Background:Catheter ablation is useful to treat patients with scar-related heart disease and ventricular tachycardia (VT). QDOT Micro catheter is a next generation catheter. Its optimized temperature control and micro-electrode technology are designed to provide more efficient and consistent lesion creation with an accurate myocardial substrate analysis. This study aims to compare the myocardial electro-anatomic maps obtained using QDOT and Pentaray (PR) catheters. Method:This study enrolled patients with symptomatic VT and indication to perform CA following the latest guidelines. Myocardial electro-anatomic maps were obtained using QDOT and Pentaray (PR) catheters. The primary objective was to assess the absence of sustained VTs or ICD interventions 12 months after the procedure. Results:Twelve patients were enrolled. The percentage of myocardial scar was higher using QDOTB map (15.5%) compared to PR (13.5%) and QDOTM-map (9%) (< 0.001). The percentage of myocardial borderzone was higher using QDOTB map (7.5%) compared to PR (6%) and QDOTM-map (3%) (p < 0.001). The average EGM amplitude acquired in the myocardial scar was higher in the QDOTM-map (0.24 mV) compared to PR (0.10 mV) and QDOTB-map (0.10 mV) (p < 0.001). The average EGM amplitude acquired in the myocardial borderzone was higher in the QDOTM-map (1.07 mV) compared to PR (0.80 mV) and QDOTB-map (0.72 mV) (p < 0.001). No sustained VT was documented at 12 month FU. No adverse events were documented. Conclusion:Microelectrode mapping allows detection of higher voltage electrograms compared to standard bipolar mapping and PR mapping. In our small population, the HPSD protocol was used inside the low voltage areas without acute procedural complications.

Abstract Background/Introduction Left lateral atrial ridge (LLR), sited between the orifices of the left pulmonary veins (PVs) and the left atrial appendage ostium, is a crossroads of different kinds of tissues. It is known as a substrate for atrial fibrillation (AF) triggers, but also as a challenging ablation site. We previously proposed the bilateral approach as a strategy to ablate this area. Purpose The aim of this study is to assess the feasibility, safety and efficacy of adding bilateral ablation of the left lateral ridge (BLLRA) to pulmonary vein isolation (PVI) in preventing arrhythmic recurrences in patients with paroxysmal AF. Methods We designed a 1:1 randomized, controlled, single-blinded, superiority trial enrolling consecutive patients undergoing first paroxysmal AF ablation. Patients were randomized to BLLRA plus PVI or to PVI only, performed using a variable loop pulse field ablation catheter supported by electro-anatomical mapping. The primary endpoint is freedom from atrial tachyarrhythmias 12 months after ablation. The secondary endpoint is a safety outcome. The sample size was calculated 121 patients per group. A structured follow up at 2, 6 and 12 months was settled. This is an interim analysis of the preliminary results of the trial. Results In this preliminary analysis, a total of 41 patients (mean age 61,5±8,4; male 61%) were enrolled between October 2024 and September 2025. 21 patients (mean age 61,5±6,8; male 76,2%) were randomized in BLLRA plus PVI group, whilst 20 patients in the PVI group (mean age 61,5±10; male 45%). Baseline characteristics were balanced between groups (fig.1). Two patients underwent the procedure but did not start the follow up. No differences were documented between groups considering procedural data, nor procedural times (fig.1 and 2). After 7,3±3,1 months of follow up, freedom from recurrent atrial arrhythmia (fig.1 and 2), without the use of antiarrhythmic medication and after 8 weeks of blanking period, was present in 18 of 20 patients (90%) assigned to BLLRA plus PVI, compared with 15 of 19 (78,9%) assigned to PVI alone (between-group difference, –11,9%; hazard ratio [HR], 0.52 [95% CI, 0.10-2,59]; log rank p = 0,43). Evaluating the type of arrhythmia, freedom from AF was documented in 90% of patients of the intervention group and 84,3% of the control group (log rank p = 0,69); whereas freedom from atrial flutter occurred in 100% of BLLRA plus PVI group and 94,8% in PVI only group (log rank p = 0,31). No events occurred concerning the safety outcome in the overall population. Two vascular complications occurred, one for each group, related to groin puncture issues. Conclusion(s) Bilateral left lateral ridge ablation plus pulmonary veins isolation is a feasible and safe treatment for paroxysmal atrial fibrillation. There is a favorable trend toward efficacy when compared to PVI only, but more data, patients and time are needed to provide definite evidence of superiority.TablesBLLRA plus PVI vs PVI comparison

La cardiomiopatia correlata a PRKAG2 rappresenta una fenocopia metabolica della cardiomiopatia ipertrofica ed è caratterizzata da ipertrofia ventricolare, pre-eccitazione e aritmie sopraventricolari, con frequenti errori di classificazione diagnostica. Descriviamo il caso di un uomo di 44 anni con anamnesi familiare positiva sul versante materno per cardiomiopatia ipertrofica e storia di fibrillazione atriale sottoposto a risonanza magnetica cardiaca che mostrava ipertrofia asimmetrica, esteso late gadolinium enhancement e iniziale rimodellamento dilatativo, suggerendo un fenotipo sovrapposto di cardiomiopatia ipertrofica/cardiomiopatia aritmogena del ventricolo sinistro. Dopo impianto di defibrillatore in prevenzione primaria, il test genetico identificava la variante eterozigote PRKAG2 c.1024G>A, p.(Glu342Lys), di origine materna e classificata dal laboratorio come patogenetica. La rivalutazione dell’ECG evidenziava intervallo PR corto, pre-eccitazione ventricolare e blocco di branca destra, consentendo la riclassificazione diagnostica. Il caso sottolinea l’importanza di una visione d’insieme e del riconoscimento delle “red flags” all’ECG per evitare errori diagnostici nei fenotipi ipertrofici.

Extracorporeal membranes oxygenation (ECMO) has been proposed as a useful tool to support ablation of unstable ventricular arrhythmias (VAs). The aim of this study is to assess the clinical outcome of cardiopulmonary support of VAs catheter ablation during a long-term follow-up. In this retrospective observational study, we included 47 patients referred to our center for catheter ablation of repeated episodes of hemodynamically unstable sustained VAs between April 2016 and February 2025. All patients underwent catheter ablation, supported by ECMO, of ventricular arrhythmias symptomatic for syncope or presyncope. The primary endpoint is overall cardiovascular death, including death due to heart failure, cardiogenic shock or ventricular arrhythmias. In particular, arrhythmic death was defined as death occurring during an electrical storm. After a median follow-up of 28 (7–63.5) months, cardiovascular death occurred in 26 patients (55.3%) but arrhythmic death befell only 11 patients (23.4%). All deaths occurred within 6–7 years of follow-up. No difference exists between ischemic and non-ischemic cardiomyopathy with regard to primary endpoints. Moreover, arrhythmic recurrences occurred in 21 patients (44.7%), among whom only 15 (31.9%) had ICD shocks; 25 patients (55.3%) encountered further hospitalizations. ECMO may facilitate procedural mapping and acute ablation success in selected high-risk patients, while long-term prognosis remains mainly driven by advanced heart failure.

Background:A novel ultra-high-resolution mapping system (Clarysense, Biosense Webster, Inc) has been developed that consists of a 100-electrode deflectable bidirectional basket-shaped high-density mapping catheter that incorporates a central TRUEref electrode and is integrated with the CARTO 3 system. Objective:This study aimed to assess the clinical safety and performance of the novel system for mapping in complex atrial and ventricular arrhythmias. Methods:This prospective, single-arm, multicenter study included patients undergoing catheter mapping and ablation of atrial and ventricular arrhythmias. Mapping was performed with the study catheter, and participants were ablated per the investigator's standard of care. The primary effectiveness endpoint was completion of preablation electroanatomic mapping without resorting to a nonstudy catheter. The primary safety endpoint was the incidence of device-related serious adverse events within 7 days. Physician feedback on catheter performance was collected using a 7-point Likert scale. Results:40 participants (mean age 58.0 ± 15.73 years; 62.5% male; 30 with atrial arrhythmias, 10 with ventricular arrhythmias) underwent mapping with the study catheter. The primary effectiveness endpoint was achieved in all participants; ≥1 area of interest for mappable rhythms was identified in 23 of 30 participants with atrial arrhythmia. One serious adverse event of transient complete atrioventricular block was reported in a participant with persistent atrial fibrillation during preablation mapping, with full recovery. Physician feedback indicated that the device met or exceeded expectations for signal quality; most responders rated highly on bipolar signal quality in atria and noise encountered. Conclusion:In this first-in-human study, the novel mapping system improved high-density mapping in complex arrhythmias with high-quality signals and map resolution. The catheter exceeded operators' expectations in signal fidelity.

Cardioneuroablation is conceivable for functional bradyarrhythmias caused by a dysregulation of the autonomic nervous system. Cardioneuroablation is an ablation technique that targets epicardial ganglionic plexi to reduce syncope burden and avoid pacemaker implantation in patients with vasovagal syncope and functional forms of sinus node dysfunction and atrioventricular block. The ergometric test and the atropine test are useful for differentiating intrinsic from extrinsic bradyarrhythmias, fundamental distinctions before considering subjecting a patient to the CNA procedure. Zanubrutinib is a Bruton’s tyrosine kinase inhibitor. Although heart block is not known as its side effect, there is some evidence that this drug could create second–degree heart block. In this study, we report the case of a 68–year–old woman affected by non–Hodgkin lymphoma treated with Zanubrutinib. The patient comes to our attention for the finding of atrioventricular conduction disorders (AV block 1st degree, AV block 2nd degree Mobitz I (Wenckebach) and AV block 2nd degree 2:1). During hospitalization she performed echocardiogram and treadmill stress test (Figure 1). During effort, evidence of progressive increase in heart rate and reduction of the PQ interval. During the electrophysiological study, evidence, after infusion of atropine (0.02 mg/kg/ev), of improvement of the Wencheback point (from 408 to 320 ms). Using the CARTO mapping system, neuromodulation procedure of the atrioventricular node ganglion is performed (Figure 2). The procedure was performed with a QDOT ablation electrocatheter by delivering radiofrequency at the infero–posterior wall of the coronary sinus ostium with an ablation index of 440 and, specularly, to the previous lesion at the infero–septal mitral ridge with an ablation index of 600. During ablation, evidence of irritative rhythm starting from the coronary sinus ostium (Figure 3). At the end of the procedure, minimal shortening of the PQ was noted. The patient continued telemetric monitoring and performed 24–hour Holter ECG without evidence of atrioventricular blocks. Although not yet included in current guidelines, the CNA procedure could be used to treat AV node dysfunction in young subjects. However, more randomized studies are needed. In this particular case, neuromodulation was useful in the management of atrioventricular blocks in a patient, allowing us to continue antineoplastic therapy.Figure 1 Figure 2 Figure 3

BackgroundCardioneuroablation (CNA) is a new approach to treat reflex syncope and functional bradyarrhytmias caused by autonomic imbalance. We report our experience using CNA.MethodFrom September 2022 to July 2023, we took care of 21 patients (mean age 42 ± 21 years; 62% male) affected by reflex syncope or functional bradyarrhythmias. All patients underwent CNA under conscious sedation targeting the superior and/or inferior paraseptal ganglionated plexus (GPs).ResultsNine patients were affected by vasovagal syncope (VVS) and twelve by functional bradyarrhythmias. In 3 cases (14%) the ablation was performed only on the GPs of the right atrium, while in the remaining 86% of cases we performed biatrial lesions. As regards the acute results, we highlighted an increase in sinus heart rate (12 ± 15 bpm, p = 0.001), a shortening of the PQ interval (−18 ± 18 msec, p < 0.001), a reduction of the correct sinus node recovery times (cSNRT) (−142 ± 204 msec, p = 0.114), a shortening of the AH interval (−31 ± 26 msec, p = 0.008), a reduction of the effective refractory period of the atrio-ventricular node (−156; interquartile range from −30 to −160 msec, p = 0.042) and an increase in the Wencheback point (27 ± 20 bpm, p < 0.001). At follow-up, a single patient, due to persistent symptoms and bradyarrhythmic disorder, underwent permanent pacemaker implantation; no other patient had recurrence of syncope, and all remained persistently asymptomatic.ConclusionOur results confirm the efficacy and safety of CNA for the treatment of VVS and functional bradyarrhythmias, although further studies are needed to support these findings.

The left ventricular summit (LVS) is a triangular area located in the most superior portion of the left epicardial ventricular region. The approach to the LVS can be performed through the surrounding structures as there is rich coronary arterial and venous vasculature within the confines of the LVS. The ablation of ventricular arrhythmias originating from the LVS is performed by alcoholic ablation of cardiac tissue drained from peripheral branches of the coronary sinus by selectively cannulating the latter. However, this approach cannot often be used due to the technical difficulties due to anatomical variability of the peripheral coronary venous system. This case report shows how to ablate ventricular arrhythmias originating from LVS with an endo–epicardial approach. 74–year–old man suffering from chronic ischemic heart disease previously subjected to PTCA and CABG (left IMA on LAD and right IMA on AML, 2016). Hospitalized at our department for very frequent monomorphic and repetitive premature ventricular contractions (PVCs) for non–sustained ventricular tachycardia (NSVT). Coronary angiography documented patent bypasses and absence of critical coronary lesions. The echocardiogram documented moderate left ventricular pump dysfunction with alterations in segmental kinetics and mild right ventricular pump dysfunction. Antiarrhythmic therapy with beta–blocker was ineffective for persistence of PVCs and NSVT. Ablation of the ventricular arrhythmias was therefore performed. The electrocatheter was inserted into the outflow tract of the right ventricle, identifying areas of maximum precocity at the septal level (pace–mapping with morphology corresponding to 96% of clinical PVCs) (Fig. 1-2). Radiofrequency were applied in this area with a clear reduction in the arrhythmia burden. The arrhythmia in the coronary sinus was mapped in the mirror image of the previously ablated area, identifying the area with good precocity. Radiofrequency was applied on this site with a further reduction in the arrhythmic burden without, however, achieving complete extinction of the PVCs. Further ablation was performed in the outflow tract of the left ventricle in the mirror image of the previously ablated areas, obtaining complete extinction of the arrhythmias (Fig. 3). No arrhythmic relapses at subsequent monitoring. In this case the endo–epicardial approach for the ablation of the PVCs originating the LVS was effective, as already demonstrated by our series of ablation of these arrhythmias.Figure 1 Figure 2 Figure 3

Introduction and Background: Pulsed field ablation (PFA) is a new non-thermal energy source with a selective effect on myocardial cells that limits damage to other tissues. Because it is more painful, it needs to be performed under general anesthesia or deep sedation. Research Questions: We would assess if PFA compared to radiofrequency ablation (RFA) could have an impact on procedural organization and workflow of atrial fibrillation (AF) ablation, including effects on vagal nervous system. Methods: In this retrospective case-control study we analyzed paroxysmal or persistent AF ablations by pulmonary vein isolation, performed over the last year, 2024, in our high-volume center. The population was divided into two matched samples: PFA group under deep sedation and RFA under light sedation. All procedures were supported by electro-anatomical mapping. We collected all procedural times as primary outcome, then we examined all other procedural data and vagal ganglionated plexi (GPs) involvement. Results and Data: This study included 110 Caucasian patients (mean age 57±11,9, 61,8% males), 55 in PFA (mean age 58,1±8,7, 63,6% males) and 55 RFA group (mean age 55,9±14,3, 60% males). Baseline characteristics of patients are reported in fig.1. Longer post-procedural time (43,9±25,2 vs 19,3±8,3 min; p <0,001) was reported in PFA group. On the contrary, shorter skin to skin times (93,5±28,6 vs 131,9±35,2 min; p <0,001), mapping times (6,27±3,5 vs 13,1±4,1 min; p <0,001) and left atrium dwell times (45,6±8,6 vs 73,7±21,6 min; p <0,001) were evidenced for electroporation. No statistical differences were documented between PFA and RFA about pre-procedural (32±10,9 vs 28,1±6,8 min; p 0,96), ablation (22,2±7,5 vs 22,4±9,1 min; p 0,66) and total procedural times (169,47±34,3 vs 179,4±35,2 min; p 0,05). Interestingly, fluoro-time was shorter in RFA (5,3±2,9 vs 3,3±3,2 min; p <0,001), but fluoro-dose was similar (15,3±17,2 vs 13±13,4 mGy/m 2 ; p 0,56). Complication rate was very low for both. About GPs involvement, heart rate variation before and after procedure was similar between PFA and RFA (fig.1). Interstingly, vagal reflexes were more frequently induced using PFA (67,2% vs 30,1%; p <0,001) and atropine use was more in RFA group (20% vs 65,4%; p <0,001). Conclusions: PFA is efficient, safe and feasible with mild impact on periprocedural workflow and organization of AF ablation using deep sedation. Vagal effects were often induced by PFA without clinical effects as compared to RFA.

A 20 years old boxer had undergone usual sport medicine examination complaining palpitations and some ventricular premature beats (PVC) were documented at ECG. He had no remarkable past medical history except for known right bundle branch block (RBBB) and bicuspid heart valve with minimum valve regurgitation but no aortic dilation. He showed up in our arrhythmia clinic. The 12 leads, 24 hours ECG Holter showed very high PVC burden (58000, 51% of overall beats), including some non sustained ventricular tachycardia. PVC morphology was monomorphic (fig.1), RBBB pattern, V1 transition, inferior axis, negative wave in I lead, pseudo–delta wave, QS in the most negative lead aVL corresponding to lateral left ventricular summit (LVS). Transthoracic echocardiogram and ergonometric test documented no relevant finds. Due to PVC morphology, MRI was carried out documenting mid lateral subtle area of sub–epicardial late gadolinium enhancement (LGE), but normal bi–ventricular function, suggesting idiopathic PVC in a patient with structural heart disease. Anti–arrhythmic therapy failed so we decided to pursue catheter ablation. However, LVS ablation is complex due to epicardial location and the presence of coronary vessels, so we performed an heart CT scan to merge it with electro–anatomical mapping (EAM). Vantage point ablation strategy was chosen. First of all we performed right ventricle outflow tract (RVOT) mapping: pace mapping was not so good, but we found an early as much as rounded EGM during PVC (fig. 2). Then, we mapped coronary venous system identifing a sharp and early EGM (fig. 2) as good pace mapping in the great cardiac vein, where we started ablation. CT was fundamental to keep the right distance from inter ventricular artery. PVC burden was not abolished so we unsuccessfully tried to ablate RVOT site (fig. 3). Finally, by retrograde approach via femoral artery, we reached left ventricular outflow tract finding the earliest site of activation near left main (fig. 3), CT and EAM merge help to control distance (fig. 3), so we safely ablated it obtaining PVC disappearance, also during isoproterenol infusion. During long term follow up, the patient remained asymptomatic and no further PVC have been recorded. Due to the presence of LGE at cardiac MRI, regular follow up will be continue. LVS ablation can be often approached by sequential ablation of the surrounding structures and heart CT scan merging with EAM improving the success rate and the safety.Figure 1 Figure 2 Figure 3

A 22 years old young man with transposition of the great arteries, ventricular septal defect and pulmonary stenosis, repaired by previous Rastelli–type operation, showed up to our emergency department (ED) because of arrhythmic storm. Then, s–ICD had been implanted for secondary prevention, reaching clinical stability after two ablations and the addition of sotatol. In the ED, the patient was hemodynamically stable. Basal ECG was normal. Monomorphic VTs (289 ms CL, triggered by short couple extrasystole) had LBBB morphology, late transition, inferior axis, negative DI and QS morphology in the most negative lead aVL suggesting septal left ventricular summit, maybe between ventricular outflow tract (fig.1). A transthoracic echocardiogram showed normal bi–ventricular function and s–ICD interrogation appropriate interventions. Given the arrhythmogenesis, hydroquinidine was unsuccessfully added, so catheter ablation was pursued. Therefore, a CT heart scan was made and merged with electro–anatomical mapping (EAM). VT was induced localizing it near valved conduit in septal RVOT but only far field EGM were detected by a multi–spline catheter. Due to the intra–myocardial origin, we decided to perform coronary venous system (CVS) ethanol infusion. First of all the CVS angiography and EAM until the ostium of anterior inter ventricular vein (AIV) were carried out. Then, using a decapolar 4F micro–catheter we mapped septal branches of AIV identifying the best pace mapping and the earliest site of activation in the first branch (fig. 2), mirroring endocardial far field EGM. Angiography revealed collateral circulation between the first two branches. So an angioplasty balloon catheter was advanced over a wire in CS until the first branch; then, we moved forward a second balloon, distally over the ostium of second septal branch to avoid alcohol dissipation or infusion in non–targeting zones (fig. 3). At this point, after inflating baloons, ethanol infusion began with 1 ml every 40 seconds and overall 4 ml. Arrhythmia disappeared and no further VTs were inducible. During days after ablation, some non sustained VT were recorded so we continued sotalol therapy, referring the patient for stellectomy operation. Now he is asymptomatic and no further arrhythmias occurred. Left ventricular summit ablations are even more challenging in repaired congenital heart disease patients. Also in this case CVS ethanol infusion can be a feasible and effective approach.Figure 1 Figure 2 Figure 3

Baseline folate status is an under–recognized measure of individual health. Folate metabolism is thought to be a metabolic cornerstone in eucaryotic cells and it is committed to ensure proper functioning across a wide spectrum of task encompassing myelinization, endothelial function via 1–carbon–unit metabolism, embryogenesis. It is commonly accepted that folates–deficiency leads to an higher risk of stroke and death this supporting folate fortification. On the other side there is no knowledge of higher folate–status as a risk factor for death. We investigated association between high folate status and mortality risk, by conducting a meta–analysis of studies expressing quartiles of folates. We explored the relationship between folate levels and mortality, focusing on the highest quartile of folate with respect to the sum of second and third quartiles concentrations. Due to significant heterogeneity of involved studies, a meta–regression analysis was performed to evaluate age as a covariate. We included 9 studies in our meta–analysis, encompassing 439,052 person–year, with 7,195 –years events reported. Using a random–effects models, risk ratios (RR) were calculated. Heterogeneity was quantified using tau², I², and Q statistics, while meta–regression was applied to determine whether age influenced the relationship between folate and mortality. The random–effect model indicated a statistically significant reduction in mortality risk for intermediate folate status levels with respect to the higher quartile (RR = 0.7575, 95% CI: 0.6167–0.9305, p = 0.0081 – Graph 1.). Nonetheless, a significant heterogeneity across studies (I² = 93.9%, tau² = 0.0797) was found. A meta–regression with age was assessed. Notably, in the meta–regression, age did not emerge as a significant moderator (estimate = 0.0100, p = 0.5875 – Graph.2 ). Our findings highlight a relationship between high folate levels and mortality risk. While moderate folate concentrations appear protective. The lack of moderation by age underscores the need to explore subgroup, to explain such heterogeneity. These results have significant public health implications, warranting a reevaluation of folic acid fortification policies and reconsidering baseline higher folate–status as a risk factor for death from any cause. Future research should prioritize identifying subgroups at risk and clarifying the biological mechanisms underlaid.Graph 1 Graph 2

Background: Arrhythmias in pregnancy are complex to manage due to the teratogenic effects of many antiarrhythmic drugs and the common use of ionizing radiation during catheter ablation procedures. Furthermore, pregnant women are extremely vulnerable and difficult to treat because of the progressive physical and hormonal changes that occur during the nine months of pregnancy. Case Presentation: In this case report, we describe a complex clinical case of a 34-year-old pregnant woman who was affected by an incessant right atrial tachycardia, with signs and symptoms of initial hemodynamic instability. This tachycardia was refractory to antiarrhythmic drugs, so a zero-fluoroscopy ablation was performed. The first procedure was complicated by cardiac tamponade, quickly resolved without further complications for the mother or the fetus. In the following days, a deep venous thrombosis occurred at the femoral venous access. After a few days, the patient underwent a second procedure that was successful and resulted in the restoration of a sinus rhythm. Conclusions: The management of this clinical case was complex both from a procedural and a clinical (cardiological and gynecological) point of view. Finally, the integration of the various skills led to an excellent result.

Abstract Clinical Case The clinical case focuses on a 19–year–old women with a non–congenital third degree atrio–ventricular block (AVB), symptomatic for dyspnoea for mild efforts, with structurally normal heart, no other comorbidities and no medications taken. Both the exercise stress test and the atropine test documented a sinus tachycardia at 190 bpm with a 2:1 AVB and a narrow QRS, and 1:1 AV conduction until a sinus rate of 90 bpm. She underwent CNA procedure, targeted the inferior paraseptal ganglionated plexus (IPSGP), both the right and left atrial sides, with gradual improvement of impulse conduction. After the procedure, we observed a persistence of only first degree AVB (PQ interval 260 msec) and a complete regression of symptoms, persistent at 6–month follow–up. Conclusions A strategy of modulation of ganglionated plexi by endocardial ablation is conceivable for the treatment of pathological conditions due to parasympathetic hyperactivity. Patients with functional atrioventricular block (FAVB), even without organic damage to the conduction system, often present disabling symptoms with a significant reduction in quality of life. Treatment with drugs and/or pacemakers has given poor results; pacemaker implantation is not well accepted and is accompanied by significant psychological discomfort, as well as carrying a risk of infection and long–term ventricular desynchronization. The absence of an organic disease as well as a presumed benign course of the disease make the decision more difficult. Current guidelines recommend the implantation of a definitive pacemaker in patients with paroxysmal or permanent third degree AVB, regardless of symptoms. Although not yet included in current guidelines, the CNA procedure could be used in the future to treat AV node dysfunctions in young subjects with a dominant functional component.

Abstract The clinical case deals with a 46–year–old man, severely obese and suffering from type II diabetes mellitus and arterial hypertension, a smoker. He was admitted to our department for iterative ventricular fibrillation (VF) following a recent acute myocardial infarction with ST–segment elevation treated with percutaneous coronary angioplasty (PTCA) and implantation of drug–eluting stents on the anterior interventricular. Control coronary angiography showed good results of previous PTCA. On the echocardiogram, left ventricular pump function moderately reduced (EF 45%) with district alterations of the kinetics and aneurysmal dilatation of the ascending aorta. During hospitalization, iterative episodes of VF despite maximal antiarrhythmic therapy, promptly treated with DC shock. Continuous telemetry monitoring showed frequent early premature ventricular complex (PVC) triggering VF episodes. A 12–lead Holter ECG was performed to better identify the morphology of these PVC, documenting PVC of morphology compatible with origin from Purkinjie fibres. An electrophysiological study and mapping of the left ventricle were performed with extracorporeal membrane oxygenation (ECMO) support. During mapping of the middle left interventricular septum, VF occurred several times and was promptly treated with DC shock. In this area have been documented Purkinje fibers and low voltage and multifragmented areas; ablation was then performed by delivering radiofrequency in this area until the all potentials were completely eliminated. After ablation, no more ventricular arrhythmias were induced. Cardiac magnetic resonance imaging was performed which showed large areas of late gadolinium enhancement. The patient underwent automatic defibrillator implantation. Ventricular arrhythmias were no longer documented during telemetric monitoring. In this complex case of significant arrhythmic instability in ischemic heart disease with moderate left ventricular pump dysfunction, ECMO assistance allowed us to effectively and safely perform the ablation of the arrhythmic substrate triggering the iterative episodes of VF.

Abstract The aim of our prospective Non–randomized study was to evaluate the efficacy and safety of Cardioneuroablation (CNA) in patients with recurrent cardioinhibitory vaso–vagal syncope (VVS) or functional bradyarrhythmias. From September 2022 to June 2023, a total of 10 ablation procedures were performed on 10 patients who met the inclusion criteria (30% female, mean age 51.9 years, range 19–81 years). In 5 cases the CNA was guided by HFS with documentation of vagal response, while in the other 5 cases it was performed with an anatomical approach. In 3 cases the ablation was performed only on the GPs of the right atrium, while in the remaining 70% of cases biatrial lesions were performed. As regards the acute endpoints, we observed an increase in sinus heart, a shortening of the PQ interval, a reduction in TRNSc, a shortening of the AH interval and an increase in PW. During follow–up, a single patient, due to persistence of symptoms and bradyarrhythmic disorder, underwent definitive pacemaker implantation. No other patient had a recurrence of syncope and all reported being persistently asymptomatic. As regards the secondary endpoints, we highlighted a persistence of the increase in the minimum and average heart rate, a shortening of the PQ interval, a reduction in time and frequency domain parameters in the HRV analysis on the Holter ECG performed at follow–up. An increasing trend was also highlighted for maximum heart rate, although not significant. There were no significant changes in the QTc interval and no patient developed arrhythmic episodes. Discussion Cardioneuroablation is a relatively recent and still developing technique that aims to promote persistent cardiac vagal denervation through endocardial ablation of parasympathetic ganglia. In our prospective study of patients without structural heart disease suffering from recurrent cardioinhibitory VVS or symptomatic functional bradyarrhythmias, CNA was effective in reducing the syncopal burden and other symptoms complained of by patients before the procedure, and safety (only one case of pericardial effusion that did not require any therapy; low rate of exposure to ionizing radiation; not any increase in arrhythmic risk related to a prevalent sympathetic activity; no patient reported discomfort in feeling an average higher heart rate), with a notable improvement in the quality of life.

Catheter ablation of atrial fibrillation (AF) may increase the risk of complication in aged patients. Stereotactic arrhythmia radioablation (STAR) is a non-invasive therapeutic alternative for cardiac arrhythmia. This sub-study evaluated left atrial strain (LAS) in elderly AF patients underwent STAR. Symptomatic paroxysmal AF patients aged > 70 years, with antiarrhythmic drugs failure or intolerance, enrolled in a phase II trial that have demonstrated the feasibility of LINAC-based STAR (total dose of 25 Gy single fraction delivered in 3 min), performed a 15-day electrocardiogram Holter monitoring to detect AF episodes (≥ 30 s) and an echocardiographic LAS evaluation before and after STAR (at 1-, 3-, 6- and 12-month). Out 18 patients underwent STAR in the trial, 16 (7 males, 78 ± 5 years) completed the follow-up for LAS study. No baseline difference in echocardiographic and LAS parameters was observed between the 9 patients with AF recurrence during follow-up and those who maintained sinus rhythm. At 6- and 12-month after STAR, LAS reservoir was lower in patients with AF episodes than those without (respectively, p = 0.039 and p = 0.001). Values of left atrial area and volume as well as LAS conduit and contractile phase were not statistically significant different by patient’s outcome across evaluations. Although no baseline LAS parameter before STAR seems predict AF recurrence after treatment in elderly patients, lower values of reservoir phase were observed during follow-up in those experiencing AF episodes. More research is needed to better assess the value of LAS monitoring in paroxysmal AF patients underwent Stereotactic cardiac radioablation.

Left atrial or left atrial appendage thrombosis (LAT) is contraindication to cardiac ablation (CA) or cardioversion (CV) of atrial fibrillation (AF). This study was aimed to compare the frequency of LAT detected by transesophageal echocardiography (TEE) before CA or CV in AF patients under treatment with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs). We searched PubMed, Scopus, Web of Science and Cochran Library databases from inception through July 13, 2023 to select studies reporting data on LAT identification before CA or CV by using TEE in patients with AF treated with DOACs or VKAs. Pooled Odds Ratios (ORs) with 95% confidence interval were calculated with a random effect model. Studies retrieved were 50 (38 observational), 29 on CA, 15 on CV and 6 on both procedures (17096 patients on DOACs and 13666 on VKAs). The overall prevalence of LAT was lower in DOACs than VKAs with an OR of 0.66 (0.52-0.84) confirmed at sensitivity analysis and in most of subgroups. Finding was consistent for the three most reported DOACs: the pooled OR for LAT was 0.68 (0.50-0.90) in Apixaban, 0.67 (0.51-0.88) in Dabigatran, 0.61 (0.43-0.89) in Rivaroxaban, and 1.10 (0.74-1.64) in Edoxaban (not significant). In conclusion, in this large meta-analysis on AF patients, the prevalence of LAT by TEE evaluation performed before CV or CA appears lower in those treated with DOACs than VKAs. Additional research may help in better understanding differences among these classes of anticoagulant drugs in the setting of protection against AF-related left atrial thrombotic formation.

BackgroundThere are some functional bradyarrhythmias that are caused by a dysregulation of the autonomic nervous system, for which a therapeutic strategy of cardioneuroablation (CNA) is conceivable.Case summaryIn this study, we report the case of a 19-year-old woman with a non-congenital third-degree atrioventricular block (AVB), symptomatic for lipothymia and dyspnea caused by mild exertion. She had a structurally normal heart and no other comorbidities. The atropine test and the exercise stress test documented a sinus tachycardia at 190 bpm with a 2:1 AVB, a narrow QRS, and an atrioventricular conduction of 1:1 until reaching a sinus rhythm rate of 90 bpm. She underwent the CNA procedure, which targeted the inferior paraseptal ganglion plexus, with a gradual change in the ECG levels recorded during the radiofrequency delivery from a third-degree AVB to a first-degree AVB. After the procedure, we observed a complete regression of the third-degree AVB, with evidence of only a first-degree AVB and a complete regression of symptoms until the 6-month follow-up.ConclusionsAlthough not yet included in current guidelines, the CNA procedure could be used to treat AV node dysfunction in young subjects, as it could represent an alternative to pacemaker implantation. However, more randomized studies are needed to assess the long-term efficacy of this promising technique.