Impact of dexmedetomidine on electrophysiological properties and arrhythmia inducibility in adult patients referred for reentrant supraventricular tachycardia ablation.

BACKGROUND: Drugs used for sedation/analgesia may affect the basic cardiac electrophysiologic properties or even supraventricular tachycardia (SVT) inducibility. Dexmedetomidine (DEX) is a selective alpha-2 adrenergic agonist with sedative and analgesic properties. A comprehensive evaluation on use of DEX for reentrant SVT ablation in adults is lacking. The present study aims to systematically assess the impact of DEX on cardiac electrophysiology and SVT inducibility. METHODS: Hemodynamic, electrocardiographic, and electrophysiological parameters and SVT inducibility were assessed before and after DEX infusion in patients scheduled for ablation of reentrant SVT. RESULTS: The population of this prospective observational study included 55 patients (mean age of 58.7 ± 14 years, 29 males [52.7%]). A decrease in systolic and diastolic blood pressure and in heart rate was observed after DEX infusion (p = 0.001 for all). DEX increased corrected sinus node refractory time, atrial effective refractory period, AH interval, AV Wenckebach cycle length, and AV node effective refractory period without affecting the His-Purkinje conduction or ventricular myocardium refractoriness. No AV blocks or sinus arrests occurred during DEX infusion. Globally, there was no difference in SVT inducibility in basal condition or after DEX infusion (46/55 [83.6%] vs. 43/55 [78.1%] patients; p = 0.55), without a difference in isoprenaline use (p = 1.0). In 4 (7.3%) cases, the SVT was inducible only after DEX infusion. In 34.5% of cases, DEX infusion unmasked the presence of an obstructive sleeping respiratory pattern, represented mainly by snoring. CONCLUSIONS: DEX depresses sinus node function and prolongs atrioventricular refractoriness without significantly affecting the rate of SVT inducibility in patients scheduled for reentrant SVT ablation.

The role of fibrosis, inflammation, and congestion biomarkers for outcome prediction in candidates to cardiac resynchronization therapy: is "response" the right answer?

Background: Cardiac resynchronization therapy (CRT) is an established treatment in selected patients suffering from heart failure with reduced ejection fraction (HFrEF). It has been proposed that myocardial fibrosis and inflammation could influence CRT "response" and outcome. Our study investigated the long-term prognostic significance of cardiac biomarkers in HFrEF patients with an indication for CRT. Methods: Consecutive patients referred for CRT implantation were retrospectively evaluated. The soluble suppression of tumorigenicity 2 (sST2), galectin-3 (Gal-3), N-terminal portion of the B-type natriuretic peptide (NT-proBNP), and estimated glomerular filtration rate (eGFR) were measured at baseline and after 1 year of follow-up. Multivariate analyses were performed to evaluate their correlation with the primary composite outcome of cardiovascular mortality and heart failure hospitalizations at a mean follow-up of 9 ± 2 years. Results: Among the 86 patients enrolled, 44% experienced the primary outcome. In this group, the mean baseline values of NT-proBNP, Gal-3, and sST2 were significantly higher compared with the patients without cardiovascular events. At the multivariate analyses, baseline Gal-3 [cut-off: 16.6 ng/ml, AUC: 0.91, p < 0.001, HR 8.33 (1.88-33.33), p = 0.005] and sST2 [cut-off: 35.6 ng/ml AUC: 0.91, p < 0.001, HR 333 (250-1,000), p = 0.003] significantly correlated with the composite outcome in the prediction models with high likelihood. Among the parameters evaluated at 1-year follow-up, sST2, eGFR, and the variation from baseline to 1-year of Gal-3 levels showed a strong association with the primary outcome [HR 1.15 (1.08-1.22), p < 0.001; HR: 0.84 (0.74-0.91), p = 0.04; HR: 1.26 (1.10-1.43), p ≤ 0.001, respectively]. Conversely, the echocardiographic definition of CRT response did not correlate with any outcome. Conclusion: In HFrEF patients with CRT, sST2, Gal-3, and renal function were associated with the combined endpoint of cardiovascular death and HF hospitalizations at long-term follow-up, while the echocardiographic CRT response did not seem to influence the outcome of the patients.

Subcutaneous versus transvenous implantable cardioverter-defibrillator among drug-induced type-1 ECG pattern Brugada syndrome: a propensity score matching analysis from IBRYD study.

No real-world data are available about the complications rate in drug-induced type 1 Brugada Syndrome (BrS) patients with an implantable cardioverter-defibrillator (ICD). Aim of our study is to compare the device-related complications, infections, and inappropriate therapies among drug-induced type 1 BrS patients with transvenous- ICD (TV-ICD) versus subcutaneous-ICD (S-ICD). Data for this study were sourced from the IBRYD (Italian BRugada sYnDrome) registry which includes 619 drug-induced type-1 BrS patients followed at 20 Italian tertiary referral hospitals. For the present analysis, we selected 258 consecutive BrS patients implanted with ICD. 198 patients (76.7%) received a TV-ICD, while 60 a S-ICD (23.4%). And were followed-up for a median time of 84.3 [46.5-147] months. ICD inappropriate therapies were experienced by 16 patients (6.2%). 14 patients (7.1%) in the TVICD group and 2 patients (3.3%) in S-ICD group (log-rank P = 0.64). ICD-related complications occurred in 31 patients (12%); 29 (14.6%) in TV-ICD group and 2 (3.3%) in S-ICD group (log-rank P = 0.41). ICD-related infections occurred in 10 patients (3.88%); 9 (4.5%) in TV-ICD group and 1 (1.8%) in S-ICD group (log-rank P = 0.80). After balancing for potential confounders using the propensity score matching technique, no differences were found in terms of clinical outcomes between the two groups. In a real-world setting of drug-induced type-1 BrS patients with ICD, no significant differences in inappropriate ICD therapies, device-related complications, and infections were shown among S-ICD vs TV-ICD. However, a reduction in lead-related complications was observed in the S-ICD group. In conclusion, our evidence suggests that S-ICD is at least non-inferior to TV-ICD in this population and may also reduce the risk of lead-related complications which can expose the patients to the necessity of lead extractions.

Radiation awareness in an Italian multispecialist sample assessed with a web-based survey.

INTRODUCTION: The awareness of radiation doses and risks, also during interventional cardiology procedures, is essential today in order to apply the risk-benefit assessment and to reinforce the principles of justification and optimisation in clinical practice. METHODS: A voluntary survey with 10 questions and multiple-choice answers was run on a popular cardiology website (www.cardiolink.it) independently by a scientific publisher, in order to evaluate the contemporary level of radiation awareness in a multi-speciality sample of physicians in Italy. RESULTS: One thousand eight hundred and sixty-one physicians completed the test. The survey showed good results since both prescribers and practitioners (mostly cardiologists) working in Italy are largely aware of the cancer and non-cancer risks of medical radiation use, regardless of their subspecialty background. CONCLUSION: Physicians are largely aware of the cancer and non-cancer risks of medical radiation use, regardless of their subspecialty background. However, there is still broad space for improvement; in the future, the awareness of radiation risk is a prerequisite to create a culture of respect for radiation hazard and a commitment to minimise exposure and maximise protection.

Sleep-disordered breathing and effectiveness of cardiac resynchronization therapy in heart failure patients: gender differences?

OBJECTIVES: This study evaluated heart failure (HF) patients who underwent cardiac resynchronization therapy (CRT) and who had device-documented sleep-disordered breathing (SDB). We found gender differences in acute changes in SDB due to CRT impact. BACKGROUND: SDB typically occurs in HF patients. However, the role of SDB and its response to CRT in HF patients, as well as the relation with gender are currently not fully researched. METHODS: Among 63 consecutive patients who received CRT with an SDB algorithm, 23 patients documented SDB at one-month cardiac device interrogation and represented our population. We defined a Sleep apnoea Severity SCore(SSSC), and consequently, patients were categorized to have mild, moderate, and severe sleep apnoea syndrome divided into two groups: Group-1: 18 males (78%); Group-2: 5 females (22%). We evaluated the variation of apnoea burden and CRT response based on gender differences. RESULTS: A significantly higher proportion of patients in the male group were non-responders to CRT at 12-months follow-up (p = 0.076) while in the female population 5/5 patients (100%) were responders to CRT at the same follow-up time (p = 0.021). Among Group-2 subjects, we documented a significant linear decrease in SSSC(p > 0,01) while in Group-1 the CRT effect on SSSC was variable. At 12-months follow-up, the difference in SSSC between the two groups was statistically significant (p < 0.001). CONCLUSIONS: Our study reports a correlation between CRT response and sleep apnoea burden considering gender differences. In particular, HF-women responders to CRT demonstrate a significant linear decrease in sleep apnoea burden determined through a device algorithm, when compared to a similar male population. Further research is needed to confirm these findings.

Long-term outcomes after "Zero X-ray" arrhythmia ablation.

PURPOSE: Radiation exposure related to conventional tachyarrhythmia radiofrequency catheter ablation (RFCA) carries small but definite risk for both patients and operators. Today, non-fluoroscopic mapping systems enable to perform catheter ablation with minimal or zero fluoroscopy. The purpose of this study was to evaluate the long-term outcome of patients who had undergone "Zero X-ray" ablation, since no information is available on the very long-term benefits. METHODS: A total of 272 arrhythmias in 266 patients have been treated with catheter ablation by means of a zero-ray approach guided only by a nonconventional mapping system (EnSite NavX™, Ensite™ Velocity™ mapping system; subsequently Ensite™ Precision™ Abbott, St. Paul, MN). Fluoroscopy was never used. RESULTS: Over a period of 6 years, patients were followed up for an average of 2.9 ± 1.6 years. A 100% rate of acute success was observed in the study population, with a complication rate of 0.8%. Chronic success was achieved in 90.8% of the total number of procedures (272). Patients in whom the same arrhythmia recurred during follow-up underwent to a redo catheter ablation procedure in 60.0% of cases, while the remaining 40.0% underwent pharmacological treatment. A new post-ablation arrhythmia occurred in 7.7% of the sample. CONCLUSIONS: The non-fluoroscopic approach is a feasible and safe alternative to fluoroscopy for arrhythmias ablation. This method ensures low complications rates, high acute procedural success rates, and comparable long-term outcomes with clinical benefits for both patients and physicians. The complete elimination of fluoroscopy during catheter ablation is advantageous and does not reduce patient safety.

Ablation of recurrent malignant idiopathic ventricular tachycardia: When proper diagnosis and success is a matter of contact.

Effective and stable contact between the catheter tip and the tissue is crucial for both mapping and lesion formation during cardiac ablation procedures. Contact force catheter may be not only a therapeutic approach to arrhythmias, but also a tool for achieving accurate characterization of the arrhythmic substrate.

Recurrences in the Blanking Period and 12-Month Success Rate by Continuous Cardiac Monitoring After Cryoablation of Paroxysmal and Non-Paroxysmal Atrial Fibrillation.

INTRODUCTION: Recurrences within the blanking period (early recurrences) are common after atrial fibrillation (AF) ablation by pulmonary vein isolation (PVI), but their clinical significance is still controversial. We aimed at evaluating the significance of within-blanking recurrences at 12-month follow-up after cryoballoon (CB) PVI, and to assess the real procedural success rate by continuous monitoring of cardiac rhythm. METHODS AND RESULTS: Sixty consecutive AF patients (34 paroxysmal, 56.7%) underwent their first CB-PVI at one Italian center (May 2013 to April 2015), and subsequent implantation of an implantable loop recorder (ILR). Overall, 12-month success rate after the blanking period was 55%. The shortest detected event was 7 minutes long. Late recurrences were more frequent in non-paroxysmal (19/26, 73.1%) than in paroxysmal AF (8/34, 23.5%; P <0.001). Early recurrences occurred in 17 (28.3%) patients, with 14 also having late recurrences (82.3%), while only 13 out of 43 (30.2%) without within-blanking recurrences experienced post-blanking events (P <0.001). Overall, early recurrences showed 51.8% sensitivity (95% CI 31.9-71.3%) and 90.9% specificity (95% CI 75.7-98.1%) for later recurrences, with 82.3% (95% CI 56.6-96.2%) positive and 69.8% (95% CI 53.9-82.8%) negative predictive value. The positive likelihood ratio was 5.7 (95% CI 1.8-17.8). At multivariable analysis, non-paroxysmal AF (HR: 3.113; 95% CI 1.309-7.403; P = 0.010) and within-blanking recurrences (HR: 3.453; 95% CI 1.544-7.722; P = 0.003) were independent predictors of post-blanking AT/AF. CONCLUSION: CB-PVI for paroxysmal AF shows a 12-month success rate of 76.5% after one single procedure, as assessed by continuous cardiac rhythm monitoring. Within-blanking recurrences predict the ablation failure in more than 80% of patients.

Left ventricular rotational dyssynchrony before cardiac resynchronization therapy: a step forward into ventricular mechanics.

AIMS: Heart failure patients show impaired left ventricular rotation and twist. In patients undergoing cardiac resynchronization therapy (CRT) significance of preimplant left ventricular rotational timing between different ventricular regions is unknown. We thoroughly evaluated, in patients eligible for CRT, baseline left ventricular rotational mechanics, also assessing segmental rotational timing, and investigated whether the presence of rotational dyssynchrony may be associated with echocardiographic response. METHODS: By two-dimensional speckle-tracking echocardiography, baseline peak apical and basal rotation, peak twist, and time-related parameters, such as delays between opposite segments at base and apex, were assessed in 55 CRT patients and 11 healthy participants. RESULTS: At 6 months, 30 (54%) patients were echocardiographic responders. Left ventricular rotation and twist had no association with response. All time-related parameters were significantly altered in CRT patients. Maximum basal and apical segments delay, and anteroseptal-posterior delays at base and apex, were longer in responders than in nonresponders (P < 0.05 for all), regardless of the presence of left bundle branch block (LBBB) and QRS duration. At multivariable analysis, apical anteroseptal-posterior delay resulted as independently associated with response [odds ratio (OR): 1.022 (1.007-1.038); P = 0.004]. A cut-off value of 97.5 ms for apical anteroseptal-posterior delay predicted response with 96% specificity and 57% sensitivity (AUC = 0.83). Magnitude of left ventricular reverse remodeling was significantly related to apical anteroseptal-posterior delay (P = 0.001). CONCLUSION: In heart failure patients eligible for CRT, left ventricular rotational timing is altered. Dyssynchrony in rotational mechanics shows a specific pattern in responders regardless of the presence of LBBB. Apical anteroseptal-posterior rotational delay is independently associated with left ventricular reverse remodeling.

Correlations between NT-proBNP, outcome and haemodynamics in patients with septic shock.

AIM: The aim of this study was to determine the role of NT-proBNP in predicting the outcome of septic patients and to evaluate possible correlations between NT-ProBNP and haemodynamics in sepsis. METHODS: Forty consecutive patients with severe sepsis were prospectively evaluated. Patients were treated with the gold standard therapy for sepsis. NT-BNP levels, endotoxin activity (EA), SOFA score and SAPS II score, cardiac index (CI), mean arterial pressure (MAP) and pulmonary arterial pressure (PAP) were evaluated at admission and after 72 hours. Survival was evaluated at 28 days after admission. RESULTS: At 4-week follow-up, 22 patients had died (55%). Survival was not associated with age, gender, baseline EA and treatment, while it was associated with NT-proBNP levels at admission and after 72 hours. NT-proBNP>1,000 pg/ml at 72 hours was a robust independent predictor of survival. The area under the curve (AUC) of NT-proBNP at admission was 0.73 and 0.99 after 72 hours. At 72 hours, AUC for SOFA score was 0.94, for SAPS II score 1, for EA 0.73. Levels of NT-proBNP>1,000 pg/ml at 72 hours were associated with an adverse outcome (sensitivity 95.5%, specificity 94.4%). NT-proBNP at 72 hours correlated with CI, MAP and PAP (P<0.01, <0.01,<0.05 respectively). CONCLUSIONS: Increased NT-proBNP levels at 72 hours could predict mortality at 28 days in patients with septic shock and are correlated with haemodynamics.

Cryoablation of typical AVNRT: Younger age and administration of bonus ablation favor long-term success.

BACKGROUND: Cryoablation (CA) is an emerging tool for the treatment of supraventricular tachyarrhythmias. Determinants of long-term success still need clarification. OBJECTIVE: The purpose of this study was to assess which patients' and procedural features affect the long-term efficacy of CA for typical atrioventricular nodal reentrant tachycardia (AVNRT). METHODS: Eighty-five consecutive patients undergoing CA for typical AVNRT were divided into 3 groups of age: group A, ≤20 years, n = 20 (23.5%); group B, 21-50 years, n = 30 (35.3%); group C, ≥51 years, n = 35 (41.2%). CA was performed for 5 minutes at -75°C in all; 4-minute bonus CA was delivered if not contraindicated (ie, transient PR interval lengthening during the first application and narrow triangle of Koch). The efficacy end point was the absence of recurrences at 12-month follow-up. RESULTS: CA was acutely successful in all 85 patients (100%). Bonus ablation was performed in 69 (81.2%). No permanent complications were observed. At follow-up, AVNRT recurrences occurred in 9 patients (10.6%): group A, 0 (0%); group B, 2 (6.7%), group C, 7 (20%). Incidence of recurrences was significantly different between age groups (P = .047) and between patients receiving (7.2%) and not receiving (25.0%) bonus CA (P = .038). In multivariable analysis, age groups (odds ratio [OR] 5.917; 95% confidence interval [CI] 1.372-25.518; P = .017) and bonus CA (OR 0.115; 95% CI 0.018-0.724; P = .021) were the only independent predictors of recurrences. Furthermore, age as a continuous variable remained statistically associated with recurrences (OR 1.046; 95% CI 1.002-1.091; P = .038). CONCLUSION: CA is effective and safe for typical AVNRT ablation. Younger age and bonus CA administration are independent predictors of success at 12 months. Incidence of recurrences is low in patients younger than 21 years.

Echocardiographic and biohumoral characteristics in patients with AL and TTR amyloidosis at diagnosis.

BACKGROUND: Few studies have analyzed the clinical and echocardiographic differences between light-chain (AL) and transthyretin (TTR) amyloidosis. HYPOTHESIS: The aim of the present research was to compare, in a real-world setting, the clinical and echocardiographic profiles of these kinds of amyloidosis, at the time of diagnosis, using new-generation echocardiography. METHODS: Seventy-nine patients with AL and 48 patients with TTR amyloidosis were studied. RESULTS: According to the criterion of mean left ventricular (LV) thickness >12 mm, 45 AL (C-AL) and all TTR patients had cardiac amyloidotic involvement, whereas 34 AL patients did not. TTR patients had increased right ventricular (RV) and LV chambers with increased RV and LV wall thickness and reduced LV ejection fraction and fractional shortening. Furthermore, TTR patients showed lower N-terminal pro Brain Natriuretic Peptide concentrations and New York Heart Association functional class when compared with C-AL. CONCLUSIONS: Our data show that at time of first diagnosis, TTR patients have a more advanced amyloidotic involvement of the heart, despite less severe symptoms and biohumoral signs of heart failure. We can hypothesize that we observed different diseases at different stages. In fact, AL amyloidosis is a multiorgan disease with quick progression rate, that becomes rapidly symptomatic, whereas TTR amyloidosis might have a slow progression rate and might remain poorly symptomatic for a greater amount of time.

Impact of Uncontrolled Hypertension on Atrial Fibrillation Ablation Outcome.

OBJECTIVES: The goal of this study was to evaluate the impact of hypertension on the outcome of atrial fibrillation (AF) ablation. BACKGROUND: Hypertension is a well-known independent risk factor for incident AF. METHODS: A total of 531 consecutive patients undergoing AF ablation were enrolled in this study and divided into 3 groups: patients with uncontrolled hypertension despite medical treatment (group I, n = 160), patients with controlled hypertension (group II, n = 192), and patients without hypertension (group III, n = 179). Pulmonary vein (PV) antrum and posterior wall isolation was always performed, and non-PV triggers were identified during isoproterenol infusion. All patients underwent extensive follow-up. RESULTS: Three groups differed in terms of left atrial (LA) size, non-PV triggers, and moderate/severe LA scar. Non-PV triggers were present in 94 (58.8%), 64 (33.3%), and 50 (27.9%) patients in groups I, II, and III, respectively (p < 0.001). After 19 ± 7.7 months of follow-up, 65 (40.6%), 54 (28.1%), and 46 (25.7%) patients in groups I, II, and III had recurrences (log-rank test, p = 0.003). Among patients in group I who underwent additional non-PV trigger ablation, freedom from AF/atrial tachycardia was 69.8%, which was similar to groups II and III procedural success (log-rank p = 0.7). After adjusting for confounders, uncontrolled hypertension (group I) (hazard ratio [HR]: 1.52, p = 0.045), non-PV triggers (HR: 1.85, p < 0.001), and nonparoxysmal AF (HR: 1.64, p = 0.002) demonstrated significant association with arrhythmia recurrence. CONCLUSIONS: Controlled hypertension does not affect the AF ablation outcome when compared with patients without hypertension. By contrast, uncontrolled hypertension confers higher AF recurrence risk and requires more extensive ablation.

QRS duration in left bundle branch block does not affect left ventricular twisting in chronic systolic heart failure.

PURPOSE: Left ventricular (LV) torsion is an important parameter of LV performance and can be influenced by several factors. Aim of this investigation was to evaluate whether QRS prolongation in left bundle branch block (LBBB) may influence global LV twist and twisting/untwisting rate in chronic systolic heart failure (HF) patients. METHODS: We prospectively evaluated 30 healthy subjects (control group) and 100 chronic HF patients with severely impaired LV systolic function (ejection fraction ≤ 35%). Patients were divided into three groups according to QRS duration: A: QRS < 120 ms (n 49), B: 120 ≤ QRS ≤ 150 ms (n 28) and C: QRS > 150 ms (n 23). Patients in groups B and C presented LBBB. All subjects underwent standard trans-thoracic echocardiography and two-dimensional speckle-tracking echocardiography evaluation. Categorical variables were compared by the chi-square or the Fisher's exact test. Continuous variables were compared using the ANOVA test. Correlations between variables were analysed with linear regression. RESULTS: Control subjects presented higher torsion parameters, when compared with patients in any HF group. Among the three HF groups, no differences were detected in global twist (4.79 ± 3.54, 3.8 ± 3.0 and 4.15 ± 3.14 degrees, respectively), twist rate max (44.81 ± 25.03, 37.94 ± 19.09 and 37.61 ± 24.49 degrees s(-1), respectively) and untwist rate max (-36.31 ± 30.89, -27.68 ± 34.67 and -39.62 ± 26.27 degrees s(-1), respectively) (P>0.05 for all). At linear regression analysis, there was no relation between QRS duration and any torsion parameter (P>0.05 for all). CONCLUSIONS: In patients with chronic severe systolic heart failure, QRS duration and LBBB morphology do not affect LV twisting and untwisting.

Simplified Selvester Score: a practical electrocardiographic instrument to predict response to CRT.

AIMS: To investigate the LBBB Selvester Scoring System (LBBB-SSc) and the Simplified-SSc prognostic impact in predicting response to CRT, all cause and cardiac mortality, heart failure (HF) hospitalizations and onset of arrhythmias in HF patients undergoing CRT. METHODS: We retrospectively evaluated LBBB-SSc and Simplified-SSc of 172 consecutive HF patients with true-LBBB who underwent CRT. Response to CRT was defined as the improvement of LVEF of at least 10% or as the reduction of LVESV of at least 15% at 6-month follow-up. Logistic regression analysis and Cox proportional hazard analysis were performed to evaluate each endpoint related risk according to LBBB-SSc and Simplified-SSc. RESULTS: The LBBB-SSc and the Simplified-SSc were inversely correlated with response to CRT. Myocardial scar at both scores was independently associated to non-response to CRT. No correlation was observed between LBBB-SSc or Simplified-SSc and other endpoints. CONCLUSIONS: In HF patients with true-LBBB, Simplified-SSc is able to predict response to CRT.

Management of refractory atrial fibrillation post surgical ablation.

Over the past two decades, invasive techniques to treat atrial fibrillation (AF) including catheter-based and surgical procedures have evolved along with our understanding of the pathophysiology of this arrhythmia. Surgical treatment of AF may be performed on patients undergoing cardiac surgery for other reasons (concomitant surgical ablation) or as a stand-alone procedure. Advances in technology and technique have made surgical intervention for AF more widespread. Despite improvements in outcome of both catheter-based and surgical treatment for AF, recurrence of atrial arrhythmias following initial invasive therapy may occur.Atrial arrhythmias may occur early or late in the post-operative course after surgical ablation. Early arrhythmias are generally treated with prompt electrical cardioversion with or without antiarrhythmic therapy and do not necessarily represent treatment failure. The mechanism of persistent or late occurring atrial arrhythmias is complex, and these arrhythmias may be resistant to antiarrhythmic drug therapy. The characterization and management of recurrent atrial arrhythmias following surgical ablation of AF are discussed below.

Visual, tactile, and contact force feedback: which one is more important for catheter ablation? Results from an in vitro experimental study.

BACKGROUND: During radiofrequency ablation, effective contact is crucial in determining lesions efficacy. OBJECTIVE: The purpose of this study was to compare operators' ability to assess contact pressure using visual and tactile feedbacks together or alone in an experimental model. METHODS: In a in vitro experimental setup replicating manual catheter manipulation and recording the applied force, evaluators were asked to identify three levels of force (first, ablation, and maximum contact) as the catheter contacted the tissue model using (1) visual feedback only by fluoroscopy, "blinded" to touch; (2) tactile feedback only, blinded to fluoroscopy; and (3) both tactile and visual feedback together. The latter was regarded as reference. The experiment was repeated using a catheter force sensing technology during robotic navigation. RESULTS: During manual navigation, tighter association was shown for the visual method than for the tactile method: median difference with reference: first contact -1 (P = .97) vs -2 (P = .90); ablation contact 2 (P = .1) vs -7 (P = .03); maximum contact 2 (P = .06) vs -28 (P = .02). Bland-Altman plot and Deming regression confirmed for the visual method the good agreement with reference and the absence of bias at any level and showed for the tactile higher values and proportional bias that reached statistical significance at ablation and maximum contact. During robotic navigation, agreement was higher for the tactile than for the visual only method. CONCLUSION: During manual navigation, visual feedback alone is in better agreement with the reference compared to the tactile only approach. During robotic navigation, agreement is looser for the visual only approach. More objective feedback of contact pressure during ablation procedures is desirable.

CHADS2 and CHA2DS2-VASc scores to predict morbidity and mortality in heart failure patients candidates to cardiac resynchronization therapy.

AIMS: CHADS2 and CHA2DS2-VASc scores are pivotal in assessing the risk of stroke in atrial fibrillation patients, and were recently proved to predict hospitalizations and mortality in specific clinical settings. Aim of this study was to evaluate whether these scores could predict clinical outcomes [first hospitalization for heart failure (HF) and a combined event of HF hospitalization and death for any cause] in patients candidates to cardiac resynchronization therapy and implantable defibrillator (CRT-D). METHODS AND RESULTS: In a retrospective multicentre Italian study, we enrolled 559 consecutive HF patients candidates to CRT-D, and we grouped them in three pre-specified risk classes: low (CHADS2/CHA2DS2-VASc 1-2), moderate (CHADS2/CHA2DS2-VASc 3-4), and high (CHADS2 5-6/CHA2DS2-VASc 5-8). All patients underwent regular follow-up at implanting centres every 6 months; data collection was extended till the 72th month of follow-up. At a median FU of 30 months, 143 patients (25.4%) were hospitalized for HF and 110 (19.5%) died. Event-free survival analysis showed a significant difference according to baseline CHADS2 and CHA2DS2-VASc scores (Log-Rank for HF P < 0.001 for CHADS2 and CHA2DS2-VASc; Log-Rank for combined end-point P = 0.001 for CHADS2, P < 0.001 for CHA2DS2-VASc). At multivariate analysis, independent predictors of endpoints were: previous atrial fibrillation (AF) or AF at implant, NYHA class, QRS duration and the CHA2DS2-VASc score (for HF hospitalization P = 0.013; for the combined event, P = 0.007), while the CHADS2 score was not independently associated with either the end-points. CONCLUSION: In CRT-D patients, pre-implant CHA2DS2-VASc score is an independent predictor of major clinical events at 30-month follow-up.