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Background: This report describes the findings of the 2020 Italian Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC)., Methods: Data collection was retrospective. A standardized questionnaire was completed by each of the participating centers., Results: A total of 10 378 ablation procedures were performed by 66 institutions. Most centers (70%) have an electrophysiology laboratory, and 23% a hybrid cardiac surgery laboratory. All centers have a 3D mapping system. The median number of electrophysiologists and nurses involved in the electrophysiology laboratory was 3.5 and 3, respectively. An electrophysiology technician was involved in 35% of all centers. In 88.2% of cases, catheter ablation was performed for supraventricular arrhythmias; the most frequently treated arrhythmia was atrial fibrillation (39.4%), followed by atrioventricular nodal reentrant tachycardia (18.6%), and common atrial flutter (10.6%). In 72.9% of patients, catheter ablation was performed using a 3D mapping system, with a "near-zero" fluoroscopic approach in 37.7% of all patients., Conclusions: The 2020 Italian Catheter Ablation Registry confirmed that the electrophysiology activity was markedly affected by the COVID-19 pandemic; atrial fibrillation is the most frequently treated arrhythmia with an increasing number of procedures performed with a 3D mapping system and a "near-zero" approach.

Background: This report describes the findings of the 2019 Italian Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC)., Methods: Data collection was retrospective. A standardized questionnaire was completed by each of the participating centers., Results: A total of 15 201 ablation procedures were performed by 91 institutions. Most (78%) of the centers has one electrophysiology laboratory, and 17% of them has a hybrid cardiac surgery laboratory. Almost all (98%) centers have a 3D mapping system. The median number of electrophysiologists and nurses involved in the electrophysiology laboratory was 3 and an electrophysiology technician was involved in 30% of all centers. In 88.4% of cases, ablations were performed for supraventricular arrhythmias, and among these the most frequently treated arrhythmia was atrial fibrillation (32.9%), followed by atrioventricular nodal reentrant tachycardia (23.9%), and common atrial flutter (11.7%). In 10 256 (67.4%) patients catheter ablation was performed by means of a 3D mapping system, with a "near-zero" fluoroscopic approach in 4626 (30.4%) of all patients., Conclusions: The 2019 Italian Catheter Ablation Registry confirmed that atrial fibrillation is the most commonly treated arrhythmia in the ablation centers with an increasing number of procedures performed with a 3D mapping system and a "near-zero" approach.

Sudden cardiac death is defined as a natural death due to termination of cardiac activity associated with loss of consciousness, spontaneous breathing and circulation. Nowadays, the prevention of sudden cardiac death represents a major issue and many areas of uncertainty are not met by current evidences. Among those, reliable tools for risk stratification are still lacking, as well as solution for patients in which the risk of sudden cardiac death is due to a transient or correctable condition.The concept of the wearable cardioverter defibrillator is based on a potential solution for such grey areas. It merges long-term monitoring capabilities, shockable rhythm discrimination and shock delivery without the need for bystander assistance or invasive procedures. The present review aims to summarize current problems in dealing with this insidious condition, and to discuss potential options for patients in whom sudden cardiac death could be prevented more safely and cost-effectively.

In patients with cardiac implantable electronic devices (CIEDs) (implantable cardioverter-defibrillators [ICDs] and pacemakers [PMs]), the potential risk of suddenly being unable to drive, and hence of causing road accidents, is higher than in the general population. In ICD patients, this risk stems from the possibility that an arrhythmic event leading to loss of consciousness may occur while driving. In PM patients, it may be the result of a device malfunction in a PM-dependent patient. To determine a CIED patient's ability to drive, two variables must be taken into account: (i) the risk of events, which depends on the type of underlying heart disease (ICD patients have a higher risk than PM patients); (ii) the time spent driving and the type of vehicle driven (professional drivers are at higher risk than private drivers). This position paper reports the recommendations of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) regarding driving by patients with CIEDs, on the basis of the available literature and the European reference recommendations.

In the last decade the field of cardiac pacing and electrophysiology underwent major advancements thanks to both new ways of arrhythmia management and technological innovations. At the same time, the clinical competence and the procedural qualitative level of Cardiac Rhythm Centers have increased significantly. In 2010 an ad hoc Committee of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) and the Italian Federation of Cardiology (FIC) published a consensus document on the organization of Cardiac Rhythm Centers and on the standards of professional practice in pacing and electrophysiology in Italy. In particular, this document focused on the minimal requirements of a Center to be qualified as suitable to perform first, second and third-level cardiac pacing and electrophysiology activities. However, most of these indicators have been overcome over time. Thus, an update of the previously published organizational model appeared necessary. In this document several new requirements and indicators about the organization and performance of both operators and Cardiac Arrhythmia Centers have been introduced. These include: (i) "structural and procedural requirements" (types of diagnostic and therapeutic procedures performed, logistic structures, healthcare staff and technologies), (ii) "activity indicators" (number of procedures performed); (iii) "appropriateness indicators" (adherence to guideline recommendations); (iv) "outcome indicators" (procedural success and complications); and (v) "quality of care indicators" (management and continuity of care levels). By applying these requirements and indicators, each center can optimize its procedures, increasing its performance and effectiveness. Finally, a new model for the organization of the Italian network of Cardiac Arrhythmia Centers is also suggested.

Background: This report describes the findings of the 2017 Catheter Ablation Registry of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC)., Methods: Data collection was retrospective. A standardized questionnaire was completed by each of the participating centers., Results: A total of 15 601 ablation procedures were performed by 91 institutions, with a mean of 184 ± 213 procedures per center. The most frequently treated arrhythmia was atrial fibrillation (34%), followed by atrioventricular nodal reentrant tachycardia (25%) and common atrial flutter (14%). About 10% of overall ablation procedures were performed in patients with ventricular arrhythmias. On-site cardiothoracic surgery was available in 42% of the centers performing ablation and in 49% of the centers performing atrial fibrillation ablation. In most patients, the ablation procedure was guided by a three-dimensional mapping system, and in 15% of patients a near-zero X-ray strategy was used., Conclusions: The Italian Catheter Ablation Registry systematically collected 1-year data on ablation procedures performed in Italy, revealing that atrial fibrillation is the most commonly treated arrhythmia in the ablation centers with an increasing number of patients treated for ventricular tachycardia.

Antiarrhythmic agents are among the therapeutic options available for the treatment of atrial fibrillation when a rhythm control strategy is required. Although their efficacy seems to be generally comparable to that of nonpharmacological interventions, the use of these agents remains controversial. In particular, among this class of drugs, the use of dronedarone in clinical practice is a matter of debate. In this paper, the authors aimed to address these issues, involving a team of expert cardiologists who discussed about the potential use of dronedarone in different clinical scenarios. The RAND/UCLA appropriateness method was used to develop appropriateness measures for the optimal management of patients treated with dronedarone, by combining the best available scientific evidence with the collective judgment of experts. To this purpose, a group of experts was identified and asked to rate the benefit-to-harm ratio of 52 clinical scenarios. Each indication was classified as "appropriate", "uncertain" or "inappropriate" in accordance with the panelists' median score. The classification of each scenario has led to the development of several recommendations for clinical practice. The use of dronedarone for the management of paroxysmal and persistent atrial fibrillation has evolved over time: this antiarrhythmic drug appears to be useful not only in monitoring symptoms, but also in reducing hospitalization and mortality rates in patients with atrial fibrillation.

Background: Junctional beats (JB) are often recorded during slow pathway (SP) radiofrequency (RF) ablation in patients with atrioventricular nodal reentrant tachycardia (AVNRT). Neither the correlation between JBs and SP potentials nor the role of mechanically-evoked JBs has been clarified yet., Methods: Two hundred-eleven consecutive patients, with common AVNRT, underwent RF transcatheter ablation guided by Jackman SP potential searching. If we were unable to record an SP potential or if 4 RF pulses delivered on ideal ablation sites were ineffective, the ablation was carried out on anatomical landmarks. Light pressure was applied with the ablation catheter to each ablation site before RF delivery in order to evaluate the inducibility of JBs., Results: Transcatheter ablation was performed successfully in 209/211 (99%) patients. In 17 (8.1%) patients, no SP potential was recorded. JBs were observed more often delivering RF in the mid-septal region, whereas SP potentials were more often recorded at the base of the Koch triangle. The success rate (successful pulses/overall pulses) was higher in the mid-septal (58.6% in M1, 77.8% in M2) than in the postero-septal region (4% in PSC, 16.8% in P1). JBs showed a higher specificity (73.2 vs 5.3%), positive (55.5 vs 24.6%) and negative predictive value (97.3 vs 63.8%) than SP potential in identifying the successful ablation site. Mechanical JBs were evoked in 23 patients on 29 ablation sites, and 18/29 (62.1%) of them were successful ablation sites., Conclusions: The recording of JBs during or before RF ablation is a useful parameter to guide SP ablation in patients with AVNRT. Although the underlying mechanism has not been clarified yet, their preferential occurrence in the mid-septal region suggests that they might be due to thermal stimulation of compact atrioventricular node.

Background: Recently radiofrequency (RF) catheter ablation (CA) of atrial tachycardia (AT) showed to be highly effective with a low incidence of compliance. Aim of our study was to report the results and follow-up of RFCA of drug-refractory AT in 59 consecutive patients (pts)., Methods: Two mapping techniques were used to localize the ablation site of AT: the earliest atrial activation and the pace-mapping. Traumatic interruption of AT was used to verify the ablation site identified by the previous procedures. Moreover we evaluated the sensitivity, specificity and the positive predictive value of the three mapping techniques., Results: AT was successfully treated in 55/59 (93.2%) pts with a mean of 4.0 +/- 3.8 (range 1-16) RF pulses for patient. The mean procedure time was 185.2 +/- 48.5 min with a mean rx-time of 41.5 +/- 21.3 min. An interval between the onset of the intracavitary atrial deflection and the onset of the P-wave, during atrial tachycardia, (AP interval) > or = 30 ms and pace-mapping concordant sequence were highly sensitive (90.9% and 89.1%) but less specific (49.2% and 33.9%) in identifying the site of ablation. By using atrial tachycardia traumatic interruption combined with the AP interval > 30 ms or the pace-mapping concordant sequence we obtained a specificity of 78.7% and 77.0% respectively and a positive predictive value of 48.0% and 46.8% respectively. Four recurrences (7.3%) were observed during a mean follow-up of 23.4 +/- 13.3 months. In the 22 (37.3%) pts with dilated cardiomyopathy, chest Xr and echocardiography showed a significant decrease of cardiothoracic index (0.56 +/- 0.08 pre ablation, 0.43 +/- 0.07 post ablation, p < 0.001) and end-diastolic diameter (64 +/- 8 mm pre ablation, 52 +/- 8 mm post ablation, p < 0.001) and a significant improvement of left ventricular ejection fraction (37 +/- 9% pre ablation, 48 +/- 11% post ablation, p < 0.05)., Conclusion: The RFCA of AT was effective and safe. Moreover we observed a hemodynamic improvement in patients with reduced ejection fraction and increased cardiac volumes. An AP interval > or = 30 ms and the pace-mapping concordant sequence were reliable features to predict the outcome of the ablation procedure. Traumatic ablation of atrial tachycardia improved the specificity and the positive predictive value of these two mapping techniques and was able to predict the response to radiofrequency with a high specificity.

Disturbances of anal continence and evacuation are frequent. Numerous techniques are now available to measure anorectal function. There is also a better understanding of the anatomy and physiology of the pelvic floor which has a major role in anorectal function. ANORECTAL MANOMETRY. Manometry of the anal canal is an index of the resistance of sphincters to the passage of faeces. Resting pressure is due mainly to the internal anal sphincter whereas voluntary contraction is due mainly to the external anal sphincter. Anorectal manometry is essential in measuring the length of the anal canal and in establishing the presence of the rectoanal inhibitory reflex. Several techniques are employed to evaluate anorectal manometry which is useful in the investigation of patients with faecal incontinence and constipation. PUDENDAL LATENCIES: Pudendal latencies are valuable in the study of the innervation of the external anal sphincter. Pudendal latencies are measured thanks to the stimulation of the S2-S4 nerves lying in the proximity of the ischial spine through the use of a special glove (St Mark's glove). Prolonged pudendal latencies are typical of neurogenic faecal incontinence but it can be brought about by childbirth, rectal prolapse, obstructed defecation and old age. ELECTROMYOGRAPHY. Electromyography is useful in the study of the function of the pelvic floor. This technique can be performed with single fibre needles which make it possible to measure the action potentials and the fibre density of the muscular fibres. Fibre density is raised in neurogenic faecal incontinence and the action potentials are polyphasic in this condition. Concentric needles are employed to map the anal sphincters and this is useful for evaluating the extent of the damage caused by traumatic events like a third degree tear. ANAL ENDOSONOGRAPHY. Anal ultrasound is very effective in the study of the morphology of the anal sphincters and it requires a rectal probe fitted with a 7-MHz transducer. It is as accurate as electromyography in evaluating the damage to the anal sphincters but it is not painful and it is more acceptable to the patient. DEFECOGRAPHY. This radiological test is a dynamic study of the pelvic floor during defecation. It is very useful for investigating the function and the morphology of the rectum and the pelvic floor during defecation. Important parameters like: the anorectal angle, the opening of the anal canal, the position of the pelvic floor and the descent of the perineum can be evaluated with this test. Defecography is useful in the study of patients with rectal prolapse and constipation. CONCLUSION. All these tests provide extremely useful information on the pelvic floor and are reproducible. They can be of great help in evaluating patients with pelvic floor disorders but they are no substitute for clinical judgement.

Aim of our study was to retrospectively evaluate atrioventricular conduction 24 hours after selective radiofrequency catheter ablation of the fast pathway or after selective ablation of the slow pathway of the atrioventricular nodal reentrant tachycardia circuit. Electrophysiologic modifications were retrospectively analyzed in 47/48 patients successfully submitted to fast pathway ablation and in 90/93 patients successfully submitted to slow pathway ablation. The atrioventricular conduction intervals (P-Q and A-H), both anterograde and retrograde Wenckebach point, the effective refractory period of atrioventricular node and the atrioventricular node function curve were evaluated before and after selective radiofrequency catheter ablation of slow and fast pathway. We identified the fast pathway ablation potential as: A:V ratio > or = 2:1, His electrogram < or = 150 microV. The slow pathway potential was identified as the widest, sharpest and latest atrial electrogram recorded during sinus rhythm in the posteroseptal region of the atrioventricular junction or as the widest, sharpest and earliest observed during retrograde conduction. We observed a significant increase in the P-Q and A-H intervals in patients submitted to fast pathway ablation, while no significant modification of these parameters was appreciated in patients submitted to slow pathway ablation. No significant modification of anterograde Wenckebach point (NS) was observed in patients submitted to successfully ablation of fast pathway while a statistically significant increase in anterograde Wenckebach point (p = 0.03) was observed in patients submitted to slow pathway ablation. After selective fast pathway ablation, retrograde conduction was absent in 82.9% of patients submitted to ablation; in the remaining 17.1% a significant increase of retrograde Wenckebach point was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical or catheter ablation of accessory pathways by means of high energy shock has been substantial associated with morbidity and mortality. On the contrary radiofrequency current, an alternative energy source for ablation, has a low incidence of complications and a very high success rate. Aim of this study was to relate about the results using catheter ablation of accessory pathways by radiofrequency current in our Electrophysiologic laboratory. Radiofrequency current (20-40 W) was delivered between a large-tip catheter electrode positioned against the mitral or tricuspid anulus and a standard adhesive electrosurgical dispersive pad applied to the left chest wall. When possible radiofrequency delivery was guided by catheter recordings of accessory pathway activation. Ablation was attempted in 181 patients with 191 accessory pathways. We obtained successful ablation of 187/191 accessory pathways and accessory pathway conduction was eliminated in 177/181 patients. During a mean follow-up of 14 +/- 10 months preexcitation returned in 7 patients (3.9%). All underwent a second successful ablation. In 1 patient, during the procedure, we observed a transient ischemic attack, with no complications. In accordance to other reports we conclude that radiofrequency ablation is highly effective in ablating accessory pathways, with low morbidity and no mortality.

Aim of this study is to suggest our methodological approach for transcatheter ablation of Kent bundles by radiofrequency energy as to the potential ablation sites, the need in unipolar or bipolar recording mode, single catheter or multiple catheters mapping of anomalous pathways, the vascular approach for both left sited and right sited anomalous pathways, and finally the duration and power to supply. The recording of Kent potential and/or a Va-QRS interval > or = 0 ms have been considered significant predictors of success (respectively p < 0.001 and p < 0.05). The unipolar recording mode has been considered critical in the choice of ablation site in 47 (29.9%) patients. A 6-catheter approach for both diagnostic electrophysiologic studies and mapping allowed us to easily localize accessory pathways and to record either a probable or possible Kent potential in a high percentage of patients and to reduce the permanence of the ablation catheter in the left ventricle. By transaortic retrograde approach in ablating left sited anomalous pathways, we obtained a high success rate, while right sited accessory pathway were approached from the inferior vena cava. In right sited anomalous pathway we delivered radiofrequency energy for a longer time in order to avoid a relapse soon after the procedure. We performed ablation of 174/178 (97.7%) anomalous pathways in 165/169 (97.6%) patients. We observed a 3.8% relapse during a mean follow up of 13 +/- 9 months.