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Aims: This report describes the findings of the 2018 Italian Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC)., Methods: The Italian Catheter Ablation Registry systematically collects data on the ablation procedures performed in Italy. Data collection was retrospective. A standardized questionnaire was completed by participating centres., Results: We collected data on 15 714 catheter ablation procedures performed in Italy during 2018 in 94 electrophysiology centres. In most centres (75/94, 80%), a single electrophysiology laboratory was available, and a hybrid electrophysiology laboratory was available in 15% (14/94) of centres. In most (93%) centres, at least two electrophysiologists were involved in the catheter ablation procedures. In only 13 out of 94 (14%) electrophysiology laboratories, an anaesthesiologist assists every electrophysiology procedure; in most cases (74/94, 79%), an on-demand anaesthesiology service was available. On-site cardiothoracic surgery was reported in 43 out of 94 (46%) centres.Nonfluoroscopic navigation systems were available in most centres (88/94, 93%). Intracardiac echocardiography was used in 59 out of 94 (63%) electrophysiology laboratories. Atrial fibrillation (31%) was the most frequently treated ablation target, followed by atrioventricular nodal re-entrant tachycardia (20%) and cavo-tricuspid isthmus (15%). In 61.7% of all procedures, a 3D mapping system was used. In about one-third of procedures, a near-zero approach was performed., Conclusion: In most Italian electrophysiology centres, a single electrophysiology laboratory was available and at least two electrophysiologists were involved in the ablation procedures. An increasing number of procedures were performed by means of a nonfluoroscopic mapping system with a near-zero approach., (Copyright © 2021 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Aim: To report the Italian data deriving from the European Society of Cardiology-EURObservational Research Program atrial fibrillation ablation long-term registry., Methods and Results: Ten Italian centers enrolled up to 50 consecutive patients undergoing atrial fibrillation ablation. Of the 318 patients included, 5 (1.6%) did not undergo catheter ablation, 1 had ablation partially done and 62 were lost at 1-year follow-up. Women were less represented (23.6%) and the median age was 60.0 years. A total of 195 patients (62.3%) suffered paroxysmal atrial fibrillation, whereas only 9 (2.9%) had long-standing persistent atrial fibrillation. Most Italian patients (92.3%) were symptomatic but suffering fewer symptomatic events than patients enrolled in other countries (median of two events in the month preceding the ablation vs. three, respectively; P < 0.0001). The main finding of the study is that the success rate at 1 year, with and without antiarrhythmic drugs, was 76.4%, consistently with other participating countries (73.4%). This result was obtained however, with a significantly lower prevalence of 1-year adverse events (7.3 vs. 16.6%, P < 0.0001). Procedure duration and fluoroscopy total time resulted as being shorter in Italy (145 vs. 160, P = 0.0005 and 16.9 vs. 20.0 min, P = 0.0018, respectively); however, the radiation dose per BSA was greater (37.5 vs. 26.0 mGy/cm, P = 0.0022)., Conclusion: The demographic characteristics of patients undergoing atrial fibrillation ablation are similar to those reported in other countries. The success rate in Italy is consistent with those in other countries, whereas the complications rate is lower.

Aims: We evaluated the ability of an ultrahigh mapping system to identify the most convenient Rhythmia ablation target (RAT) in intra-atrial re-entrant tachycardias (IART) in terms of the narrowest area to transect to interrupt the re-entry., Methods: A total of 24 consecutive patients were enrolled with a total of 26 IARTs. The Rhythmia mapping system was used to identify the RAT in all IARTs., Results: In 18 cases the RAT matched the mid-diastolic phase of the re-entry whereas in 8 cases the RAT differed. In these patients, the mid-diastolic tissue in the active circuit never represented the area with the slowest conduction velocity of the re-entry. The mean conduction velocity at the mid-diastolic site was significantly slower in the group of patients in which the RAT matched the mid-diastolic site (P = 0.0173) and that of the remaining circuit was significantly slower in the group in which the RAT did not match (P = 0.0068). The mean conduction velocity at the RAT was comparable between the two groups (P = 0.66)., Conclusion: Identifying the RAT in challenging IARTs by means of high-density representation of the wavefront propagation of the tachycardia seems feasible and effective. In one-third of cases this approach identifies an area that differs from the mid-diastolic corridor.

Aims: The aim of this survey was to assess the management and organization of cardiac implantable electronic device (CIED) replacement in Italy., Methods: A questionnaire consisting of 24 questions on organizational aspects and on the peri-procedural management of anticoagulant therapies and antibiotic prophylaxis was sent via the Internet to 154 Italian arrhythmia centers., Results: A total of 103 out of 154 centers completed the questionnaire (67% response rate). In 43% of the centers, the procedures were performed under day-case admission, in 40% under ordinary admission, and in 17% under either day-case or ordinary admission. The most frequent reason (66%) for choosing ordinary admission rather than day-case admission was to obtain full reimbursement. Although warfarin therapy was continued in 73% of the centers, nonvitamin K oral anticoagulants were discontinued, without bridging, 24 h or less prior to replacement procedures in 88%. Prophylactic antibiotic therapy was systematically administered in all centers; in 97%, the first antibiotic dose was administered 1-2 h prior to procedures. Local antibacterial envelopes were also used in 43% of the centers in patients with a higher risk of device infection., Conclusion: This survey provides a representative picture of how CIED replacements are organized and managed in current Italian clinical practice. The choice of the type of hospitalization (short versus ordinary) was more often motivated by economic reasons (reimbursement of the procedure) than by clinical and organizational factors. Peri-procedural management of anticoagulation and prophylactic antibiotic therapy was consistent with current scientific evidence.

Aims: Accurate selection of patients with left bundle branch block (LBBB) may help increasing response to cardiac resynchronization therapy (CRT). There is no agreement on LBBB definition. The aim of the study was to investigate the prevalence of 'true-LBBB' according to Strauss in patients undergoing CRT., Methods and Results: The study population included 414 consecutive patients (71.9% men; mean age 69.7 ± 9.6 years), who underwent CRT according to 2010 European Society of Cardiology (ESC) guidelines. Patients were classified into three groups: traditional LBBB according to American Heart Association, LBBB according to Strauss and intraventricular conduction delay (IVCD). Subsequently, they were re-classified into classes of recommendations, according to the current 2013 ESC Guidelines. Traditional LBBB was recorded in 229 patients (55%), an LBBB according to Strauss in 153 (37%) and an IVCD in 32 (8%). Patients with an LBBB according to Strauss showed a significantly more prolonged QRS duration (P < 0.001), greater baseline end-systolic and end-diastolic volumes (P = 0.011 and P = 0.013, respectively) compared with those with IVCD. The prevalence of mid-QRS notching in at least two contiguous leads was 100% in LBBB according to Strauss; 24% in traditional LBBB and 21.9% in IVCD (P < 0.001). At multivariate analysis, PR interval less than 200 ms and QRS of at least 150 ms were independent predictors of mid-QRS notching [odds ratio (OR) 1.78; 95% confidence interval (95% CI) 1.10-2.88; P = 0.02 and OR 2.88; 95% CI 1.80-4.62;P < 0.0001]. Applying stricter criteria for LBBB according to Strauss, a significant reduction in Class I recommendation and an increase in Class II was observed (90.1 vs. 37%; P < 0.0001 and 9.9 vs. 63%; P < 0.0001)., Conclusions: Applying stricter criteria, only 37% of patients undergoing CRT showed a true-LBBB according to Strauss. Accurate identification of true-LBBB may have a potential additional value in better selecting patients.

Background: The prognosis of chronic heart failure (CHF) may be substantially improved by strict adherence to current therapeutic guidelines., Aim and Methods: To assess the adherence to current guidelines, 660 CHF patients consecutively referred to the ARCA (Associazioni Regionali Cardiologi Ambulatoriali Campania) cardiologists were evaluated. As indicators of adherence to the guidelines, we considered use of angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers, beta-blockers, loop diuretics, aldosterone antagonists, digoxin, anticoagulant therapy, and implantation of cardiac devices., Results: The adherence to guidelines has been characterized in patients with reduced ejection fraction, who represent the majority in the ALERT-HF (Adherence to Guidelines in the Treatment of patients with Chronic Heart Failure) trial and in whom the current guidelines are well defined and shared. Among 528 patients affected by CHF with ejection fraction 45% or less, 399 (75.6%) were treated with a beta-blocker, 282 (53.4%) received an angiotensin-converting enzyme inhibitor and 199 (37.7%) an angiotensin receptor blocker. Four hundred and sixty-nine patients (88.9%) used loop diuretics, but only 163 patients (30.9%) an aldosterone antagonist. Among 148 patients with atrial fibrillation, 95 (64.2%) were treated with anticoagulants. As few as 31 patients received cardiac electrical stimulation devices: 10 patients were implanted with a cardioverter-defibrillator and 21 received a device for cardiac resynchronization therapy., Conclusion: The study reveals poor adherence to current therapeutic guidelines for CHF, particularly with regard to aldosterone antagonists and anticoagulant therapy in the presence of atrial fibrillation. Even poorer is the adherence to guidelines as regards the use of implantable cardiac devices. The underlying reasons are discussed in relation to the data of other registries.

Aims: A variable proportion, up to 30%, of patients who undergo cardiac resynchronization therapy (CRT) do not benefit from treatment. The aim of the Cardiac Resynchronization Therapy MOdular REgistry (CRT MORE) is to determine whether specific electrocardiographic and radiographic parameters can be used to predict clinical and echocardiographic response to CRT., Methods: The CRT MORE is a prospective, single-arm, multicenter cohort study designed to evaluate the electrocardiographic and radiographic predictors of response to CRT. All study patients receive a pacemaker or implantable defibrillator for CRT delivery in accordance with current guidelines. Enrollment started in December 2011 and is scheduled to end in November 2013. Approximately 1100 consecutive patients will be enrolled in 30 Italian centers and will be followed up for 60 months after implantation. The primary endpoint is the improvement in clinical (Clinical Composite Score) and echocardiographic (a decrease of ≥ 15% in left ventricular end-systolic volume) parameters at the 6-month follow-up visit., Conclusion: This study might provide important information about which electrocardiographic and radiographic parameters better predict CRT response.

Background: Less than 50% of patients implanted with an implantable cardioverter-defibrillator (ICD) receive device therapy during the follow-up. The aim of our study was to prospectively evaluate the predictive role of appropriate ICD therapy on long-term survival of patients implanted for primary or secondary sudden death prevention., Methods: From 2002 to 2003, 139 consecutive patients [mean age 66±9 years, male 77%, ischemic heart disease 56%, New York Heart Association functional class >II (74%), primary prevention 74%, mean left ventricular ejection fraction 30±9%, cardiac resynchronization ICD 65%] were enrolled. We collected and evaluated device therapies for at least 18 months and recorded survival status for more than 5 years., Results: Over a median follow-up of 18 months, 54 (39%) patients received at least one ICD intervention, with 28 patients receiving only appropriate ICD therapies, 13 only inappropriate therapies and 13 receiving both therapies. At a mean follow-up of 63±12 months, 30 deaths occurred in 130 patients (23%); for nine patients, we had no survival status information. Death was classified as cardiac in 22 (73%) patients, the most common cause was progressive heart failure. In a Cox proportional regression model, an appropriate ICD therapy was associated with a significant increase in the subsequent risk of death (hazard ratio 3.02, P=0.003)., Conclusion: In patients implanted with ICD or cardiac resynchronization therapy with ICD devices, for primary or secondary sudden cardiac death prevention, appropriate ICD therapy predicts a three-fold greater risk of death.

Objectives: Little is known about coronary sinus lead performance in patients with cardiac resynchronization therapy devices. We evaluated the impact of clinical and technical parameters on coronary sinus lead performance over long-term follow-up., Methods: From February 1999 to July 2004, 235 patients (181 men; mean age, 68 +/- 9 years; mean left ventricular ejection fraction, 26.5 +/- 6.5%; idiopathic dilated cardiomyopathy, 49%; ischemic, 48%; and other cause, 3%) underwent cardiac resynchronization therapy (pacemaker or defibrillator) implantation., Results: On implantation, the only statistically significant difference was observed in mean pacing impedance, which was lower for unipolar leads than for bipolar leads (763 +/- 250 vs. 847 +/- 270 Omega, P = 0.02), and lower in patients with ischemic cardiomyopathy than in those with idiopathic cardiomyopathy (758 +/- 204 vs. 837 +/- 291 Omega, P = 0.03). After a mean follow-up of 41.7 +/- 14.7 months, a significant decrease was observed in mean pacing impedance (from 811 +/- 261 to 717 +/- 284 Omega, P = 0.0026) and mean R-wave amplitude (from 13.2 +/- 6.7 to 10.5 +/- 5.5 mV, P = 0.002), whereas the mean pacing energy threshold increased from 3.6 +/- 10.4 to 9.5 +/- 28 microJ (P = 0.004). On analysis of variance, unipolar lead (P = 0.016) and posterior coronary sinus position (P = 0.049) were related to a greater energy threshold increase. On multivariate analysis (Cox regression), only posterior coronary sinus lead position (P = 0.013) proved to be an independent predictor of long-term significant increase in the stimulation energy threshold., Conclusion: Over the long-term follow-up of coronary sinus leads, pacing impedance and R-wave amplitude decreased, whereas the energy threshold increased; unipolar leads and posterior lead location in the coronary sinus were related to a greater energy threshold increase.

Background: Whether cooling catheters should be preferred for atrial fibrillation (AF) ablation is not yet clear., Methods: From April 2005 to October 2006, 991 (74% men) consecutive patients who underwent AF ablation were prospectively enrolled in 10 Italian centers. For the present subanalysis, patients were ranked in the two study groups on the basis of the catheter system chosen: 8-mm tip was used in 86 patients (9% conventional group) and open-irrigated tip in 905 patients (91% cooled group)., Results: The registry clinical data of both groups showed marked heterogeneity due to the fact that the higher number of patients of the cooled group had longer AF history (4.9+/-4.1 versus 1.2+/-1.8 years; P=0.0001), permanent/persistent AF (41.2 versus 27.9%; P=0.01), and larger left atrium (LA) size (44.1+/-6.2 versus 33.4+/-10.5 mm; P

We report a case of a tailored approach to atrial fibrillation based on the substrate. In a patient with paroxysmal atrial fibrillation, electroanatomic mapping showed that atrial fibrillation was limited to a large area around the ostia of right pulmonary veins. The patient was successfully treated by catheter anatomic isolation of this area from the remaining part of the left atrium.