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Aims Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist and share an increased risk of thrombo-embolism (TE). CKD concomitantly predisposes towards a pro-haemorrhagic state. Our aim was to evaluate the prognostic value of CKD in patients undergoing percutaneous left atrial appendage occlusion (LAAO). Methods and results A total of 2124 consecutive AF patients undergoing LAAO were categorized into CKD stage 1+2 (n = 1089), CKD stage 3 (n = 796), CKD stage 4 (n = 170), and CKD stage 5 (n = 69) based on the estimated glomerular filtration rate at baseline. The primary endpoint included cardiovascular (CV) mortality, TE, and major bleeding. The expected annual TE and major bleeding risks were estimated based on the CHA2DS2-VASc and HAS-BLED scores. A non-significant higher incidence of major peri-procedural adverse events (1.7 vs. 2.3 vs. 4.1 vs. 4.3) was observed with worsening CKD (P = 0.14). The mean follow-up period was 13 ± 7 months (2226 patient–years). In comparison to CKD stage 1+2 as a reference, the incidence of the primary endpoint was significantly higher in CKD stage 3 (log-rank P -value = 0.04), CKD stage 4 (log-rank P -value = 0.01), and CKD stage 5 (log-rank P -value = 0.001). Left atrial appendage occlusion led to a TE risk reduction (RR) of 72, 66, 62, and 41% in each group. The relative RR of major bleeding was 58, 44, 51, and 52%, respectively. Conclusion Patients with moderate-to-severe CKD had a higher incidence of the primary composite endpoint. The relative RR in the incidence of TE and major bleeding was consistent across CKD groups. [ABSTRACT FROM AUTHOR]

Aims: Cryoballoon (CB) based pulmonary vein isolation (PVI) is a widely used technique for treatment of atrial fibrillation (AF); however the ideal energy dosing has not yet been standardized. This was a single-centre randomized clinical trial aiming at assessing the safety, acute efficacy, and clinical outcome of an individualized vs. a fixed CB ablation protocol using the fourth-generation CB (CB4) guided by pulmonary vein (PV) potential recordings and CB temperature.Methods and Results: Patients were randomized in a 1:1 fashion to two different dosing protocols: INDI-FREEZE group (individualized protocol): freeze-cycle duration of time to effect plus 90 s or interruption of the freeze-cycle and repositioning CB if a CB temperature of -30°C was not within 40 s. Control group (fixed protocol): freeze-cycle duration of 180 s. No-bonus freeze-cycle was applied in either patient group. The primary endpoint was freedom from atrial tachyarrhythmia at 12 months. Secondary end points included procedural parameters and complications. A total of 100 patients with paroxysmal AF were prospectively enrolled. No difference was seen in the primary endpoint [INDI-FREEZE group: 38/47 (81%) vs. control group: 40/47, (85%), P = 0.583]. The total freezing time was significantly shorter in the INDI-FREEZE group (157 ± 56 s vs. 212 ± 83 s, P < 0.001), while procedure duration (57.9 ± 17.9 min vs. 63.2 ± 20.2 min, P = 0.172) was similar. No differences were seen in the minimum CB and oesophageal temperatures as well as in periprocedural complications.Conclusion: Compared to the fixed protocol, the individualized approach provides a similar safety profile and clinical outcome, while reducing the total freezing time. [ABSTRACT FROM AUTHOR]

Background: Pulmonary vein isolation is the cornerstone of catheter ablation in patients with atrial fibrillation (AF). However, with advanced left atrial (LA) structural changes, additional targeted catheter ablation of low‐voltage zones (LVZs) has produced favorable results. Therefore, with the advent of single‐shot techniques, it would be helpful to predict the presence of LVZs before an ablation procedure. Objective: We hypothesized that computed tomography (CT)‐derived left atrial volume index (LAVI), in combination with other objective parameters, could be used to develop a score able to predict the presence of LVZs. Methods: In a large cohort of patients undergoing their first AF ablations, comprehensive echocardiographic evaluations and cardiac CT were performed. During the electrophysiological studies, LA geometry and electroanatomic voltage maps were created. LVZs were defined as areas ≥1 cm2 with bipolar peak‐to‐peak voltage amplitudes ≤0.5 mV. Results: In a derivation cohort of 374 patients, predictors of LVZs were identified by regression analysis and used to build the Zentralklinik Bad Berka and University of L'Aquila (ZAQ) score (age ≥65 years; female sex; and CT‐LAVI ≥57 mL/m2). The ZAQ score of 2 points accurately identified the presence and the extent of LVZs (area under the curve [AUC], 0.809; 95% confidence interval [CI], 0.758‐0.861; P <.001 and 3 [interquartile range, IQR, 1.5‐4.5] vs 7 cm2 [IQR 4‐9]; P =.001). In a validation cohort of 103 patients, the predictive value of the score was confirmed (AUC, 0.793; 95% CI, 0.709‐0.878; P <.001 and 4 [IQR, 2‐7] vs 11.5 cm2 [IQR, 8‐16.5]; P =.001). Conclusions: The ZAQ score identifies LVZs and may be useful for planning the ablation strategy ahead of time. [ABSTRACT FROM AUTHOR]

Purpose: Pericardial effusion (PE) may occur during the lead extraction procedure (TLE). Little is known about the incidence, causes, and predictors of this complication.Methods: From January 2009 to October 2016, TLE was attempted for 297 leads in 212 patients (age 69.3 ± 12.9 years, 169 male, BMI 27.2 ± 9.9 m²/kg, LVEF 43.4 ± 24.6%) for lead dysfunction (62.7%), upgrade (16.0%), infection (14.2%), or other (7.0%) indications. TLE was performed under general anesthesia with continuous invasive arterial blood pressure and transesophageal echocardiography (TEE) monitoring. For lead removal, the mechanical approach was first attempted, followed by the laser-assisted technique when needed. Severity of PE was defined by the presence of hemodynamically significant PE > 10 mm at TEE.Results: Clinical success was achieved for 292 leads (98.3%). New-onset PE was observed in 14 patients (6.6%) [mild entity in 7 patients (3.3%) and severe in 7 (3.3%)]. In these latter patients, intra-procedural management included surgery (n = 3), pericardiocentesis (n = 2), or a conservative approach (n = 2). Right ventricular (RV) site lesions were treated with a simple fluid infusion. Laceration of the superior vena cava and other vessels resulted in rescue surgery. Lesions of the right atrial free wall (n = 1) and coronary sinus (n = 1) were treated with pericardiocentesis. NYHA III/IV, LVEF < 35%, renal impairment, right-sided implant, and ≥2 leads targeted for TLE were associated with new-onset PE. More than two factors identified a higher risk group (16.2%, 95% CI 6.2-32.0%, P = 0.02).Conclusions: New-onset PE is common during TLE and is associated with specific factors. PE severity and subsequent patient management depend on the site of injury. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The aim of this study was to evaluate 17-year actual clinical outcomes of patients undergoing coronary artery bypass graft (CABG) using skeletonized versus pedicled bilateral internal mammary arteries (BIMAs). METHODS: FromSeptember 1991 to June 1996, 548 consecutive patients underwent CABG formultivessel disease using BIMA. After propensity matching, 350 patients were enrolled: 175 patients with skeletonized BIMA (Group S) and 175 with pedicled BIMA (Group P). The two groups were adequately comparable. Composite end-point: deaths, new revascularization and new myocardial infarctions were defined as 'events'. RESULTS: Group S provided a higher rate of total arterial myocardial revascularization (94.3 vs 82.9%, P 0.001) with a higher average number of arterial anastomoses (3.1 ± 0.8 vs 2.7 ± 0.8, P < 0.001) and BIMA anastomoses (2.5 ± 0.3 vs 2.1 ± 0.3, P < 0.001). In Group S, the incidence of sequential grafts was higher (37.7 vs 17.7%, P < 0.001). The rate of sternal wound healing problems was lower (1.7 vs 7.4%, P = 0.010). Thirty-day mortality and morbidity were similar. The median survival time of survivors was 17.8 years (min-max = 17.0-21.5); 17.3 (17.0-18.0) in Group S vs 19.1 (18.1-21.5) in Group P, P < 0.001. Seventeen-year actual outcomes were better in Group S: deaths (8.7 vs 27.9%, P < 0.001), cardiac deaths (4.7 vs 13.4%, P = 0.005), cardiac events (10.5 vs 22.1%, P = 0.003), new revascularization (2.9 vs 8.7%, P = 0.021) and events (15.1 vs 36.1%, P < 0.001). CONCLUSIONS: Skeletonization of BIMA allows one to achieve a higher rate of arterial grafting and better outcome if compared with pedicled BIMA. [ABSTRACT FROM AUTHOR]

A correction is presented to the article "Giuseppe Patti" which appeared in the previous issue.