as shared mechanisms linking diverse pregnancy-related cardiovascular conditions. Strengthening multidisciplinary care through Pregnancy Heart Teams, integrating obstetric and cardiologic expertise, and establishing structured postpartum follow-up pathways are essential to improve outcomes.