Background-aimsRecently, the etiopathogenetic role of rotational activity (RotAct) in atrial fibrillation (AF) has been proposed. We designed a prospective multicenter study using CARTO Finder to evaluate the presence/distribution of RotActs in persistent AF (persAF), pulmonary vein isolation (PVI)influences on RotActs, and the impact of its elimination on top of PVI on procedural outcomes.MethodsFor this study, 76 patients with pers AF ablation were enrolled. Procedural steps involved (1) using a CARTO-Finder map to look for RotActs (physician blinded); (2) PVI; (3) using a new map to look for residual/new RotActs; (4) ablation of RotActs, if present; (5) and finally using a new map to confirm RotAct elimination. Populations were divided based on the presence or absence of structural heart disease (Group I and II) and the presence or absence (R+ and R−) of RotActs before PVI. Presence, number, and distribution of RotAct at STEP 1, the impact of PVI on RotAct at STEP 3, and maintenance of sinus rhythm (SR) during follow-up were evaluated. 56 AF patients undergoing standard ablation protocol were included as a control group.ResultsRotAct was identified in 29 (38%) patients at STEP1. RotAct did not differ between GI and GII patients. PVI significantly modified the number and localization of RotActs (p = 0.012). RotActs which were present at STEP 1 were different after PVI, with disappearance in 18 and new appearance in 5 patients. 71 patients completed a mean 13 ± 6 months follow-up and 91.5% were in stable SR. No difference in relapses was seen between R + and R- and GI and GII. RotAct ablation significantly reduced arrhythmia relapse during the follow-up compared to the control group (freedom from arrhythmia 91.5% vs. 78.6%, p = 0.025).ConclusionRotAct was present in 38% in persAF patients. PVI influenced the number and distribution of RotActs. A tailored ablation strategy provided a high success rate (91.5%) at the follow-up.

Background Anderson-Fabry disease (AFD) is a rare cause of left ventricular hypertrophy (LVH) that can be challenging to diagnose, particularly when comorbidities are present. Case Summary We report a 70-year-old man with controlled hypertension, diabetes mellitus, chronic kidney disease, prior percutaneous coronary intervention on the left anterior descending artery, evaluated for progressive LVH and electrocardiogram (ECG) changes during follow-up. ECG showed an atypical pattern with right bundle branch block. Cardiac magnetic resonance then demonstrated reduced native T1 values. Genetic testing identified the p.N215S (p.Asn215Ser) GLA mutation, confirming late-onset AFD. Disease-specific management was subsequently initiated. Discussion Late-onset AFD is frequently underdiagnosed, particularly in older patients with multiple cardiovascular comorbidities. Careful ECG analysis may provide key diagnostic clues and prompt advanced imaging and genetic testing. Take-Home Messages AFD should be considered in older patients with unexplained LVH. Careful evaluation of ECG abnormalities may be sufficient to trigger targeted, second-level, diagnostic tests.

ABSTRACT Background Recent advancements in ultra‐high‐density mapping (UHDM) featuring automated functionalities have enhanced our understanding of micro‐reentrant atrial tachycardias (mAT) circuits and the precise localization of the origin. Purpose To evaluate the diagnostic support provided by an automated UHDM algorithm in guiding the ablation of mATs. Methods Consecutive patients eligible for AT ablation in 22 Italian centers were prospectively enrolled. All ATs were comprehensively mapped in either the left or right atrium utilizing the RHYTHMIA mapping system. The LUMIPOINT tool was systematically employed to confirm electrogram fragmentation within this defined area. Results Among 159 ATs analyzed, 97 (61.0%) were identified as macro‐reentrant ATs, 50 (31.4%) as focal ATs and 12 (7.5%) as mATs. Concerning the mAT group, the targeted activity was localized in the anterior wall in 4 cases (33.3%), in proximity to PVs in 3 cases (25%), along the left ridge in 2 cases (16.6%), and at the roof, in the free wall and along the CTI in 1 case (8.3%), respectively. Low voltage areas (< 0.1 mV) were detected in all mAT cases and colocalized with the origin site. Over a median of 288 [248–349] days of follow‐up, 5 (3.1%) patients suffered from an AT/AF arrhythmia recurrence: 3 (3.1%) were in the MAT group, 1 (2%) in the focal AT and 1 (8.3%) in the mAT group. Conclusion A novel automated algorithm for mAT identification, coupled with ORION catheter, enables mAT description and transcatheter ablation of the localized origin of this rare form of AT results in a satisfactory procedural success rate. Trial Registration Catheter Ablation of Arrhythmias With High‐Density Mapping System in the Real World Practice (CHARISMA). http://clinicaltrials.gov/ Identifier: NCT03793998.

BACKGROUND:In patients with implantable cardioverter-defibrillators (ICDs), inappropriate therapies (ITs) are often caused by supraventricular tachyarrhythmias (SVTs). OBJECTIVE:We aimed to estimate the incidence of IT in modern single-lead ICDs. METHODS:The THINGS study enrolled patients with single-lead ICDs with 2 SVT discrimination modalities: dual chamber (DC) with an atrial floating dipole or single chamber (SC) with morphology criterion. All devices were programmed with 2-zone therapy: ventricular tachycardia (VT) zone from 170 beats/min with ≥15 seconds (≥36 beats) detection time and SVT discriminators; and ventricular fibrillation (VF) zone from 214 beats/min with ≥7 seconds (≥24 beats) detection time. The primary end point was the first occurrence of IT, adjudicated by an independent board. RESULTS:A total of 526 patients (median age, 66 years; 83% male), 183 (34.8%) with DC and 343 (65.2%) with SC discrimination, were observed for a median of 2.2 years. The incidence rate of IT was 4.2% (95% confidence interval [CI], 2.7%-6.4%) at 1 year and 7.1% (95% CI, 5.0%-9.9%) at 2 years. Younger age (adjusted hazard ratio, 0.97; 95% CI, 0.95-0.99; P = .013) and history of atrial fibrillation (adjusted hazard ratio, 2.67; 95% CI, 1.30-5.46; P = .007) were significantly associated with increased IT risk. In a propensity score-matched comparison, DC discrimination showed a trend toward reduced IT rates compared with SC discrimination in the VT zone (1-year incidence, 1.8% vs 3.5%; P = .105). CONCLUSION:High-rate VF cutoff and prolonged detection time programming resulted in a low IT rate in single-lead ICD patients with modern SVT discriminators. A trend favoring the DC system was observed in the VT zone.

Abstract Fabry disease (FD) is rare genetic syndrome which determines a lysosomal storage disorder caused by pathogenic variants in the alpha–galactosidase A (GLA) gene that lead to alpha–galactosidase A (AGAL– A) enzyme activity disfunction.The fenotipic effect is a left ventricular hypertrophy (LVH) that is frequently misdiagnosed as hypertrophic cardiomyopathy (HCM).This disease in still unfamiliar for the most part of cardiologists cause of the fenotipic familiarities with other more common and wellknown diseases and according to recent data the prevalence of FD among unexplained LVH is 0.93%.These characteristics drive to a heavy under diagnosis of a disease with many therapy chances. The prompt initiation of these treatments, subsequently an early diagnosis, is actually considered the best strategy to improve the natural course of the disease.The critical evaluation of the clinical history and basic cardiomiopaty assessments could drive the cardiologist to the diagnosis.Precisely, we present an example of three family pedigree discovered in a couple of months subsequently the unmasking of proband male patients with decennary misdiagnosis of HCM. The ambulatory suspect of non sarcomeric disease in LVH drove us to critically reexaminate EKGs and previous CMR scans finding respectively PR shortage associated with right bundle block and basal inferolateral late gadolinium enhancement (figure 1). In a proband it is not possible to perform MRI with gadolinium due to the presence of renal failure and the diagnostic suspicion arose by analyzing the T1 mapping signal (figure 2).The score ID FABRY–HCM were applied resulting suggestive too.Having thus corroborated the suspicion, blood spot tests were performed finally detecting a very low AGAL–A activity. The following GLA genetic tests identified the tipical mutation of late onset Fabry’s disease (p.N215Ser). Fulfilling the consensus criteria for the therapy initiation, the patients were treated with enzyme replacement therapy. We completed families predigree identifying other six famale gene mutation carriers with almost preserved AGAL–A activity. The diagnosis of FD allowed us to perform the specific therapy in affected patients hopefully effecting their quality of life and their prognosis and to bring out healthy carriers.The initial suspect questioning a previous diagnosis starting to simple clinical and routine strumental elements were crucial.

Ospedale Maggiore, Bologna, Policlinico Sant’Orsola-Malpighi, Bologna, Santa Maria Nuova Hospital, Reggio Emilia, Ramazzini Hospital, Carpi Modena, Guglielmo da Saliceto Hospital, Piacenza, Azienda Socio Sanitaria Territoriale Lariana, Como, Azienda O.U. Policlinico G. Rodolico San Marco, Catania, Conegliano General Hospital, Conegliano, Università Vanvitelli-AO Monaldi, Napoli, Bentivoglio Hospital, Bentivoglio, Infermi Hospital of Rimini, Rimini, San Luca Hospital, Lucca and Biotronik Italia spa, Milano, Italy

Abstract Introduction COronaVIrus Disease 2019 (COVID–19) exerts a significant impact on public health since it has reached a pandemic level in March 2020 and a high rate of negative mental health outcomes has been reported in the Italian general population. Purpose We aimed to investigate the pandemic impact on the psychological status of, COVID–19 negative, cardiac patients and if there are any gender differences. Methods Consecutive COVID–19 free patients who were presented to the cardiac outpatient clinic of Conegliano general hospital were divided into 2 groups according to their presentation, either before or during the COVID–19 Pandemic. The presence or absence of stress symptoms was established based on the patient’s self–assessment psycho–emotion questionnaire based on a reproduced form of Cohen’s perceived stress scale. Results A total of 310 patients were included in this analysis. Patients’ mean age was 65±18.5 years, males were 57% with 128 (41%) and 132 (59%) patients presented before and during the pandemic respectively. Both patients’ groups shared most of the demographic and clinical characteristics. In all patients, stress symptoms were reported in (52% VS 60%; p = 0.15) for patients who were presented before and during the pandemic, respectively. In male patients, stress symptoms were more frequent in patients who were presented during the pandemic (59%) compared to the pre–pandemic presented male patients (43%); (p = 0.03). Yet, no difference in the frequency of stress symptoms was observed in female patients. In an age–adjusted logistic regression analysis, psychological stress was significantly higher in male patients who were presented during the pandemic (Odds Ratio [OR]=2.0; 95% confidence interval [CI]=1.1–3.6; p = 0.03). Although, no significant difference was observed in female patients (OR = 0.8; 95% CI = 0.4–1.7; p = 0.63). Same results were obtained using the fully adjusted model, (OR = 1.9; 95% CI = 1.0–3.5; p = 0.04) and (OR = 0.8; 95% CI = 0.4–1.7; p = 0.64), for male and female patients, respectively. Conclusion Psychological stress symptoms has been observed more frequently in male patients seen during the COVID–19 pandemic, with almost double risk compared to the pre–pandemic, independently from baseline clinical characteristics. No difference in the frequency of stress symptoms was observed in female patients.

[This corrects the article DOI: 10.3389/fcvm.2022.964694.].

Abstract Background Non cardiac outcomes after ACS are seldom reported specially on the long term. In the literature, aspects of parallelism between the atherosclerotic, inflammatory, and neoplastic process have been observed. However, there is a lack of prospective studies looking for potential association between ACS and future neoplasia. Aim To describe the presence, incidence of malignant neoplasia long after ACS. Comparison with the general population registries incidence rate worldwide and in Italy was also considered. Methods This prospective study included 541 patients who were discharged alive after index hospitalization with ACS in three hospitals and followed for 22 years. Results All but 3 patients completed the follow–up or were followed until death. Pre–existing malignancy was noted in 15 patients, whereas 106 patients developed cancer during the follow–up period, which represented 6232 person–years. The most common sites were the lungs (22%), colorectal (19%), and prostate (15%), as well as the pancreas (5%), breast (5%), and leukaemia (5%). A total of 99 (18%) patients died due to malignancy (Figure 1). The risk of malignancy after ACS in the present study, appears higher than that of general population; as we observed a cancer incidence rate approximating 17.8 case per 1000 person–year, while in general population estimates carried out globally, in Europe, Italy and in Veneto Region, the age standardized cancer incidence rate was reported to be 3.27, 4.64, 4.73 and 4.70 cases per 1000 person–years, respectively [according to GLOBOCAN 2020]. Conclusions In this prospective, long–term study, we observed an increase in the risk of malignant neoplasia in patients who survived ACS, notably higher than the risk observed in the general population globally, in Europe, in Italy and in Veneto region. Further understanding of the delicate interaction between CV disease and cancer may lead to better prevention, earlier detection, and safer treatment strategies.

Abstract Funding Acknowledgements Type of funding sources: None. Background Optimal criteria in clinical practice differentiating microreentrant atrial tachycardias (mAT) from macroreentrant atrial arrhythmias (MAT) have not yet been clarified. The use of multielectrode catheters and the recent development of ultra high-density mapping (UHDM) with automated features has improved our knowledge of mAT circuits and foci location. Purpose In the present study, we systematically evaluated AT mechanisms in a large consecutive cohort of patients with MAT identifying the precise mAT circuits using the Rhythmia mapping system. Methods Consecutive patients indicated for MAT ablation from January 2021 to November 2021 at 33 centers were prospectively included. All MATs were completely mapped in the left or right atrium by means of the Rhythmia mapping system and the 64-poles Orion basket catheter. For study purpose, a mAT was defined as an AT with slow continuous low fragmented potentials covering at least 50% of tachycardia cycle length (CL) in a small area (set as a circuit within < 1 cm2) and in a couple of closed splines of the Orion catheter and a centrifugal activation pattern to the remainder of the atria. The Lumipoint tool was systematically used to confirm EGM fragmentation inside this area. Data are reported as mean±SD. Results One-hundred eighty-seven MATs were analyzed: 100 (53.7%) atypical left atrial flutter, 27 (14.3%) left AT and 60 (32%) right AT. A total of 7 MAT (prevalence of 3.7%) was identified as mATs (6 atypical left atrial flutter and 1 AT), with 5 out 7 with a previous history of AF ablation procedure. The percentage of atrial surface with a voltage level below 0.1 mV was 19±17%. The CL was 329±78ms. The electrical activity spanning the whole CL was detected by 2±0.6 pairs of close bipoles of the Orion catheter, and was actually confined to a region of 0.4±0.2cm2 with continuous highly fractionated potential covering 68±10% of the CL (longest component of fractionated EGM per spline=74±18% of the CL). Voltage level was 0.3±0.1mV at RF delivery site and 0.2±0.1mV at the site of longest duration of the fragmented potential, respectively. Targeted mAT activity was identified closer to PVs in three cases and at the mid portion of the anterior wall and at the roof in two cases each, respectively. In all cases a single shot RF delivery terminated each arrhythmia at targeted location. Consolidative RF ablations were then delivered in the adjacent area. No complication occurred. At three months follow-up all patients remained free from any AT recurrence. Conclusions In this standard of care clinical experience with UHDM system, the prevalence of mAT seems to be higher than previously reported in literature. A technique based on mAT identification through a novel automated algorithm and matched area of electrogram fractionation captured by the Orion catheter may limit the extent of ablation needed.

Aims LBBB is rare in healthy young adults, and its long-term prognosis is uncertain. Methods 56 subjects (aged <50 years), in whom an LBBB was discovered by chance in the absence of clinical and echocardiographic evidence of heart disease, were collected in a multicenter registry. Results 69% were males. Mean age at the time of discovery of LBBB was 37 ± 11 years. Mean QRS duration was 149 ± 17 m sec and 35% had left axis deviation. All patients had a normal echocardiogram, except for left ventricular dyssynchrony; 37 patients underwent coronary angiography (30) or myocardial scintigraphy during effort Eriksson and Wilhelmsen (2005), and in all cases obstructive coronary artery disease was excluded. In 2/30 patients who underwent coronary angiography, an anomalous origin of the CX artery from the right coronary sinus was found. Thirty patients underwent cardiac magnetic resonance; in 60% it was normal, while in 40% it revealed late enhancement, which in 33% was localized in the basal septum, suggesting fibrosis of the left bundle branch. During follow-up (12+/10 years, median 10 years) no sudden death occurred. At the end of follow-up, all patients were alive, except for one who suffered accidental death. Two patients (3.5%) underwent PM implantation owing to syncope. The echocardiogram at the end of follow-up revealed LV dysfunction in only one patient. Conclusions In young adults without apparent heart disease, LBBB is a heterogeneous condition. In the vast majority of cases, the prognosis is good and no ventricular dysfunction occurs over time. However, as only 18% of our patients were aged >60 years at the end of follow-up, we cannot establish the prognosis in older age-groups.

Background: Brugada syndrome (BrS) is associated with mutations in the cardiac sodium channel gene, SCN5A. However, genetic studies of patients with BrS with arrhythmic events have been limited. We sought to compare various clinical, ECG, and electrophysiological parameters according to SCN5A genotype in a large cohort of BrS probands with first arrhythmic event. Methods: Survey on Arrhythmic Events in Brugada Syndrome is a survey of 10 Western and 4 Asian countries, gathering 678 patients with BrS with first arrhythmic event. Only probands were included, and SCN5A genotype adjudicated. Patients without appropriate genetic data were excluded. Associations of genotype with clinical features were analyzed. Results: The study group comprised 392 probands: 92 (23.5%) SCN5A+(44 pathogenic/likely pathogenic [P/LP] and 48 variants of unknown significance) and 300 (76.5%) SCN5A-. SCN5A missense variants and the patients hosting them were similar regardless of adjudication. A higher proportion of patients with P/LP were pediatric (<16 years) compared with SCN5A- (11.4% versus 3%, P=0.023). The proportion of females was higher among patients with P/LP compared with SCN5A- (18.2% versus 6.3%, P=0.013). P/LP probands were more likely to have a family history of sudden cardiac death compared with SCN5A- (41.9% versus 16.8%, P<0.001). A higher proportion of patients with P/LP were White compared with SCN5A- (87.5% versus 47%, P<0.001). Ethnicity (odds ratio, 5.41 [2.8-11.19], P<0.001) and family history of sudden cardiac death (odds ratio, 2.73 [1.28-5.82], P=0.009) were independent variables associated with P/LP genotype following logistic regression. Conclusions: The genetic basis of BrS has a complex relationship with gender, ethnicity, and age. Probands hosting a P/LP variant tended to experience their first arrhythmic event at a younger age and to have events triggered by fever compared with patients with SCN5A-. In addition, they were more likely to be White and to have family history of sudden cardiac death. Among females, a P/LP variant suggests an increased risk of being symptomatic. This association should be further studied on an ethnically specific basis in large prospectively collected international cohorts.

Aim The aim of the present prospective clinical study was to evaluate the effectiveness of orally administered probiotic Lactobacillus reuteri in the treatment of peri-implant mucositis. Materials and methods Eighty patients showing peri-implant mucositis were enrolled and assigned to two different treatment groups. In the test group subjects were instructed to take one probiotic lozenge daily for 30 days. In the control group, patients received placebo. Periodontal indices including plaque index (PI), bleeding on probing (BOP), and probing depth (PD) were clinically recorded around natural teeth and implants at baseline and after a period of 1 month and 3 months. Results After 3-month evaluation in the test group the differences of plaque and bleeding indices remained statistically significantly lower compared to baseline at both teeth and implants. Contrariwise, no statistically significant differences of PI and BOP were observed in the control group. The intergroup comparison at 3 months yielded statistically significantly lower values for all periodontal parameters around teeth when the probiotic was used. Conversely, no statistically significant differences in periodontal parameters were observed between test and control groups at 3 months around implants. Conclusions Probiotic intake was effective in reducing PI, BOP, and PD scores around natural teeth and dental implants affected by peri-mucositis, in particular around natural teeth at 3 months.

BACKGROUND:Which technique is better for repeat ablation in patients with atrial fibrillation (AF) remains unclear. The aim of the study was to compare long-term efficacy of repeat ablation using the alternative technique for the first redo ablation procedure: (a) cryoballoon (CB) re-ablation after a failed index pulmonary vein isolation (PVI) with radiofrequency (RF) ablation, RF-then-CB group or (b) RF repeat ablation following a failed CB ablation, CB-then-RF group. METHODS:Within the 1STOP Italian Project, consecutive patients undergoing repeat ablation with a different technique from the index procedure were included. RESULTS:We studied 474 patients, 349 in RF-then-CB and 125 in CB-then-RF group. Less women (21% vs 30%; P = .041), more persistent AF (33% vs 22%; P = .015), longer duration of AF (60 vs 31 months; P < .001), and more hypertension (50% vs 36%; P = .007) were observed in the RF-then-CB cohort as compared with the CB-then-RF group. The number of reconnected PVs was 3.7 ± 0.7 and 1.4 + 1.3 in RF-then-CB and CB-then-RF group, respectively (P < .001). During the follow-up, significantly less AF recurrence occurred in the CB-then-RF group (22% vs 8%, HR = 0.46; 95% CI: 0.24-0.92; P = .025). Cohort designation was the only independent predictor of AF recurrence. CONCLUSION:Alternation of energy source for repeat ablation was safe and effective, regardless the energy used first. However, patients initially treated with CB PVI undergoing repeat ablation with RF current had less AF recurrence at long-term follow-up as compared with those originally treated by RF ablation receiving a CB repeat ablation.

Microreentrant atrial tachycardias (AT) can be defined as atrial arrhythmias with a cycle length (CL) coverage greater than 85% in a small area (arbitrarily set as a circuit with a diameter <2–3 cm) and a centrifugal activation to the rest of the atrial chamber.1 Although debate is still ongoing in the literature as to the precise definition of microreentry,2 it is common practice to refer to the phenomenon in terms of the more general concept of localized reentry, since the size of the reentrant circuit is presumed to be in the order of centimeters.

INTRODUCTION:Atrial tachycardia/fibrillation (AT/AF) episodes are common in implantable cardioverter-defibrillator (ICD) recipients and can be undetected by standard single-chamber devices. This study aims to explore whether a single-lead ICD with an atrial dipole (ICD DX; BIOTRONIK SE & Co, Berlin, Germany) could improve the AT/AF diagnosis and management as compared to standard ICD (ICD VR).METHODS AND RESULTS:We selected patients without AT/AF history from the THINGS registry which included consecutive patients implanted with ICD for standard indications. The ICD VR and the ICD DX groups included 236 (62.8%) and 140 (37.2%) patients, respectively, and had no significant differences in baseline characteristics. During a median follow-up of 27 months, there were 7 AT/AF diagnoses in the ICD VR and 18 in the ICD DX group. The 2-year incidence of AT/AF diagnosis was 3.6% (95% confidence interval [CI]: 1.6%-9.6%) for the ICD VR and 11.4% (95% CI: 6.8%-18.9%) for the ICD DX group (adjusted hazard ratio [HR]: 3.85 [95% CI: 1.58-9.41]; P = .003). Initiation of oral anticoagulation (OAC) due to AT/AF diagnosis was reported in 15 patients. The 2-year incidence of OAC onset was 3.6% (95% CI: 1.6%-7.8%) for the ICD VR and 6.3% (95% CI: 3.0%-12.7%) for ICD DX group (adjusted HR: 1.99 [95% CI: 0.72-5.56]; P = .184).CONCLUSION:We observed that atrial sensing capability in single-chamber ICD patients without evidence of atrial arrhythmias at implant is associated with a greater likelihood of detecting AT/AF episodes. The management of these diagnosed arrhythmias often led to clinical interventions, mainly represented by initiation of OAC therapy.

The management of device implantation during the COVID-19 infection has not well defined yet. This is the first case of complete atrioventricular block in a symptomatic patient affected by the COVID-19 infection treated with early pacemaker implantation to minimize the risk of virus contagion.