Background: Atrial arrhythmias represent a frequent long-term complication in patients with atrial septal defects (ASDs). Interatrial block (IAB), reflecting delayed or impaired conduction across Bachmann's bundle, has been proposed as an electrophysiological substrate predisposing to atrial arrhythmogenesis. However, evidence regarding its prevalence and clinical correlates in pediatric patients with ASD remains limited. The present study aimed to characterize interatrial conduction patterns and assess the occurrence of IAB in children with large secundum ASD undergoing percutaneous closure. Methods: Between January 2020 and March 2024, 37 consecutive pediatric patients (median age 6 years, range 5-11) with large ostium secundum ASD were included in a retrospective analysis of a prospectively maintained institutional database. Standard 12-lead electrocardiograms were recorded before and within 24 h after defect closure. P-wave morphology and duration were systematically analyzed, and IAB was classified according to the Bayés de Luna criteria. Results: The median Qp/Qs ratio was 1.69 (1.32-2.24), with a mean pulmonary artery pressure of 19 mmHg (17-22). IAB was identified in 24.3% of patients before the procedure, predominantly as first-degree IAB. Following device implantation, IAB prevalence (29.7%) and P-wave parameters remained unchanged, with no significant differences compared with baseline. No associations were observed between IAB and defect size, hemodynamic burden, or device characteristics, whereas anthropometric variables, including weight, height, and body surface area, showed a significant correlation with IAB occurrence. During a median follow-up of 199 days, no atrial arrhythmias were documented. Conclusions: In this pediatric cohort with large ASD, IAB was present in approximately one quarter of patients and appeared unrelated to anatomical or procedural factors, supporting the hypothesis of an underlying congenital conduction abnormality. Early recognition of IAB may therefore have implications for long-term arrhythmic risk stratification in this population.

AIMS:Cryoballoon pulmonary vein isolation (CB-PVI) has become an established treatment for atrial fibrillation and, recently, it has been proposed as first-line therapy for the treatment of paroxysmal atrial fibrillation. Nevertheless, some concerns remain regarding the safety of this thermal energy-based approach. This prospective analysis aimed to assess the procedural complication rate of CB-PVI in a large cohort of consecutive patients over a nearly 13-year period. METHODS:Data from consecutive patients treated with CB-PVI for atrial fibrillation between April 2012 and November 2024 in 35 institutions were analyzed. All complications occurring from patient admission up to 3 months postprocedure were recorded. RESULTS:Eight thousand five hundred and thirty-one patients were enrolled (27.2% women, mean age 60.8 ± 10.5 years, 75.7% with paroxysmal atrial fibrillation), and 211 of them (2.49%) experienced at least one procedural adverse event related to CB-PVI. Of note, one cardiac tamponade event led to a sudden cardiovascular death (0.01%). A statistically significant reduction in complication rates was observed amongst three cohorts of product usage: from 2012 to 2015 ( n  = 1326 patients, 5.0%), from 2016 to 2019 ( n  = 3487 patients, 2.5%), and from 2020 to 2024 ( n  = 3718 patients, 1.6%; P  < 0.001). Multivariate logistic regression analysis identified use of the Arctic Front Advance PRO balloon as a significant protective factor against complications [OR 0.26 (0.17-0.40), P  < 0.001], whereas female sex emerged as the strongest predictor of adverse events [OR 1.54 (1.11-2.13), P  < 0.01]. CONCLUSION:CB-PVI for atrial fibrillation ablation has proven to be a well tolerated procedure, with a steadily decreasing complication rate over time.

The vein of Marshall (VoM) is a promising therapeutic target for persistent atrial fibrillation (PeAF) treatment. Ethanol infusion into the VoM (VoM-EI) has demonstrated high effectiveness in facilitating mitral isthmus (MI) block, a fundamental part of the anatomical ablation setup for the treatment of PeAF. However, reliable indexes for optimal ethanol delivery are still lacking, and the role of voltage analysis after VoM-EI in predicting MI block has been poorly explored. To evaluate the role of voltage analysis after VoM-EI in predicting acute bidirectional MI block and the need of coronary sinus (CS) radiofrequency (RF) applications. Fifty-three PeAF patients who underwent catheter ablation were retrospectively enrolled. Left atrial (LA) high-density bipolar voltage mapping was performed before and after VoM-EI. Low voltage areas (LVA) were assessed for all LA maps using the area measurement tool, and the difference in area width between pre- and post-VoM-EI was defined as ∆LVA. An anatomical lesion set including VoM-EI, pulmonary vein isolation (PVI) and linear lesion for dome, lateral MI, and cavo-tricuspid isthmus (CTI) was performed. In case of residual conduction across MI, additional endocardial and/or epicardial ablations approaching the CS musculature were performed. The time required to achieve bidirectional MI block (AblTime-MI) was collected and the VoM length was measured. Forty-eight out of 53 patients enrolled (90.5

Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF) [1], but for persistent AF PVI appears to be suboptimal and any kind of additional lesion has been proven to not enhance the efficacy of the ablation [2-3]. In this setting, the Vein of Marshall ethanol infusion (VOM-EI) has shown to improve the efficacy of AF ablation as compared to PVI [4]. In all previous studies VOM-EI and AF ablation were different step of the same procedure [5]. Nevertheless, performing voltage map right after the VOM-EI could lead to an overestimation of ethanol-induced scar due to the possibility of certain amount of reversible oedema. For that reason, we started performing VOM ethanol infusion in day surgery setting one month before the ablation procedure, demonstrating that VOM-EI related scar is indeed smaller as compared to conventional procedure. To evaluate safety, efficacy and feasibility of single day discharge VOM-EI. All patients referred for de novo ablation of persistent AF have been enrolled. In day 0 VOM-EI was performed according to previously described method (5) but by echo-guided left axillary vein access. Ethanol infusion was considered successful if repeat angiograms between the 3 injections showed: stability of the angioplasty balloon; visualization of the distal VOM arborization; absence of contrast leakage back in the coronary sinus; absence or limited dissection of the VOM; and progressive appearance of tissue contrast staining (tattoo). Mean procedure time was 39,1±7,8 min and X-Ray time was 4,2±0,9 min. At least 30 days after ablation procedure was performed using The Bordeaux group protocol (PVI, ridge and saddle, posteriors box, mitral isthmus and cavo-tricuspid isthmus). We compared our data with previously published 700 patients cohort [5] We enrolled 63 patients (81% male, 67±7.6 years old). Analyzing the safety, rate of failure and feasibility of the procedure we demonstrated that single day discharge is comparable to ordinary setting for VOM-EI. Failure rate was 19% (6% due to non-identification of VOM, 13% due to VOM dissection), peri-operative complication rate was 3.2%: notably there were only pericarditis without neither significant pericardial effusion nor cardiac tamponade (which was 1% in Kamakura cohort). This would probably be related to the absence of heparin treatment which is needed for the ablation procedure protocol in the conventional procedure. These preliminary data shows that VOM-EI in day surgery is feasible and very promising in terms of safety. It would be also theoretically more effective in improving long term efficacy of AF ablation but this needs to be addressed in specific trial.Map of the Scar Complications and failures

Procedural strategy for repeated ablation in persistent atrial fibrillation (PeAF) patients is a great challenge, especially in patients with already isolated pulmonary veins (PVs). Vein of Marshall ethanol infusion (VOM–EI) is a promising but poorly investigated approach for PeAF treatment. In this prospective observational study, we analysed PeAF patients undergoing repeated AF ablation with VOM–EI and a standardized anatomical ablation setup. We aimed to evaluate the outcome of this procedural setup based on the previous ablation strategy. 39 PeAF patients were scheduled for repeated ablation, classified by AF type into early PeAF (≤3 months), PeAF (3–12 months), and long–lasting PeAF (›12 months). Based on prior ablation strategy, patients were grouped into PVI or PVI+ (PVs isolation only vs combined with linear lesions and/or CFAEs abolition). We applied a systematic anatomical ablation setup. After VOM–EI (Figure 3), eventual PVI reconnections were targeted. Bidirectional block across prior ablation lines was assessed and touch–up ablation performed if needed. Ablation of the Left Atrial dome, lateral Mitral Isthmus, and cavo–tricuspid isthmus line were sistematically performed and validated. Antiarrhythmic drugs were ceased after 1 month. The primary endpoint was AT/AF recurrences lasting ›30 seconds. Kaplan–Meier analysis with Log Rank test and Cox regression analysis evaluated recurrence based on prior ablation setup and AF phenotype (Figure 1). 39 PeAF patients were analysed, 26/39 (67%) were PVI and 13/39 (33%) were PVI+. In accordance with AF duration, 11 patients (27%), 10 (27%) and 18 (46%) were respectively classified as early PeAF, PeAF and long–lasting PeAF. Mean follow–up (FU) was 14.4±7.5 months. 8/39 patients (21%) had recurrence of AF/AT during FU. Recurrences occurred in 5/26 (19%) PVI patients and 3/13 (23%) PVI+ ones (p=0.76). Univariate analysis shows PVs reconnection and long–standing AF as significant determinants of arrhythmic recurrences (p=0.05 and p=0.04). PVI reconnection, especially in the PVI group, was associated with arrhythmias–free outcome (p=0.006) (Figure 2). Regardless of previous procedural setup, VOM–EI in addition to PVI and anatomical scheme validation represents a valid option in repeated ablation for PeAF patients. Patients with PVI reconnection showed a better outcome compared to those with PVI already obtained. Long–lasting PeAF patients had worse outcome.Figure 1 Figure 2 Figure 3

The optimal ablation treatment for persistent atrial fibrillation (PeAF) patients is still debated. The vein of Marshall ethanol infusion (VOM–EI) seems to be a good option but more data need. The aim of our study is to evaluate the incidence of AF recurrences in a PeAF population treated with a standard ablation approach consisting of VOM–EI combined with a linear set of ablation lesions. Consecutive patients undergoing the first ablation procedure of catheter ablation (CA) for PeAF were enrolled. All patients underwent VOM–EI, pulmonary vein isolation, a left atrial (LA) roofline (validated by pacing), mitral line (guided by the newly formed lesion after alcohol infusion into the VOM and validated by pacing from LA appendage) and cavotricuspid isthmus line. LA voltage mapping before and after VOM–EI was also performed (Figure 1). Eighty–four consecutive patients affected by PeAF were included in this study. In 8 patients (9%) VOM–EI was not performed because of the absence of VOM. Seventy–three patients (65 ± 8 years and 78% male) underwent VOM–EI. PV isolation and lines were validated in all subjects. The VOM–EI procedural time is 20 ± 9.6 min. The ML block was achieved in 65 (89%) patients in a mean time of within 7.3 ± 6.9 min. One (1%) cardiac tamponade and three (4%) pericarditis occurred. At a mean follow–up of 12 ± 8 months, 61 out of 73 (83%) patients remained free from AT/AF recurrences after a blanking period of 2 months. Nine patients (12%) needs electrical cardioversion. Three patients (4.1%) underwent REDO ablation. At the end follow–up 69 (94%) patients maintained sinus rhythm. At univariate analysis long persistent AF (›12 months) was the only predictor of recurrences (p=0.023) (Figure 2). In our experience VOM–EI systematically combined with an anatomical ablation set was safe and effective in maintaining sinus rhythm in patients with PeAF, in particular in patients with AF ‹ 12 months.Figure 1 Figure 2

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

Brugada syndrome (BrS) is diagnosed in the presence of a 2mm ST-segment coved-type elevation; a type-1 phenotype after drug test (using a class I antiarrhythmic drug) is diagnostic only in the presence of additional clinical criteria. The endocardial electroanatomical differences between spontaneous and drug-induced phenotype have been scarcely investigated. To evaluate the differences in depolarization, repolarization and voltage detected by endocardial unipolar right ventricular (RV) mapping between Brugada patients with a spontaneous type-1 pattern and ajmaline-induced pattern. Data from endocardial mapping with the CARTO3 system of 20 BrS with spontaneous type-1 pattern (S-BrS) and 13 BrS undergoing ajmaline test (A-BrS) were retrospectively analysed. A-BrS had a history of spontaneous type-1 but did not present it at baseline at the time of the study; mapping in this cohort was performed after ajmaline-induced type-1 ECG was evident. Data was exported from CARTO and converted into MATLAB format using OpenEP; a region of interest (ROI) including sub-pulmonary RV outflow tract (RVOT) and RV free wall was selected using Paraview. Depolarization was assessed using RV activation time (RVAT), time difference between beginning of surface depolarization and minimum -dV/dt of the latest depolarizing point in RVOT. By dividing RVAT color scale in 5 ms steps (isoSteps), isochronal activation areas were identified. Repolarization was evaluated in each point of the ROI using activation recovery intervals, calculated with a semi-automated algorithm based on the Wyatt method and corrected for heart rate using Bazett formula (ARIc). ARIc values were interpolated to create ARIc maps. Low voltage areas (LVAs) were defined as areas in the ROI with unipolar voltage <5.3 mV. A-BrS tended to have shorter RVAT and less isoSteps compared to S-BrS, but the differences were not significant (respectively 101[22.5] ms with 10 isoSteps vs 111[44.3] ms with 14 isoSteps; p=0.58). Interestingly, A-BrS had significantly longer ARIc in comparison to S-BrS (332.6±16.6 ms vs 307.0± 6.8 ms; p<0.001). Unipolar LVAs were present in 12 A-BrS (92%) and in 17 S-BrS (85%). Considering patients with LVAs, there were no differences between A-BrS and S-BrS (6.8[5.1] cm2 vs 8.2[13.7] cm2; p=0.80). Ajmaline-induced type-1 phenotype is associated with significantly prolonged endocardial repolarization compared to spontaneous type-1 phenotype in Brugada patients. Using endocardial mapping, no significant differences between these two groups were observed regarding depolarization and voltage. Such results, which need to be confirmed on larger cohorts, could impact both research designs and clinical management of BrS.Methods Results

BACKGROUND:Cryoballoon pulmonary vein isolation has become an established treatment for atrial fibrillation (AF). However, data on long-term outcomes beyond 5 years are scarce. This prospective analysis aimed to evaluate the long-term outcome after cryoballoon pulmonary vein isolation. METHODS:Data from consecutive patients treated with cryoballoon pulmonary vein isolation for symptomatic AF between 2012 and 2018 in 13 institutions were analyzed. Patients with ≥5-year follow-up after the index procedure were included. Arrhythmia recurrence was defined as AF or atrial tachycardia lasting >30 seconds beyond a 3-month blanking period. RESULTS:A total of 1330 patients were enrolled (28.4% female patients, mean age was 60.1±10.5 years). Patients with paroxysmal AF accounted for 73.1%; the median history of AF was 36.0 (13.0-75.0) months. The rate of AF/atrial tachycardia recurrences progressively increased over time (event rate: 52.5% [49.4%-55.8%] at 8-year follow-up). A low incidence of progression to permanent AF was seen in the entire cohort (7.0%). Importantly, 15.7% of patients underwent a redo ablation for AF during follow-up; in 45.9% of these cases, all PVs were isolated at the redo procedure, with a median number of PVs isolated after the index procedure being 3 (1-4) veins. Independent predictors of arrhythmia recurrences were AF type (persistent AF: hazard ratio, 1.36 [95% CI, 1.14-1.62]; P<0.001) and chronic kidney disease (hazard ratio, 1.77 [95% CI, 1.12-2.81]; P=0.016) in multivariate analysis. CONCLUSIONS:Cryoballoon pulmonary vein isolation as the index procedure for AF ablation resulted in a favorable long-term outcome in patients with symptomatic AF, with limited progression towards permanent AF during follow-up. Persistent AF was the strongest predictor of recurrences at long-term follow-up.

Repolarization hypothesis states that a transmural repolarization dispersion in right ventricular outflow tract (RVOT) determines type-1 ECG phenotype in Brugada syndrome (BrS). So far only few evidences support it, whilst depolarization impairment has been widely described. To investigate the changes in depolarization mapping through endocardial unipolar J-elevation mapping of RVOT in BrS patients and in controls undergoing ajmaline and their relations with activation time (AT), marker of local depolarization. Consecutive BrS patients with spontaneous type-1 ECG pattern and controls underwent RV endocardial mapping with the CARTO3 system. Mapping in both groups was performed before (pre) and after (post) ajmaline administration as none expressed a baseline type-1 ECG pattern. Data were exported and converted into Matlab format using OpenEP. J-elevation for each point was calculated as the amplitude in mV of the unipolar signal at J-point from zero-line. For each point AT was defined as the difference between local depolarization (minimum -dV/dt of the unipolar signal) and surface ECG depolarization (minimum of V2). Corresponding pre and post points were selected; patients having <200 corresponding points were discarded. In each patient, pre and post AT and J-elevation maps were created; a region of interest (ROI) covering the RVOT was selected based on the tricuspid valve position. For each ROI point delta-J and delta-AT were calculated as the difference between post and pre, and interpolated to obtain RVOT differential maps. A point-by-point correlation analysis was performed between delta-J and delta-AT. A maximum and a minimum variation area (ROImax and ROImin, respectively) within RVOT were identified for both delta-J and delta-AT. 24 BrS patients and 2 controls were included (1092±633 average corresponding points); all BrS patients presented type-1 ECG after ajmaline, while no control did. Examples of RV maps, ROI selection and RVOT pre, post and differential maps can be seen in Figure 1. In BrS, ROImax delta-J was significantly higher with respect to ROImin (1.68 vs 0.6 mV, p<0.001) while delta-AT ROImax was significantly longer compared to delta-AT ROImin (24.1 vs 8.72 ms, p=0.004). In controls no differences between ROImax and ROImin were observed for delta-J, nor for delta-AT. (Figure 2). In BrS population, a point-by-point correlation between delta-J and delta-AT was present in patient BrS4 (Pearson R coefficient=0.61, p<0.001) and in patient BrS20 (R=0.53, p> 0.001). Localized repolarization and depolarization abnormalities in the RVOT are typically found in BrS patients but not in controls. High-density unipolar endocardial mapping pre and post-ajmaline unveils the critical electrophysiological substrate unmasking local repolarization and depolarization dispersion area. In BrS, higher repolarization dispersion area, located in the RVOT, correlates to slow-conducting zones.Methods Results

INTRODUCTION:Vein of Marshall ethanol infusion (VOM-EI) in patients with Atrial Fibrillation (AFib) triggers local injury, which may increase the subsequent radiofrequency catheter ablation (RFCA) success rate in persistent atrial fibrillation (PeAF). The long-term durability of VOM-EI induced low-voltage area (LVA), might condition the success of RFCA after VOM-EI. We hypothesized that the amount of LVA after VOM-EI decreases over time. METHODS:Consecutive patients with recurrent PeAF and no history of previous ablation were enrolled in this prospective, center-cluster, case-control study. In the experimental group, RFCA was performed 1 month after VOM-EI. In the control group, VOM-EI and RFCA were performed concomitantly. The primary endpoint was the bipolar VOM-EI LVA measured immediately prior to RFCA. RESULTS:We studied 80 consecutive patients who met the inclusion criteria. The two groups did not differ in baseline characteristics. The mean bipolar VOM-EI-LVA measured before RFCA was significantly smaller in the 40 patients who underwent VOM-EI 1 month earlier than in the group of 40 patients who underwent the standard procedure (2.6 ± 2.4 vs. 10.0 ± 7.0 cm2, p = 0.012). At a mean follow-up of 19.6 ± 7.3 months, freedom from AF/AT recurrences was promisingly higher in the investigational group compared to the control group (90.0% vs. 82.5%). CONCLUSION:These data suggest that the endocardial newly-formed lesion induced by VOM-EI decreases over time, probably due to progressive resolution of perilesional oedema. These results merit larger studies testing the hypothesis that postponing RFCA 1 month after VOM-EI may increase its effectiveness in terms of fewer recurrences of atrial fibrillation.

BACKGROUND:D-transposition of the great arteries is a complex congenital heart disease characterized by discordant ventriculoarterial connections. Surgical reconstruction of the right ventricular outflow tract with prosthetic material may create anatomic isthmuses that sustain ventricular tachycardia (VT). CASE SUMMARY:A patient with a history of D-transposition of the great arteries, corrected with the Réparation à l'Etage Ventriculaire procedure, underwent VT ablation for out-of-hospital cardiac arrest via single jugular access. VT mapped at the anatomic isthmus between the neo-pulmonary valve and the right ventricular septal patch effectively rendered VT noninducible despite aggressive stimulation protocols and isoproterenol infusion. Stenotic right ventricular outflow tract revalving was performed after the ablation procedure. DISCUSSION:In the literature, no case reports are available on transcatheter ablation of VT after the Réparation à l'Etage Ventriculaire procedure. This case raises the question of whether patients with congenital heart defects other than tetralogy of Fallot should undergo a prophylactic electrophysiological study. TAKE-HOME MESSAGES:Similarities among different congenital defects may prompt preoperative electrophysiological evaluation. outflow.

Background Mitral isthmus (MI) conduction block is a fundamental step in anatomical approach treatment for persistent atrial fibrillation (PeAF). However, MI block is hardly achievable with endocardial ablation only. Retrograde ethanol infusion (EI) into the vein of Marshall (VOM) facilitates MI block. Fluorographic myocardial staining (MS) during VOM-EI could be helpful in predicting procedural alcoholization outcome even if its role is qualitatively assessed in the routine. The aim was to quantitatively assess MS during VOM-EI and to evaluate its association with MI block achievement. Methods Consecutive patients undergoing catheter ablation for PeAF at Fondazione Toscana Gabriele Monasterio (Pisa, Italy) from February 2022 to May 2023 were considered. Patients with identifiable VOM were included. A proposed index of MS (MSI) was retrospectively calculated in each included patient. Correlation of MSI with low-voltage zones (LVZ) extension after VOM-EI and its association with MI block achievement were assessed. Results In total, 42 patients out of 49 (85.8%) had an identifiable VOM. MI block was successfully achieved in 35 patients out of 42 (83.3%). MSI was significantly associated with the occurrence of MI block (OR 1.24 (1.03–1.48); p = 0.022). A higher MSI resulted in reduced ablation time ( p = 0.014) and reduced radiofrequency applications ( p = 0.002) to obtain MI block. MSI was also associated with MI block obtained by endocardial ablation only (OR 1.07 (1.02–1.13); p = 0.002). MSI was highly correlated with newly formed LVZ extension ( r = 0.776; p = 0.001). Conclusions In our study cohort, optimal MSI predicts MI block and facilitates its achievement with endocardial ablation only.

INTRODUCTION:Repolarization dispersion in the right ventricular outflow tract (RVOT) contributes to the type-1 electrocardiographic (ECG) phenotype of Brugada syndrome (BrS), while data on the significance and feasibility of mapping repolarization dispersion in BrS patients are scarce. Moreover, the role of endocardial repolarization dispersion in BrS is poorly investigated. We aimed to assess endocardial repolarization patterns through an automated calculation of activation recovery interval (ARI) estimated on unipolar electrograms (UEGs) in spontaneous type-1 BrS patients and controls; we also investigated the relation between ARI and right ventricle activation time (RVAT), and T-wave peak-to-end interval (Tpe) in BrS patients. METHODS:Patients underwent endocardial high-density electroanatomical mapping (HDEAM); BrS showing an overt type-1 ECG were defined as OType1, while those without (latent type-1 ECG and LType1) received ajmaline infusion. BrS patients only underwent programmed ventricular stimulation (PVS). Data were elaborated to obtain ARI corrected with the Bazett formula (ARIc), while RVAT was derived from activation maps. RESULTS:39 BrS subjects (24 OType1 and 15 LTtype1) and 4 controls were enrolled. OType1 and post-ajmaline LType1 showed longer mean ARIc than controls (306 ± 27.3 ms and 333.3 ± 16.3 ms vs. 281.7 ± 10.3 ms, p = .05 and p < .001, respectively). Ajmaline induced a significant prolongation of ARIc compared to pre-ajmaline LTtype1 (333.3 ± 16.3 vs. 303.4 ± 20.7 ms, p < .001) and OType1 (306 ± 27.3 ms, p < .001). In patients with type-1 ECG (OTtype1 and post-ajmaline LType1) ARIc correlated with RVAT (r = .34, p = .04) and Tpec (r = .60, p < .001), especially in OType1 subjects (r = .55, p = .008 and r = .65 p < .001, respectively). CONCLUSION:ARIc mapping demonstrates increased endocardial repolarization dispersion in RVOT in BrS. Endocardial ARIc positively correlates with RVAT and Tpec, especially in OType1.

AbstractAimsTo investigate the prognostic significance of heterogeneity in the refractoriness of right ventricular (RV) outflow tract (RVOT) and RV apex at the electrophysiological study (EPS) in Brugada syndrome (BrS).Methods and resultsA cohort of BrS patients (primary prevention) from five Italian centres was retrospectively analysed. Patients with spontaneous or drug-induced Type-1 electrocardiogram (ECG) + symptoms were offered an EPS for prognostic stratification. The primary endpoint was a composite of sudden cardiac death (SCD), resuscitated cardiac arrest, or appropriate intervention by the implantable cardioverter-defibrillator (ICD). Three hundred and seventy-two patients with BrS were evaluated (44 ± 15 years, 69% males, 23% with ICD): 4 SCDs and 17 ICD interventions occurred at follow-up (median 48, interquartile range: 36–60 months). Family history of SCD, syncope, and a spontaneous Type-1 ECG pattern were univariate predictors of the primary endpoint in the whole population. In patients undergoing EPS (n = 198, 53%, 44 ± 12 years, 71% males, 39% with ICD), 3 SCD and 15 ICD interventions occurred at follow-up. In this subset, the primary endpoint was not only predicted by ventricular tachycardia/fibrillation inducibility but also by a difference in the refractory period between RVOT and RV apex (ΔRPRVOT-apex) >60 ms. ΔRPRVOT-apex > 60 ms remained an independent predictor of SCD/ICD shock at bivariate analysis, even when adjusted for the other univariate predictors, showing the highest predictive power at C-statistic analysis (0.75, 95% confidence interval 0.63–0.86).ConclusionsHeterogeneity of RV refractory periods is a strong, independent predictor of life-threatening arrhythmias in BrS patients, beyond VT/VF inducibility at EPS and common clinical predictors.

Background: The best ablation treatment for persistent atrial fibrillation (PeAF) patients is still debated. The vein of Marshall (VOM) seems to be a promising target for ablation and could be combined with a linear set of ablation lesions. The aim of our study is to evaluate the incidence of AF recurrences in a PeAF population treated with a comprehensive ablation approach consisting of VOM ethanol infusion (EI), pulmonary vein isolation (PVI), a left atrial (LA) roofline, a mitral line (guided by the newly formed lesion after alcohol infusion into the VOM and validated by pacing), and a cavotricuspid isthmus line. Methods: Consecutive patients undergoing the first ablation procedure of catheter ablation (CA) for PeAF were enrolled. All patients underwent VOM-EI, PVI, and ablation lines along the roof of the LA, mitral, and cavotricuspid isthmus. LA voltage mapping before and after VOM-EI was also performed. An implantable loop recorder (ILR) was implanted at the end of the ablation in each patient. Results: Thirty-one consecutive patients (66 ± 8 years and 71% male) affected by PeAF were included in this study. The VOM-EI procedural phase lasted 21.4 ± 10.1 min. PV isolation and lines were validated in all subjects. The ML block was achieved within 10.8 ± 8.7 min. At a mean follow-up of 12 ± 7 months, 27 out of 31 (87%) patients remained free from AT/AF recurrences. Among the patients with recurrences, two (50%) had incomplete ablation lesions and three (75%) had “suboptimal” VOM-EI. In 23/31 patients (74%), antiarrhythmic drugs (AADs) were discontinued after 1 month of follow-up. No significant complications were reported during the follow-up. Conclusions: this single-center experience demonstrates that VOM-EI systematically combined with an anatomical ablation set in patients with PeAF resulted in feasible, safe, and effective freedom from AF/AT recurrences in 87% of the population after a 1-year follow-up period according to an ILR.

The subcutaneous implantable cardioverter-defibrillator (S-ICD) is a new technology for the management of ICD patients. But what is the patients' perspective? Previous studies on the transvenous ICD (TV-ICD) showed that device implantation is related not only to anxiety and depression because of the fear of ICD shocks, but also to many biopsychosocial factors like body image changes, perceived reduction of socialization and limitation in professional and sports activities. Anxiety and distress are more evident in younger women because of aesthetic reasons. The scar size and the position of the S-ICD can help these patients and positively influence their social relationships. Moreover, the position of the S-ICD reduces possible complications from catheters due to stress injury and can improve patients' professional life by avoiding some work activity limitations. An S-ICD can be also a good option for athletes in avoiding subclavian crash and reducing inappropriate shocks. However, some questions remain unsolved because an S-ICD is not suitable for patients with indications for pacing, cardiac resynchronization therapy or anti-tachycardia pacing. In conclusion, the use of an S-ICD can assist physicians in reducing the negative impact of implantation on the well-being of some groups of patients by helping them to avoid depression and anxiety as well as improving their noncompliance with their medical treatment.