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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.

Background Granulomatosis with polyangiitis (GPA), previously known as Wegener's granulomatosis, is a pulmonary-renal syndrome affecting small and medium sized blood vessels. Cardiac involvement is rare and generally includes pericarditis, myocarditis and aortic valve disease. We report a case of recurrent sustained ventricular tachycardia (VTs) in a patient with GPA. Case summary A 67-year-old man with past medical history of GPA presented palpitations, chest pain and episodes of presyncope. Electrocardiographic tracing upon ED presentation showed sustained monomorphic VT (fig.1) associated with global hypokinesia of the left ventricle and moderately reduced ejection fraction at transthoracic echocardiography (TTE). As the patient was hemodynamically stable, prompt treatment with amiodarone was adopted with successful recovery of sinus rhythm. After a few hours, TTE was normal. However, as troponin I was markedly elevated, coronarography was performed and coronary disease was ruled out. Contrast-enhanced cardiac magnetic resonance imaging (ceCMR) revealed late gadolinium enhancement in basal anteroseptal mid wall, suggestive of myocardial scar tissue with non-ischemic pattern. No sustained ventricular arrhythmias were induced during electrophysiological study (EPS), even with an aggressive protocol (up to 4 extra stimuli and ventricular refractoriness) and electro-anatomical mapping of both ventricles failed to show any arrhythmic substrate. An implantable cardioverter defibrillator (ICD) was then implanted. After 4 months the patient was admitted for multiple episodes of sustained VT (with cycle length in the ICD monitoring window) refractory to drugs and three external defibrillations. Repeated EPS failed to induce sustained arrhythmias. High-density electroanatomical mapping of the right ventricle, however, showed fragmented potentials in the mid-posterior septal wall (fig. 2-3). After myocardial biopsy of the region of interest, radiofrequency catheter ablation of the area was performed with regression of the potentials. The results of endomyocardial biopsy demonstrated fibrosis. At 5 months of follow-up, the patient didn't relapse. Discussion Multimodality imaging is of paramount importance in identifying arrhythmogenic substrate and in characterizing the specific anatomical–functional components of VT circuits. In our patient high-density electroanatomical mapping was able to identify fragmented potentials and define the ablation target area, despite the mismatch with ceCMR.

Objective The likelihood of common bile duct (CBD) stones considers liver blood tests (LBTs) if they are markedly altered only. The aim of our study was to find a reliable tool based on LBTs to predict the presence of CBD stones. Methods We retrospectively considered all patients who underwent magnetic resonance cholangiopancreatography (MRCP) because of suspected CBD stones from January 2014 to June 2019. Demographic, clinical data, and LBT values were collected and analyzed. Results We selected 191 patients, 64 (33.5%) with positive MRCP and 127 (66.5%) with negative MRCP. The analysis showed that our compound LBT-based score had 83.6%, 90.7%, and 90.6% sensitivity, specificity, and negative predictive values, respectively, in determining MRCP results. Conclusion We designed a weighted score with high diagnostic power in determining MRCP results that could help in differentiating between candidates for primary cholecystectomy and patients who benefit from preoperative MRCP.

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 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 Children's renal biopsy data were gathered for 3 consecutive years (1992-1994) by the Group of Renal Immunopathology of the Italian Society of Pediatric Nephrology, which opened a paediatric section of the Italian Registry of Renal Biopsies. MATERIALS The Registry recorded the histological diagnosis and the clinical data at renal biopsy of 432 children < or = 15 years old (mean age 8.96 +/- 3.7 years). RESULTS The most common glomerulonephritis (GN) at renal biopsy was idiopathic IgAGN (18.8%) and the most frequent secondary GN was Henoch-Schonlein purpura (HSP) nephritis (11.6%). Minimal-change disease (MCD) accounted for 11.6%, focal and segmental sclerosis (FSG) 8.5%, mesangial proliferative GN (MPGN) 9.5%, membranoproliferative GN 5.5%, and thin-membrane disease 5%. Lupus nephritis was diagnosed in 5% and Alport's GN in 3.9% of the cases. The annual incidence of primary GN in Italian children was 11.1 cases per million children population (p.m.c.p.), IgAN accounting for 3.1 cases, MCD 2.3, and HSP nephritis 1.9 cases p.m.c.p. respectively. Italian children underwent renal biopsy because of isolated microscopic haematuria in 19.3% of the cases, non-nephrotic proteinuria with or without microscopic haematuria in 31.2%, and nephrotic-range proteinuria in 34.2%, less frequently (15.3%) because of acute or chronic renal failure. Children with persistent isolated microscopic haematuria had most frequently IgAN (34.9%) or thin-membrane disease (25.3%), while those with non-nephrotic proteinuria had IgAN (30.4%) and HSP nephritis (23%). In cases with nephrotic proteinuria renal biopsy showed MCD in 34.5% of the cases, FSG in 16.9%, and MPGN in 12.2%. When renal biopsy was performed in chronic renal failure, chronic interstitial renal disease was detected in 62.5% of the cases. CONCLUSIONS This National Registry provides data on the indications for performing renal biopsy in Italian children and on the frequency and annual incidence of histological lesions detected. IgAN, primary or related to HSP, was the most common nephritis in Italian children undergoing renal biopsy.

Background. Children's renal biopsy data were gathered for 3 consecutive years (1992-1994) by the Group of Renal Immunopathology of the Italian Society of Pediatric Nephrology, which opened a paediatric section of the Italian Registry of Renal Biopsies. Materials. The Registry recorded the histological diagnosis and the clinical data at renal biopsy of 432 children ≤15 years old (mean age 8.96±3.7 years). Results. The most common glomerulonephritis (GN) at renal biopsy was idiopathic IgAGN (18.8%) and the most frequent secondary GN was Henoch-Schonlein purpura (HSP) nephritis (11.6%). Minimal-change disease (MCD) accounted for 11.6%, focal and segmental sclerosis (FSG) 8.5%, mesangial proliferative GN (MPGN) 9.5%, membranoproliferative GN 5.5%, and thin-membrane disease 5%. Lupus nephritis was diagnosed in 5% and Alport's GN in 3.9% of the cases. The annual incidence of primary GN in Italian children was 11.1 cases per million children population (p.m.c.p.), IgAN accounting for 3.1 cases, MCD 2.3, and HSP nephritis 1.9 cases p.m.c.p. respectively. Italian children underwent renal biopsy because of isolated microscopic haematuria in 19.3% of the cases, non-nephrotic proteinuria with or without microscopic haematuria in 31.2%, and nephrotic-range proteinuria in 34.2%, less frequently (15.3%) because of acute or chronic renal failure. Children with persistent isolated microscopic haematuria had most frequently IgAN (34.9%) or thin-membrane disease (25.3%), while those with non-nephrotic proteinuria had IgAN (30.4%) and HSP nephritis (23%). In cases with nephrotic proteinuria renal biopsy showed MCD in 34.5% of the cases, FSG in 16.9%, and MPGN in 12.2%. When renal biopsy was performed in chronic renal failure, chronic interstitial renal disease was detected in 62.5% of the cases. Conclusions. This National Registry provides data on the indications for performing renal biopsy in Italian children and on the frequency and annual incidence of histological lesions detected. IgAN, primary or related to HSP, was the most common nephritis in Italian children undergoing renal biopsy.

The CFU-Gm content of liver, spleen and bone marrow of human fetuses was determined from the 8th to 28th week of gestational age. The study of progenitor cells from 43 fetal livers revealed that the CFU-Gm increased from 8 to 12 weeks, was relatively stable through 16 weeks and thereafter declined by 22 to 24 weeks. The total number of liver CFU-Gm rose from 10(4) to greater than 10(6) CFU-Gm by the 16th week of gestation and declined to approximately 4 X 10(5) progenitor cells by 22 to 24 weeks. Peak values of bone marrow CFU-Gm were noted at 10 to 14 weeks of gestation. Generally, the numbers of these progenitor cells declined by 16 to 18 weeks; however, several high values were obtained at later times. Splenic CFU-Gm were relatively constant in number between 12 and 28 weeks of gestation with no correlation with fetal age. Thus, these studies indicate that certain fetal tissues contain substantial numbers of hemopoietic progenitor cells. Based on the quantity of CFU-Gm obtained, it appears feasible to use fetal liver cells as a source of progenitor cells for transplantation.