Pulsed-field ablation of pulmonary vein and left atrial posterior wall combined with left atrial appendage occlusion as single procedure

Pulmonary vein isolation and left atrial posterior wall ablation using the Farapulse system, followed by left atrial appendage occlusion, have been achieved as single combined procedure to treat long-standing persistent atrial fibrillation in a patient at high hemorrhagic risk.

A real-world multicenter study on left atrial appendage occlusion: The Italian multi-device experience

Background

Transcatheter left atrial appendage occlusion (LAAO) has emerged as an alternative treatment for stroke prevention in patients with atrial fibrillation (AF) at high risk of thromboembolism, who cannot tolerate long-term oral anticoagulation (OAC). Questions persist regarding effectiveness and safety of this treatment and the optimal post-interventional antithrombotic regimen after LAAO.

Methods

We retrospectively gathered data from 428 patients who underwent percutaneous LAAO in 6 Italian high-volume centres, aimed at describing the real-world utilization, safety, and effectiveness of LAAO procedures, also assessing the clinical outcomes associated with different antithrombotic strategies.

Results

Among the entire population, 20 (4.7 %) patients experienced a combination of pericardial effusion and periprocedural major bleeding: 8 (1.9 %) pericardial effusion, 1 (0.3 %) fatal bleeding, and 3 (0.7 %) non-fatal procedural major bleeding. Patients were discharged with different antithrombotic regimens: dual (DAPT) (27 %) or single (SAPT) (26 %) antiplatelet therapy, OAC (27 %), other antithrombotic regimens (14 %). Very few patients were not prescribed with antithrombotic drugs (6 %). At a medium 523 ± 58 days follow-up, 14 patients (3.3 %) experienced all-cause death, 6 patients (1.4 %) cardiovascular death, 3 patients (0.7 %) major bleeding, 10 patients (2.6 %) clinically relevant non-major bleeding, and 3 patients (0.7 %) ischemic stroke. At survival analysis, with DAPT as the reference group, OAC therapy was associated with better outcomes.

Conclusions

Our findings confirm that LAAO is a safe procedure. Different individualized post-discharge antithrombotic regimens are now adopted, likely driven by the perceived thrombotic and hemorrhagic risk. The incidence of both ischemic and bleeding events tends to be low.

Pulsed field ablation technology for pulmonary vein and left atrial posterior wall isolation in patients with persistent atrial fibrillation

INTRODUCTION

Limited data exist on pulsed-field ablation (PFA) in patients with persistent atrial fibrillation (PeAF) undergoing left atrial posterior wall isolation (LAPWI).

METHODS

The Advanced TecHnologies For SuccEssful AblatioN of AF in Clinical Practice (ATHENA) prospective registry included consecutive patients referred for PeAF catheter ablation at 9 Italian centers, treated with the FARAPULSETM-PFA system. The primary efficacy and safety study endpoints were the acute LAPWI rate, freedom from arrhythmic recurrences and the incidence of major periprocedural complications. Patients undergoing pulmonary vein isolation (PVI) alone, PWI + LAPWI and redo procedures were compared.

RESULTS

Among 249 patients, 21.7% had long-standing PeAF, 79.5% were male; mean age was 63 ± 9 years. LAPWI was performed in 57.6% of cases, with 15.3% being redo procedures. Median skin-to-skin times (PVI-only 68 [60-90] vs. PVI + LAPWI 70 [59-88] mins) did not differ between groups. 45.8% LAPWI cases were approached with a 3D-mapping system, and 37.3% with intracardiac echocardiography. LAPWI was achieved in all patients by means of PFA alone, in 88.8% cases at first pass. LAPWI was validated either by an Ultrahigh-density mapping system or by recording electrical activity + pacing maneuvers. No major complications occurred, while 2.4% minor complications were detected. During a median follow-up of 273 [191-379] days, 41 patients (16.5%) experienced an arrhythmic recurrence after the 90-day blanking period, with a mean time to recurrence of 223 ± 100 days and no differences among ablation strategies.

CONCLUSION

LAPWI with PFA demonstrates feasibility, rapidity, and safety in real-world practice, offering a viable alternative for PeAF patients. LAPWI is achievable even with a fluoroscopy-only method and does not significantly extend overall procedural times.

Early Clinical Outcomes and Advantages of a Novel-Size Adjustable Second-Generation Cryoballoon: A Proof-of-Concept Study

(1) Background/Objective Balloon-guided catheter ablation (CA) has emerged as an alternative option for atrial fibrillation (AF) management. The recent introduction of a novel-size adjustable second-generation cryoballoon (CB) system offers innovations, but clinical outcomes remain unexplored. This study aims to assess the acute performance of the POLARx FIT™ CB system in AFCA. (2) Methods: Consecutive patients undergoing AF ablation with the POLARx FIT™ CB system in our center were included. The primary outcome was the rate of 31 mm balloon-size utilization, with secondary outcomes including acute pulmonary vein isolation (PVI) rate, periprocedural complications, and in-hospital AF recurrences. (3) Results: Twenty-four patients with a mean age of 59.5 years, predominantly male (87.5%), and exhibiting paroxysmal AF (91.7%) were enrolled. Procedural characteristics demonstrated a high acute success rate (100% PV isolation) with a favorable safety profile. Notably, the 31 mm CB configuration was utilized in 51% of applications, showcasing its adaptability in challenging anatomies. No major complications occurred, with two patients experiencing in-hospital self-limiting AF recurrences. (4) Conclusions: This study represents the first comprehensive assessment of the POLARx FIT™ CB system in AF ablation. While acknowledging the study's limitations, this novel CB emerges as a promising tool, warranting further exploration in larger studies with extended follow-up periods.

Intracardiac echocardiography-guided pulsed-field ablation for successful ablation of atrial fibrillation: a propensity-matched analysis from a large nationwide multicenter experience

BACKGROUND

Intracardiac echocardiography (ICE) is increasingly employed in atrial fibrillation (AF) ablation procedures, with the potential to enhance procedural efficacy. Nevertheless, there is currently a lack of evidence assessing the impact of ICE on the efficiency, effectiveness, and safety outcomes in the context of novel pulsed-field ablation (PFA) for AF.

PURPOSE

We aimed to assess whether the use of ICE could improve procedural parameters in a large population undergoing AF ablation with FARAPULSE™ catheter.

METHODS

Consecutive patients who had undergone PFA of AF from nine Italian centers were included. In procedures where the ICE catheter was employed for guidance (ICE-guided group), it was used to maneuver the PFA catheter within the left atrium to achieve optimal contact with atrial structures.

RESULTS

We analyzed 556 patients: 357 (66%) with paroxysmal AF, 499 (89.7%) de novo PVI. ICE-guided procedures (n = 138) were propensity matched with patients with a standard approach (n = 138), and their outcomes were compared. During ICE-guided procedures, no improvement in procedural metrics was recorded (ICE vs Standard, 23 ± 6 min vs 18.5 ± 9 min for time to PVI, p < 0.0001; 38.8 ± 7 vs 32.5 ± 5 number of PFA deliveries to achieve PVI, p < 0.0001; 68.8 ± 19 min vs 71.8 ± 29 min for primary operator time, p = 0.5301; 16.1 ± 8 min vs 18.2 ± 10 min for fluoroscopy time, p = 0.5476) except for support time (76.8 ± 26 min vs 91.4 ± 37 min, p = 0.0046). No major procedure-related adverse events were reported.

CONCLUSION

Our findings confirmed that PFA could be consistently performed in a rapid, safe, and efficacious manner. The use of ICE to guide PFA was not associated with an improvement in procedural metrics.

Pulmonary vein isolation by means of a novel cryoballoon technology in paroxysmal atrial fibrillation patients: 1-year outcome from a large Italian multicenter clinical registry

INTRODUCTION

Recently, a new cryoballoon (CB) technology (POLARx; Boston Scientific) has come onto the market. Preliminary data have shown that its acute safety and efficacy are similar to those of the first-generation CB. The aim of this study was to assess the medium-term outcome of pulmonary vein isolation (PVI) with the POLARxTM CB in a large multicenter registry.

METHODS

We prospectively collected data on 125 consecutive patients with paroxysmal atrial fibrillation (AF) who underwent PVI by means of a novel CB system. Two cases of transient phrenic nerve palsy occurred, with full recovery in the 48h post procedure; no major procedure-related adverse events were reported. During the 90-day blanking period, 4 (3.2%) patients experienced an early recurrence. After the blanking period, over a mean follow-up of 411 ± 62 days, 19 patients (15.2%) suffered an AF/atrial tachycardia (AT) recurrence. The 1-year freedom from AF/AT recurrence was 86.4% (n = 17): 10 (8%) patients had an AF recurrence, 6 (4.8%) had an AT occurrence and 1 (0.8%) suffered both events. Patients with AF/AT recurrences had both a shorter deflation time and total deflation time. Moreover, CB ablations with measured TTI < 90 s and TTI < 60 s were more frequent in patients without AF/AT recurrence (88.5% and 77.4%, respectively) than in those who experienced at least one AF/AT recurrence (67.5% and 55.0%, p = .001 and p = .005, respectively).

CONCLUSION

The novel POLARx cryo-balloon system is safe and effective for PV isolation, displaying a 1-year freedom from atrial arrhythmia recurrence of 86.4%, which is in line to that reported with AFA-Pro CB or RF ablation.

CLINICAL TRIAL REGISTRATION

Catheter Ablation of Arrhythmias with a High-Density Mapping System in Real-World Practice (CHARISMA). URL: http://clinicaltrials.gov/ Identifier: NCT03793998. Registration date: January 4, 2019.

Intra-Cardiac versus Transesophageal Echocardiographic Guidance for Left Atrial Appendage Occlusion with a Watchman FLX Device

This study aimed to compare the peri-procedural success and complication rate within a large registry of intra-cardiac echocardiography (ICE)- vs. transesophageal echocardiography (TEE)-guided left atrial appendage occlusion (LAAO) procedures with a Watchmann FLX device. Data from 772 LAAO procedures, performed at 26 Italian centers, were reviewed. Technical success was considered as the final implant of a Watchmann FLX device in LAA; the absence of pericardial tamponade, peri-procedural stroke and/or systemic embolism, major bleeding and device embolization during the procedure was defined as a procedural success. One-year stroke and major bleeding rates were evaluated as outcome. ICE-guided LAA occlusion was performed in 149 patients, while TEE was used in 623 patients. Baseline characteristics were similar between the ICE and TEE groups. The technical success was 100% in both groups. Procedural success was also extremely high (98.5%), and was comparable between ICE (98.7%) and TEE (98.5%). ICE was associated with a slightly longer procedural time (73 ± 31 vs. 61.9 ± 36 min, p = 0.042) and shorter hospital stay (5.3 ± 4 vs. 5.8 ± 6 days, p = 0.028) compared to the TEE group. At one year, stroke and major bleeding rates did not differ between the ICE and TEE groups. A Watchmann FLX device showed high technical and procedural success rate, and ICE guidance does not appear inferior to TEE.

Pre-procedural high serum visfatin and tumor necrosis factor-α might predict recurrent atrial fibrillation after catheter ablation

BACKGROUND

Many patients would require repeated ablation procedures owing to recurrent atrial fibrillation with its associated symptoms. Identifying those who are at risk of recurrent AF could assist us to develop preventive strategies and to properly select those who will benefit more from catheter ablation. Our aim is to study the role of preprocedural serum level of certain biomarkers in the prediction of AF recurrence after catheter ablation.

RESULTS

The present study included 117 patients: 26 patients with persistent and 91 patients with paroxysmal AF. Blood samples for estimation of serum levels of studied cytokines were obtained prior to the procedure. Pulmonary vein isolation was performed in all patients through point-by point radiofrequency ablation guided by 3D electroanatomical mapping system. Patients were followed for 12 months for AF recurrence. Forty-one (35%) patients developed AF recurrence. Those patients were significantly older, had significantly higher BMI, lower ejection fraction, and wider maximal left atrial diameter (LAD). Serum hs-CRP, IL-6, TNF-α, visfatin, and adiponectin levels were significantly higher compared to those who did not develop AF recurrence. Correlation analysis showed positive correlations between the incidence of RAF and patients' age, BMI, and maximum LAD and elevated cytokine levels and maximal LAD showed significant correlations with the type of AF and elevated serum TNF-α, visfatin, and adiponectin. Statistical analyses defined elevated serum levels of TNF-α, visfatin, and adiponectin as positive predictors for RAF, and automatic linear modeling analysis showed that elevated serum visfatin, TNF-α, and adiponectin can predict RAF by accuracy rates of 50%, 34%, and 16%, respectively.

CONCLUSIONS

RAF is most probably an outcome of the interplay between patients' clinical data, obesity, and inflammation. Pre-procedural estimation of serum levels of visfatin and TNF-α might determine patients with probability for RAF.

Periprocedural outcome in patients undergoing left atrial appendage occlusion with the Watchman FLX device: The ITALIAN-FLX registry

Introduction

The Watchman FLX is a novel device for transcatheter left atrial appendage occlusion (LAAO) specifically designed to improve procedural performance in more complex anatomies with a better safety profile. Recently, small prospective non-randomized studies have shown good procedural success and safety compared with previous experiences. Results from large multicenter registries are needed to confirm the safety and efficacy of the Watchman FLX device in a real-world setting.

Methods

Italian FLX registry is a retrospective, non-randomized, multicentric study across 25 investigational centers in Italy including consecutive patients undergoing LAAO with the Watchman FLX between March 2019 and September 2021 (N = 772). The primary efficacy outcome was the technical success of the LAAO procedure (peri-device flow ≤ 5 mm) as assessed by intra-procedural imaging. The peri-procedural safety outcome was defined as the occurrence of one of the following events within 7 days after the procedure or by hospital discharge: death, stroke, transient ischemic attack, major extracranial bleeding (BARC type 3 or 5), pericardial effusion with tamponade or device embolization.

Results

A total of 772 patients were enrolled. The mean age was 76 ± 8 with a mean CHA2DS2-VASc score of 4.1 ± 1.4 and a mean HAS-BLED score of 3.7 ± 1.1. Technical success was achieved in 772 (100%) patients with the first device implanted in 760 (98.4%) patients. A peri-procedural safety outcome event occurred in 21 patients (2.7%) with major extracranial bleeding being the most common (1.7%). No device embolization occurred. At discharge 459 patients (59.4%) were treated with dual antiplatelet therapy (DAPT).

Conclusions

The Italian FLX registry represents the largest multicenter retrospective real-world study reporting periprocedural outcome of LAAO with the Watchman FLX device, resulting in a procedural success rate of 100% and a low incidence of peri-procedural major adverse events (2.7%).

Novel cryoballoon ablation system for pulmonary vein isolation: multicenter assessment of efficacy and safety-ANTARCTICA study

AIMS

Pulmonary vein isolation (PVI) either by balloon devices or radiofrequency forms the cornerstone of invasive atrial fibrillation (AF) treatment. Although equally effective cryoballoon (CB)-based PVI offers shorter procedure duration and a better safety profile. Beside the worldwide established Arctic Front Advance system, a novel CB device, POLARx, was recently introduced. This CB incorporates unique features, which may translate into improved efficacy and safety. However, multicentre assessment of periprocedural efficacy and safety is lacking up to date.

METHODS AND RESULTS

A total of 317 patients with paroxysmal or persistent AF were included and underwent POLARx CB-based PVI in 6 centres from Germany and Italy. Acute efficacy and safety were assessed in this prospective multicenter observational study. In 317 patients [mean age: 64 ± 12 years, 209 of 317 (66%) paroxysmal AF], a total of 1256 pulmonary veins (PVs) were identified and 1252 (99,7%) PVs were successfully isolated utilizing mainly the short tip POLARx CB (82%). The mean minimal CB temperature was -57.9 ± 7°C. Real-time PVI was registered in 72% of PVs. The rate of serious adverse events was 6.0% which was significantly reduced after a learning curve of 25 cases (9.3% vs. 3.0%, P = 0.018). The rate of recurrence-free survival after mean follow-up of 226 ± 115 days including a 90-day blanking period was 86.1%.

CONCLUSION

In this large multicentre assessment, the novel POLARx CB shows a promising efficacy and safety profile after a short learning curve.

P377 CHALLENGING RISK STRATIFICATION IN BRUGADA SYNDROME: A CASE OF VENTRICULAR TACHYCARDIA IN A LOW–RISK PATIENT

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.

In vivo Lesion Index (LSI) validation in percutaneous radiofrequency catheter ablation

INTRODUCTION

Lesion Index (LSI) has been developed to predict lesion efficacy during radiofrequency (RF) catheter ablation. However, its value in predicting lesions size has still to be established. The aim of our study was to assess the lesions size reproducibility for pre-specified values of LSI reached during RF delivery in an in vivo beating heart.

METHODS

Ablation lesions were created with different values of LSI in 7 domestic pigs by means of a contact force sensing catheter (TactiCath^TM , Abbott). Lesions were identified during RF delivery by means of a 3D mapping system (EnSite^TM Precision, Abbott) and measured after heart explantation. Histology was carried out after gross examination on the first 3 lesions to confirm the accuracy of the macroscopic evaluation.

RESULTS

A total of 64 myocardial lesions were created. Thirty-nine lesions were excluded from the analysis for the following reasons: histological confirmation of macroscopic lesion measurement (n=3), transmurality (n=24), unfavorable anatomic position (n=10), not macroscopically identifiable (n=2). In a final set of 25 non-transmural lesions, injury width and depth were respectively 4.6±0.6 mm and 2.6±0.8 mm for LSI=4, 7.3±0.8 mm and 4.7±0.6 mm for LSI=5, and 8.6±1.2 mm and 7.2±1.1 mm for LSI=6. A strong linear correlation was observed between LSI and lesion width (r=0.87, p<0.00001) and depth (r=0.89, p<0.00001). Multiple linear regression analysis identified LSI as the only ablation parameter that significantly predicted lesion width (p<0.001) and depth (p<0.001).

CONCLUSION

In our in vivo study, LSI proved highly predictive of lesion size and depth. This article is protected by copyright. All rights reserved.

Novel cryo-balloon ablation technology for pulmonary vein isolation in patients with atrial fibrillation: preliminary experience from a multicenter clinical practice

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 &gt;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 &lt; 60 sec achieved in 99.2% of the cryoapplications; the mean thaw time to 0 °C was 18.6 ± 5.8 sec (thaw time &gt;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.

Cryoballoon atrial fibrillation ablation: Single-center safety and efficacy data using a novel cryoballoon technology compared to a historical balloon platform

INTRODUCTION

Catheter ablation is superior to drugs regarding atrial fibrillation (AF) recurrence, symptoms improvement, and mortality reduction in heart failure. POLARx™ is a novel cryoballoon, with technical improvements seeking to improve outcomes. So far, its clinical evidence is restricted to a case report.

METHODS

To compare the POLARx™ cryoballoon procedural safety and efficacy to the already established Arctic Front Advance PRO™ (AFAP) in a single-center cohort study, consecutive patients undergoing AF cryoablation with the POLARx™ were enrolled. Data were prospectively gathered. POLARx™ patients were compared with a historical cohort of patients submitted to AF cryoablation with the AFAP.

RESULTS

Seventy patients were analyzed, 20 in POLARx™, and 50 in the AFAP group. They all underwent first-time pulmonary vein isolation, 77% were male, 94% had paroxysmal AF, median age was 62.5 years, median CHA₂ DS₂ -VASc 1, left-atrium size 34 ml/m², and 65% were receiving anticoagulation. The primary end-point, all pulmonary veins isolation, was 100% in both groups. The complication rate was similar (0% POLARx™ vs. 5.7% AFAP, p = .39). The median total procedural time was longer in the POLARx™ group (90 min vs. 60 min, p < .001), but the overall time-to-isolation (TTI; 44.8 s vs. 39 s, p = .253) and ablation time (15 min vs. 13.7 min, p = .122) was similar between POLARx™ and AFAP groups, respectively. Despite equal TTI, the POLARx™ had a lower minimal temperature reached (-57°C vs -47°C, p < .001).

CONCLUSION

The novel POLARx™ cryoballoon had similar efficacy and safety compared with the AFAP. It was also associated with longer procedural times, similar TTI, and lower minimum temperature reached.

Multimodality Approach for Endovascular Left Atrial Appendage Closure: Head-To-Head Comparison among 2D and 3D Echocardiography, Angiography, and Computer Tomography

Background: Percutaneous left atrial appendage closure (LAAC) requires accurate pre- and intraprocedural measurements, and multimodality imaging is an essential tool for guiding the procedure. Two-dimensional (2D TOE) and three-dimensional (3D TOE) transoesophageal echocardiography, cardiac computed tomography (CCT), and conventional cardiac angiography (CCA) are commonly used to evaluate left atrial appendage (LAA) size. However, standardized approaches in measurement methods by different imaging modalities are lacking. The aims of the study were to evaluate the LAA dimension and morphology in patients undergoing LAAC and to compare data obtained by different imaging modalities: 2D and 3D TOE, CCT, and CCA. Methods: A total of 200 patients (mean age 70 ± 8 years, 128 males) were examined by different imaging techniques (161 2D TOE, 103 3D TOE, 98 CCT, and 200 CCA). Patients underwent preoperative CCT and intraoperative 2D and 3D TOE and CCA. Results: A significant correlation was found among all measurements obtained by different modalities. In particular, 3D TOE and CCT measurements were highly correlated with an excellent agreement for the landing zone (LZ) dimensions (LZ diameter: r = 0.87; LAA depth: r = 0.91, p < 0.001). Conclusions: Head-to-head comparison among imaging techniques (2D and 3D TOE, CCT, and CCA) showed a good correlation among LZ diameter measurements obtained by different imaging modalities, which is a parameter of paramount importance for the choice of the LAAC device size. LZ diameters and area by 3D TOE had the best correlation with CCT.

Atrial fibrillation ablation in athletes: 5-years experience of a single italian third-level center

Background

The number of master athletes is increasing and treatment of AF is mandatory for sports continuation. However, few data exist about the effectiveness of catheter ablation (CA) in athletes and the feasibility of resuming vigorous exercise afterwards.

Objectives

Aim of our study was to analyze the efficacy and safety of AF CA in athletes and to evaluate the feasibility of resuming vigorous exercise.

Methods

We report a retrospective registry of athletes referred to our center for AF CA in the last five years. All athletes were previously declared non-eligible to competitive sport because of recurrences of AF or evidence of persistent asymptomatic AF. CA was performed as per practice and recurrences were defined as recrudescence of symptoms and/or any documentation of AF lasting more than 30 sec. At the end of the follow-up all pts were asked about resuming sport.

Results

We ablated 40 athletes (38 males, 95%) with a mean age of 48±13 years. Mean left atrium volume was 36±11 ml/m2 and mean ejection fraction was 61±5%. Distribution between AF characteristics was: 31 (78%) paroxysmal AF, 8 (20%) early-persistent AF, 1 (2%) long-persistent AF.

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%). 7 athletes underwent a redo procedure and all of them were then free of recurrences with an overall freedom from recurrences of 84%. No major complication was observed. Athletes practicing endurance sports showed a negative trend in terms of recurrences (p = ns).

Most (72%) of the athletes resumed vigorous exercise after at least 3 months from the CA as per Italian sport protocols.

Conclusions

CA is safe and efficient in treating AF also in athletes. Resuming high intensity sports is often possible after 3 months from CA.

Funding Acknowledgement

Type of funding source: None

P1799 The importance of 3D imaging techniques in left atrial appendage closure: landing zone eccentricity influence on peri-device leak incidence and its implication in long-term clinical outcomes

Background

A complex left atrial appendage (LAA) morphology and a non-circular landing zone (LZ) are frequently encountered in patients undergoing percutaneous LAA occlusion (LAAO). Three-dimensional (3D) imaging modalities as 3D transoesophageal echocardiography (3D TOE) and cardiac computed tomography (CCT) should be preferred over two dimensional techniques for better evaluation of LAA diameters, especially for the LZ. In fact, non-circular shape could impair the choice of occluder device size and may be implicated in the occurrence of residual leaks. Incomplete LAA occlusion is recognized to be associated with thromboembolic events.

Purpose

The aim of the study was to evaluate the utility of 3D imaging techniques to predict LAA device size and the landing zone eccentricity index as a potential predictor of residual peri-device leaks and to assess their clinical implications on long-term follow-up.

Methods

It was a retrospective, single-center study including 137 consecutive patients undergoing successful LAAO from January 2010 to July 2018. Pre-procedural 3D TOE and CCT were used to predict device size based upon LZ diameters and quantify LAA orifice eccentricity. Leaks were defined as the presence of peri-device flow at 2D TOE immediately after the device implantation and at 3 months follow-up. Leaks were classified as significant (color jet width ≥4 mm) or minor (&lt;3 mm). A clinical evaluation of thromboembolic events was performed at 48 ± 27 months from the procedure.

Results

LAAO closure was performed implanting either Amulet or Watchman devices (n = 98 and n = 40, respectively). The assessment of LZ measurements with 3D TOE and CCT showed a significant correlation with the device size selected on the basis of 2D techniques (r = 0.82 and r = 0.74, respectively). As concerns the peri-device leaks, the presence of an eccentric LZ (eccentricity index &gt;0.20) was not associated to the development of post-procedural leaks in the overall population; a significant correlation was detected only in the subgroup of patients treated with the Amulet device (p = 0.045). Residual leaks included only 1 significant leak (0.7%) after Amulet device implantation, which was related to a major neurological event (stroke) and 47 (34%) minor leaks (n = 28 in the Amulet group, n = 19 in the Watchman group). In this last population, 2 patients (1.5%) developed minor neurological events (transient ischemic attack).

Conclusions

3D TOE and CCT better predict device size overcoming the limit of 2D imaging techniques undersizing. In eccentric LAA, Watchman device may reduce the incidence of peri-device leaks. The presence of significant residual leaks is uncommon but associated with major clinical events, whilst minor leaks are relatively frequent but do not seem to be related to life-threatining thromboembolic accidents.

P3682Myocardial structural abnormalities in nonischemic patients presenting with ventricular arrhythmias

Background

The diagnosis of concealed cardiomyopathies in patients with ventricular arrhythmias (VAs) is one of the major challenging issues faced by physicians.

Purpose

We aimed at reporting the cardiomyopathic substrate in patients with recurrent arrhythmias of ventricular origin.

Methods

Consecutive patients with unexplained VAs underwent a complete diagnostic work-out, including endomyocardial biopsy (EMB).

Results

Ninety-seven patients were enrolled (76.3% male, age 39.7±13.3 yrs). The presenting arrhythmic manifestation was aborted cardiac arrest in 30 (30.9%) patients, sustained ventricular tachycardia (VT) in 9 (9.3%), nonsustained VT in 15 (15.5%) and frequent premature ventricular complexes in 43 (44.3%). Overall, 350 biopsies were collected (3.6/patient). The incidence of procedure-related complications was 5.1% (n=5): 4 major complications (1 rupture of a tricuspid chorda tendinea w/o hemodynamic impairment, 1 dissection of right external iliac artery treated with stent, 1 thrombotic occlusion of left superficial femoral artery which required surgical treatment, 1 TIA) and 1 minor complication (groin hematoma) occurred. The final diagnosis was arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) (n=41; 42.3%), followed by myocarditis (n=20; 20.6%), dilated cardiomyopathy (n=6; 6.2%), cardiac sarcoidosis (n=6; 6.2%), and myocarditis in ARVD/C (n=5; 5.1%). Among the 25 patients whose final diagnosis was consistent with myocarditis, an acute stage of the disease was documented in 7 (7.2%), while a chronic myocarditis in 18 (18.5%). Additionally, according to medical history and diagnostic workout, in 2 of the 6 patients the dilated cardiomyopathy had a likely post-inflammatory etiology. Absence of myocardial abnormalities was documented in 15 (15.5%) patients: this group included 1 case of methadone-induced torsade de pointes. The remaining 4 (4.1%) patients were diagnosed with a cardiac hypertrophy (n=2, 2.1%, secondary to exercise or Fabry disease), a dilated mitochondrial cardiomyopathy (n=1, 1.0%), a dilated cardiomyopathy in Emery-Dreifuss muscular dystrophy (n=1; 1.0%).

Conclusion

In our series, approximately 45% of patients with unexplained VAs had a final diagnosis of ARVD/C.

P3687Abnormal voltage recordings in patients with ventricular arrhythmias: comparison between right and left cardiomyopathy

Background

Arrhythmogenic Cardio-Myopathy (ACM) is characterized by epi-endocardial fibro-fatty replacement. Depending on the most affected ventricle, right dominant (RDACM) or left dominant (LDACM) phenotypes can be defined. RDACM voltage mapping characteristics have already been described, with late potentials strongly correlating with arrhythmia recurrence risk; LDACM voltage features have not been described yet.

Purpose

To analyze voltage map characteristics in LDACM patients (pts) and compare them with RDACM; to assess if there is any correlation between late potentials and recurrence rate in LDACM as well.

Methods

We retrospectively enrolled all consecutive ACM patients treated c/o our center and diagnosed according to the 2010 Task Force Criteria. Procedural and follow up data were collected. Patient were sorted by ventricular involvement lateralization. Recurrence rates were evaluated and linearly regressed for the presence of late potentials.

Results

89 ACM patients were enrolled (67 RDACM, 22 LDACM; 76% males, 69±4 y.o.) in our study. All patients underwent endocardial voltage mapping; procedurally, 43 (48%) pts underwent catheter ablation, while 46 (52%) were managed conservatively with anti-arrhythmic drugs.

Bipolar pathological potentials were found in 43 (64%) and 13 (59%), unipolar pathological potentials in 45 (67%) and 14 (63%), while late potentials in 19 (31%) and 8 (36%) in the RDACM and LDACM group respectively [p = 0.66, p=0.63, and p=0.33].

The average follow-up was 18 months [14–48]; 15 (22%) in the RDACM and 9 (40%) in LDACM arrhythmic recurrences were respectively encountered; recurrences in both groups were regressed for the presence of late potentials. Results were as follows: the presence of late potentials correlated with recurrences with an 4,3 [1.15–16.1; p=0.03] OR and with an 11 [0.4–85; p=0.022] OR in the RDACM and LDACM group respectively.

Conclusion

Pathologically low unipolar, bipolar and late potentials can be found in comparable % both in RDACM and LDACM; like in RDACM, late potentials represent an important risk factor for arrhythmic recurrence in LDACM as well.

P4652Magnetic resonance and electroanatomical guided endomyocardial biopsy as a diagnostic tool in the clinician's box: a 5 year experience

Background

Percutaneous endo-myocardial biopsy (EMB) is an invasive diagnostic test used to reach or confirm a diagnosis when structural or substrate anomalies are suspected, such as in cardiomyopathies or myocarditis evaluation. In recent years, cardiac magnetic resonance imaging (MRI) and endo-cavitary electro-anatomical mapping (EAM) have been used to localize the most significant myocardial area to sample, therefore increasing EMB overall effectiveness and reliability.

Purpose

To describe and characterize safety, feasibility and anatomical findings of a large cohort of patients (pts) undergoing diagnostic EMB and to assess its impact on the treatment decision making algorithm.

Methods

A cohort of all pts undergoing a percutaneous EMB at our Institution from January 2014 to January 2019 was analyzed. All EMB procedures were guided by a pre-procedural cardiac MRI radiological alteration analysis and an endo-cavitary EAM. Intra-cardiac echography (ICE) was used in all procedures, to directly visualize the sample area and to evaluate in real time post-EBM complications. Demographics, clinical data, MRI data, pathological EMB features, and peri-procedural data were systematically retrieved.

Results

One-hundred and eleven pts were enrolled (78% male, 47±4 y.o., 33% athletes). EMB indication was abnormal MRI findings in 94 (85%), pathological EMB voltages in 10 (9%) and clinical suspect and patient history in 7 (6%) pts.

EMB sample area was determined by both MRI and EAM pathological area analysis in 92 (83%) pts, while by EAM alone in 19 (17%) pts (n=6 pathological unipolar EAM; n=13 bipolar and unipolar pathological EAM). The sample site was the right ventricle in 89 (80%), the left ventricle in 20 (18%), and both in 3 (2%) pts.

In 103 (93%) pts a concomitant electrophysiological induction study was performed (40% positive for sustained ventricular arrhythmias) and 35 (32%) pts underwent a trans-catheter ablation (TCA) (n=8 epicardial TCA; n=2 endo-epicardial TCA; n=25 endocardial ATC). Only 2 (2%) peri-procedural adverse events were witnessed, specifically femoral pseudo-aneurysms, requiring surgical repair. EMB analysis allowed to confirm 58 (52%) pre-procedural diagnosis and to reach 32 (29%) new diagnosis, while resulting inconclusive or non-specific in the diagnostic process only in 21 (19%) cases [Figure1]. A total of 33 (30%) intra-cardiac devices (ICDs) were implanted contextually in the cohort, of which 9 (8%) solely upon EMB indication; in 4 (4%) other patients, biopsy represented a strong decisional factor in the multi-modality decision process for abstaining from ICD implant.

Dashed lines: diagnosis changed upon EMB

Conclusion

MRI and EAM guided EMBs allowed to finely define a large cohort of patients by representing a disease defining parameter in over 80% of the enrolled pts while and a decision shifting parameter in ICD implant algorithm in a high % of pts.

P5560Assessing etiology in a cohort of patients with myocarditis presenting with complex ventricular arrhythmias: can the percutaneous endomyocardial biopsy help?

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.

P993Diagnostic accuracy of cardiac magnetic resonance and endomyocardial biopsy for arrhythmogenic right ventricular dysplasia/cardiomyopathy and myocarditis

Introduction

Patients with myocarditis may fulfill the cardiac magnetic resonance (CMR) criteria set forth by the 2010 Task Force for arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C), thereby increasing the risk of misdiagnosis.

Purpose

We sought to evaluate the role of CMR and endomyocardial biopsy (EMB) in the differential diagnosis between myocarditis and ARVD/C.

Methods

Consecutive patients presenting with ventricular arrhythmias, underwent a complete diagnostic work-out, which included CMR and EMB. The final diagnosis served as the gold standard to assess the diagnostic accuracy of CMR and EMB.

Results

Overall, 74 consecutive patients presenting with VAs underwent a complete diagnostic workout at our institution. The cohort was 70.3% male, with a mean age of 38.9±12.1 years. A final diagnosis of ARVD/C was made in 30 (40.5%) patients, whereas 19 (25.7%) had a diagnosis of myocarditis.

The McNemar's test showed significant differences in the diagnostic performance of EMB and cardiac MRI (p=0.003 for ARVD/C, p=0.04 for myocarditis).

At receiver operating characteristic (ROC) analyses, the area under the curve (AUC) to discriminate between controls and ARVD/C patients was 0.711 (95% CI: 0.59–0.83) for MRI and 0.944 (95% CI: 0.88–1.00) for biopsy (p<0.001). The AUC to discriminate between controls and patients with myocarditis was 0.656 (95% CI: 0.51–0.80) for MRI and 0.893 (95% CI: 0.80–0.99) for biopsy (p=0.006).

Diagnostic performance of CMR and EMB

Conclusion

Even though CMR has good diagnostic performances as single technique, a complete diagnostic work-out including EMB may frequently reduce the risk of misdiagnoses.

P5556Impact of viral genome detection in endo-myocardial biopsy of arrhythmogenic cardiomyopathy substrate

Background

Arrhythmogenic cardiomyopathy (ACM) is a genetically inherited cardiomyopathy characterized by myocardial fibro-fatty replacement. A pathogenetic role of viral myocardial infections in ACM natural history has been proposed over the years, although no definitive conclusion has been reached yet.

Purpose

To describe viral genome presence into a cohort of ACM biopsy proven patients (pts) and its impact on clinical features and outcome.

Methods

A cohort of all ACM pts undergoing an invasive third level evaluation at our institution was enrolled. All pts underwent a cardiac magnetic resonance (MR), an invasive electrophysiological study (EPS) with endo-cavitary electro-anatomical mapping (EAM), and a EAM guided endo-myocardial biopsy (EMB). Viral genome research through molecular biology techniques was performed on all biopsied samples.

According to arrhythmic risk evaluation, a trans-catheter ablation (TCA) and/or an internal cardioverter device (ICD) implant was performed. Clinical arrhythmic presentation, MR data, arrhythmia inducibility at EPS, EAM and EMB characteristic, and arrhythmic events at a 12-month follow up visit were retrieved in all pts and compared between the viral genome positive (v+ACM) and negative group (v-ACM).

Results

Forty-five pts were enrolled in our study (48±13 years; 66% male); the EMB samples of 7 (15%) pts presented a lymphocytic infiltrate and tested positive for viral genome (n=3 B19 Parvovirus; n=2 for Citomegalovirus; n=2 for Ebstein-Bar Virus) [Figure1].

At arrhythmic presentation, complex ventricular arrhythmias (NSVT, SVT and FV) were more frequent in the v+ACM group (86% vs 50%; p=0.039). Both left and right ventricular ejection fraction at MR resulted more depressed in the v+ACM group (44±7 vs 52±2 and 47±2 vs 52±2; p=0.047 and p=0.041). Complex ventricular arrhythmia inducibility at EPS was more frequent in v+ACM (72% vs 34%; p=0.032), while no differences in pathological potentials rate and extension at unipolar and bipolar EAM were found. TCA was performed in 55% and 57% and an ICD was implanted in 29% and 42% in the v+ACM and v-ACM group respectively. No differences in 12-months arrhythmic event rates (39% vs 42%) between the two groups were described.

EBM at different magnifications/stains

Conclusion

In our cohort a viral infection super-imposed to the fibrofatty infiltration was found in 15% of the patients. ACM pts testing positive for viral genome at the EMB had a more severe arrhythmic disease presentation, a more impaired heart function, and a higher rate of complex ventricular arrhythmias at disease presentation, but seemed to respond as well as viral genome negative ACM to ablative and pharmacological treatment

CMR for Identifying the Substrate of Ventricular Arrhythmia in Patients With Normal Echocardiography

OBJECTIVES

This study sought to determine whether cardiac magnetic resonance (CMR) may identify structural heart disease (SHD) in patients with ventricular arrhythmia who had echocardiography ruled out pathological findings.

BACKGROUND

Approximately one-half of sudden cardiac deaths are attributable to malignant VA. Echocardiography is commonly used to identify SHD that is the most frequent substrate of VA.

METHODS

A single-center prospective study was conducted in consecutive patients with significant VA, categorized as >1,000 but <10,000 ventricular ectopic beats [VEBs]/24 h; ≥10,000 VEBs/24 h; nonsustained ventricular tachycardia, sustained ventricular tachycardia, or a history of resuscitated cardiac arrest, and no pathological findings at echocardiography, requiring a clinically indicated CMR. Primary endpoint was CMR detection of SHD. Secondary endpoints were a composite of CMR detection of SHD and abnormal findings not specific for a definite SHD diagnosis.

RESULTS

A total of 946 patients were enrolled (mean 41 ± 16 years of age; 64% men). CMR studies were used to diagnose SHD in 241 patients (25.5%) and abnormal findings not specific for a definite SHD diagnosis in 187 patients (19.7%). Myocarditis (n = 91) was the more frequent disease, followed by arrhythmogenic cardiomyopathy (n = 55), dilated cardiomyopathy (n = 39), ischemic heart disease (n = 22), hypertrophic cardiomyopathy (n = 13), congenital cardiac disease (n = 10), left ventricle noncompaction (n = 5), and pericarditis (n = 5). The strongest univariate and multivariate predictors of SHD on CMR images were chest pain (odds ratios [OR]: 2.52 and 2.38, respectively) and sustained ventricular tachycardia (ORs: 2.67 and 2.23, respectively).

CONCLUSIONS

SHD was able to be identified on CMR imaging in a sizable number of patients with significant VA and completely normal echocardiography. Chest pain and sustained ventricular tachycardia were the strongest predictors of positive CMR imaging results.

A left atrial appendage closure combined procedure review: Past, present, and future perspectives

BACKGROUND AND OBJECTIVE

Atrial fibrillation (AF) represents the most common cardiac arrhythmia worldwide; it poses a great burden in terms of quality of life reduction and yearly stroke risk. Left atrial appendage closure (LAAC) is a stroke prevention strategy that has been proven a viable alternative to antithrombotic regimens in nonvalvular AF patients. LAAC can be performed as a standalone procedure or alongside a concomitant AF transcatheter ablation, in a procedure known as "Combined procedure". Aim of this study is to summarize the scientific evidence backing this combined strategy.

METHODS

We reviewed the whole Medline indexed combined procedure literature, to summarize all the combined procedure study data.

RESULTS

Nine published studies regarding combined procedure were found. Data, aims, and scientific rationales were reported and commented.

CONCLUSION

LAA combined procedure appears to be a safe and effective procedure; a careful patient selection is necessary to maximize its benefit.

Cryoballoon pulmonary vein ablation and left atrial appendage closure combined procedure: A long-term follow-up analysis

BACKGROUND

The combined left atrial appendage closure (LAAC) and cryoenergy pulmonary vein isolation (PVI) procedure has been proven safe and effective in managing stroke in patients with nonvalvular atrial fibrillation (AF), although most data refer to procedures performed using radiofrequency as the main energy source.

OBJECTIVE

The purpose of this study was to evaluate long-term follow-up of patients with AF undergoing concomitant LAAC and cryoenergy PVI.

METHODS

Patients undergoing LAAC and cryoballoon PVI at our institution were enrolled. At 3, 6, and 24 months from the index procedure, we determined the atrial arrhythmia recurrence rate, the extent of LAAC, and the rate of cerebrovascular/bleeding events.

RESULTS

Forty-nine patients (mean age 69 ± 8 years; 32/49 (67%) men; CHA₂DS₂-VASc score 2.8 ± 1.2; HAS-BLED score 3 ± 1) with a guideline-recommended LAAC indication were included. Acute PVI and complete LAAC were achieved in 100% of patients. All patients completed at least 24 months of follow-up. At 8 weeks and 6 months, complete or satisfactory (<5 mm leak) LAAC rates were achieved in 40 (82%) and 9 (18%) and in 42 (86%) and 7 (14%) of patients, respectively. The overall freedom from atrial arrhythmia rate at 24 months was 29 (60%), and 45 (92%) of patients were off antithrombotic drugs. The observed annualized stroke and bleeding rates were 1% and 2%, respectively, a 71% and 60% risk reduction in comparison to event rates predicted from CHA₂DS₂-VASc and HAS-BLED scores.

CONCLUSION

Concomitant cryoballoon ablation and LAAC procedures appear safe and effective at long-term follow-up, with high antithrombotic drug withdrawal rates at 24 months.

Percutaneous left atrial appendage occlusion in patients with atrial fibrillation and left appendage thrombus: feasibility, safety and clinical efficacy

AIMS

The aim of this study was to investigate the feasibility, safety and efficacy of percutaneous closure for prevention of thromboembolic events in patients with atrial fibrillation (AF) and left atrial appendage (LAA) thrombus.

METHODS AND RESULTS

The study included consecutive patients with AF and LAA thrombus who underwent transcatheter occlusion in eight high-volume centres. Clinical and transoesophageal echocardiography (TEE) follow-up was carried out as per each centre's protocol. Twenty-eight patients were included. The location of the LAA thrombus was distal in 100% of cases. Technical and procedural success was achieved in all patients. A cerebral protection device was used in six cases. There were no periprocedural adverse events. Follow-up was complete in all patients (total 32 patient-years). No death or thromboembolic events were reported. There was one major bleeding during follow-up. Among the 23 patients undergoing TEE, device thrombosis was present in one patient. No significant peri-device leaks were observed.

CONCLUSIONS

In this multicentre study, percutaneous closure in selected patients with distal LAA thrombus appears to be feasible and safe, and is associated with high procedural success and a favourable outcome for the prevention of AF-related thromboembolism. Special implant techniques avoiding mechanical mobilisation of the thrombotic mass and the liberal use of cerebral embolic protection devices are recommended.

Left atrial appendage closure guided by 3D computed tomography printing technology: A case control study

BACKGROUND

We sought to evaluate the additional value of left atrial appendage (LAA) 3D printing derived from computed tomography (CCT) in determining the size for LAA occlusion (LAAO) devices as compared to standard measurement by using occurrence of LAA leak as endpoint.

METHODS

We evaluated 6 patients with LAA leak (cases) and 14 matched patients without LAA leak (controls) after LAAO. For each group, a patient-specific 3D printed model of LAA was manufactured using CT pre-operative images. The size recommended by the 3D printed model was compared with the size of the implanted device.

RESULTS

Compared to the 3D printed model, 55% of the devices were underestimated, the two sizing approaches agreed in 35% of the patients, while the 3D printed model overestimated the size in 10% of patients. The prevalence of LAA leak was significantly higher in the subset of patients with underestimation of prosthesis implanted with the standard approach as compared to the other patients (p = 0.019).

CONCLUSION

3D printing of the LAA may provide additional value to standard practice for LAAO device prosthesis sizing with the potential impact to reduce LAA leak.

X-Ray Exposure in Cardiac Electrophysiology: A Retrospective Analysis in 8150 Patients Over 7 Years of Activity in a Modern, Large-Volume Laboratory

Background

Only a few studies have systematically evaluated fluoroscopy data of electrophysiological and device implantation procedures. Aims of this study were to quantify ionizing radiation exposure for electrophysiological/device implantation procedures in a large series of patients and to analyze the x‐ray exposure trend over years and radiation exposure in patients undergoing atrial fibrillation ablation considering different technical aspects.

Methods and Results

We performed a retrospective analysis of all electrophysiological/device implantation procedures performed during the past 7 years in a modern, large‐volume laboratory. We reported complete fluoroscopy data on 8150 electrophysiological/device implantation procedures (6095 electrophysiological and 2055 device implantation procedures); for each type of procedure, effective dose and lifetime attributable risk of cancer incidence and mortality were calculated. Over the 7‐year period, we observed a significant trend reduction in fluoroscopy time, dose area product, and effective dose for all electrophysiological procedures (P<0.001) and a not statistically significant trend reduction for device implantation procedures. Analyzing 2416 atrial fibrillation ablations, we observed a significant variability of fluoroscopy time, dose area product and effective dose among 7 different experienced operators (P<0.0001) and a significant reduction of fluoroscopy use over time (P<0.0001) for all of them. Considering atrial fibrillation ablation techniques, fluoroscopy time was not different (P = 0.74) for radiofrequency catheter ablation in comparison with cryoablation, though cryoablation was still associated with higher dose area product and effective dose values (P<0.001).

Conclusions

Electrophysiological procedures involve a nonnegligible x‐ray use, leading to an increased risk of malignancy. Awareness of radiation‐related risk, together with technological advances, can successfully optimize fluoroscopy use.

Rescue Leadless Pacemaker Implantation in a Pacemaker-Dependent Patient with Congenital Heart Disease and no Alternative Routes for Pacing

Congenital heart disease patients are considered a unique group of patients regarding their high risk of conduction abnormalities , whether de novo or surgically induced , and the challenges in both implantation and management of device related complications. We present a case of a pacemaker-dependent patient with congenital heart disease who experienced complications of both previous epicardial and transvenous pacing which rendered her a non-suitable candidate of both routes.

Early Dislodgment and Migration of a Left Atrial Appendage Closure Device

A 68-year-old man underwent pulmonary vein isolation with cryoballoon combined with left atrial appendage closure using a LAmbre device. The device was dislodged and embolized early after implantation with no symptoms, and it was retrieved percutaneously. An early in-hospital check of the device position after implantation is important for early recognition of any possible device-related complication.

Pulmonary vein isolation cryoablation for patients with persistent and long-standing persistent atrial fibrillation: Clinical outcomes from the real-world multicenter observational project

BACKGROUND

Pulmonary vein isolation (PVI) is a cornerstone ablation strategy in the management of patients with atrial fibrillation (AF). Consensus guidelines and statements recommend PVI during the index catheter ablation procedure in patients with paroxysmal and persistent AF.

OBJECTIVE

The objective of this analysis was to evaluate patients with persistent and long-standing persistent AF who were treated with the cryoballoon ablation catheter by PVI technique.

METHODS

Consecutive patients with drug-refractory symptomatic persistent and long-standing persistent AF who underwent cryoballoon catheter ablation by a PVI-only procedure were prospectively included in this single-arm multicenter evaluation. Data on procedural characteristics, safety, and long-term freedom from AF recurrence were analyzed.

RESULTS

Four hundred eighty-six subjects (mean age 60.8 ± 9.3 years; 389 (80%) men; 434 (89.3%) with persistent AF; 52 (10.7%) with long-standing persistent AF; left atrial diameter 44.6 ± 6.2 mm) underwent cryoballoon ablation in 35 Italian centers. The mean procedure time (skin-to-skin) was 109.9 ± 52.9 minutes, and the mean fluoroscopy time was 29.6 ± 14.5 minutes. Periprocedural complications were observed in 21 subjects (4.3%), and the acute PVI success rate was 97.6% across all patients. Using a 90-day blanking period, the single procedure Kaplan-Meier estimates of AF event-free survival were 63.9% at 12 months and 51.5% at 18 months.

CONCLUSION

In this multicenter evaluation of cryoballoon ablation, the PVI procedure was safe, effective, and efficient with regard to the treatment of patients with persistent and long-standing persistent AF. The reasonable mid-term success rates agree with current clinical studies that establish PVI as a cornerstone index ablation strategy.

Benefits of electroanatomic ablation of conventional cardiac arrhytmias: from fluoroscopy to zero X-ray mapping

Electrophysiology procedures are traditionally performed under fluoroscopic guidance. Nowadays a growing interest in the radiation risk associated to these procedures has been cultivated, since radiation exposure has non-negligible stochastic and deterministic effects on health. A correlation between radiation exposure and lifetime malignancy effect is difficult to establish and the threshold of a completely safe exposure dose is unknown. Thus, electrophisiologists have become aware of the use of fluoroscopy and they have tried to use all the complementary imaging technologies available in order to reduce the radiological exposure. This review is aimed at evaluating the radiation exposure risk, both for the patients and the operators. We describe electroanatomical mapping systems and technologies, which allow the reduction of radiation exposure. We review the main literature based on different catheter ablation procedures with the use of the abovementioned technologies, specifically focusing on feasibility, safety, and radiation exposure. Finally, we highlight the necessity of increasing the radiological risk awareness among operators and cardiological scientific societies.

Predictors of arrhythmia recurrence after balloon cryoablation of atrial fibrillation: the value of CAAP-AF risk scoring system

PURPOSE

In the present study, we aimed to test the value of CAAP-AF score for prediction of atrial fibrillation (AF) recurrence at follow-up in a group of our patients treated by balloon cryoablation.

METHODS

A total of 283 symptomatic drug-refractory AF patients [261 (92%) with paroxysmal AF] who underwent pulmonary vein isolation (PVI) with second-generation cryoballoon between April 2012 and October 2016 were included. The CAAP-AF score was calculated for every patient.

RESULTS

A total of 283 patients [68 female (20%), mean age 59.8 ± 11.4 years] were included in the present analysis. Eighty-nine patients (31%) had hypertension and 13 (4%) had coronary artery disease. The mean left atrial diameter and left ventricular ejection fraction were 40.6 ± 7.0 mm and 60.0 ± 9.1%, respectively. The mean CHA₂DS₂-VASc score was 1.2 ± 1.1, and mean number of prior failed antiarrhythmic drugs was 1.4 ± 0.8. At 18 ± 6 months follow-up, 25 patients (8.87%) developed AF recurrence. The recurrence rate was as follows: 3.17% (score 0-3), 8.47% (score 4), 16.28% (score 5), 6.67% (score 6), 23.08% (score 7), and 36.36% (score ≥8). The recurrence rate was 4.86% at a score <5 and 16.49% at a value ≥5; a score cutoff ≥5 predicted AF recurrence with a sensitivity 64% and specificity 68%.

CONCLUSIONS

The present analysis suggests the usefulness of CAAP-AF scoring system, with its simple and easily obtained six clinical variables, to predict AF recurrence after PVI by means of second-generation cryoballoon. A score value ≥5 predicted AF recurrence with a sensitivity 64% and specificity 68%.

Contrast Dye ICE Cap Embolization Using the Third-Generation Cryoballoon

Cryoballoon ablation is a widely diffuse technology to perform paroxysmal atrial fibrillation ablation. The new generation cryoballoon catheters have been redesigned in order to improve the cooling capability. During cryoballoon ablation, it is not unusual to observe the formation of a contrast dye ice cap on top of the balloon itself. The automated balloon deflation before dissolution of the ice cap may increase the risk of embolization of large ice-mixed-contrast crystals in the systemic circulation. In the case hereby reported, we describe an uneventful embolization of this contrast dye ice cap in the systemic circulation.

Concomitant cryoballoon ablation and percutaneous closure of left atrial appendage in patients with atrial fibrillation

AIMS

Pulmonary veins (PVs) isolation is the cornerstone of atrial fibrillation (AF) ablation and can be achieved either by conventional radiofrequency ablation or by cryoenergy. Left atrial appendage (LAA) closure has been proposed as alternative treatment to vitamin K antagonists (VKA). We aimed to evaluate the feasibility of combining cryoballoon (CB) ablation and LAA occlusion in patients with AF and a high thromboembolic risk or contraindication to antithrombotic therapy.

METHODS AND RESULTS

Thirty-five patients (28 males, 74 ± 2 years) underwent CB ablation. Left atrial appendage occlusion was carried out by using two occluder devices (Amplatz Cardiac Plug, ACP, St. Jude Medical, MN, USA, in 25 patients; Watchman, Boston Scientific, MA, USA, in 10 patients). Thirty patients (86%) had previous stroke/TIA episodes, 6 patients (17%) had major bleeding while on VKA therapy, and 7 patients (20%) had inherited bleeding disorders. Over the follow-up (24 ± 12 months), atrial arrhythmias recurred in 10 (28%) patients. Thirty patients (86%) had complete sealing; 5 patients (14%) showed a residual flow (<5 mm) at first transoesophageal echocardiography (TEE) check, while at 1-year TEE residual flow was detected in 3 patients. In 13 patients (37%), VKA therapy was immediately discontinued. Six patients (17%) received novel oral anticoagulants treatment and then discontinued 3 months thereafter. No device-related complications or clinical thromboembolic events occurred.

CONCLUSION

Combined CB ablation and LAA closure using different devices appears to be feasible in patients with non-valvular AF associated with high risk of stroke or contraindication to antithrombotic treatment.

Left Atrial Appendage Closure Guided by 3D Printed Cardiac Reconstruction: Emerging Directions and Future Trends

INTRODUCTION

Percutaneous left atrial appendage (LAA) occlusion has emerged as an alternative therapeutic approach to medical therapy for stroke prevention in patients with atrial fibrillation. 3D printing is a novel technology able to create a patient specific model of any given anatomical portion of the heart.

RESULTS

Herein we report the first 2 cases of LAA occlusion procedure with 2 different systems, the Wave Crest device (Coherex Medical, Inc., USA) and the Amplatzer Amulet device (St. Jude Medical, St. Paul, MN, USA), in which a 3D printed LAA model (Care Tronik, Prato, Italy) was used in a rehearse phase. Both patients had history of paroxysmal AF and previous transient ischemic attack (TIA) occurred during oral anticoagulation with correct INR. In the first patient the occlusive device was positioned within the LAA after a rehearse occlusion using the 3D printed LAA plus a 27 mm Coherex Wavecrest device, demonstrating a good compression and sealing, particularly considering a proximal lobe of the appendage. In the second patient an attempt with the 27 mm Amulet device delivered within the 3D printed LAA, based on angiography and transesophageal echocardiographic (TEE), revealed insufficient covering of the proximal part of LAA vestibule; the device was released only after a second test with the 31 mm Amulet demonstrating a good sealing.

CONCLUSION

These 2 cases demonstrated that 3D model could help in finding the correct position within LAA, sizing the device and guiding the choice of the closure device despite the measurements provided by angiography and TEE.