Cryoballoon pulmonary vein isolation (CB-PVI) has become an established treatment for atrial fibrillation (AF). However, data on long-term outcomes beyond 5-years is scarce. This prospective analysis aimed to evaluate the very long-term outcome after CB-PVI. Data from consecutive patients treated with CB-PVI for symptomatic AF between 2012 and 2018 in 13 institutions were analyzed. Patients with ≥5-year follow-up after the index procedure were included. Arrhythmia recurrence was defined as AF or atrial tachycardia (AT) lasting >30 seconds beyond a 3-month blanking period. 1330 patients were enrolled (28.4% female, mean age was 60.1±10.5 years). Median (IQR) CHA2DS2-VASc was 1.0 (0.0-2.0) while median (IQR) EHRA score was 2.0 (1.0-2.0). Paroxysmal AF patients were 73.1%, median AF duration was 36.0 (13.0-75.0) months. Overall, 4.4% of patients experienced a periprocedural complication with the most frequent being a transient diaphragmatic paralysis (2.3%). The rate of AF/AT recurrences progressively increased over time [event rate: 17.1% (15.2%-19.3%) at 1-year, 34.7% (32.2%-37.3%) at 5-year, 52.5% (49.4%-55.8%) at 8-year follow-up]. 78.3% patients were free from antiarrhythmic drug therapy at last available follow-up. Kaplan-Meier curves showing incidence of AF recurrences, stratified per AF pattern and per the use of AADs have been shown in Figure 1. Recurrences were mostly paroxysmal, with a low incidence of progression to permanent AF in the entire cohort (n=93; 7.0%). Importantly, 15.7% patients underwent a redo ablation for AF during follow-up. Among those, in 45.9% of cases all PVs were isolated; the median number of PVs isolated after the index procedure was 3 [1-4] veins. The only independent predictor of arrhythmia recurrences was AF type (Persistent AF: HR=1.37; CI 1.20-1.43, p<0.001) at multivariate analysis. In terms of adverse events during follow-up, there were 6 thromboembolic events (0.5%, including 4 strokes and 2 TIAs) and 4 major bleeding events (0.3%). CB-PVI as the index procedure for AF ablation resulted in a favorable long-term outcome in patients with symptomatic AF, with limited progression towards persistent AF during follow-up. Persistent AF was the strongest predictor of recurrences at long-term follow-up.Figure 1

Background:Slow pathway (SP) ablation is the cornerstone for atrioventricular nodal reentry tachycardia (AVNRT) treatment, and a low-voltage bridge offers a good target during mapping using low x-ray exposure. We aimed to assess a new tool to identify SP by activation mapping using the last CARTO3® version, i.e., CARTO PRIME® V7 (Biosense Webster, Diamond Bar, CA, USA).Methods and results:Right atrial septum and triangle of Koch 3D-activation map were obtained from intracardiac contact mapping during low x-ray CARTO 3® procedure. In 60 patients (mean age 60.3 ± 14.7, 61% females) undergoing ablation for AVNRT, an automatic activation map using a DECANAV® mapping catheter and CARTO® Confidense™, Coherent, and FAM DX software modules were obtained. The SP was identified in all patients as the latest atrioventricular node activation area; RF catheter ablation (RFCA) in that region elicited junctional beats. The mean procedural time was 150.3 ± 48.3 min, the mean fluoroscopy time exposure was 2.9 ± 2 min, the mean dose-area product (DAP) was 16.5 ± 2.7 cGy/cm2. The mean number of RF applications was 3.9 ± 2, the mean ablation index was 428.6 ± 96.6, and the mean contact force was 8 ± 2.8 g. There were no adverse event during the procedure, and no AVNRT recurrences occurred during a mean follow-up of 14.3 ± 8.3 months.Conclusion:Ablation of the SP by automatic mapping using Confidense™, Coherent, and FAM DX software modules is an innovative, safe, and effective approach to AVNRT ablation. The CARTO3® V7 system shows on a 3D map the latest AV node activation area during sinus rhythm allowing low fluoroscopy time and highly effective RFCA.

Interventional Cardiology Sandro Hospital, Rome, Italy Correspondence to Alessandro Sciahbasi, MD, PhD, UOC Cardiologia – Sandro Pertini Hospital-ASL Roma 2, Rome, Italy Tel: +39 06 41433870; fax: +39 06 41433481; e-mail: [email protected] Received 27 June, 2022 Revised 29 August, 2022 Accepted 5 September, 2022

Interventional cardiologists are significantly exposed to X- rays and no dose of radiation may be considered well tolerated or harmless. Leaded aprons protect the trunk and the thyroid gland, leaded glasses protect the eyes. The operator's legs, arms, neck and head are, instead, not fully protected. In fact, the operator's brain remains the closest part to the primary X-ray beam and scatter in most interventional procedures and specifically the physician's front head is the most exposed region during device implantation performed at the patient's side. After the initial description of cases of brain and neck tumours, additional reports on head and neck malignancies have been published. Although a direct link between operator radiation exposure and brain cancer has not been established, these reports have heightened awareness of a potential association. The use of lead-based cranial dedicated shields may help reduce operator exposure but upward scattered radiation, weight and poor tolerability have raised concerns and hindered widespread acceptance. The purpose of this review is to describe current knowledge on occupational X-ray exposure of interventional cardiologists, with a special focus on the potential risks for the head and neck and efficacy of available protection devices.

A young male with β-thalassemia major was implanted with a single-chamber Implantable cardioverter-defibrillator (ICD) for a cardiac arrest due to ventricular fibrillation. He received multiple inappropriate shocks due to atrioventricular nodal re-entrant tachycardia (AVNRT) treated with radiofrequency catheter ablation and then to high-rate atrial tachycardia refractory to amiodarone and not inducible during electrophysiological study. He refused empirical pulmonary vein isolation. Upgrading to biventricular ICD and performing atrioventricular node ablation avoided further inappropriate shocks.

Aims Radiation use in medicine has significantly increased over the last decade, and cardiologists are among the specialists most responsible for X-ray exposure. The present study investigates a broad range of aspects, from specific European Union directives to general practical principles, related to radiation management among a national cohort of cardiologists. Methods and results A voluntary 31-question survey was run on the Italian Arrhythmology and Pacing Society (AIAC) website. From June 2019 to January 2020, 125 cardiologists, routinely performing interventional electrophysiology, participated in the survey. Eighty-seven (70.2%) participants are aware of the recent European Directive (Euratom 2013/59), although only 35 (28.2%) declare to have read the document in detail. Ninety-six (77.4%) participants register the dose delivered to the patient in each procedure, in 66.1% of the cases both as fluoroscopy time and dose area product. Years of exposition (P = 0.009) and working in centers performing pediatric procedures (P = 0.021) related to greater degree of X-ray equipment optimization. The majority of participants (72, 58.1%) did not recently attend radioprotection courses. The latter is related to increased awareness of techniques to reduce radiation exposure (96% vs. 81%, P = 0.022), registration of the delivered dose in each procedure (92% vs. 67%, P = 0.009), and X-ray equipment optimization (50% vs. 36%, P = 0.006). Conclusion Italian interventional cardiologists show an acceptable level of radiation awareness and knowledge of updated European directives. However, there is clear space for improvement. Comparison to other health professionals, both at national and international levels, is needed to pursue proper X-ray management and protect public health.

BACKGROUND Temporary transvenous cardiac pacing (TTCP) is a standard procedure in current practice, despite limited coverage in consensus guidelines. However, many authors reported several complications associated with TTCP, especially development of infections of cardiac implantable electronic devices (CIED). The aim of this survey was to provide a country-wide picture of current practice regarding TTCP. METHODS Data were collected using an online survey that was administered to members of the Italian Association of Arrhythmology and Cardiac Pacing. RESULTS We collected data from 102 physicians, working in 81 Italian hospitals from 17/21 regions. Our data evidenced that different strategies are adopted in case of acute bradycardia with a tendency to limit TTCP mainly to advanced atrioventricular block. However, some centers reported a greater use in elective procedures. TTCP is usually performed by electrophysiologists or interventional cardiologists and, differently from previous reports, mainly by a femoral approach and with nonfloating catheters. We found high inhomogeneity regarding prevention of infections and thromboembolic complications and in post-TTCP management, associated with different TTCP volumes and a strategy for management of acute bradyarrhythmias. CONCLUSION This survey evidenced a high inhomogeneity in the approaches adopted by Italian cardiologists for TTCP. Further studies are needed to explore if these divergences are associated with different long-term outcomes, especially incidence of CIED-related infections.

Despite an intensive search for predictors of the response to cardiac resynchronization therapy (CRT), the QRS duration remains the simplest and most robust predictor of a positive response. QRS duration of ≥ 130 ms is considered to be a prerequisite for CRT; however, some studies have shown that CRT may also be effective in heart failure (HF) patients with a narrow QRS (<130 ms). Since CRT can now be performed by pacing the left ventricle from multiple vectors via a single quadripolar lead, it is possible that multipoint pacing (MPP) might be effective in HF patients with a narrow QRS. This article reports the design of the MPP Narrow QRS trial, a prospective, randomized, multicenter, controlled feasibility study to investigate the efficacy of MPP using two LV pacing vectors in patients with a narrow QRS complex (100–130 ms).

BACKGROUND Small-diameter implantable cardioverter-defibrillator (ICD) Sprint Fidelis and Riata leads have been recalled owing to an increased risk of lead failure, thus arousing the suspicion that lead size might be a critical issue.OBJECTIVE To compare the incidence of failure of small-diameter (<= 8 F) and standard-diameter (>8 F) ICD leads implanted in a singe center.METHODS From January 2003 to December 2010, 190 Sprint Fidelis, 182 Riata/Riata ST, 99 Optim (Riata Optim/Durata), and 419 standard-diameter leads were implanted in our center.RESULTS During a median follow-up of 33 months, the overall failure rate was 6.3%. Follow-up duration was similar for Sprint Fidelis, Riata, and standard-diameter leads but shorter for the Optim group. The failure rate was significantly higher in Sprint Fidelis leads than in both standard-diameter (4.8%/year vs 0.8%/year; P < .001) and Riata/Riata ST (4.8%/year vs 2.6%/year; P = .03) leads. The incidence of lead failure in Riata/Riata ST leads proved significantly higher than in standard-diameter leads (2.6%/year vs 0.8%/year; P = .001). No cases of lead failure were recorded in the Optim group. On multivariable analyses, small-diameter (hazard ratio [HR] 5.03, 2.53-10.01, P < .001), Sprint Fidelis (HR 6.3, 3.1-13.3, P < .001), or Riata/Riata ST (HR 4.5, 1.9-10.5, P = .001) leads and age < 60 years (HR 2.3, 1.3-4.3, P = .005) were found to independently increase the risk of lead failure.CONCLUSIONS Compared with standard-diameter leads, both Sprint Fidelis and Riata/Riata ST small-diameter ICD leads are at an increased risk of failure, although the incidence of events is significantly lower in the Riata than in the Sprint Fidelis group.

UNLABELLED Aim Conflicting evidence exists as to whether the mitral E/E' ratio can be a reliable predictor of the left ventricular end-diastolic pressure (LVEDP). Our aim was to assess the value of the mitral E/E' ratio for the estimation of left ventricular diastolic pressures (LVDP) in patients without heart failure (HF). METHODS AND RESULTS Echo-Doppler examination and left heart catheterization were carried out in 100 consecutive patients to assess the correlation between echo-Doppler parameters and the LVDP. The E/A ratio showed the best correlation with the pre-a LVDP and the LVEDP, whereas septal and mean E/E' ratios were significantly correlated with pre-a LVDP but not with the LVEDP. No difference in the echo-Doppler parameters was found between patients with normal and elevated LVEDP. Mitral E/E' ratio was significantly higher in patients with an ejection fraction (EF) <50% compared with those with the EF ≥ 50% and in patients with a dilated left ventricular (LV) compared with those with a normal LV. No significant difference in mean LVEDP was found among the three groups with E/E' ratios of <8, 8-15, and >15. The best cut-off values identified by receiver operating characteristic curve analysis for septal, lateral, and mean E/E' had sensitivities of 53, 68, and 54% and specificities of 66, 51, and 69% for identifying a >15 mmHg LVEDP. CONCLUSION In patients without HF mitral E/E' ratio is influenced by EF and LV volumes and is better correlated with the pre-a LVDP than with the LVEDP. The suboptimal sensitivity and specificity of E/E' for predicting increased LVDP suggest that the mitral E/E' ratio is of limited clinical value in patients without HF.

Introduction. Every year 350.000 to 750.000 cases of cardiac arrest occur in the US and in Europe. Since 1974 seven editions of CPR-ECC guidelines have been published and many aspects have been changed. In particular more and more empahis has been given on CPR and the suggested compression to ventilation ratio has progressively been increased (5:1 before 2000, 15:2 from 2000 to 2005 and 30:2 after 2005). The aim of our study is to evaluate, based on a review of the literature, the impact of changes in guidelines on survival to hospital discharge after out of hospital cardiac arrest (OHCA). Material and methods. We searched PubMed for studies on “survival to hospital discharge after OHCA”. Mandatory inclusion criteria included the report of survival to hospital discharge in all patients regardless of presenting rhythm. All data were analyzed according to the year of inclusion: group 1 before 2000; group 2 between 2000 and 2005 and group 3 after 2005. Survival/mortality rates were computed for each group, together with their 95% binomial confidence interval (95%CI). In-hospital mortality rates were compared between groups by means of a group frequency weighted log linear model. Risk ratios (RR) and 95%CI were reported. Results. Among 558 studies retrieved, 45 met our inclusion criteria, with a total of 119,111 of OHCA patients evaluable (65,601 in group 1; 35,954 in group 2 and 17,556 in group 3). The mean call to response time was similar in the three groups: 7.9 ± 2.7 min,; 7.5 ± 2.3 min and 6.9 ± 2.0. min in group 1, 2 and 3, respectively. Survival to hospital discharge in the 3 groups was 6.2% (95%CI 6.0-6.4), 6.4% (95%CI 6.2-6.7) and 9.9% (95%CI 9.5-10.4), respectively (log linear model p<0.001). Specifically a significant decrease in risk of hospital death was observed in group 3 vs group 2 (RR 0.69 (95%CI 0.95-0.97, p<0.001), but not in group 2 vs group 1 (RR 1.00 (0.99-1.00, p=0.14). Conclusion. This quantitative review of the literature demonstrated that survival to hospital discharge after OHCA has significantly increased after 2005 guidelines changes. The cardio-centric revolution in CPR and in advanced care with more high quality CPR resulted in a 30% improvement in survival after OHCA.

Objectives We assessed the clinical profile of patients with acute coronary syndrome (ACS) and nonobstructive coronary artery disease (CAD) in a real world setting, focusing on pattern of care and on prognosis. Methods Each nonobstructive CAD (<50% stenosis in any epicardial coronary artery) patient was matched with an obstructive CAD patient; adjusted estimates of prescription of guideline-recommended drugs at discharge and of long-term prognosis were evaluated. Results Among 2995 consecutive ACS patients who underwent coronary angiography, 125 (4.2%) had nonobstructive CAD. Nonobstructive CAD patients had significantly lower odds of receiving aspirin [odds ratio (OR) 0.31, 95% confidence interval (CI): 0.14–0.68], thienopyridines (OR 0.01, 95% CI: 0.00–0.07), statins (OR 0.31, 95% CI: 0.17–0.58), beta-blockers (OR 0.32, 95% CI: 0.17–0.63) and angiotensin converting enzyme-inhibitors /angiotensin receptor blockers (OR 0.36, 95% CI: 0.17–0.91) compared with matched patients. During a 3-year follow-up, nonobstructive CAD patients had significantly fewer cardiovascular deaths and myocardial infarctions but numerically more episodes of unstable angina. Conclusions The prevalence of nonobstructive CAD appears lower (4.2%) compared with published data. After extensive adjustment, patients with nonobstructive CAD were significantly less likely to be treated with guideline-recommended therapy, including aspirin and statins. Multicenter prospective studies targeting this specific population and the potential benefit of guideline-recommended therapies appear warranted.