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Funding Acknowledgements Type of funding sources: None. AIMS Estimation of left ventricle (LV) filling pressure is one of the most important parameters to provide information in clinical practice. However, the challenging in investigating this parameter through invasive methods makes it difficult to be used. The study aims to investigate the association between cardiac structure and function derived by transthoracic echocardiography (TTE) and left atrial (LA) invasive pressure (LAP). Methods The study was a multi-center prospective study enrolling 73 patients (mean age 65 ± 8, 27% female) undergoing primary catheter ablation for AF. Patients were evaluated and enrolled from June 2021 to April 2022. Complete TTE assessing measures of LV, LA and right ventricle (RV) structure and function including speckle tracking echocardiography, was performed at baseline. Echocardiographic data have been assessed the same day of the invasive measurement of the LAP during AF ablative procedure. Linear regression analysis has been performed to assess the relationship between measures of cardiac structure and function and LAP. Logistic regression analysis assessed the parameters associated with elevated LAP (≥ 15mmHg). Results Baseline clinical characteristics of the study population did not differ according to elevated LAP vs. non-elevated LAP. Patients with elevated LAP showed instead abnormal measures of LV global longitudinal strain, measures of LA structure and function, except for LA maximal volume, and RV structure and function. After multivariable adjustment, including demographic factors and comorbidities, E/e`(p = 0,024), LA minimal volume (p = 0,009), LA emptying fraction (LAEF) (p = 0,012), LA Reservoir (p = 0,039), TAPSE (p= 0,010) and RV free wall strain (p= 0,028), but not LA maximal volume (p=0,11), were significantly associated with LAP. Similarly, these measures, but nor LA maximal volume, were significant determinants of elevated LAP. Overall, LA minimal volume and LAEF showed the best diagnostic accuracy to predict elevated LAP (AUC 0.72 and 0.73, respectively). Conclusions Novel measures of LA structure and function, but not standard assessment by LA maximal volume, were significantly associated with LAP in patients affected by AF. These measures, along with measures of LV and RV function may be used in the diagnostic assessment of filling pressure in ambulatory settings.

Funding Acknowledgements Type of funding sources: None. Background Highly localized impedance (LI) measurements in combination with a catheter-tissue contact force (CF) during atrial fibrillation (AF) ablation may improve tissue characterization and lesion prediction during pulmonary vein isolation (PVI). Purpose This analysis explores the relationship between LI parameters, ablation spot locations and procedural success during ablation of PVs in a large population of consecutive AF patients. Methods Two-hundred twelve consecutive patients from 16 European centers undergoing de novo AF radiofrequency (RF) catheter ablation with a novel open-irrigated tip catheter enabled by CF and LI measurement capabilities (Stablepoint) were included. Ablation was guided by the magnitude and time-course of LI drop during RF delivery. The interlesion distance between each ablation spot was set ≤6 mm. First pass isolation (FPI) was defined as successful PVI at or before completion of the first encircling lesion set regardless of visual gaps. Procedural endpoint was the achievement of the PVI as assessed by entrance and exit block. Data are reported as mean±SD. Results A total of 13891 ablation spots performed around PVs were analyzed (baseline LI=161.2±19 Ω; LI drop=21.9±9 Ω; LI drop rate=3.1±2 Ω/s; RF Delivery time=9.2±4 s; CF=12.5±7 g). LI drop was predicted by baseline LI (r=0.56, 95%CI:0.55 to 0.57, p20Ω (Sensitivity=56.8%, Specificity=93.2%, PPV=99.7%, Area under the ROC curve=0.7841, p21Ω at anterior sites and >18Ω at posterior sites. No steam pops or complications were reported during the procedures. All PVs were successfully isolated in all study patients Conclusions In a large, international population of consecutive de novo AF cases, an ablation strategy guided by LI and CF information results in a very high first pass isolation rate. LI drop is predictive of PV segment isolation. A regional approach to RF ablation guided by LI information may be useful in patients with AF.

Funding Acknowledgements Type of funding sources: None. Background Automatic capture algorithms periodically measure the minimal quantity of current needed for pacing, self-adjusting output to guarantee consistent myocardial capture, enhancing patient safety in case of an unexpected rise in threshold and reducing current drain. Left bundle branch area pacing (LBBAP) is an emerging conduction system pacing (CSP) technique which overcomes technical issues and weaknesses of pure Hisian pacing. Purpose The aim of our study was to evaluate safety and efficacy of automatic threshold algorithms in a population of patients with LBBAP. Methods We prospectively enrolled patients receiving LBBAP with different companies which provide LBBAP material) and we evaluated automatic capture threshold algorithms safety and accuracy at 24 hours and at 3 months after implantation. Moreover, when available, home monitoring was used for follow up. Results We included 45 consecutive patients who underwent LBBAP from January 2022 to August 2022. At 24 hours, mean manual LBBAP threshold was 0.5±0.2 V at 0.4 msec, while automatic LBBAP threshold was 0.5±0.3 V at 0.4 msec (p = 0.30). At 3 months mean manual LBBAP threshold was 0.6±0.2V at 0.4 msec vs 0.6±0.2V at 0.4 msec (p = 0.25). Sensing and impedance measures where optimal at 24 hours and improved during 3 months follow up, respectively from 13.7±4.8 mV to 13.9±4.8 mV (p = 0.6) and from 460.1±130 Ohm to 417.1±96.2 Ohm (p = 0.1). Conclusion Automatic threshold algorithms are able to effectively measure LBBAP capture threshold both in the acute phase and during follow up. The possibility to safely use automatic threshold algorithms, thus preserving battery and protecting patients against possible future threshold rises, represents another advantage of LBBAP.

Funding Acknowledgements Type of funding sources: None. Background Left bundle branch pacing (LBBAP) seems to carry advantages compared to His bundle pacing, such as superior electrical performances and less steep learning curve. Aim of this study was to evaluate technical feasibility, safety, electrical parameters and ventricular synchrony with LBBAP. Methods We prospectively enrolled patients receiving LBBAP, such as those with preserved (>50%) left ventricular ejection fraction (LVEF) and narrow QRS, with preserved LVEF and wide QRS, and with LVEF Results We enrolled a total of 58 patients, in whom, according to currently validated criteria, LBBAP was successful in 56 (97%) patients. In the overall population mean baseline QRS duration was 124.1±30.7 msec, while paced QRS duration was 107.7±13.6 msec (p < 0.001). LVEF improved from 52.9±10.5% to 56.9±8.4%, (p=0.004). Improvement was also observed for interventricular synchrony, by reduction of TPSD difference between LV and RV from 27.9 (10.2–41.5) to 13.9 (4.3-28.7) (p=0.001), and for LV synchrony, by decrease of TPSD delta between LV segments from 38.2 (13.6–53.9) to 15.1 (8.3–31.5) (p Conclusion LBBAP improves LVEF and both intraventricular (LV) and interventricular (LV-RV) synchronization, irrespective of pacing indication, baseline QRS duration and LV function.

Aims In patients with prolonged atrioventricular (AV) conduction and pacemaker (PM) indication due to sinus node disease (SND) or intermittent AV-block who do not need continuous ventricular pacing (VP), it may be difficult to determine which strategy to adopt. Currently, the standard of care is to minimize unnecessary VP by specific VP avoidance (VPA) algorithms. The superiority of this strategy over standard DDD or DDD rate-responsive (DDD/DDDR) in improving clinical outcomes is controversial, probably owing to the prolongation of the atrialventricular conduction (PR interval) caused by the algorithms. Conduction system pacing (CSP) may offer the most physiological-VP approach, providing appropriate AV conduction and preventing pacing-induced dyssynchrony. Methods and results PhysioVP-AF is a prospective, controlled, randomized, single-blind trial designed to determine whether atrial-synchronized conduction system pacing (DDD-CSP) is superior to standard DDD-VPA pacing in terms of 3-year reduction of persistent-AF occurrence. Cardiovascular hospitalization, quality-of-life, and safety will be evaluated. Patients with indication for permanent DDD pacing for SND or intermittent AV-block and prolonged AV conduction (PR interval > 180 ms) will be randomized (1:1 ratio) to DDD-VPA (VPA-algorithms ON, septal/apex position) or to DDD-CSP (His bundle or left bundle branch area pacing, AV-delay setting to control PR interval, VPA-algorithms OFF). Approximately 400 patients will be randomized in 24 months in 13 Italian centres. Conclusion The PhysioVP-AF study will provide an essential contribution to patient management with prolonged AV conduction and PM indication for sinus nodal disease or paroxysmal 2nd-degree AV-block by determining whether CSP combined with a controlled PR interval is superior to standard management that minimizes unnecessary VP in terms of reducing clinical outcomes.

Background Coronary sinus is the target of an increasing number of percutaneous interventional procedures. Thus, in some patients, conventional cardiac resynchronization therapy (CRT) may not be feasible or preferable, and ‘alternative’ CRT approaches should be applied. Case summary We present the case of a successful CRT via direct left bundle branch permanent pacing (LBBP) in a patient with relative contraindication to conventional CRT because of previous percutaneous indirect mitral annuloplasty. Discussion LBBP is emerging as a promising technique for physiological cardiac pacing and CRT. It may represent the technique of choice when coronary sinus is not viable for the implant of a conventional left ventricular catheter.

Cerebellar ataxias represent a heterogeneous group of disabling disorders characterized by motor and cognitive disturbances, for which no effective treatment is currently available. In this randomized, double-blind, sham-controlled trial, followed by an open-label phase, we investigated whether treatment with cerebello-spinal transcranial direct current stimulation (tDCS) could improve both motor and cognitive symptoms in patients with neurodegenerative ataxia at short and long-term. Sixty-one patients were randomized in two groups for the first controlled phase. At baseline (T0), Group 1 received placebo stimulation (sham tDCS) while Group 2 received anodal cerebellar tDCS and cathodal spinal tDCS (real tDCS) for 5 days/week for 2 weeks (T1), with a 12-week (T2) follow-up (randomized, double-blind, sham controlled phase). At the 12-week follow-up (T2), all patients (Group 1 and Group 2) received a second treatment of anodal cerebellar tDCS and cathodal spinal tDCS (real tDCS) for 5 days/week for 2 weeks, with a 14-week (T3), 24-week (T4), 36-week (T5) and 52-week follow-up (T6) (open-label phase). At each time point, a clinical, neuropsychological and neurophysiological evaluation was performed. Cerebellar-motor cortex connectivity was evaluated using transcranial magnetic stimulation. We observed a significant improvement in all motor scores (scale for the assessment and rating of ataxia, international cooperative ataxia rating scale), in cognition (evaluated with the cerebellar cognitive affective syndrome scale), in quality-of-life scores, in motor cortex excitability and in cerebellar inhibition after real tDCS compared to sham stimulation and compared to baseline (T0), both at short and long-term. We observed an addon-effect after two repeated treatments with real tDCS compared to a single treatment with real tDCS. The improvement at motor and cognitive scores correlated with the restoration of cerebellar inhibition evaluated with transcranial magnetic stimulation. Cerebello-spinal tDCS represents a promising therapeutic approach for both motor and cognitive symptoms in patients with neurodegenerative ataxia, a still orphan disorder of any pharmacological intervention.

Funding Acknowledgements Type of funding sources: None. Background Cardiac implantable electronic device (CIED) infective complications are associated with high morbidity and mortality. Selection of proper antibiotic prophylaxis therapy is mandatory, as it can decrease the infective risk. Purpose of the Study Aim of the present study was to compare two different antibiotic strategy in term of procedural-related infective complications in a two-years follow-up. Material and Methods Patients undergoing CIED procedure (implant, replacement, or revision), with cefuroxime antibiotic prophylaxis during 2009 were consecutively enrolled as study group, with the purpose to have a long follow-up available (10 years). Patients undergoing CIED procedure (implant, replacement, or revision), with cefazolin antibiotic prophylaxis during 2020 were consecutively enrolled as control group. Primary endpoint was the evaluation of infective complications in the first 2 years follow-up (pocket infection, endocarditis and infective complication requiring CIED complete extraction). Multivariate analysis was performed to evaluate association between covariates resulted significantly different between the two study groups and study endpoint. Long-term follow-up incidence of infective complications was evaluated in the cefuroxime group. Results 340 patients were enrolled in the cefuroxime prophylaxis group and 239 patients in the cefazolin prophylaxis group. There was no significative difference of median age between the two study groups. Patients in the cefazolin prophylaxis group compared to the cefuroxime group showed higher rate of diabetes (33.1% vs 22.1%, p=0.003), dyslipidemia (46.4% vs 36.5%, p=0.02) and higher rate of antiplatelet (45.2% vs 40.6%, p At 10 years follow-up, 11 (3.2%) infective procedure-related complications were recorded in the cefuroxime group, 5 pocket infection, 5 pocket infection with erosion and 1 endocarditis. Conclusion Cefazolin antibiotic prophylaxis is effective as cefuroxime prophilaxis in reducing CIED procedure-related infections, even if patients in the cefazolin group showed higher prevalence of comorbidities and more complex device procedure (ICD and CRT implant).

Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation is frequent in patients undergoing cardiac implantable electronic device (CIED) intervention. Such population require oral anticoagulation therapy, which increases risk of procedure related bleeding. There is a lack on data on procedure-related bleeding outcome with non-vitamin K antagonist anticoagulants (NOACs) vs vitamin K antagonist anticoagulants (VKAs) in patients with AF undergoing CIED intervention. Study purpose Aim of the present stud was to evaluate whether NOACs have a safety benefit compared to VKAs in terms of fewer hemorrhagic complications at the site of CIED implant. Methods Consecutive AF patients receiving NOACs or VKAs at the time of CIED procedure were included in this observational, retrospective, monocentric investigation. Primary endpoint was the incidence of post-intervention clinically significant pocket hematoma. Multivariate analysis was performed to investigate the association between covariates and the primary endpoint. Results A total of 311 patients were enrolled, 146 on NOACs and 165 on VKAs. The incidence of pocket hematoma was 3.4% in the NOAC vs 13.3% in the VKA group (p=0.002) (Figure 1). Primary outcome-free survival at 30-days was 96.6 % in patients on NOACs and 86.0% in those on VKAs (p=0.019) (Figure 2). Multivariate analysis, adjusted by propensity-score calculation of inverse-probability-weighting, showed a significantly lower occurrence of pocket hematoma in patients receiving NOACs vs VKAs (HR 0.35, 95% CI 0.13-0.96, p=0.042). Such NOACs benefit was confirmed vs patients on VKAs without peri-procedural bridging with low-molecular weight heparin (HR 0.34, 95% CI 0.11-0.99, p=0.048). The incidence of pocket infection, surgical pocket evacuation, ischemic events and major bleeding complications at 30 days (secondary endpoints) was similar in the two groups. Conclusion Among patients with AF undergoing implantable cardiac defibrillator or pace-maker intervention, the use of NOACs vs VKAs is associated with significant reduction of post-procedural pocket hematoma, regardless of bridging with low molecular-weight heparin in the VKA group.

Aims To evaluate the risk of syncopal recurrences after pacemaker implantation in a population of patients with syncope of suspected bradyarrhythmic aetiology. Methods and results Prospective, multicentre, observational registry enrolling 1364 consecutive patients undergoing pacemaker implantation for syncope of bradyarrhythmic aetiology (proven or presumed). Before pacemaker implantation, all patients underwent a cardiac work-up in order to establish the bradyarrhythmic aetiology of syncope. According to the results of the diagnostic work-up, patients were divided into three groups: Group A, patients in whom a syncope-electrocardiogram (ECG) correlation was established (n = 329, 24.1%); Group B, those in whom clinically significant bradyarrhythmias were detected without a documented syncope-ECG correlation (n = 877, 64.3%); and Group C, those in whom bradyarrhythmias were not detected and the bradyarrhythmic origin of syncope remained presumptive (n = 158, 11.6%). During a median follow-up of 50 months, 213 patients (15.6%) reported at least one syncopal recurrence. Patients in Groups B and C showed a significantly higher risk of syncopal recurrences than those in Group A [hazard ratios (HRs): 1.60 and 2.66, respectively, P Conclusion In selecting patients with syncope of suspected bradyarrhythmic aetiology for pacemaker implantation, establishing a correlation between syncope and bradyarrhythmias maximizes the efficacy of pacing and reduces the risk of syncopal recurrences.

Aims Direct oral anticoagulants (DOACs) are known for lower bleeding risk than vitamin K antagonist (VKA) in patients with atrial fibrillation (AF). To date, it has not been established whether in such population DOAC may offer reduction of bleeding complication in patients undergoing cardiac implantable electronic device (CIED) implant or revision (substitution, upgrade, or downgrade). We evaluated whether DOACs compared to VKAs, decrease bleeding complications at the time of CIED implant in patients with AF, requiring oral anticoagulant therapy. Methods and results We present a monocentric observational retrospective study. Patients undergoing implant, generator replacement, or upgrading/downgrading of an intracardiac device (PM, ICD, or CRT) between January 2015 and March 2021 with AF undergoing DOAC or VKA were included. The comparison of risk of clinically significant pocket hematoma at 30-days follow-up in the two-treatment group [DOAC vs. VKA and DOAC vs. VKA without low molecular weight eparin (LMWH) bridge] was performed. Cox proportional hazards regression analysis including main clinical findings was performed to test the primary endpoint. Propensity score matching analysis was performed, with inversed proportional weighted (IPW) propensity score included in the multivariate analysis. 311 patients were included, 146 (46.9%) treated with DOAC and 165 (53.1%) treated with VKA. The incidence pocket haematoma was significantly reduced in patients treated with DOAC compared with VKA (3.4% vs. 13.3%, respectively, P = 0.002), a finding confirmed on multivariate analysis (HR: 3.02, CI: 1.10–8.29, P = 0.032). The incidence of pocket haematoma in patients on DOAC vs. VKA without LMWH bridge therapy was found to be significantly higher in the latter group of patients (P = 0.033, HR: 2.93, CI: 1.01–8.49, P = 0.48). After adjusting at propensity score with IPW, DOAC use showed decreased risk of pocket haematoma (HR: 0.29, CI: 0.09–0.95, P = 0.42). Conclusions In patients with atrial fibrillation undergoing CIED implant or revision, DOAC therapy appears to be associated with lower risk of event-related pocket haematoma at 30-day follow-up, even in the absence of bridging with LWMH. Such findings are hypothesis-generating.

Background Scheduled electrical cardioversion (CV) of persistent atrial fibrillation (AF) can be performed after an adequate period of oral anticoagulation (OAC) therapy to reduce thromboembolic complications. Exclusion of left atrial appendage (LAA) thrombi can be achieved by transoesophagel echocardiography (TOE), that is indicated if early CV is desired in patients (pts) with ≥48 hours-lasting arrhythmia, while is not recommended after at least 3 weeks of OAC. Purpose We investigated with TOE the presence of LAA thrombi in a consecutive series of ambulatory pts scheduled for electrical CV of AF and treated with DOAC for at least 3 weeks. Methods We evaluated 93 pts referred to our Clinic for CV of persistent AF (October 2017–December 2018), all treated with DOAC. We collected clinical history, physical examination, 12-lead ECG, lab tests and transthoracic echocardiography measures. Right before cardioversion we systematically performed TOE to exclude LAA thrombi. If absent, we proceeded to CV, while in case of grade III echo-contrast and/or thrombotic stratification we didn't perform the procedure. All values are reported, as appropriate, as mean±SD or number and percentage. All results were considered statistically significant when p Results 76 out of 93 pts (82% – group A) were free from intracavitary thrombi and underwent successful electrical CV; the other 17 pts (18% – group B) had thrombi in LAA that contraindicated electrical CV. Group B pts (74±10 years old, 65% male sex) had higher CHA2DS2-VASc score (4,1±2 vs 3,1±1,4, p=0,014), they were significantly more affected by chronic kidney disease (CKD, 59% vs 32%, p=0.035), peripheral artery disease (PAD, 35% vs 12%, p=0.017), they had larger LA dimension (48±5 vs 45±5 mm, p=0,09 - non significant) and as expected they had reduced LAA emptying velocity (76% vs 30%, p Conclusions Current Guidelines recommend at least three weeks of OAC before electrical CV of persistent AF. TOE is recommended only if early cardioversion is needed. We observed that in a significant part of pts treated with DOAC for more than 3 weeks TOE still identified LAA thrombi, especially in pts with multiple comorbidities. Even if we currently don't have data on clinical endpoints in this population, CV of patients with LAA thrombi despite adequate DOAC therapy may lead to an increased risk of thromboembolic events. We think it's necessary to identify more accurate predictors (i.e. CKD) to stratify the thromboembolic risk. Further randomized studies are needed to identify whether there are patients in which CV shouldn't be performed without TOE, irrespective of anticoagulation duration.

Aims The occurrence of left ventricular (LV) anodal activation during pacing with modern multipolar cardiac resynchronization therapy (CRT) systems has never been reported. The aim of our study was to demonstrate, by means of electrocardiogram (ECG) analysis, the occurrence of simultaneous cathodal–anodal LV capture with quadripolar LV leads. Methods and results We studied 10 first-time recipients of a CRT device equipped with a quadripolar LV lead. During follow-up, standard supine 12-lead ECGs were obtained in available cathode-to-anode LV pacing configurations with a pulse amplitude equal to twice the pacing threshold. The occurrence of simultaneous cathodal–anodal LV capture was defined as the presence of variations in electrocardiographic ventricular activation (EVA) when the distal tip (cathode)-to-device can (anode) pacing configuration was compared with the distal tip (cathode)-to-proximal ring (anode) configuration. In eight patients, we found differences in EVA when different LV sites were paced through the unipolar LV tip and unipolar LV ring configurations. In these patients, a difference in EVA was detected in 61.5% (59 of 96) of the ECG leads (marked difference in 31.3%, slight difference in 30.2%). Changes in EVA between unipolar tip-to-can and bipolar tip-to-ring pacing that were suggestive of cathodal–anodal LV capture were found in six patients. In these patients, a total of 30 (41.7%) ECG leads showed a difference in EVA (marked difference in 20.8%, slight difference in 20.8%). Conclusion In our experience, additional anodal capture by the proximal LV ring during LV pacing is provable in most recipients of a resynchronization device equipped with a multipolar LV lead.

Background: Carbohydrates play a major role in cell signaling in many biological processes. We have developed a set of glycomimetic drugs that mimic the structure of carbohydrates and represent a novel source of therapeutics for endothelial dysfunction, a key initiating factor in cardiovascular complications. Purpose: Our objective was to determine the protective effects of small molecule glycomimetics against free fatty acid­induced endothelial dysfunction, focusing on nitric oxide (NO) and oxidative stress pathways. Methods: Four glycomimetics were synthesized by the stepwise transformation of 2,5­dihydroxybenzoic acid to a range of 2,5­substituted benzoic acid derivatives, incorporating the key sulfate groups to mimic the interactions of heparan sulfate. Endothelial function was assessed using acetylcholine­induced, endotheliumdependent relaxation in mouse thoracic aortic rings using wire myography. Human umbilical vein endothelial cell (HUVEC) behavior was evaluated in the presence or absence of the free fatty acid, palmitate, with or without glycomimetics (1µM). DAF­2 and H2DCF­DA assays were used to determine nitric oxide (NO) and reactive oxygen species (ROS) production, respectively. Lipid peroxidation colorimetric and antioxidant enzyme activity assays were also carried out. RT­PCR and western blotting were utilized to measure Akt, eNOS, Nrf­2, NQO­1 and HO­1 expression. Results: Ex vivo endothelium­dependent relaxation was significantly improved by the glycomimetics under palmitate­induced oxidative stress. In vitro studies showed that the glycomimetics protected HUVECs against the palmitate­induced oxidative stress and enhanced NO production. We demonstrate that the protective effects of pre­incubation with glycomimetics occurred via upregulation of Akt/eNOS signaling, activation of the Nrf2/ARE pathway, and suppression of ROS­induced lipid peroxidation. Conclusion: We have developed a novel set of small molecule glycomimetics that protect against free fatty acidinduced endothelial dysfunction and thus, represent a new category of therapeutic drugs to target endothelial damage, the first line of defense against cardiovascular disease.

Background and methods Portal vein thrombosis (PVT) has been reported as a complication of IBD in some case reports. We describe the presentation, diagnostic approaches, underlying risks factors and clinical outcome of 8 IBD patients with PVT. Case-series The patients presented with partial PVT (4 patients) or portal cavernoma. Five patients had undergone surgery. In 2 patients portal biliopathy was diagnosed after detection of PVT. In 4 patients, the diagnosis of PVT was made while IBD was in remission. Five patients showed at least one risk factor for hypercoagulability: lupus anti-coagulant (one patient), increased von Willebrand factor (2 patients) or homocysteine levels (4 patients). Four patients received anticoagulant therapy for 6 months. None experienced other thrombotic events during a median of 5 years (range 2–8 years). Conclusion PVT is a potential complication of IBD, usually associated with acquired or inherited risks factors for hypercoagulability and with a benign outcome.

AIMS: The relation between left atrial (LA) electrical and mechanical activity is a challenging field of investigation. The availability of echocardiographic strain analysis techniques has enhanced our ability to non-invasively assess LA wall mechanical synchrony and performance. The aim of our study was to investigate how new strain analysis tools describe the improvement in LA mechanical function after sinus rhythm (SR) restoration as a result of electrical cardioversion (CV) and how such improvement mirrors endocrine profile changes. METHODS AND RESULTS: Seventy-three patients, with persistent atrial fibrillation (AF) who underwent successful electrical CV, were prospectively studied with transthoracic echocardiography 1 week before CV and 1 month after SR. Speckle-tracking 2D-strain evaluation and asynchrony quantification were performed according to the standard deviation of time-to-peak (TP-SD) of deformation of six segments automatically located along the perimeter of the LA cavity, as imaged in an apical four-chamber view. We also calculated classic echocardiograhic parameters such as mitral regurgitation (MR) jet area, LA volume, LV diastolic and systolic volumes, as well as E-wave velocity and deceleration time (DT) on transmitral pulsed wave Doppler. Specimens for plasmatic brain natriuretic peptide (BNP) were also obtained before and 1 month after CV. After 1 month of SR, we detected a significant reduction in TP-SD (from 17.5 +/- 7.4 to 15.2 +/- 7.5%, P = 0.022), this being the expression of improved LA asynchrony, together with a marked increase in LA deformation (peak strain from 11.4 +/- 5.2 to 17.2 +/- 7.5%, P < 0.001) and a reduction in LA volume (-4.5 +/- 36%, P = 0.012). BNP decreased by one-third (from 127 +/- 96 to 86 +/- 89 pg/mL, P = 0.01). We also noticed improved ventricular pump performance [LV ejection fraction (EF) from 53 +/- 10 to 57 +/- 8%, P =