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Funding Acknowledgements Type of funding sources: None. Background A high incidence of pulmonary vein (PV) reconnection has been reported in patients with clinical recurrences of AF. Detailed characterization of PV gaps in terms of local impedance (LI) is still lacking. Purpose to characterize PV gaps with a novel local impedance algorithm during redo PV ablation in AF patients (pts). Methods Consecutive pts undergoing repeated AF ablation from the CHARISMA registry with complete characterization of PV gaps through local impedance at 6 Italian centers were included. A complete map of the left atrium and PVs was performed prior and after ablation through the Rhythmia mapping system. A novel RF ablation catheter with dedicated algorithm (DirectSense) was used to measure LI at the distal electrode of this catheter. Each gap was characterized in terms of LI and its variations during ablation procedure according to different ablation sites around the PVs. 7 sites around the left and right pair of PV for LI evaluation during ablation were defined: 2 for posterior sites (PS) (posterior inferior and posterior superior), 2 for anterior sites (AN) (anterior inferior and anterior superior), 1 for interior site (INF), 1 for superior site (SUP) and 1 for the carina (CAR). Ablation endpoint was PVI as assessed by entrance and exit block. Results Eighteen cases of redo AF ablation were analyzed (9 after prior RF ablation, 9 after prior cryoablation). A total of 41 PV gaps were detected (20 after RF ablation, 21 after cryoablation; mean number of gaps per pt = 2.3 ± 1.1): one gap was identified In five (27.8%) pts, 2 gaps were present in 7 (38.9%) pts, 3 gaps were detected in 2 (11.1%) pts and 4 gaps were identified in the remaining 4 (22.2%) pts. PV gaps were most common at AN sites (17, 41.5%), followed by PS sites (12, 29.3%) and CAR sites (11, 28.6%). The mean LI at gap sites was 113.9 ± 15Ω prior to ablation: it was significantly higher than LI at scar tissue closer to gap (99.7 ± 8Ω, p Conclusion In our preliminary experience, PV gaps after failed PVI were most common at anterior, followed by posterior and carina sites. LI characteristics at PV gaps significantly differ from both scar and healthy tissue and could be used to target ablation deliveries.

Aims Per standard of care, dual-chamber pacemakers are programmed in DDDR mode with fixed atrioventricular (AV) delay or with long AV delay to minimize ventricular pacing. We aimed to evaluate whether the PR interval may be a specific criterion of choice between standard DDDR, to preserve AV synchrony in long PR patients, and managed ventricular pacing (MVP), to avoid ventricular desynchronization imposed by right ventricle apical pacing, in short PR patients. Methods and results In the MINERVA trial, 1166 patients were randomized to Control DDDR, MVP, or atrial anti-tachycardia pacing plus MVP (DDDRP + MVP). We evaluated the interaction of PR interval with pacing mode by comparing the risk of atrial fibrillation (AF) longer than 7 consecutive days as a function of PR interval. Out of 906 patients with available data, the median PR interval was 180 ms. The PR interval was found to significantly (P = 0.012) interact with pacing mode for AF incidence: the risk of AF > 7 days was lower [hazard ratio (HR) 0.58, 95% confidence interval (95% CI) 0.34-0.99; P = 0.047] in patients with short PR (shorter than median PR) if programmed in MVP mode compared with DDDR mode and it was lower (HR 0.65, 95% CI 0.43-0.99; P = 0.049) in patients with long PR (equal to or longer than median PR) if programmed in DDDR mode compared with MVP. Conclusion Our data show that PR interval may be used as a selection criterion to identify the optimal physiological pacing mode. Persistent AF incidence was lower in short PR patients treated by right ventricular pacing minimization and in long PR patients treated by standard dual-chamber pacing.

Funding Acknowledgements NO FUNDING OnBehalf RHYTHM DETECT Registry Background The class of recommendation for S-ICD implantation in patients who have inadequate vascular access is I according to AHA-ACC-HRS Guidelines and IIb according to ESC Guidelines. Data are lacking about the use of S-ICD for patients in which a transvenous ICD is not a viable option because of the inability to deploy a transvenous lead. Purpose To describe current practice and to measure outcomes associated with S-ICD use in patients in which a transvenous ICD is not a viable option. Methods 942 consecutive patients underwent S-ICD implantation at 22 Italian centers from 2014 to 2019. We identified 101 (11%) patients who received S-ICD because of the reported impossibility of deploying a transvenous lead. Results 21 patients presented with inadequate vascular access but no previous device in place. One patient had a mechanical prosthesis in tricuspid position. The remaining 79 patients received the S-ICD after removal of a prior system implanted, and venous occlusion was diagnosed after lead extraction, or partially or completely failed lead removal. In 24 of these patients a functional transvenous pacing system was left in place for persisting pacing needs. Patients were 60 ± 15 years old, 85% were male, 77% had ischemic or non-ischemic dilated cardiomyopathy, ejection fraction was 36 ± 13%. At implantation, acute conversion test was performed in 64 patients and shock energy of ≤65J was successful in 62 (96.9%) patients. During a median follow-up of 18 months, 6 patients died for non-device related reasons and 1 patient underwent heart transplantation. One patient underwent device replacement for battery depletion and one patient underwent leadless pacemaker implantation. Minor complications (hematomas not requiring system revision) were reported in 2 patients. Appropriate therapies were delivered in 4 patients and 8 patients experienced inappropriate therapies (in 3 patients due to double counting during pacing); all resolved with device reprogramming. Conclusions: In current clinical practice, a minority of S-ICD patients receive the device because of inadequate vascular access. The profile of these patients is similar to that of the typical ICD population in the context of primary sudden death prevention, but many of them present with pacing indications. Acute and mid-term efficacy of S-ICD seemed high. Few complications occurred during follow-up. Particular attention must be paid to device programming for those patients with concomitant pacing systems, in order to prevent inappropriate therapies.

Background. Atrial fibrillation (AF) is the most frequent sustained arrhythmia found in clinical practice. Its prevalence significantly grows with age. The proportion of elderly individuals with depression varies between 4.2 and 10.6% according to the different criteria used for diagnosis. Interestingly, AF and depression synergistically act to increase mortality. Purpose. Aim of this study was to identify the clinical variables associated with depressive symptoms in elderly individuals with persistent AF. Methods. All patients consecutively admitted in a Day-Hospital setting to undergo electrical cardioversion of AF were enrolled in the study. No exclusion criteria were specified. Population was studied with instruments exploring neurocognitive performance (Mini-Mental State Examination - MMSE; range: 0-30; abnormal values 5). In this case, lower scores identified a healthier emotional profile. Results. Between January 2018 and August 2019, 111 patients were evaluated (age: 77 ± 9 years; women: 39.6%; weight: 78 ± 15 Kg; height: 171 ± 11 cm). Lone AF and brady- tachy- syndrome were diagnosed in 12.6% of cases. Hypertension and structural heart disease (coronary artery disease, heart failure, valvular heart disease) were responsible of the arrhythmia in 30.6% and 56.8% of patients, respectively. Left ventricular ejection fraction was 60 ± 12%, with a heart rate equal to 78 ± 17 bpm. MMSE and SPPB score were 28 ± 3 and 8.7 ± 2.9. An abnormal GDS score was observed in 19.8% of cases (mean: 3.0 ± 2.7). Interestingly, in univariate analysis, depressive symptoms increased with age (p = 0.002) and the CHA2DS2-VASc score ( =6: 4.4 ± 2.8; p Conclusions. In a population of elderly patients with persistent AF, the prevalence of depression is not negligible. Importantly, depressive symptoms are significantly associated with the CHA2DS2-VASs score, and, at multivariate analysis, with renal function, to live alone and physical performance. Paradoxically, after adjustment for these factors, GDS score decreases with age per se.