Abstract Background Head-to-head comparisons between stand-alone left atrial appendage closure (LAAC) and a same-procedure LACC + cryoballoon (CB) pulmonary vein isolation (PVI) (combined procedure) are currently lacking. Purpose To compare acute and long-term outcomes between stand-alone LAAC vs a LAAC+CB-PVI combined procedure. Methods All patients undergoing LAAC at our institution, having at least 2 years follow-up, were analyzed to assess the impact of additional CB-PVI. The primary efficacy and safety endpoints of our study were the acute procedural success rate and the peri-procedural complications rate. As secondary endpoints, major bleeding, and ischemic events, as well as sinus rhythm rate at 2 years follow-up were assessed. Results Among 126 LAAC patients meeting inclusion criteria (males=64.2%), n=55 (43.7%) underwent a combined procedure. LAAC-only patients were older (72.5±7.2 vs 68.9±8.6, p<0.05) and less frequently having paroxysmal AF (23.9% vs 47.3%, p<0.05). Baseline CHA2DS2-VASc was similar among groups (3.3±1.3 vs 2.9±1.1, p=0.07) while LAAC-only patients had higher HAS-BLED at enrollment (3.4±1.1 vs 3.0±1.0, p=0.04). Additional CB-PVI was not a risk factor for incomplete LAA occlusion (OR 0.24–3.78, p=0.96), presence of residual lateral flow (OR 0.26–4.05; p=0.96), intraprocedural need for occluder device resizing compared to pre-procedural assessment (OR 0.27–3.05; p=0.884), and peri-procedural complications (OR 0.25–6.74, p=0.749). At 3-month post-procedural trans-esophageal echocardiography, a combined procedure was not associated with higher risk of incomplete occlusion (OR 0.33–1.59, p = 0.432), nor larger peri-device leakages (coefficient k: -0.65–+0.20, p=0.291). Overall and by-group ischemic (red) and bleeding (blue) relative risk reduction from CHA2DS2-VASc and HAS-BLED predicted yearly rates during follow-up was reported in Figure1. Over a median follow-up of 40 [26–56] months, a combined procedure was not a risk factor for major bleeding (OR 0.31–5.48, p=0.715) or ischemic (OR 0.11–3.56, p=0.599) events. As expected, additional CB-PVI was strongly associated with a reduction of AF recurrences (OR 0.16–0.86, p<0.05), after excluding permanent AF patients from the analysis. Conclusion Combined LAAC + CB-PVI procedure does not appear to be a risk factor for worse LAAC-related outcomes, while reducing AF recurrences in non-permanent AF patients.Figure 1

Abstract Background Complete electrical pulmonary vein isolation (PVI) by cryo-balloon approach is a well-established ablation strategy of atrial fibrillation (AF). While contrast findings exist regarding the influence of variant pulmonary vein (PV) anatomy on predicting AF recurrence, limited data are currently available specifically for cases involving the POLARx cryoablation system during PVI. Purpose We report the real-world experience of POLARx in the context of de novo AF ablation in a multicenter Italian registry. Methods Consecutive patients undergoing AF ablation from the CHARISMA registry at 10 Italian centres were included. Protocol-directed cryoablation was delivered for 180 sec or 240 sec according to operator’s preference for isolation achieved in ≤60 sec, or 240 sec if isolation occurred >60 sec or when time to isolation was not available. The ablation endpoint was PVI as assessed by entrance and exit block. All patients were followed-up for at least 12 months after the procedure. Results Four-hundred twenty-nine patients were included (n=358, 83.4% paroxysmal AF, n=71, 16.6% persistent AF, mean age 60.7±10 years, 28.3% female, mean LVEF 58±8%). PVI was achieved in all pts using only cryoablation. Twenty-eight (6.6%) patients exhibited an anatomical variant: 17 (4.0%) a common ostium and 11 (2.6%) an adjunctive PV. The mean number of freeze applications per patient was 5.1 (1.2 for LSPV, 1.3 for LIPV, 1.2 for RSPV and 1.3 for RIPV). Over a median of 398[370-461] days of follow-up, 14 (3.2%) patients experienced an early recurrence of AF during the 90-day blanking period. Overall, 63 patients (14.7%) suffered an AF recurrence after the 90-day blanking period (median time to recurrence 342[171-381] days). The proportion of patients exhibiting AF/AT recurrences was higher in the persistent AF group (17 out 71, 23.9%) than in the paroxysmal AF group (46 out 358, 12.8%, p=0.026), with a hazard ratio of 2.02 (95%CI: 1.2 to 3.5, p=0.0137) whereas patients with anatomy variant showed a similar AF/AT recurrence rate (5 out 28, 17.9%) than in the standard anatomy group (58 out of 401, 14.5%) with a hazard ratio of 1.43 (0.6 to 3.6, p=0.441). Four (0.9%) transient phrenic nerve palsy were observed, both with full recovery in the 48-h post procedure; no major procedure-related adverse events were reported. Conclusion In this multicenter study, the cryo-balloon system demonstrated safety and efficacy in treating both paroxysmal and persistent AF patients, yielding a low incidence of AF/AT recurrence during follow-up, regardless of the presence of variant PV anatomy.

Abstract Background The POLARx-FIT cryoballoon (CB) system introduces a unique feature, allowing the selection of two distinct balloon sizes within a single catheter. This innovation holds promise for treating larger pulmonary veins (PV), providing increased flexibility to achieve optimal occlusions. However, there is a scarcity of clinical data supporting its application in this context. Purpose To compare the benefits and safety of the new POLARx-FIT system to those of the existing POLARx system currently in use for PV isolation (PVI) in patients with atrial fibrillation (AF). Methods The first 140 consecutive patients who underwent CB-based PVI with the POLARx-FIT system were retrospectively compared with 300 consecutive patients treated with the POLARx system. Protocol-directed cryoablation was delivered for 180 sec or 240 sec according to operator’s preference for isolation achieved in ≤60 sec, or 240 sec if isolation occurred >60 sec or when time to isolation was not available. The ablation endpoint was PVI as assessed by entrance and exit block. In the POLARx-FIT group the choice of balloon size (28 or 31 mm) was determined during the procedure while attempting to occlude each vein. Results Two-thousand one-hundred fifty-five cryo-applications (CBA) from 440 patients were analysed (300, 68.2% POLARx; 140, 31.8% POLARx-FIT). PVI was achieved with cryoablation only in all patients. The mean number of freeze applications per patient was similar between groups (5.0±1.4 in the POLARx-FIT vs 5.3±1.8 in the POLARx group, p=0.207) whereas the number of PVs treated in a single-shot fashion was higher in the POLARx-FIT group (444, 80.7% with one shot; 75, 13.7% with 2 shots; 31, 5.6% with more than 2 shots) than in the POLARx one (1168, 70.2% with one shot, p=0.0002; 294, 17.7% with two shots and 143, 8.6% with more than two shots). Among the POLARx-FIT cases, in 54.2% (n=298) of applications, the 31-mm diameter was employed as a first choice, while in the remaining 45.8% (n=252) of applications, the 28-mm diameter was adopted. A switch to a different balloon diameter was applied in 11.6% of cases. The first pass isolation (i.e. a single shot CBA to achieve PVI) was slightly higher when using a 31 mm diameter (n=250, 83.9%) than a 28 mm diameter (n=194, 77.0%, p=0.05). Three (0.7%) transient phrenic nerve palsy were observed (all in the POLARx group, 0.9%, p=0.554), with full recovery in the 48-h post procedure; no major procedure-related adverse events were reported at 30 days post-procedure. Conclusion In this first multicentric experience in a clinical practice setting, this novel cryo-balloon system proved to be safe and effective and resulted in a high proportion of successful single-freeze isolation. The intraprocedural flexibility of balloon size contributed to its versatility, leading to a variation in balloon diameter in about 12% of freeze applications.

Abstract Funding Acknowledgements Type of funding sources: None. Background Previous studies have demonstrated that cardiac biomarkers elevate after both cryoballoon (CB) and radiofrequency atrial fibrillation (AF) ablation, depending on the amount of energy delivered and the site of ablation. To date no comparison has been made between these thermal energy source and a novel non-thermal pulsed-field ablation (PFA) technology based on cells electroporation. Purpose Our analysis aims to compare acute myocardial injury through cardiac troponin I variation after pulmonary vein isolation (PVI) performed with different technologies (PFA vs CB). Methods All consecutive patients undergoing paroxysmal AF ablation with CB and PFA at our center from July to November 2022 were included. Protocol-directed cryoablation (CBA) was delivered for 180 sec or 240 sec according to operator’s preference for isolation achieved in ≤60 sec, or 240 sec if isolation occurred >60 sec or when time to isolation was not available. A standard PFA protocol-directed PVI was applied using 2kV with eight applications per vein (four applications each in the basket and flower poses). The ablation endpoint was PVI as assessed by entrance and exit block. Pre- and post-procedure samples of cardiac troponin I (CTpI) were collected before CBA/PFA and at 24h after ablation. Only patients with normal baseline values for myocardial injury were included. Results A total of 71 patients met inclusion criteria and were included in this analysis. The CBA group consists of 50 (70%) patients and the PFA group comprises 21 (30%) patients. The number of CBA applications to reach PVI was 5.0±1.4 and the number of PFA applications to achieve PVI was 32±4. All (100%) patients were in sinus rhythm at the time of the procedure. Evaluating the kinetic of CTpI, baseline values were homogeneous between CBA and PFA groups (p=0.979) whereas CTpI values significantly rose from baseline (7±2 ng/L) to 24h (8979±3691 ng/L, p<0.0001) and were significantly different between groups after CBA/PFA (8148±3311 ng/L for CBA vs 11900±7143 ng/L for PFA, p=0.0056). PVI was achieved in all patients (100%) using only CB or PFA. No major procedure-related adverse events were reported. Conclusion Our preliminary results showed that cardiac troponin I enzyme level increased after PVI by means of both cryoballoon and pulsed-field ablation and were higher after cellular electroporation by PFA than cryoablation.

Abstract Background Patients on chronic dialysis are less likely to receive percutaneous coronary intervention (PCI) for treatment of acute myocardial infarction (AMI). This is due to the lack of evidence from randomized trials, concerns about possible PCI-related side effects, and multimorbidity. Thus, routine use of PCI for treatment of dialysis patients with AMI remains an unresolved issue. Purpose We analyzed data of patients on chronic dialysis hospitalized with AMI (both ST-elevation myocardial infarction [STEMI] and non-ST-elevation myocardial infarction [NSTEMI]) from 2003 to 2018, by using the administrative Lombardy Health Database (Italy). Patients were grouped according to whether they were treated or not with PCI during hospitalization. The primary outcome was in-hospital mortality while 1-year mortality was the secondary endpoint. Results During the study period, 265,048 patients were hospitalized with AMI in Lombardy. Of them, 3,206 (1.2%) were on chronic dialysis (age 71±11; 72% males). Among dialysis patients, 44% were treated with PCI, while 54% underwent PCI among non-dialysis patients (P<0.0001). Dialysis was an independent predictor of conservative treatment with medical therapy only (OR 0.75 [95% CI 0.70-0.81]). In-hospital mortality in the dialysis cohort was 15%. It was significantly lower in patients treated with PCI than in those not treated with PCI (11% vs. 19%; P<0.0001). One-year mortality was 47% and it was lower in PCI-treated patients (33% vs. 52%; P<0.0001). The adjusted risk of the study endpoints was significantly lower in dialysis patients treated with PCI: OR 0.62 (95% CI 0.50-0.76) for in-hospital mortality; HR 0.63 (95% CI 0.56-0.71) for 1-year mortality. Similar results were found in STEMI and NSTEMI patients considered separately. Conclusions Our real-world data showed that in patients with AMI on chronic dialysis, PCI use is associated with a significant in-hospital and 1-year survival benefit.

Abstract Background Older patients, generally defined as individuals age >75 years, are less likely to receive percutaneous coronary intervention (PCI) for treatment of acute myocardial infarction (AMI) compared to younger patients. This is due to the paucity of evidence derived from randomized trials, concerns about possible PCI–related side effects, and multimorbidity. We investigated the prognostic impact of PCI in a large population of patients hospitalized with AMI in the period 2003–2018, by using the administrative Lombardy Health Database. Methods We analyzed data of all patients >75 years hospitalized with AMI (both STEMI and NSTEMI) from 2003 to 2018 in Lombardy. Patients were grouped according to whether they were treated or not with PCI during index hospitalization. The primary outcome was in–hospital mortality. One–year mortality and 1–year re–hospitalization for acute heart failure (AHF) or AMI were considered as secondary endpoints. Results During the study period, 116,063 patients (mean age 83±6; 48% males; 46% STEMI) were hospitalized with a primary diagnosis of AMI. Thirty–seven percent of them (n=42,912) were treated with PCI. The in–hospital mortality rate in the entire cohort was 12%. It was significantly lower in patients treated with PCI than in those not treated with PCI (6% vs. 15%; P<0.0001). In the overall population, 1–year mortality was 32% and 1–year re–hospitalization for AHF/AMI was 19%. Both these endpoints were less frequent in PCI–treated patients (16% vs. 41% and 15% vs. 21%, respectively; P<0.0001). The adjusted risk of the study endpoints was significantly lower in patients treated with PCI: OR 0.37 (95% CI 0.36–0.39) for in–hospital mortality; HR 0.37 (95% CI 0.36–0.38) for 1–year mortality; HR 0.74 (95% CI 0.71–0.77) for 1–year re–hospitalization for AHF/AMI. Similar results were found in STEMI and NSTEMI patients considered separately. Conclusions Our real–world data showed that in patients with AMI >75 years of age, PCI use is associated with a significantly lower in–hospital mortality and up to 1 year. This work was partly financed by the Italian Ministry of Health and the Lombardia Region (Grant NET–2016–02364191; EASY–NET)

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Pulsed-field ablation (PFA) is a new non-thermal, tissue-specific ablation technique. Through the application of a local electric field, it is possible to induce a selective electroporation of cardiomyocytes membranes, resulting in myocytic apoptosis and sparing of non-myocardial structures (nerves, connective tissue, esophagus, vessels). Purpose A new PFA system for atrial fibrillation (AF) ablation has recently been introduced in our hospital. The aim of this retrospective review is to share the initial results of our experience in terms of acute efficacy and safety. Methods A total of 41 adult patients suitable for AF percutaneous ablation underwent PFA between April and November 2022 in our Institute. PFA system consisted of a current generator, a deflectable sheath and a multielectrode PFA catheter. Once inside the left atrium (LA), the PFA catheter was directed to the pulmonary veins (PVs) ostia through an over-the-wire system. Then, 8 electric impulses were applied for each PV to achieve electrical isolation; in some cases, applications to the posterior left atrium wall (LAPW) were delivered to obtain LAPW isolation (LAPWI). A moderate-to-deep sedation was provided by an anesthesiologist during all the procedures. Acute ablation efficacy was defined as absence of intracavitary signals at the electroanatomic mapping and local capture failure at the pacing maneuvers. Intra and peri-procedural safety was defined as the absence of major complications (pericardial effusion/ tamponade, stroke, vascular complications, death) during the procedure and the hospitalization period. Results Of the 41 patients included, 24 (58.5%) were treated for paroxysmal AF and 17 (41.5%) for persistent AF. In almost all cases (n=40, 97.6%) pulmonary veins isolation (PVI) was performed; in 14 cases (34.1%, almost all persistent AF patients) a LAPWI was performed with the application of a variable number of pulses (mean value = 13). In most of the cases (n=28, 68.3%) an electroanatomic mapping was acquired before and after the ablation. Acute efficacy was observed in all PVI cases (n=40, 100%) and in all LAPWI cases (n=14, 100%). No periprocedural major complications were observed (n=0, 0%). Conclusions PFA is a promising ablation technique capable of inducing selective myocytic apoptosis through electroporation, causing a thick damage across the muscle with no injury of other tissues, and could become a game changer in electrophysiology in the next future. Our initial data report a combination of ease of use and high efficacy and safety profiles.

Abstract A 22–year–old healthy athlete was referred to our hospital for electrocardiographic findings consistent with intermittent type–1 Brugada pattern. A routine electrocardiogram (ECG) performed during a check–up showed sinus rhythm, normal PR interval and QRS duration, rSR’ with a coved type ST–segment elevation in V2 lead (Figure 1).The patients denied history of syncope or palpitations and his family history did not show sudden cardiac death or Brugada syndrome (BrS). Transthoracic echocardiography was normal and a 12–lead Holter monitoring revealed the intermittence of the type–1 Brugada pattern. The patient was hospitalized for further investigation. On admission, ECG showed a type–2 Brugada pattern; therefore, Ajmaline challenge test (1 mg/kg injection in 10 minutes) was performed and resulted positive. Subsequently, the patient underwent an electrophysiological study (EPS) which was negative for induction of sustained arrhythmias. The protocol adopted consisted of double extrastimuli programmed electrical stimulation until refractoriness (drive 600/220 ms and 400/210 ms), at double sites (right ventricle apex and right ventricular outflow tract). Furthermore a genetic test was performed using next–generation sequencing, showing a heterozygous mutation in the SCN5A gene, encoding for sodium channel alpha subunit (variant c.5363delA), not previously described in the literature. Since the low arrhythmic risk, the patient was implanted with a loop recorder (ILR, Medtronic Reveal LINQ), entering a program of home monitoring. After a 15–months follow–up, an episode of ventricular polymorphic tachycardia lasting 2 minutes and 11 seconds, associated with lightheadedness and palpitations, was detected by the remote monitoring (Figure 2). The patient was therefore hospitalized. During the in–hospital stay a cardiac magnetic resonance was performed to exclude other underlying diseases, identifying an enlarged right ventricle (EDVi 114 ml/m2) and abnormal free wall motion (Figure 3), thus reaching one major criteria of arrhythmogenic cardiomyopathy (however not sufficient for the diagnosis). The patient was then implanted with a subcutaneous implantable cardiac defibrillator (Boston Scientific EMBLEM MRI S–ICD). We presented a case of complex arrhythmic risk stratification in a possible overlap of an arrhythmogenic cardiomyopathy and a Brugada Syndrome in a young athlete who experienced a sustained ventricular tachycardia during loop–recorder monitoring.

Abstract Background Cardiogenic shock (CS) is the most severe form of acute heart failure, characterized by life-threatening end-organ hypoperfusion resulting from a low cardiac output state. Data on epidemiology of CS has been mostly drawn from registries focusing on acute myocardial infarction (AMI). However, recent evidence in a contemporary cohort in North America has shown that more than two thirds of all CS cases were related to causes other than AMI and that these patients had outcomes at least as poor as patients with AMICS. Purpose To provide data on profile, management, outcome, and evolution over time of CS patients admitted to ICCU/ICU and to compare them between patients with AMICS and acute decompensated heart failure (ADHF-CS). Methods The Altshock-2 Registry is a multicenter national prospective data collection, part of the Italian Altshock-2 program. Recruitment started on 2 March 2020 with 11 Italian Centers contributing to patients' enrolment. A total of 238 patients were hospitalized with confirmed diagnosis of CS between March 2020 and February 2022 in a multicenter national initiative. The mean age of this patient population was 64 years (interquartile range [IQR] 54–74) and 76% were male. Ninety-seven patients (41%) were admitted for AMICS, whereas 84 patients (35.3%) had ADHF-CS; 57 patients (24%) had other causes. As compared to AMICS patients, those admitted for ADHF-CS were younger, but with a higher burden of comorbidities (renal, liver, thyroid disease, atrial fibrillation, anemia), pre-existing decreased ejection fraction and a higher number of chronic drugs. Patients with ADHF-CS had a prevalent cardio-metabolic phenotype upon admission with prevalent congestion. Mechanical ventilation was more commonly used in patients with AMICS, compared to ADHF-CS, along with an increased inotropic score. Conversely, sodium nitroprusside was used in about sixty percent of patients with ADHF-CS. Sixty percent of the included population received a temporary mechanical circulatory support (MCS) device, which was intra-aortic balloon pump (IABP) in the eighty percent of the supported patients. Pulmonary artery catheter was used for monitoring only in the 18% of the included patients whereas an extensive echocardiographic approach was applied. Twenty-one patients (25%) underwent heart replacement therapy in the ADHF-CS patients versus 2 (2%) in the AMICS. Thirty-day mortality occurred in 32 patients (33%) in the AMICS group versus 23 (27%) in the ADHF-CS group (p=0.41). Conclusions Different diagnostic approaches and uses of mechanical circulatory support devises and inotropes are implemented in transatlantic settings. Uniform definitions and more homogenous protocols tailored on CS etiologies and clinical and biochemical phenotypes are needed in prospective initiatives in order to effectively compared results and outcome. Funding Acknowledgement Type of funding sources: None.

Abstract Funding Acknowledgements Type of funding sources: None. Background Complete electrical pulmonary vein isolation (PVI) by cryo-balloon approach is a well-established ablation strategy of atrial fibrillation (AF). Recently, a new cryoablation system (POLARx) with unique features has been made available for clinical use. To date, limited data exist on acute and follow-up outcome of this system in a multicentric clinical practice. Purpose We reported the preliminary experience of this novel technology in a multicenter Italian registry. Methods Consecutive patients (pts) undergoing AF ablation from the CHARISMA registry at 6 Italian centres were included. Protocol-directed cryoablation was delivered for 180 sec or 240 sec according to operator’s preference for isolation achieved in ≤60 sec, or 240 sec if isolation occurred >60 sec or when time to isolation (TTI) was not available. The ablation endpoint was PV isolation as assessed by entrance and exit block. Rhythm monitoring during the follow-up examinations was performed via the clinical assessment of AF recurrence, ECG and Holter monitoring, according to the clinical practice of each center. All patients were followed-up for at least 6 months after the procedure. Arrhythmia recurrences within the first 3 months (blanking period) were classified as early recurrences and were not considered procedural failures Results Six-hundred twenty-four cryoapplications from 112 pts (439 PVs) were analyzed (n=89, 79.5% paroxysmal AF, n=23, 20.5% persistent AF, mean age 61.5±9 years, 76% male, 22% with an history of AT, mean LVEF 49±10%). PVI was achieved in all pts using only cryoablation. The mean number of freeze applications per pt was 5.6±2.1 (1.4±1.2 for LSPV, 1.5±1.1 for LIPV, 1.3±0.8 for RSPV and 1.3±0.8 for RIPV), with 318 (72.4%) PVs treated with a single cryoablation (92, 21% with 2 cryoablation; 29, 6.6% with more than 2 cryoablations). Fourty-four (39.3%) pts were treated with a single application to each of the PVs. Over a median of 296[245 to 382] days of follow-up, five (4.5%) patients experienced an early recurrence of AF/AT during the 90-day blanking period. Overall, 12 patients (10.7%) suffered an AF/AT recurrence after the 90-day blanking period (median time to recurrence 200[124 to 297] days). Specifically, 8 (7.1%) patients had AF recurrence only, 3 (2.7%) had AT recurrence only and 1 (0.9%) experienced both events. One (0.9%) patient underwent a repeated ablation procedure. The proportion of patients exhibiting AF/AT recurrences was similar between AF types (10 out 89, 11.2% for paroxysmal AF vs 2 out 23, 8.7% for persistent AF, p=1.00) with a hazard ratio of 0.9 (95%CI: 0.2 to 3.9, log-rank p=0.8894). One transient phrenic nerve palsy was observed, with full recovery in the 48-h post procedure; no major procedure-related adverse events were reported. Conclusion In this first multicentric experience, the novel cryo-balloon system proved to be safe and effective and resulted in a very low rate of AF/AT recurrence during follow-up.

Abstract Background Eosinophilic granulomatosis with polyangiitis (EGPA), previously known as Churg–Strauss, is a rare multisystem disorder characterized by chronic rhinosinusitis, asthma, and prominent peripheral blood eosinophilia (PE). Cardiac involvement may include eosinophilic myocarditis and it is a serious manifestation of EGPA. Case Presentation A 67–year–old woman presented to the emergency department with 2–weeks history of dyspnea, orthopnea and asthenia. She had history of asthma, PE, adjuvant radiotherapy after right mastectomy (July 2021). The patient was diagnosed with new onset atrial fibrillation in the previous month. At admission, the patient was hemodynamically stable and with signs of congestion. Complementary exams showed sinus rhythm and T–wave inversion on lateral leads; PE (2010/uL), elevated troponin and BNP values; and severe biventricular systolic dysfunction with diffuse hypokinesia and apical akinesia. The patient was admitted to the ICU and was treated with intravenous diuretics and levosimendan. Optimal HF therapy was introduced. Serial echocardiography revealed partial recovery of LVEF and blood analysis showed a decrease in troponin levels, with persistent eosinophilia (6330/uL). Computed tomography (CT) excluded significant coronary disease, and showed bilateral basal ground–glass opacities, areas of air–space consolidation and bilateral reticular–nodular pattern. Cardiac magnetic resonance revealed increased T2 values/signs of myocardial edema in anterior wall, interventricular septum and apex and no late gadolinium enhancement, compatible with myocarditis. An endomyocardial biopsy (EMB) was performed and confirmed the diagnosis of eosinophilic myocarditis. Oral corticosteroids were started. Paranasal CT scan showed signs of chronic sinusitis, without polyposis, and antineutrophil cytoplasmic antibodies were positive, making the diagnosis of EGPA, according to ACR criteria. Discussion In a patient presenting with new onset heart failure and with history of asthma and eosinophilia, it is important to suspect eosinophilic myocarditis, as this is a rare but reversible life–threatening condition. EMB plays an important role in the diagnosis and should be done promptly. Conclusion We described a multidisciplinary management of a case of a patient with eosinophilic myocarditis and EGPA, presenting with severe acute biventricular dysfunction.

Abstract Funding Acknowledgements Type of funding sources: None. Background Complete electrical pulmonary vein isolation (PVI) by cryo-balloon approach is a well-established ablation strategy of atrial fibrillation (AF). Recently, a new cryoablation system (POLARx) with unique features has been made available for clinical use. To date, no data exist on procedural characteristics of this system in a multicentric clinical practice. Purpose We aimed to characterize the initial experience of this technology in the Italian clinical practice. Methods Consecutive patients (pts) undergoing AF ablation from the CHARISMA registry at 5 Italian centres were included. Protocol-directed cryoablation was delivered for 180 sec or 240 sec according to operator’s preference for isolation achieved in ≤60 sec, or 240 sec if isolation occurred >60 sec or when time to isolation (TTI) was not available. The ablation endpoint was PV isolation as assessed by entrance and exit block. Results Two-hundred sixty-two cryoapplications from 49 pts (194 PVs) were analyzed. PVI was achieved with cryoablation only in all pts. The mean number of freeze applications per pt was 5.3 ± 1.5 (1.3 ± 0.6 for LIPV, LSPV and RSPV, 1.6 ± 1.3 for RIPV), with 143 (73.7%) PVs treated in a single-shot fashion (38, 19.6% with 2 shots; 13, 6.7% with more than 2 shots). Sixteen (33%) pts were treated with a single freeze to each of the PVs. The mean nadir temperature was -55.5 ± 6.9 °C and was colder than -50°C in 83% of the PVs. TTI information was evaluable in 120 (46%) cryoapplications with a median TTI of 47 [32-75] sec (median temperature at TTI = -49 [-53 to -42] °C). The mean time to target -40 °C (TTT) was 30.1 ± 6.9 sec with a TTT < 60 sec achieved in 99.2% of the cryoapplications; the mean thaw time to 0 °C was 18.6 ± 5.8 sec (thaw time >15 sec in 70.3% of the cryoapplications). The mean PV occlusion grade (rank 1-4) was 3.6 ± 0.6 (grade 2 in 5.2% of the cases, grade 3 in 25.6% and grade 4 in 69.2%). No complications were observed at 30 days post-procedure. Conclusion In this first multicentric experience in a clinical practice setting, the novel cryo-balloon system proved to be safe and effective and resulted in a high proportion of successful single-freeze isolation. Cooling parameters seem to be slightly different from reference cryo-balloon technology.

Background Ventricular tachycardia (VT) is a life-threatening condition, which usually implies the need of an implantable cardioverter defibrillator in combination with antiarrhythmic drugs and catheter ablation. Stereotactic body radiotherapy (SBRT) represents a common form of therapy in oncology, which has emerged as a well-tolerated and promising alternative option for the treatment of refractory VT in patients with structural heart disease. Objective In the STRA-MI-VT trial, we will investigate as primary endpoints safety and efficacy of SBRT for the treatment of recurrent VT in patients not eligible for catheter ablation. Secondary aim will be to evaluate SBRT effects on global mortality, changes in heart function, and in the quality of life during follow-up. Methods This is a spontaneous, prospective, experimental (phase Ib/II), open-label study (NCT04066517); 15 patients with structural heart disease and intractable VT will be enrolled within a 2-year period. Advanced multimodal cardiac imaging preceding chest CT-simulation will serve to elaborate the treatment plan on different linear accelerators with target and organs-at-risk definition. SBRT will consist in a single radioablation session of 25 Gy. Follow-up will last up to 12 months. Conclusions We test the hypothesis that SBRT reduces the VT burden in a safe and effective way, leading to an improvement in quality of life and survival. If the results will be favorable, radioablation will turn into a potential alternative option for selected patients with an indication to VT ablation, based on the opportunity to treat ventricular arrhythmogenic substrates in a convenient and less-invasive manner.

Abstract Background Patients with acute cardiovascular disease admitted to the Intensive Cardiac Care Unit (ICCU), especially those with more severe critical illness, experiment agitation and delirium during hospitalization. Iatrogenic, environmental, or related to the severity of acute illness factors may concur to determine these two conditions. However, their epidemiological, clinical, and prognostic relevance in this specific clinical context are not well defined, yet. As a result, current recommendations on the evaluation and management of these complications are lacking. The aim of this prospective, multicenter, observational registry was to evaluate the incidence of agitation and delirium in patients admitted to the ICCU for an acute cardiac event, their in-hospital prognostic impact, and their treatment. Methods We enrolled consecutive patients with acute cardiovascular events in four Italian tertiary-care centers. Agitation levels were ranked from Richmond Assessment Sedation Scale (RASS), and the presence of delirium was detected by Confusion Assessment Method-Intensive Care Unit (CAM ICU) at least twice a day and in case of variation of the state of consciousness. The primary endpoint was the incidence of agitation and/or delirium. The secondary endpoints were: 1) the association between these complications and in-hospital outcome and 2) the therapies adopted for their management. Results Overall, 723 patients were included in the registry. Of them, 116 (16%) presented agitation and/or delirium during ICCU stay. Delirium subtypes were: 6% hypoactive, 64% hyperactive, and 30% mixed. Patients with agitation/delirium had worse in-hospital outcomes than patients without.. Indeed, they had a higher ICCU mortality (10% vs. 2%; P<0.001) and a higher rate of major complications: ventricular arrhythmias (26% vs. 12%; P<0.001), atrial fibrillation (29% vs. 15%; P<0.001), sepsis (15% vs. 9%; P=0.06), and bleeding (17% vs. 7%; P<0.001). Moreover, they were more frequently treated with mechanical procedures: invasive and non-invasive ventilation (58% vs. 18%; P<0.001), circulatory support (20% vs. 5%; P<0.001), continuous renal replacement therapy (6% vs. 1%; P<0.001). Finally, ICCU length of stay was longer (8 vs. 4 days; P<0.001). The drugs more likely used for agitation treatment were benzodiazepine (32%), dexmedetomidine (31%), opioids (10%), and antipsycotic drugs (1%). Delirium was mainly treated with dexmedetomidine (46%), benzodiazepine (23%), antipsycotic drugs (16%), and opioids (8%). Conclusions This study demonstrates that agitation and delirium are frequent complications also in the acute cardiac setting and are associated with poor in-hospital outcome. In this particular context, the treatment of choice and its possible impact on prognosis remain to be established. Funding Acknowledgement Type of funding source: Private hospital(s). Main funding source(s): Centro Cardiologico Monzino, IRCCS, MIlan, Italy.

Abstract Background Current arrhythmogenic right ventricular cardiomyopathy (ARVC) diagnostic criteria are mostly based on ventricle function and dimension. Previous studies have reported a significant overlap between ARVC and chronic myocarditis, at non-invasive assessment. Purpose Tto compare biopsy-proven ARVC and myocarditis patients, in order to identify clinical, imaging and invasive electroanatomic voltage mapping (EVM) differences between the two groups. Methods Patients with borderline diagnosis of ARVC or suspected myocarditis underwent compete assessment with cardiac magnetic resonance (CMR). All patients underwent endomyocardial biopsy (EMB) with targeted tissue sampling guided by EVM. All patients with an histological diagnosis of myocarditis or ARVC were included. Results 83 patients were included, divided into 35 (42.2%) ARVC and 48 (57.8%) myocarditis. Among ARVC patients, 25 (71.4%) had right dominant ARVC, 5 (14.3%) left dominant patter and 5 (14.3%) bi-ventricular involvement. Nine patients (23.1%) with suspected clinic diagnosis of ARVC before EMB, received and histological diagnosis of myocarditis. Two (5.7%) patients with suspected myocarditis were proven to have ARVC. When comparing patients with ARVC and patients with myocarditis, univariate analysis showed that age, sex, family history, arrhythmic disorders at presentation and ECG abnormalities were similar between the two groups (P>0.05 for all the variables). There was also no significant difference with regards to bi-ventricular function and dimension at CMR evaluation. More patients with myocarditis resulted positive at late gadolinium enhancement (LGE) evaluation, although non-significantly (P=0.082). Oedema was more frequently present in patients with myocarditis (P=0.01), while adipose tissue infiltration and segmental wall motion abnormalities were more often observed in patients with ARVC (P=0.002 and P<0.001 respectively). At EVM analysis, a significant greater number of patients had a pathological uni- and bi-polar EVM (P<0.05 in all cases) and the scar-area was greater in patients with ARVC: 18.8 vs 11.0 cmq (P=0.041). Conclusion(s) A significant number of patients who received a clinical diagnosis of Myocarditis or ARVC according to current guidelines, were subsequently reclassified after histological analysis. Patients with ARVC and myocarditis were not distinguishable on the basis of clinical features and ventricular function and dimensions. Conversely, tissue analysis with CMR demonstrated how patient with ARVC had less oedema, more adipose tissue infiltration and had more extensive scar at EVM evaluation. Funding Acknowledgement Type of funding source: None

Introduction. Few data exist about effectiveness of atrial fibrillation (AF) catheter ablation (CA) in athletes and feasibility of resuming vigorous exercise afterwards. Aims of our study were to analyze the efficacy and safety of AF CA in athletes, to compare AF CA outcomes in athletes vs Non-Athletes (NA) and to evaluate the feasibility of resuming vigorous exercise. We additionally analyze the outcome of patients that underwent concomitant cavo-tricuspid isthmus (CTI) CA. Methods and results. From January 2015 to October 2019, 38 athletes were retrospectively matched with 38 NA that underwent first time AF CA. After a median follow-up of 787 days, 62.5% of athletes were free from recurrences after one CA procedure and mostly without antiarrhythmic drugs (87%). Seven athletes underwent a redo procedure and all of them were then free of recurrences with an overall freedom from recurrences of 84%. No major complications were observed. After the first year of follow-up, athletes had a 48% reduced risk of recurrences than NA [adjusted hazard ratio (HR) on antiarrhythmic drugs, LA volume and AF subtype, HR 0.52]. Athletes that underwent also CTI ablation showed a positive trend in terms of freedom from recurrences (50% vs 21%). Most (72%) of the athletes resumed vigorous exercise after at least 3 months from the CA. Conclusion. AF CA is a safe and efficient therapeutic option in athletes and it should be considered instead of drugs to early resume competitive sport activity. Concomitant CTI ablation may have a favorable role.

Background: Atrial fibrillation (AF) is a frequent complication of acute myocardial infarction (AMI) and is associated with a worse prognosis. Patients with chronic kidney disease are more likely to develop AF. Whether the association between AF and glomerular filtration rate (GFR) is also true in AMI has never been investigated. Methods: We prospectively enrolled 2445 AMI patients. New-onset AF was recorded during hospitalization. Estimated GFR was estimated at admission, and patients were grouped according to their GFR (group 1 (n = 1887): GFR >60; group 2 (n = 492): GFR 60–30; group 3 (n = 66): GFR <30 mL/min/1.73 m2). The primary endpoint was AF incidence. In-hospital and long-term (median 5 years) mortality were secondary endpoints. Results: The AF incidence in the population was 10%, and it was 8%, 16%, 24% in groups 1, 2, 3, respectively (p < 0.0001). In the overall population, AF was associated with a higher in-hospital (5% vs. 1%; p < 0.0001) and long-term (34% vs. 13%; p < 0.0001) mortality. In each study group, in-hospital mortality was higher in AF patients (3.5% vs. 0.5%, 6.5% vs. 3.0%, 19% vs. 8%, respectively; p < 0.0001). A similar trend was observed for long-term mortality in three groups (20% vs. 9%, 51% vs. 24%, 81% vs. 50%; p < 0.0001). The higher risk of in-hospital and long-term mortality associated with AF in each group was confirmed after adjustment for major confounders. Conclusions: This study demonstrates that new-onset AF incidence during AMI, as well as the associated in-hospital and long-term mortality, increases in parallel with GFR reduction assessed at admission.

Abstract Background Myocarditis represents a common but often under-diagnosed disease, with a wide range of clinical presentations; diagnosis is often presumptive and a clear etiology leading to a specific therapeutic approach is usually not identified. Purpose To describe and assess disease etiology in a cohort of myocarditis patients (pts) with arrhythmic presentation undergoing an invasive diagnostic work-up. Methods All pts with myocarditis presenting with ventricular arrhythmias undergoing an electro-anatomical mapping (EAM) guided endo-myocardial biopsy (EMB) at our institution were enrolled. All enrolled pts also underwent cardiac magnetic resonance imaging (MRI) and an electrophysiological study (EPS). Demographics, arrhythmic presentation, MRI data, arrhythmic inducibility at EPS, EAM and EMB biopsy data were retrieved and analyzed. Molecular biology testing for cardio-tropic virus genome as well as leukocyte immunohistochemical typization were routinely performed on all EMB samples. Results Twenty-six pts were enrolled (85% male, 39±6 y.o.). Clinical presentation was an organized ventricular arrhythmia in 16 (62%) pts (n=3 non-sustained ventricular arrhythmia; n=9 sustained ventricular arrhythmia; n=4 ventricular fibrillation) while frequent (>10.000) premature ventricular complexes (PVCs) in the remaining 10 (38%) pts. MRI showed a late gadolinium enhancement (LGE) pattern consistent with myocarditis in all pts (35% left LGE; 65% right LGE). At the EPS, 10 (38%) pts showed inducibility for SVTs and underwent an intra-cardiac defibrillator (ICD) implant, while 4 (16%) more were implanted for secondary arrhythmic prevention. EAM was performed in 18 (70%), 6 (22%) and 2 (8%) pts in the right, left and in both ventricle respectively; in all cases, abnormal myocardial voltages were retrieved in the area showing LGE at MRI. Extensive myocardial scarring was detected in 7 (27%) pts. All EMB were performed without peri-procedural complications; inflammatory infiltrate and substrate alteration consistent with myocarditis were retrieved in 100% of the bioptic samples. Viral genome was identified in 13 (50%) samples (n=5 Human Herpes Virus 6; n=2 Parvovirus B 19; n=3 Adenovirus; n=1 Ebstein Barr Virus; n=1 Cytomegalovirus; n=1 Rhinovirus) and specific human immunoglobulin treatment was undergone by a single pt; eosinophilic infiltration was found in 2 (8%) patients; lymphocite invasion and auto-antibodies consistent with auto-immune myocarditis were detected in 2 (8%) patients and appropriate immunosuppressive therapy was started, while a myocardial band contraction pattern typical of toxic myocarditis was found in a single (4%) patient [Figure 1]. Different Myocarditis Etiology Rates Conclusion In our myocarditis cohort, EMB confirmed viruses to represented the first myocarditis etiological agent. Despite an invasive work-out, 31% of the cohort etiology still remains unclear.

Abstract Background Left-dominant arrhythmogenic cardiomyopathy (LDACM) represents an underdiagnosed subtype of the classical right-dominant ACM, with a fibro-fatty infiltration of the left ventricle ab disease initio. To date, ACM diagnosing criteria do not include any paradigm for LDACM and no shared consensus or position statement has been issued yet. Purpose To analyse the diagnostic work-up needed to reach a definite diagnosis in LDACM patients (pts). Methods All pts with a high clinical suspicion of ACM admitted at our institution were evaluated. Disease and familiar history, and both baseline ECG and cardiac ultrasound (US) were retrieved in all pts. Before invasive evaluation, all pts underwent cardiac magnetic resonance imaging (MRI) for morphology assessment and tissue characterization by late gadolinium enhancement (LGE). An invasive evaluation with an electrophysiological study (EPS) and an endo-cavitary electro-anatomical mapping (EAM) was then subsequently performed; EAM-guided endo-myocardial biopsy (EMB) was performed at physician discretion, for direct histological evaluation of myocardial substrate. Results 30 ACM pts (53±6 y.o.; 66% male) were defined as LDACM; 22 (73%) pts presented unspecific ECG abnormalities, with 8 (27%) pts instead presenting negative t-waves in V4-V6. Cardiac US resulted unremarkable in 27 (90%) pts. Sustained ventricular arrhythmia with right bundle brunch block were experienced in 4 (14%) pts, while frequent premature ventricular beats with the same morphology in 10 (33%). LDACM diagnosis was mainly suspected upon MRI evaluation: all 30 pts presented a late gadolinium enhancement (LGE) pattern revealing an isolate left ventricle fibro-fatty infiltration, with normal biventricular contractility (LV and RV ejection fraction 57±9% and 53±2%, respectively). Right ventricular, left ventricular and biventricular endo-cavitary EAM was performed in 10 (33%), 11 (37%) and 9 (30%) pts respectively, revealing pathologically low unipolar voltages in 7 (23%) and both unipolar and bipolar low voltages in 15 (50%) pts. In 18 (60%) pts an EMB was performed, revealing in 15 (83%) a fibro-fatty infiltrate and a fibro-fatty infiltrated with a superimposed viral myocarditis in a single pt. Genetic testing was performed in 16 (53%) pts, of which 10 (33%) showed causative mutation of desmosomal genes. If strictly adhering to the existing criteria, only 7 (23%) LDACM definite diagnosis would have been reached, even when using EMB and genetic testing. LDACM EAM with late potentials Conclusion LDACM is an underestimated ACM subtype that require MRI evaluation and an invasive work-up for definite diagnosis. Although EMB and genetic testing being the most effective diagnostic tools currently at disposal adhering to existing criteria, a definite diagnosis could be reached only in a fraction of patient population. Existing diagnostic criteria should be revised, mainly to take in consideration EAM specific role and to properly define the LDACM entity.