BACKGROUND:Risk stratification for sudden cardiac death (SCD) in nonischemic cardiomyopathy (NICM) relies on identification of myocardial scars, the substrate for ventricular arrhythmias. Scar assessment is typically performed with late gadolinium enhancement cardiac magnetic resonance (LGE-CMR). LGE-CMR images can be postprocessed by dedicated software to generate 3D scar maps that can be integrated with electroanatomic voltage mapping (EVM). OBJECTIVES:This study sought to assess the concordance and reliability between LGE-CMR-derived scar maps and EVM performed with a high-density catheter in myocardial tissue characterization. METHODS:In this multicenter, observational, cross-sectional study, we included 36 NICM patients who underwent left ventricular EVM for arrhythmic and SCD risk stratification. Each patient underwent LGE-CMR, processed with the use of dedicated software to delineate scar core and border zones. EVM depicted scar regions with the use of omnipolar technology (OT), bipolar (BIP), and unipolar (UNI) acquisition modes. Cohen's kappa coefficient and Bland-Altman methods were used to assess agreement and reliability, respectively. RESULTS:The UNI configuration showed the best agreement with subepicardial LGE-CMR maps (κ: 0.93; positive predictive value [PPV]: 97.2%; negative predictive value [NPV]: 86.5%), and OT outperformed BIP for subendocardial layers (κ: 0.97 vs 0.74; PPV: 96% vs 76%; NPV: 100% vs 96%). In reliability analysis, OT showed the least systematic bias and the narrowest limits of agreement with LGE-CMR-derived scar maps, and was associated with higher point density maps. Whereas BIP mapping had the best agreement with the 10%-20% myocardial layer, OT best aligned with the 20%-40% myocardial layer. CONCLUSIONS:EVM had high agreement with LGE-CMR images and accurately delineated endo-mid-myocardial substrates, supporting its potential role in substrate characterization for NICM patients unfit for LGE-CMR.

Background/Objectives: Excessive trabeculation of the left ventricle, previously known as left ventricular non-compaction (LVNC), is a rare phenotypic trait whose mechanisms and pathogenesis still remain conflictual. Its presentations may range from heart failure to embolism and, most importantly, ventricular arrhythmias (VAs). This study aims to find novel predictive factors for the occurrence of potentially fatal VAs in patients with left ventricular hypertrabeculation. Methods: All consecutive patients meeting the echocardiographic (Chin, Jenny or Stöllberger) and/or MRI criteria (Petersen) for hypertrabeculation were prospectively enrolled from October 2009 to December 2023. The primary outcome was a composite of sudden cardiac death, sustained ventricular tachycardias (sVTs), ventricular fibrillation (VF) or appropriate implantable cardioverter defibrillator (ICD) interventions. The secondary outcome was a composite of cardiovascular death and cardiovascular hospitalizations. Results: Overall, 64 patients (41 males, mean age 46 ± 19 years old) were enrolled and followed for a median time of 2.2 years. Six patients (9.4%) experienced a composite outcome at eight years, three with previous sVTs and three with previous non-sustained VTs (nsVTs). The strongest predictor of the primary endpoint was the anamnesis of nsVTs and sVTs before LVNC diagnosis. In addition, nsVTs and sVTs were significantly associated with the secondary outcome. Conclusions: Hypertrabeculation of the left ventricle is a complex and poorly understood condition whose status of cardiomyopathy is currently challenged. In our population, patients with a trabecular pattern experienced a high incidence of VAs, cardiovascular death and hospitalizations. VAs before LVNC diagnosis were predictive of the outcome independently from systolic function.

BACKGROUND:Ventricular arrhythmias (VAs) are a major concern in athletes. We sought to determine the prognostic role of noninvasive and invasive assessments in athletes with complex VAs. METHODS:One-hundred-ninety athletes (82% men; 28 [19-43] years; 148 [78%] competitive athletes) with frequent or exercise-induced premature ventricular complexes or nonsustained ventricular tachycardia were included in a multicenter cohort study and categorized based on VA ECG morphology into common (n=99) and uncommon (n=91) VA groups. Each athlete underwent a comprehensive diagnostic workup, including cardiac magnetic resonance in 94% (n=178) and electrophysiology study/electroanatomical mapping in 87% (n=166). The primary end point was the occurrence of sudden death or sustained VAs during long-term follow-up. RESULTS:Athletes with uncommon VA morphology had higher rates of abnormal findings at multimodality assessment and more final diagnoses of structural heart disease. Over a median follow-up of 6.2 (4.3-8.1) years, 7 (4%) athletes experienced a primary outcome event, including 1 sudden death. Interestingly, no events occurred in athletes with common morphology VAs. In univariable Cox models, factors associated with the primary end point included uncommon VA morphology (P=0.003), lack of VA suppression (P=0.049), and nonsustained ventricular tachycardia/ventricular tachycardia induction (P=0.010) during stress testing, late gadolinium enhancement (P=0.045), electroanatomical scar regions (P=0.022), and sustained VA inducibility by electrophysiology study (P<0.001). Incorporating findings of invasive tests improved prediction of primary outcome events over clinical/noninvasive findings in isolation (log-likelihood ratio for nested models, P=0.004). A survival tree model based on VA morphology, late gadolinium enhancement, VA response to exercise testing, and electroanatomical mapping allowed risk stratification, identifying subgroups of athletes without primary outcome events during follow-up. Among 148 competitive athletes, 101 (68%) regained eligibility after 3 months of detraining, but only 42 (28%) continued long-term. CONCLUSIONS:A comprehensive diagnostic assessment integrating ECG, stress testing, and imaging findings, along with the selective use of invasive electrophysiology assessments, may help refine the prognostic evaluation of athletes with complex VAs.

BACKGROUND:Catheter ablation (CA) is a first-line therapy for rhythm control in patients with atrial fibrillation (AF) and atrial flutter (AFL). Left atrial thrombus (LAT) is an absolute contraindication to CA due to the increased risk of periprocedural ischemic complications. A recent consensus statement from the European Heart Rhythm Association (EHRA) recommended the exclusion of LAT before CA in patients receiving oral anticoagulant therapy (OAT) for less than three weeks or in patients at high risk, despite the substantial reduction in the rate of periprocedural stroke achieved by anticoagulation in recent years. Consequently, many patients are frequently screened by transesophageal echocardiography (TOE) despite the lack of evidence that such a procedure is actually useful. METHODS:All consecutive patients undergoing TOE before AF or AFL CA were enrolled between January 2019 and April 2024. Inclusion criteria were AF/AFL with less than 3 weeks of optimal OAT, persistent AF/AFL, or paroxysmal AF/AFL with CHA2DS2-VASc ≥ 2. Three experienced operators performed all TOEs and were blinded to the clinical data. Risk factors associated with LAT were tested by regression analysis. RESULTS:Five hundred eighty-six patients were enrolled (age 66 ± 6 years; 72% male). A total of 14 thrombi were identified (2.4% of all patients), all located in the left atrial appendage. Patients with LAT had a higher prevalence of coronary artery disease (CAD), heart failure (HF), and persistent AF (11 vs. 3 patients, p = 0.048) as well as lower left ventricular ejection fraction (56 vs. 49%, p = 0.01) and higher systolic pulmonary artery pressure (sPAP). No LAT was found in patients with atrial flutter. According to univariate analysis, higher sPAP, CAD, HF, and persistent AF were identified as predictors of LAT formation, while LVEF > 50% was associated with lower LAT prevalence. CONCLUSIONS:LAT is a rare occurrence in candidates for CA. Patients with persistent AF, a history of CAD or HF (particularly with low ejection fraction), and higher sPAP present an elevated risk and should be considered for TOE prior to CA. Patients with AFL and no structural disease have an extremely low risk of LAT.

BACKGROUND AND AIMS:Tachycardia-induced cardiomyopathy (TCM) is a reversible form of heart failure (HF) driven by arrhythmias, often atrial fibrillation (AF). While reversible, TCM's long-term prognosis remains unclear, especially in comparison to HF with reduced ejection fraction (HFrEF). This study examines the prognosis of pure and impure TCM against other causes of HFrEF. METHODS:Prospective, monocentric, observational study of 456 patients hospitalized with de novo, acute decompensated HFrEF, classified into pure TCM, impure TCM, ischaemic HF and non-ischaemic HF. The primary endpoint was all-cause mortality, and the secondary endpoint was the incidence of unplanned cardiovascular hospitalisations. Sensitivity analyses were performed using propensity score matching between the four groups. RESULTS:During a median follow-up of 3 years (interquartile range 1.5-5.1 years), pure TCM had the highest survival rate, and ischaemic HF had the lowest (pure TCM 78.2%; impure TCM 64.8%; non-ischaemic HF 73.4%; ischaemic HF 58.5%; log-rank P < 0.0001). Pure and impure TCM presented the lowest free-from-readmission estimates over follow-up (pure TCM 43.2%; impure TCM 60.0%; non-ischaemic HF 83.2%; ischaemic HF 69.9%; log-rank P < 0.0001). An initial rhythm control strategy was associated with better overall survival in TCM (79% vs. 63%; log-rank P < 0.0001) but similar rates of unplanned hospitalization. CONCLUSIONS:Pure TCM shows a favourable survival prognosis but high readmission rates, emphasizing the need for early rhythm control and sustained monitoring for arrhythmia recurrence. An initial rhythm control strategy seems associated with an increased survival, highlighting the importance of early recognition of arrhythmias as a culprit of HF worsening.

Endothelial syndromes (ES), including sinusoidal obstruction syndrome (SOS) and transplant-associated thrombotic microangiopathy (TA-TMA), contribute to hemopoietic stem cell transplantation (HSCT) failure. Some forms of acute graft-versus-host disease (aGVHD) have also been identified as severe ES complications. However, the impact of ES on HSCT outcomes has not been systematically studied. We retrospectively analyzed the incidence and clinical impact of ES in 163 consecutive HSCT patients (median age: 58 years, IQR: 50-64) treated at a single center from February 2015 to May 2021. Patients still alive were censored at their last follow-up (November 30, 2022). The primary endpoint was cumulative incidence of non-relapse mortality (NRM), with relapse mortality (RM) and overall survival (OS) as secondary endpoints. Cox regression univariate models were used to test the association between ES and primary and secondary outcomes (NRM, relapse, and OS), comparing the effect of the covariates by the Wald test. A multivariate global model was then developed testing all independent covariates at univariate analysis for each endpoint (NRM, relapse, OS). Over a median follow-up of 23 months (IQR: 6-49 months), 81 patients (49.7%) died—36 (60.0%) with ES and 45 (43.7%) without. Relapse-related mortality occurred in 15% of ES patients and 22.3% of non-ES patients. NRM was significantly higher in ES patients (45.0% vs. 21.4%; Figure 1). Survival from NRM was worse in ES patients (51.8% vs. 76.7%; p=0.001), with 12- and 24-month survival estimates of 62.5% and 54.6% (vs. 84.0% and 78.1%). Cox regression (Table 1) confirmed ES as an independent predictor of NRM (OR 2.328; 95% CI 1.139-4.758; p=0.021), along with bone marrow as the stem cell source (OR 3.187) and aGVHD (OR 0.473). RM rates were comparable between groups (66.9% vs. 70.2%; p=0.732), but overall survival was lower in ES patients (34.7% vs. 53.9%; p=0.022), primarily due to increased NRM. However, ES was not independently predictive of OS in multivariable analysis. ES significantly increases NRM and negatively impacts OS in HSCT patients, emphasizing the need for early recognition and targeted interventions. Future research should focus on identifying high-risk patients, optimizing prophylactic strategies, and developing targeted therapies to mitigate endothelial damage. Improved management of ES could enhance post-transplant survival and overall treatment success in HSCT recipients.Figure 1.Estimated survival rates (NRM) Table 1.Cox regression model for NRM

Chimeric Antigen Receptor (CAR)-T cell therapy, a breakthrough in immuno-oncology, is increasingly utilized for treating leukemia and lymphoma. However, its association with cardiovascular complications remains poorly understood. Potential mechanisms include cytokine release syndrome (CRS)-induced myocardial depression, takotsubo cardiomyopathy, and direct CAR-T cell toxicity. This study evaluates the cardiovascular outcomes of patients undergoing CAR-T therapy at a regional referral center, in collaboration with a dedicated cardio-oncology team. We prospectively enrolled all consecutive patients referred for CAR-T therapy at our institution, starting from the program’s initiation. All participants had refractory hematological malignancies, failed at least two lines of chemotherapy, and had previously received anthracyclines. Pre-treatment cardiac evaluations included a 12-lead ECG, echocardiography, and cardiac biomarkers. Patients received autologous CAR-T cells (tisagenlecleucel) after conditioning. Follow-up evaluations were performed at discharge and at six months. Twenty patients (mean age 63±11 years; 8 males) were treated with CAR-T after a median of two lines of treatment (range 1-3). 30% developed CRS, with a median onset of 12 days (range 7-40). Two patients presented with Grade I CRS and was managed with supportive care. Three patients with Grade 2 CRS required cardioprotective therapy (ACE inhibitors and beta-blockers) due to transient left ventricular dysfunction (mean lowest LVEF 44%). One patient experienced Grade IV CRS complicated by takotsubo syndrome and cardiogenic shock on day 4, requiring vasopressor support and mechanical ventilation. Pre-treatment echocardiography showed lower baseline left ventricular ejection fraction (LVEF) and right ventricular systolic function in CRS patients compared to others (LVEF 53.6±5.9% vs. 63.2±7.7%; p=0.03; TAPSE 25±4 mm vs. 20±3 mm; p=0.02; S' 0.09±0.01 m/s vs. 0.12±0.02 m/s; p=0.03). Baseline cardiac biomarkers did not predict adverse outcomes. All CRS patients showed recovery of ventricular function and survived to discharge. Six patients died from oncological progression unrelated to cardiac complications. CAR-T therapy is associated with significant cardiovascular risks, with 30% of patients requiring cardio-oncology management. Echocardiographic assessments prior to treatment may help identify individuals at higher risk for cardiac events, aiding in early intervention and better outcomes.LVEF trend during CRS

Catheter ablation (CA) for atrial fibrillation (AF) and atrial flutter (AFL) is contraindicated is left atrial thrombus (LAT) is found. The present registry aims to provide a contemporary estimate of LAT prevalence and to identify potential subsets of patients at higher risk. All consecutive patients undergoing TOE before AF/AFL CA were enrolled between January 2019 and April 2024. Inclusion criteria were AF/AFL with less than 3 weeks optimal OAT, persistent or paroxysmal AF/AFL with CHA2DS2-VASc≥2. Risk factors associated with LAT were tested by regression analysis. 586 patients were enrolled (age 66±6 years; 72% males and 14 thrombi (2.4%), located in the left atrial appendage. Patients with LAT had a higher prevalence of coronary artery disease (CAD), heart failure (HF), and persistent AF (11 vs 3 patients, p = 0.048) as well as lower left ventricular ejection fraction (56 vs 49%, p = 0.01) and higher systolic pulmonary artery pressure (34 vs 29 mmHg, p = 0.028). No difference was found in patients according to adherence to oral anticoagulant therapy, left atrial echocardiographic characteristics or renal function. No LAT was found in patients with atrial flutter. According to univariate analysis (figure 1), CAD and HF were identified as predictors of LAT formation. LEVF was analyzed with a receiving operator characteristic curve (ROC) with an area under the curve (AUC) of 0.752 (95% CI 0.629-0.875; p=0.001) with the best cut-off at 50%. Moreover, LVEF less than 50% is a predictor of thrombi with an HR of 8.81 (95% CI; 2.89-26.87; p=0,001). Based on our data, we propose a protocol for TOE before CA in patients with AF as seen in Figure 2. LAT is a rare occurrence in candidates for CA. Patients with persistent AF, history of CAD or HF present an elevated risk and should be considered for TOE prior to CA. Patients with AFL and no structural disease have an extremely low risk of LAT.Univariate table Proposed protocol

In healthcare, patients' choice of physicians can be influenced by various factors, including age, experience, reputation, and often even the provider's gender. Gender preferences vary based on personal and cultural factors, and some patients may express a specific preference for male or female physicians, perceiving each as having different qualities. Such preferences may stem from expectations regarding communication style, comfort during procedures, or perceived empathy. Understanding patients’ preferences for healthcare providers can help EP cardiologists optimise patient management, improve care quality, and enhance patient satisfaction. We designed a questionnaire to gather data on how patients perceive and prefer different roles—such as first operator, second operator, anesthesiologist, and nurse—based on gender. This study aims to provide valuable insights into gender-related expectations within clinical settings, thus enhancing patient-provider dynamics in cardiac care. Between April 2024 and October 2024, we collected 115 anonymous questionnaires from all patients attending our ward who received EP procedures. The questionnaire was divided into two main parts: demographics, educational level, type of procedures; and gender preferences. Statistical analysis was conducted using GraphPad (GraphPad Software, Boston, MA, USA). We analysed data from 115 patients, of whom 34% were female. The mean age of patients was 58 (±16 years), with no significant age differences between genders. In our sample, we observed a difference in educational attainment: 45.3% of male patients attended college, compared to 25% of female patients. Regarding marital status, a higher proportion of male patients were married (67.5% vs. 73%). Interestingly, the majority of patients reported no preference regarding the gender of the first operator (84.8%), second operator (92%), anesthesiologist (92%), or nursing staff (85.7%). However, among those who did express a gender preference, 94.1% preferred a male first operator, while 87.5% preferred female nursing staff. A sub-analysis based on patient gender revealed that 100% of male patients preferred a male first operator, but only 66,7% preferred female nursing staff. Among female patients, 83.3% preferred a male first operator, and 100% preferred female nursing staff, as shown in Figure 2. These findings indicate that while most patients do not have strong gender preferences for their healthcare providers, some continue to exhibit gender-based preferences, especially for specific roles such as the first operator and nursing staff. Understanding these preferences can support more tailored approaches to patient care in cardiac electrophysiology.Demographic characteristics of patients Patients preference

Left ventricular hypertrabeculation is one of the most debated conditions in modern cardiology. Many studies have tried to characterise this disease by addressing the various clinical risks and diagnostic tools, but its very nosological existence is currently being challenged. The latest ESC guidelines on cardiomyopathies state that it should be addressed as a morphologic trait rather than an intrinsic disease of the cardiac muscle. Despite the huge number of diagnostic criteria and possible phenocopies, no specific consensus identifies a specific flowchart regarding the management of patients with suspected hypertrabeculation. This review aims to provide a clinical approach for patients with a phenotypical appearance of excessive trabeculation.

Tachycardia-induced cardiomyopathy (TCM) is a reversible form of heart failure (HF) driven by arrhythmias, often atrial fibrillation (AF). While reversible, TCM’s long-term prognosis remains unclear, especially in comparison to HF with reduced ejection fraction (HFrEF). This study examines the prognosis of pure and impure TCM against other forms of HFrEF. We conducted a prospective observational study hospitalized with de novo, acute decompensated HFrEF, classified into pure TCM, impure TCM, idiopathic HF, and structural HF (ischemic and valvular). Follow-up included clinical and echocardiographic assessments, tracking all-cause mortality and unplanned cardiovascular hospitalizations. Survival analysis was conducted using Kaplan-Meier, and group comparisons utilized ANOVA and chi-square tests. We consecutively enrolled 456 patients (304 males, median age 72.8 years) and divided them into the four groups previously described (Table 1). The median follow-up was 3 years (IQR 1.5-5.1 years). TCM was mainly due to atrial fibrillation (128 patients, 75.7%). A rhythm control strategy was chosen to treat the acute TCM phase in 135 patients (79.9%): electric cardioversion was performed in 60.9% of all TCM, 8.3% underwent pharmacological conversion and 10.7% went straight to ablation during the first hospitalization. All four subgroups experienced changes in clinical and laboratory parameters during hospitalization, with a significant improvement of NYHA class before discharge and a concomitant reduction of BNP. The four groups had significantly different estimates for all-cause death, with pure TCM having the highest survival rate and structural HF having the lowest survival rate over the follow-up (Figure 1). Using structural HF as a comparator, HRs for death were significantly lower for patients with pure TCM (HR 0.34; 95% CI 0.21-0.56) and idiopathic HF (HR 0.53; 95% CI 0.32-0.90), while impure TCM did not differ (HR 0.57; 95% CI 0.30-1.07). Within the TCM groups, an initial rhythm control strategy was associated with better overall survival (73% vs. 50%; log-rank p<0.0001). Unplanned hospitalizations showed a different trend compared to all cause-mortality, with pure and impure TCM having the lowest free-from-readmission estimates over follow-up (Figure 2). Moreover, the average total number of unplanned hospitalizations also differed significantly between the four groups (pure TCM 0.81; 95% CI 0.62-1.00; impure TCM 0.84; 95% CI 0.51-1.17; idiopathic HF 0.38; 95% CI 0.20-0.55; structural HF 0.89; 95% CI 0.68-1.10; p=0.019). Pure TCM shows a favorable survival prognosis but high readmission rates, emphasizing the need for early rhythm control and sustained monitoring for arrhythmia recurrence. Structured, long-term follow-up may benefit TCM patients, and further research is needed to clarify the impact of rhythm control on quality of life and hospitalization reduction.Survival CV Re-admission

BACKGROUND AND AIMS:Chest radiography (CXR) is the gold standard tool for early mechanical complications' detection after cardiac implantable electronic devices (CIED) procedures, along with CIED electrical parameters control for the diagnosis of early catheter dislodgement. However, the detection of thoracic complications using CXR is limited, and it requires radiation exposure. Thoracic ultrasound (TUS) is a more versatile and quicker alternative for the diagnosis of thoracic pathologies, although its use in cardiac electrophysiology is not yet validated. Aim of this study was to compare the diagnostic power of CXR and TUS in the diagnosis of non-infective early complications of CIED implantation. METHODS:A total of 397 patients who underwent CIED implantation were prospectively enrolled from 1 November 2021, to 30 September 2022. Following surgery, all patients underwent CXR and TUS at the patient's bed and the electrical parameters were tested before discharge. RESULTS:21 patients experienced mechanical complications (5.3%), of which the most common were pneumothorax (3.3%) and pericardial effusion (2%). TUS demonstrated non-inferior accuracy in diagnosing early mechanical complications, with increased sensitivity when compared to CXR. When associated with device interrogation, TUS was at least as accurate as CXR and device control in diagnosing lead dislodgment. CONCLUSIONS:TUS has a non-inferior diagnostic power compared to the CXR to detect early mechanical complications of CIED implantation, avoiding x-ray exposure. Our results suggest that TUS could be employed as a primary technique in association with standard electrical control to diagnose postoperative complications.

Abstract Background Hematopoietic stem cell transplant (HSCT) represents a potentially curative approach for various hematologic cancers and bone marrow disorders. Advancements in safety and efficacy have broadened the application of HSCT to older individuals and those with concurrent medical conditions predisposing them to cardiovascular (CV) issues. Despite the significant survival benefits offered by HSCT, it is accompanied by both short- and long-term complications, leading to considerable morbidity and mortality. CV complications, including heart failure, arrhythmias, acute thrombosis, pulmonary hypertension, and pericardial effusions, are among the potential adverse events following HSCT. Aim for the present registry is to determine how much CV complications are related to short-term survival in patients after HSCT. Methods Observational, monocentric cohort study consecutively enrolling all patients undergoing HSCT from 2019 to 2023. Inclusion criteria was >18 years, autologous or allogeneic HSCT, and written informed consent for the participation in the study. All patients underwent a complete cardiological examination, including 12-lead ECG, echocardiography, and cardiac biomarkers, before HSCT, and after 2,6 and 12-months. CV-related adverse events were defined as systolic dysfunction (even asymptomatic), thromboembolism (both VTE and PE), stroke, arrhythmias, pericarditis and hypertensive crises. Results 91 patients (34% female; mean age 54 +/- 12 years) were followed-up for a median of 2 years after HSCT. Major risk factors' prevalence was overall low (hypertension 28%, dyslipidaemia 33%, diabetes 9%, and only 11 patients (12%) had a positive history for CV events (6 atrial fibrillation, 4 coronary heart disease, 1 stroke) before HSCT. During follow-up, 26 patients (29%) experienced at least one CV-related adverse event, of which 7 (8%) were serious enough to require an hospital admission. CV adverse events included 5 new heart failure diagnosis, 5 new atrial fibrillation diagnosis, 10 episodes of VTE/PE, 4 pericarditis, one stroke and one hypertensive crisis. Twenty of all CV-related adverse events were reported within the first six months after HSCT (77%). Having a CV-related AE within the first six months after HSCT is associated with an increased risk of all-cause death (39% vs. 17%; log-rank p=.01; Figure 1). Conclusions CV-related adverse events are common in patients undergoing HSCT and strikes an overall young and healthy population. Having a CV-related adverse event in the six months following HSCT is a heavy prognostic factor for all-cause mortality. Therefore, an optimal prevention strategy including arrhythmia monitoring, echocardiographic follow-up and guideline-driven thromboembolic prophilaxis could improve patients' survival after HSCT.Figure 1

The clinical performance of high-power, short-duration (HPSD) pulmonary vein isolation (PVI) with the novel flexible tip TactiFlex™ (TFSE) catheter, as compared to standard-power, long-duration (SPLD) PVI using the TactiCath™ (TCSE) catheter among patients undergoing catheter ablation (CA) of atrial fibrillation (AF) is currently unknown. We conducted a prospective, observational, single-centre study including 40 consecutive patients undergoing PVI for paroxysmal/persistent AF, using HPSD ablation with the novel TFSE catheter (HPSD/TFSE group). Based on propensity score-matching, forty patients undergoing SPLD PVI with the TCSE catheter were identified (SPLD/TCSE group). In the HPSD/TFSE group, RF lesions were performed by delivering 40–50 W for 10–20 s, while in the SPLD/TCSE group, RF power was 30–35 W, targeting a lesion size index (LSI) of 4.0–5.5. The co-primary study outcomes were time required to complete PVI and first pass isolation (FPI). PVI was achieved in 100

Abstract Background Catheter ablation (CA) with pulmonary vein isolation (PVI) is an optimal treatment option in patients with paroxysmal atrial fibrillation (AF). PVI alone in patients with persistent AF has proved to have suboptimal results. Ablation of additional atrial structures, such as posterior wall (PW) and left atrial appendage has been investigated as a tool to improve procedural efficacy. Recently very high-power short-duration (vHPSD) ablation was developed to allow rapid PVI, limiting complication through the maximization of resistive heating, and minimization of conductive heating. Objectives Compare PVI plus PWI using vHPSD versus standard-power (SP) ablation index-guided CA among consecutive patients with persistent AF Methods Forty consecutive patients underwent PVI plus PW isolation using vHPSD, compared to 40 controls underwent standard power (SP) PVI plus PW isolation. The primary efficacy endpoint outcome was recurrence of atrial tachyarrhythmias after a 3-month blanking period. The primary safety outcome was a composite of major complications within 30 days of CA. Results Treated patients have a median age of 62.8±9 years, 68 (85%) are male. Median left atrial volume is 42.4 (36-50) ml/m2. 61 (78.8%) patients had never undergone catheter ablation before. There are no statistically significant differences between groups. PW isolation was obtained more commonly in the vHPSD compared to the SP group (98% vs. 75%, p=0.007), despite shorter procedure and fluoroscopy times (p<0.001). Survival free from recurrent atrial tachyarrhythmias at 18 months was 68% in the vHPSD and 47% in SP groups, respectively (log-rank p=0.071), without major adverse events. The vHPSD approach was significantly associated with reduced risk of recurrent AF at multivariable analysis (HR, 0.39, p=0.030). Conclusions The results show feasibility and safety of posterior wall vHPSD ablation for persistent AF using this new temperature-controlled catheter without intraprocedural and periprocedural major complications at follow-up. vHPSD ablation for PW isolation may be more effective in term of atrial tachyarrhythmias recurrences with a trend for superior efficacy. However, this remains a single center experience in a small group of patients. Comparative trials involving greater number of patients with long-term follow-up are necessary to definitive results.

Background: During the physiological cardiac cycle, the helix orientation of the muscle fibres induces the rotation of the apex relative to the base of the left ventricular (LV). In heart failure, LV torsion is impaired, and rotation at basal and apical levels occurs in the same direction, a phenomenon called rigid body rotation (RBR). We aimed to evaluate whether the RBR pattern and GLS together could improve the diagnosis of cardiotoxicity in patients treated with anthracyclines and/or anti-HER2. Methods: With an observational, retrospective study involving 175 patients (mean age 55 ± 12 years, 94% females), we evaluated the development of cancer therapeutic–related cardiac dysfunction (CTRCD) defined according to ESC guidelines. We characterised LV dysfunction by echocardiographic standard and speckle-tracking (GLS and RBR pattern) measurements. Patients with a previous diagnosis of structural heart disease or atrial fibrillation were excluded. Results: At the time of enrolment, the chemotherapy regimen included trastuzumab (96%), pertuzumab (21%), and anthracyclines (13%). Twenty-two patients (12.5%) developed cardiotoxicity, and thirteen patients developed an RBR within 6 months of follow-up. In all cases, the RBR pattern was associated with cardiotoxicity (p < 0.001), reporting an optimal specificity but poor sensitivity at three and six months. However, the addition of the RBR pattern to the global longitudinal strain (GLS) ≥ −16% increased the odds ratio (OR) from 25.6 to 32.6 at three months and from 32.5 to 49.6 at six months rather than GLS alone. Conclusions: The RBR pattern improves the diagnostic accuracy of GLS for the detection of cardiotoxicity secondary to anthracyclines and anti-HER2-based treatments.

Background: Cardiac amyloidoses (CAs) are an increasingly recognised group of infiltrative cardiomyopathies associated with high risk of adverse cardiac events. We sought to characterise the characteristics and clinical value of right ventricular (RV) electroanatomic voltage mapping (EVM) in CA. Methods: Fifteen consecutive patients undergoing endomyocardial biopsy (EMB) for suspected CA (median age 75 years, 1st -3rd quartiles 64-78 years], 67% male) were enrolled in an observational prospective study. Each patient underwent RV high -density EVM using a multipolar catheter and EMB. The primary outcome was death or heart failure hospitalisation at 1 -year follow-up. We recorded electrographic features at EMB sampling sites and electroanatomic data in the overall RV, and explored their correlations with histopathologic findings and primary outcomes events. Results: A final EMB-proven diagnosis of immunoglobulin light chain or transthyretin CA was formulated in 6 and 9 patients, respectively. Electrogram amplitudes in the bipolar and unipolar configurations averaged 1.55 +/- 0.44 mV and 5.14 +/- 1.50 mV, respectively, in the overall RV, with lower values in AL CA patients. We found a significant inverse correlation between both bipolar and unipolar electrogram amplitude and amyloid burden according to EMB (P = 0.001 and P = 0.025, respectively). At 1 -year follow-up, 7 patients (47%) experienced a primary outcome event; the extent of bipolar dense scar area at RV EVM was an independent predictor of primary outcome events at multivariable analysis (odds ratio 2.40; P = 0.037). Conclusions: In CA, electrogram amplitudes are around the lower limit of normal yet disproportionately low compared with the increased wall thickness. Out data suggest that RV electrogram amplitude may be a quantitative marker of amyloid burden, and that RV EVM may have prognostic value.