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Aims: Sudden cardiac death (SCD) causes high mortality and substantial societal burdens for healthcare systems (HSs). The risk of SCD is significantly increased in patients with reduced left ventricular ejection fraction after myocardial infarction (MI). Current guidelines recommend re-evaluation of cardioverter-defibrillator implantation 40 days post-MI, earliest. Medical therapy alone does not provide sufficient protection against SCD, especially in the first month post-MI, and needs time. Consequently, there is a gap in care of high-risk patients upon hospital discharge. The wearable cardioverter defibrillator (WCD) is a proven safe, effective therapy, which temporarily protects from SCD. Little information on WCD cost-effectiveness exists. We conducted this research to demonstrate the medical need of the device in the post-MI setting defining WCD cost-effectiveness. Methods & results: Based on a randomized clinical trials (RCTs) and Italian and international data, we developed a Markov-model comparing costs, patient survival, and quality-of-life, and calculated the Incremental Cost-Effectiveness Ratio (ICER) of a WCD vs. current standard of care in post-MI patients. The rather conservative base case analysis – based on the RCT intention-to-treat results - produced an ICER of €47,709 per Quality Adjusted Life Year (QALY) gained, which is far lower than the accepted threshold of €60,000 in the Italian National HS. The ICER per Life Year (LY) gained was €38,276. Conclusion: WCD utilization in post-MI patients is clinically beneficial and cost-effective. While improving guideline directed patient care, the WCD can also contribute to a more efficient use of resources in the Italian HS, and potentially other HSs as well.

Background Small amounts of high-sensitivity cardiac troponin (hs-cTn) I and T can be detected in healthy individuals or can occur in the absence of any clinical features of myocardial ischemia (myocardial injury). However, it is not possible to clinically distinguish whether and which increase in hs-cTn are due to which mechanisms. Moreover, predictive data regarding hs-cTnT in an emergency room (ER) setting are scanty. Consequently, with this monocentric retrospective study, we aimed at expanding the knowledge of this biomarker in this setting. Methods Consecutive adult patients presenting at the ER and hospitalized with a first abnormal hs-cTnT value (≥14 ng/L) were enrolled for 6 months. The baseline hs-cTnT value and the ensuing variations were correlated with the clinical presentation and diagnosis. Subsequently, multivariable models were built to assess which clinical and laboratory variables most influenced hospital admissions. Results At a first screening, 4660 patients were considered, and 4149 patients were enrolled (Figure 1). Of these, 1555 (37.5%) had a first hs-cTnT ≥14 ng/L, and 1007 (65%) were hospitalized according to the following diagnoses: acute coronary syndrome (ACS, 182; 18%), non-ACS cardiovascular disease (337; 34%) and non-cardiovascular disease (487; 48%). Higher hs-cTnT values as well as significant hs-cTnT variations were found in the ACS group (p < 0.01). Furthermore, in the latter, the mean percentage of variation of hs-cTnT was higher, while it was intermediate in the non-ACS group, and low in those with non-cardiovascular disease (407.5%, 270.6% and 12.4%, respectively). Only syncope and CRP (OR: 0.08, 95% CI: 0.02–0.39, p Conclusion In our study, differently from the investigated hs-cTnT, only clinical variables predicted hospitalizations in different patients’ subgroups.

Aims Cavotricuspid isthmus ablation is a routine procedure in electrophysiology laboratories. It is mainly performed as treatment for cavotricuspid isthmus-dependent atrial flutter, which is rare in young patients without structural heart disease. Safety and efficacy data regarding this procedure in such patients are scarce. In this case series we present the clinical characteristics and procedure related outcomes of 3 juvenile patients without overt structural heart disease who underwent cavotricuspid isthmus ablation in our Hospital for recurrent typical atrial flutter. Methods and Results Of the 1217 flutter ablation procedures performed in our Hospital from 2003 to 2022, 3 were on juvenile, otherwise healthy patients. The median patient age was 19.3 years old. All of them had a history of recurrent paroxysmal typical atrial flutter, which was initially terminated with electrical cardioversion. Given the young age no pharmacological prophylaxis was initiated, but on the subsequent recurrence we decided for an ablative strategy. Echocardiography and/or MRI excluded structural heart disease. One of them had experienced flutter induced tachycardiomyopathy, while one underwent previous cavotricuspid isthmus ablation with subsequent arrhythmia relapse. All the procedures were conducted using standard electrophysiology equipment successfully, without significant complications. Baseline electric characteristics of cavotricuspid isthmus were recorded and block of conduction was confirmed using standard protocols. Conclusion Recurrent cavotricuspid isthmus-dependent atrial flutter in young Patients without structural heart disease is exceptionally rare, and ablation is seldom performed. In this case series we present 3 patients with such characteristics, and in whom cavotricuspid isthmus radiofrequency ablation was successfully performed.

Background Cardiac myxomas, though uncommon, do represent the most frequent primary cardiac neoplasms in human beings. Their clinical presentation is mainly due to flow obstruction, cytokines hyperincretion or embolism. Coronary embolism related to the tumor is a rare finding. Here we describe the case of a left atrial cardiac myxoma with an acute coronary syndrome presentation. Case presentation A 71 year-old woman referred for chest pain, nausea and vomit. On the previous few months she had developed exertional dyspnea and fatigue. No prior history of cardiovascular diseases was reported. The 12-lead ECG showed no significant alterations. Troponin T values were elevated (224 ng/L, normal assay threshold Conclusion We reported a case of acute coronary syndrome due to left atrial myxoma. Coronary embolization induced by a cardiac myxoma is rare; however, it should be suspected in patients presenting with myocardial infarction without adjunctive coronary risk factors.

Background Dextrocardia is a rare congenital condition with a prevalence of 0.83 per 10000 pregnancies. Its most common configuration is situs inversus totalis, also known as “mirror-image dextrocardia”. This case report presents a clinical case of symptomatic sinus node dysfunction requiring permanent pacemaker implantation (PPI) in a patient with mirror-image dextrocardia. Case summary A 81-year-old female patient with known situs inversus totalis presented with recurrent syncope. Sick sinus syndrome was diagnosed after documentation of critical pauses (>6.3”) at 24-hour Holter monitoring, giving indication to elective PPI. At admission, 12-lead ECG showed sinus bradycardia and right axis deviation on the frontal plane (standard peripheral leads position and precordial leads on the right side of the chest). Transthoracic echocardiography was performed prior to the procedure with the ultrasound probe flipped and placed on the patient's right side of the thorax, thus achieving standard echocardiography windows and images. A preserved biventricular systolic function and the absence of relevant valvular disease or cardiac malformations was documented. The next day, a dual-chamber pacemaker was implanted following standard technique with the operator standing on the right side of the patient and with right subclavian vein puncture; the pacemaker pocket was created in the right pectoral region. The entire procedure was performed under fluoroscopic guidance using horizontally 180° flipped views, therefore obtaining identical images to those of standard PPI procedures, helping the operator identify anatomical structures during lead positioning. [Fig. 1 a - b] Chest X-ray confirmed correct pacemaker lead placement and absence of procedure-related complications. Stable and satisfactory lead parameters were observed at follow-up. Discussion In literature there are only a few case reports on PPI in situs inversus totalis. The symmetrical disposition of the anatomy makes transvenous PPI technically demanding. In this case the challenge was overcome by using flipped fluoroscopy images, to facilitate lead positioning maneuvres. This technique can be considered only in situs inversus totalis and not in other forms of dextrocardia, such as dextroversion and destroposition, because it is the only situation in which the anatomy is the mirror image of the normal one.

Aims The atrial septal pouch (ASP) is an incomplete fusion between septum primum (SP) and septum secundum (SS), resulting in a kangaroo pouch, that has a high prevalence in general populations (47%) and it is a potential site of blood stasis and thrombosis. After the novel coronavirus disease (COVID19) -related thrombotic complications, immunothrombosis has been widely investigated and proposed as key pathogenic mechanism linking coagulation and inflammation, leading sometimes to intracardiac thrombosis. In this paper we describe a case of thrombus in the ASP interestingly developed after COVID19 and made a literature review. Methods and Results A 85 years old woman with a history of hypertension and chronic atrial fibrillation (AF) in therapy with dabigatran, was admitted to our hospital for dyspnea, atypical chest pain and fever. Laboratory exams showed only mild leukocytosis and elevated levels of d-dimer; EKG confirmed AF with a normal ventricular rate and CT scan excluded pulmonary embolism. Transthoracic and transesophageal echocardiogram (TEE) (Figure 1) showed a mobile ovoid mass (13×26 mm) attached to a left-sided ASP mimicking a myxoma, no mass was seen in the left atrial appendage (LAA). Four months earlier she had been hospitalized for idiopathic thrombocytopenia and concurrent COVID19 infection with mild symptoms, therefore dabigatran was discontinued for a month. The patient underwent surgery and histopathology confirmed it was a thrombus. In the PubMed search we conducted for reports demonstrating ASP masses, or alleged thromboembolism (TE) from this site, we found 25 reports, whose characteristics are briefly summarized in Table 1. Interestingly mild thrombocytopenia was described just in one case. Conclusions In addition to the LAA, the atrial septal pouch is a newly described, common anatomic entity of the interatrial septum, that potentially serves as a site of stasis and thrombus formation. Despite its high prevalence, the finding of a thrombus in this site is very rare. According to Virchow triad, we assume that in this case an endothelial injury and hypercoagulability could have played a pivotal role, since the concomitant thrombocytopenia and high levels of d-dimer. This could be the first case of a thrombus in the ASP associated with COVID19-immunothrombosis.

Background Coronary angiography is the gold standard approach to assess coronary artery disease, especially in acute settings. Additional morphological and functional methods such as intravascular ultrasound (IVUS), optical coherence tomography (OCT), and fractional flow reserve or instantaneous wave free ratio (FFR or iFR) are used to confirm hemodynamic relevance of stenoses, to characterise plaque morphology and vessel size and to optimise stent implantation. This abstract presents a clinical case in which intracoronary imaging, in particular OCT, was essential in proper diagnosis and treatment of a patient presenting with acute coronary syndrome (ACS). Case Summary A 43-year-old female patient with no cardiac medical history presented with new onset chest pain occurring at rest from the night before. At admission, a 12-lead ECG showed sinus rhythm with negative T-waves in the precordial leads, hypokinesia of the anterior and apical wall of the left ventricle was found at echocardiography, and high sensitive cardiac troponin was slightly elevated at the first two measurements. The patient was admitted to the Intensive Coronary Unit with the diagnosis of non-ST segment elevation myocardial infarction and underwent coronary angiography within 24 hours of presentation. A slightly inhomogeneous distribution of dye was found at the ostium of left anterior descending artery (LAD). It was interpreted as a possible type 3 spontaneous coronary artery dissection or as the presence of a non obstructive stenoses. No significant findings were observed in the other cardiac vessels. Due to the discrepancy between the clinical presentation and the angiographic findings, additional morphological and functional assessment of LAD was performed. The OCT revealed the presence of an eccentric obstructive plaque on ostial LAD, and the functional study with FFR confirmed the hemodynamic significance of the stenosis. The patient therefore underwent revascularization with drug-eluting stent implantation on left-main/LAD axis; post-angioplasty OCT confirmed the correct stent position. The patient remained hemodynamically stable during the following hospital stay and was discharged on day 7, with a preserved global left ventricular function and persistence of apical wall hypokinesia, slow ECG evolution with regression of negative anterior T-waves and no sign of necrosis was also observed. Discussion There are several angiographically undetectable lesions that can be identified only by IVUS or OCT. In this case the angiographic findings were of difficult interpretation, coronary angiography alone would have been inconclusive and would have led to the diagnosis of myocardial infarction with non-obstructive coronary arteries. This case highlights the importance of intravascular imaging and functional study to guide revascularization also in the acute settings of an ACS.

A real-world analysis among the Italian population has been carried out to estimate the number of atrial fibrillation (AF) patients undergoing catheter ablation and to evaluate their clinical outcome and economic burden. A retrospective analysis on administrative Italian databases has been performed. Between January 2011 and December 2019, all patients diagnosed with AF were considered and those undergoing catheter ablation were identified. Overall, 3084 (3.54%) of AF patients with at least one catheter ablation were included (mean age 63.2, 67.3% males). A significant decrease in the use of AF-related medications and in hospitalizations, mainly related to AF and heart failure, was observed during the 3-year post-ablation period. The average total cost per patient during the 1-year before ablation period was significantly higher compared to the 1-year post-ablation cost (EUR 5248 vs. 4008, respectively; p < 0.001). After propensity score matching, the overall mortality of patients who underwent ablation was significantly lower compared to that assessed in patients not treated with the procedure (9.386/1000 vs. 23.032/1000 person-year, respectively; p < 0.001). Moreover, the mean total costs were significantly higher in patients who did not undergo ablation compared to those who received ablation (EUR 5516 vs. 4008, respectively; p < 0.001). This real-world data analysis shows that in Italy, although catheter ablation is performed in a minority of AF patients, it is associated with significantly better post-procedure clinical outcomes and a significant reduction in healthcare-related costs.

Fibromuscular dysplasia is a non-atherosclerotic, non-inflammatory arteriopathy, considered a rare cause of coronary artery disease. Although familial cases have been described, no specific gene association has been detected so far. When the coronary vessels are involved, the main clinical scenarios are stable angina, acute coronary syndromes, left ventricular dysfunction, and sudden death. Specific clinical and angiographic findings may suggest this as the underlying disease, but certain diagnosis histological. The involvement of the lower and upper limbs is unusual; however, it may have decisive clinical implications for the most appropriate revascularization method and the selection of the arterial graft to be used.

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.

Background. Nowadays, it is still not possible to clinically distinguish whether an increase in high-sensitivity cardiac troponin (hs-cTn) values is due to myocardial injury or an acute coronary syndrome (ACS). Moreover, predictive data regarding hs-cTnT in an emergency room (ER) setting are scarce. This monocentric retrospective study aimed to improve the knowledge and interpretation of this cardiac biomarker in daily clinical practice. Methods. Consecutive adult patients presenting at the ER and hospitalized with a first abnormal hs-cTnT value (≥14 ng/L) were enrolled for 6 months. The baseline hs-cTnT value and the ensuing changes and variations were correlated with the clinical presentation and the type of diagnosis. Subsequently, multivariable models were built to assess which clinical/laboratory variables most influenced hospital admissions in the investigated population analyzed according to the final reason for hospitalization: (1) cardiovascular vs. non-cardiovascular diagnosis, and (2) ACS vs. non-ACS one. Results. A total of 4660 patients were considered, and, after a first screening, 4149 patients were enrolled. Out of 4129 patients, 1555 (37.5%) had a first hs-cTnT ≥14 ng/L, and 1007 (65%) were hospitalized with the following types of diagnosis: ACS (182; 18%), non-ACS cardiovascular disease (337; 34%) and non-cardiovascular disease (487; 48%). Higher hs-cTnT values and significant hs-cTnT variations were found in the ACS group (p < 0.01). The mean percentage of variation was higher in patients with ACS, intermediate in those with non-ACS cardiovascular disease, and low in those with non-cardiovascular disease (407.5%, 270.6% and 12.4%, respectively). Only syncope and CRP (OR: 0.08, 95% CI: 0.02–0.39, p < 0.01 and OR: 0.9988, 95% CI: 0.9979–0.9998, p = 0.02, respectively) or CRP (OR: 0.9948, 95% CI: 0.9908–0.9989, p = 0.01) and NT-proBNP (OR: 1.0002, 95% CI: 1.0000–1.0004, p = 0.02) were independent predictors of a cardiovascular disease diagnosis. On the other hand, only chest pain (OR: 22.91, 95% CI: 3.97–132.32, p < 0.01) and eGFR (OR: 1.04, 95% CI: 1.004–1.083, p = 0.03) were associated with the ACS diagnosis. Conclusions. Differently from the investigated biomarkers, in this study, only clinical variables predicted hospitalizations in different patients’ subgroups.

Background: The Lombardy region, in Northern Italy, suffered a major outbreak of Coronavirus disease 2019 (COVID-19) at the end of February 2020. The health system was rapidly overwhelmed by the pandemic. It became evident that patients suffering from time-sensitive medical emergencies like stroke, cerebral hemorrhage, trauma and acute myocardial infarction required timely, effective and safe pathways to be treated. The problem was addressed by a regional decree that created a hub-and-spoke system for time-sensitive medical emergencies. Methods: We report the re-organizational changes adopted at a hub hospital (despite having already destined to COVID-19 patients most resources), and the number of emergent procedures for medical emergencies on the first 30-day of activity. These data were compared with the hospital activity in the same period of the previous year. Results: Organizational changes were implemented in few hours. Dedicated pathways for non-COVID-19 patients affected by a medical emergency were set up in the emergency department, in the labs and in the operating theater. Ten intensive beds were implemented from a high-dependency unit; two operating rooms were reserved 24 h/day to neurosurgical or trauma emergencies. The number of emergent procedures was not different from that of the previous year, no admission refusal, no treatment delay and no viral transmission to the treated patients were recorded. No viral transmission to health care workers was observed. Conclusions: Re-organization of a hospital in order to adopt a hub-and-spoke model resulted feasible and allowed to face acute coronary syndrome and other time-sensitive medical emergencies timely and safely.

The impact of sudden cardiac death (SCD) in heart failure (HF) patients is important and prevention of SCD is a reasonable and clinically justified endpoint if associated with a reduction in all-cause mortality. According to literature, in HF with reduced ejection fraction, only three classes of agents were found effective in reducing SCD and all-cause mortality: beta-blockers, mineralcorticoid receptor antagonists and, more recently, angiotensin-receptor neprilysin-inhibitors. In the PARADIGM trial that tested sacubitril/valsartan vs. enalapril, the 20% relative risk reduction in cardiovascular deaths obtained with sacubitril/valsartan was attributable to reductions in the incidence of both SCD and death due to HF worsening and this effect can be added to the known positive effect of implantable cardioverter-defibrillators in appropriately selected patients. In order to maximize the implementation of all the available treatments, patients with HF should be included in virtuous networks with a dialogue between all the physician involved, with commitment by all these physicians for appropriate decision-making on application of pharmacological and device treatments according to available evidence, as well as commitment for drug titration before and after device implant, taking advantage from remote monitoring, and with the safety of back up device therapy when indicated. There are potential synergistic effects of drug therapy, with all the therapies acting on neuro-hormonal and sympathetic activation, but specifically with sacubitril/valsartan, and device therapy, in particular cardiac resynchronization therapy, with added incremental benefits on positive cardiac remodelling, prevention of HF progression, and prevention of ventricular tachyarrhythmias.

Aims Limited data are available on the pathophysiological role of the right ventricle (RV) in patients with acute heart failure with preserved ejection fraction (AHF-PEF) and its impact on the main clinical manifestation such as pulmonary oedema or peripheral congestion. Mainly through right-to-left stroke volume mismatch and ventricular-arterial decoupling, right chambers size and function may play a key role leading to fluid overload or maldistributed phenotypes. Methods and results In this monocenter, prospective, observational study 80 consecutive patients with AHF-PEF were enrolled. A complete echocardiographic examination was performed within 6 hours from emergency department admission; multiparametric RV function was carefully evaluated in the very acute phase. Focusing on hypertensive pulmonary oedema (H-AHF) and decompensated AHF without pulmonary oedema (D-AHF) phenotypes, the study aims to analyze the echocardiographic peculiarities of these clinical entities in the early phase of admission and its modification at discharge (D-AHF n = 58, H-AHF n = 22). Baseline clinical characteristics were comparable in both groups, except for coronary artery disease more prevalent in H-AHF and atrial fibrillation more prevalent in D-AHF. D-AHF patients showed dilated and dysfunctional right chambers compared to H-AHF. Regarding systolic function, normal values of fractional area change (FAC) and tricuspid annular plane systolic excursion (TAPSE) were registered in H-AHF at admission and at discharge. D-AHF showed greater systolic pulmonary artery pressure (sPAP) and lower TAPSE/sPAP ratio. Left ventricular dimensions and function were comparable in both groups. Conversely, E/e’ ratio was significantly higher in H-AHF at admission. Data are summarized in the tables and figures below. Conclusion D-AHF and H-AHF represent different phenotypes of AHF-PEF. Right heart structure and function and ventricular-arterial coupling could play a crucial role in their pathophysiology. Non dilated RV with preserved systolic function seems to be crucial to develop pulmonary oedema without signs of peripheral congestion. Further investigations are needed to corroborate the hypothesis of interventricular stroke volume mismatch in the complex AHF-PEF clinical scenario.

Background The Coronavirus Disease 19 (COVID-19) pandemic brought significant disruption to in-hospital medical training. Virtual reality simulating the clinical environment has the potential to overcome this issue and can be particularly useful to supplement the traditional in-hospital medical training during the COVID-19 pandemic, when hospital access is banned for medical students. The aim of this study was to assess medical students’ perception on fully online training including simulated clinical scenarios during COVID-19 pandemic. Methods From May to July 2020 when in-hospital training was not possible, 122 students attending the sixth year of the course of Medicine and Surgery underwent online training sessions including an online platform with simulated clinical scenarios (Body Interact™) of 21 patient-based cases. Each session focused on one case, lasted 2 h and was divided into three different parts: introduction, virtual patient-based training, and debriefing. In the same period, adjunctive online training with formal presentation and discussion of clinical cases was also given. At the completion of training, a survey was performed, and students filled in a 12-item anonymous questionnaire on a voluntary basis to rate the training quality. Results were reported as percentages or with numeric ratings from 1 to 4. Due to the study design, no sample size was calculated. Results One hundred and fifteen students (94%) completed the questionnaire: 104 (90%) gave positive evaluation to virtual reality training and 107 (93%) appreciated the format in which online training was structured. The majority of participants considered the platform of virtual reality training realistic for the initial clinical assessment (77%), diagnostic activity (94%), and treatment options (81%). Furthermore, 97 (84%) considered the future use of this virtual reality training useful in addition to the apprenticeship at patient’s bedside. Finally, 32 (28%) participants found the online access difficult due to technical issues. Conclusions During the COVID-19 pandemic, online medical training including simulated clinical scenarios avoided training interruption and the majority of participant students gave a positive response on the perceived quality of this training modality. During this time frame, a non-negligible proportion of students experienced difficulties in online access to this virtual reality platform.

Graphical abstract, Highlights • The origins and courses of the coronary arteries can be detected on TTE. • Three “echo-signs” can detect an anomalous origin of the circumflex coronary artery. • A significant stenosis in the anomalous left circumflex artery can be detected on TTE.

Atypical atrial flutters (AAFL) are difficult-to-manage atrial arrhythmias, yet potentially amenable to effective radiofrequency catheter ablation (CA). However, data on CA feasibility are only sparingly reported in the literature in different clinical settings, such as AAFL related to surgical correction of congenital heart disease. The aim of this review was to provide an overview of the clinical settings in which AAFL may occur to help the cardiac electrophysiologist in the prediction of the tachycardia circuit location before CA. Moreover, the role and proper implementation of cutting-edge technologies in this setting were investigated as well as which procedural and clinical factors are associated with long-term failure to maintain sinus rhythm (SR) to find out which patients may, or may not, benefit from this procedure. Not only different surgical and non-surgical scenarios are associated with peculiar anatomical location of AAFL, but we also found that CA of AAFL is generally feasible. The success rate may be as low as 50% in surgically corrected congenital heart disease (CHD) patients but up to about 90% on average after pulmonary vein isolation (PVI) or in patients without structural heart disease. Over the years, the progressive implementation of three-dimensional mapping systems and high-density mapping tools has also proved helpful for ablation of these macro-reentrant circuits. However, the long-term maintenance of SR may still be suboptimal due to the progressive electroanatomic atrial remodeling occurring after cardiac surgery or other interventional procedures, thus limiting the likelihood of successful ablation in specific clinical settings.

Cardiac implantable electronic device (CIED) implants and electrophysiological procedures share a common step: vascular access. On behalf of the AIAC Ricerca Investigators’ Network, we conducted a survey to outline Italian common practice regarding vascular access in EP-lab. All Italian physicians with experience in CIED implantation and electrophysiology were invited to answer an online questionnaire (from May 2020 to November 2020) featuring 20 questions. In total, 103 cardiologists (from 92 Italian hospitals) answered the survey. Vascular access during CIED implants was considered the most complex step following lead placement by 54 (52.4%) respondents and the most complex for 35 (33.9%). In total, 54 (52.4%) and 49 (47.6%) respondents considered the cephalic and subclavian vein the first option, respectively (intrathoracic and extrathoracic subclavian/axillary vein by 22 and 27, respectively). In total, 45 (43.7%) respondents performed close arterial femoral accesses manually; only 12 (11.7%) respondents made extensive use of vascular closure devices. A total of 46 out of 103 respondents had experience in ultrasound-guided vascular accesses, but only 10 (22%) used it for more than 50% of the accesses. In total, 81 (78.6%) respondents wanted to increase their ultrasound-guided vascular access skills. Reducing complications is a goal to reach in cardiac stimulation and electrophysiological procedures. Our survey shows the heterogeneity of the vascular approaches used in Italian centres. Some vascular accesses were proved to be superior to others in terms of complications, with ultrasound-guided puncture as an emerging technique. More effort to produce the standardization of vascular accesses could be made by scientific societies.

Aims According to European guidelines, aborted sudden cardiac death (SCD) in Brugada syndrome (BrS) is regarded as a I class recommendation for secondary prevention implantable cardioverter defibrillator (ICD). However, the risk stratification of BrS patients for primary prevention ICD still represents a clinical conundrum. Although intracardiac electrophysiology (EP) study proved useful for the selection of high-risk patients in this setting. Therefore, aim of this study was to assess all clinical and EP variables associated with the induction of VA at EP study and the rate of appropriate/inappropriate ICD interventions and/or clinical SCD events in these patients occurring at follow-up. Methods and results From 2001 to 2021, all EP studies performed in symptomatic/asymptomatic patients (46 ± 14 years, M 88%) with/without family history of SCD spontaneous/drug-induced type I pattern (TIP) on ECG and no spontaneous ventricular arrhythmias were retrospectively considered at our study centre. Clinical variables, BrS pattern, EP study data (including right ventricular site and type of stimulation protocol), and ICD interventions (DC-shocks or Anti-Tachycardia Pacing events, ATP) and/or SCD events occurring at follow-up were all evaluated. EP study was deemed positive for any polymorphic VA induced during programmed ventricular stimulation; non-sustained episodes included. ICD was routinely implanted in all patients with a positive EP study. Follow-up data were detected by the collection of medical and home-monitoring recordings at study-site level. Follow-up data were available in 50 patients (9 ± 6 years on average). Patients were generally young with few cardiovascular comorbidities. SCD history was known in 21 (42%) with a significant number of asymptomatic patients (48%). Br patterns were equally distributed in the investigated population (spontaneous and drug-induced TIP in 52% and 48%, respectively) and AF history was fairly common (16%). In the study population, EP study tested positive in 30 patients (60%): spontaneous TIP (P = 0.0518), few extrastimuli during programmed ventricular stimulation (P = 0.0015), and right ventricular stimulation at the apical site (P ≤ 0.0001) were the only variables to be clearly associated with a positive EP study in the appraised patients. At follow-up, appropriate ICD shocks were documented in 4 out of 30 implanted patients (13%) at generally 5 ± 7 years from EP study evaluation. Although three ICD interventions (75%) occurred in patients with spontaneous TIP, one patient with drug-induced TIP pattern and positive EP study referred to Emergency Department for unrelenting VT storm after roughly 13 years from ICD implantation. Inappropriate ICD interventions for fast rate AF were detected in 10% of cases. Finally, no SCD events were documented at follow up in patients with a negative EP study. Conclusions In a retrospective analysis, EP study proved useful in the risk stratification of SCD in BrS patients. A few ventricular extrastimuli delivered at the right ventricular apex seem sufficient to prompt the induction of life-threatening VA in high-risk BrS patients during EP study. Moreover, in this setting, a negative EP study seems protective against the development of VA/SCD events at follow-up. However, not only is spontaneous TIP associated with an increased risk of arrhythmic death, but a drug-induced TIP, generally regarded as a low-risk condition, might also be associated with a long-term hazard of SCD in these patients.

Aims There are several studies that describes a possible use of periodical infusions of Levosimendan in patients with advance heart failure (AHF). In these studies, Levosimendan was administered in ambulatory settings (LevoRep, LION-HEART) or during 24 h of hospital stay (LAICA) and for a maximum of 12 months. Currently there is no strong evidence about the feasibility and safety of performing the infusions in an out of hospital setting. Aim of our study was to analyse the feasibility and safety of periodical Levosimendan infusions in AHF patients, in an out of hospital setting for palliative use. Methods and results Aretrospective study was conducted from June 2016 to September 2021 on AHF patients, followed by our centre for periodic infusion of Levosimendan. All patients were previously implanted with an ICD, were ineligible for heart transplant or for ventricular assist devices. All patients on each cycle underwent a cardiological evaluation, a blood sample (complete blood count, biochemical profile, coagulation profile, and NTproBNP), and Levosimendan was administrated with a wearable infusion pump (CADD-Legacy®; Smiths Medical). The patient went home and came back the day after, to return the pump and for reassessment. We collected data on the different infusion regimen, adapted for every patient, and on adverse events during infusions. We enrolled 11 patients with AHF, 9 (82%) of which of ischaemic origin, 2 (18%) were female, median age 72 years (IQR: 64–75), 10 with NYHA class III, 1 with a NYHA class IV, for a total of 231 infusions, with a median Follow-up of 459 days (IQR 132; 783). A total dose of 6.25 mg was administered at 0.05 μg/kg/min in 24 h. In five patients the infusion was of 12.5 mg at 0.1 μg/kg/min rate in 24 h and in other three patients at 0.05 μg/kg/min in 48 h. The median interval between administrations was 21 days (IQR: 14–24.5). Mild adverse events (i.e. that did not contraindicate successive cycles) were 7 on 231 infusions (3.0%): symptomatic hypotension (four cases, 1.7%), loss of consciousness (two cases 0.9%), bleeding for vein access misplacement (one case, 0.4%). No serious adverse event such as sustained or malignant arrhythmia, allergic reaction, or need for hospital admission were recorded. Conclusions The administration of Levosimendan at home with a wearable iv pump is safe and well tolerated. This practice allows to reduce infusion costs of day hospital regime and to lengthen the time available for drug infusion, thus reducing the events caused by a too rapid infusion.

Aims Subcutaneous air has been reported as uncommon cause of early device malfunction after implantation of subcutaneous implantable cardioverter defibrillator (S-ICD). Methods and results A 43-year-old man was admitted to our hospital due to syncopal episodes. During a brain computed tomography (CT), he was resuscitated from cardiac arrest due to ventricular fibrillation. Further investigations excluded ischaemic heart disease and cardiac magnetic resonance showed signs of prior myocarditis. After successful screening, an S-ICD was inserted for secondary prevention using the standard technique. The chest X-ray excluded acute post-procedural complications. Three days after implantation, he experienced two inappropriate shocks while conscious. Device interrogation revealed frequent high-amplitude signals followed by two shocks (Figure 1A and B) that could be interpreted as oversensing. During provocative maneuvers on the generator case, minimal and intermittent noise only on the secondary sensing vector was observed. Lateral and antero-posterior chest X-ray excluded subcutaneous air. However, the general agreement based on previous reports was that oversensing as observed in Figures 1A and B was typical for noise due to micro-air bubbles in the connection between the lead and the generator case. As a consequence, the sensing vector was successfully changed and no other inappropriate shocks were observed during follow-up. Conclusions Entrapped micro-air bubbles in the connection between the leads and the generator case can cause inappropriate shocks in the early period after S-ICD implantation. Timely recognition of this complication is important to prevent inappropriate shocks. It can occur shortly after the procedure even if the intra-procedural parameters were normal and chest X-ray excluded acute complications. As demonstrated in our case, the device can be reprogrammed using another sensing vector to solve these oversensing problems.

Aims In patients affected by heart failure with reduced (HFrEF) and preserved (HFpEF) ejection fraction, sodium–glucose cotransporter type 2 inhibitor drugs (SGLT2i) have shown unexpected and extraordinary results, regardless of the co-presence of diabetes mellitus (DM). The results of the clinical trials have recently allowed the national drug agency (AIFA) to summarize and simplify SGLT2i indications for treatment; however, the reimbursement of these drugs is currently only ensured to diabetic patients, who represent a small subgroup of heart failure (HF) population. The study aims to determine eligibility for SGLT2i in HF outpatients, according to the inclusion criteria of the main clinical trials, comparing the drug label proposed by EMA/AIFA with the current reimbursement criteria. Methods and results In this retrospective, observational study, 206 HF outpatients were enrolled from September 2018 to September 2019. The percentages of eligible patients according to the DECLARE-TIMI 58, EMPA-REG OUTCOME, DAPA-HF, EMPEROR REDUCED, and EMPEROR PRESERVED inclusion criteria were analysed, comparing the indications proposed by the EMA/AIFA label and the current reimbursement criteria. Among the 206 patients enrolled, the mean age was 71 ± 12 years, 24% were diabetic, the mean MDRD eGFR was 61 ± 22 ml/min/1.73m2, the mean ejection fraction (LVEF) was 38 ± 11% (LVEF 60 ml/min/1.73 m2; in our study only 8% of patients met these criteria. Assuming soon to extend the EMA/AIFA indication to HFpEF patients, wider eligibility for SGLT2i is expected for most patients with HF, irrespective of DM and LVEF. Conclusions Two-thirds of our HF population is currently eligible for SGLT2i prescription, according to the drug label proposed by EMA/AIFA; this eligible cohort includes almost all HFrEF patients. When the indications will be updated according to the results of HFpEF trials on SGLT2i, eligibility will be extended almost to the entire cohort of HF outpatients. Most eligible patients are not diabetic, however, they have not currently access to drug reimbursement. The constant updating of the SGLT2i label and reimbursement criteria is the main limiting factor in current clinical practice.

Aims Post-operative atrial fibrillation (POP AF) is frequent in patients who undergo cardiac surgery. However, its prognostic impact in the long-term remains unclear. Methods and results We followed for an average of 10 ± 3 years 1386 patients who underwent a variety of cardiac surgical procedures (cardiac transplantation and surgery for heart failure included) while they were in sinus rhythm. Among 1178 patents without a history of AF, 726 (62%) did not develop AF during the entire duration of the study and 452 (38%) developed new-onset POP AF during the first 30 peri-operative days after heart surgery. Other 125 patients with a positive history of paroxysmal or persistent AF were in sinus rhythm at the time of surgery and 87 of them (70%) developed POP AF. Finally, 83 patients had permanent AF when they underwent surgery. All-cause mortality was the primary outcome of the study. We tested the associations of potential determinants with all-cause mortality using univariable and multivariable statistical analyses by means of Cox proportional hazard models. Overall, 473 patients (34%) died during a long-term follow-up. Compared with patients who never developed AF, neither the patients with new-onset POP AF [adjusted HR = 1.31 (95% CI: 0.90–1.89); P = 0.1609], nor those with history of AF at the time of surgery (adjusted HR = 1.33, 95% CI: 0.71–2.49; P = 0.3736) showed a significantly increased risk of mortality (Figure 1). In new-onset POP AF patients, oral anticoagulation was not associated with mortality [adjusted HR = 1.13 (95% CI: 0.83–1.54), P = 0.4299]. Conclusions In this huge prospective cohort of patients who underwent different types of heart surgery, POP AF was not associated with an increased risk of mortality. In this setting, the role of long-term anticoagulation remains unclear.

Aims During 2020, Italy was hit by the pandemic of the ‘Coronavirus disease 2019’ (COVID-19) with an incidence/100 000 citizens characterized by two peaks. An increase in out-of-hospital cardiac arrest (OHCA) mortality during the first pandemic peak has already been described, but there are few data on the whole year. The goal of our study is to evaluate the impact of the pandemic on post-OHCA mortality. Methods We considered patients with OHCA in Varese territory from January to December 2020 with medical aetiology according with Utstein 2014 classification. The primary endpoint of the study was the assessment of acute post-arrest mortality and which parameters influence this outcome. In particular, both the role of pandemic peaks (‘first peak’ from 11 March 2020 to 23rd May 2020 and ‘second peak’ from 7 October 2020 to 31 December 2020) and the average rescue times, i.e.: (i) interval between OHCA and call for first aid (delay in activation of assistance); (ii) the interval between the call and the arrival of the rescue vehicles (delay in the arrival of the first aid) and finally; (iii) the time between the arrival of the rescue vehicles and the end of Cardiopulmonary Resuscitation (CPR), interrupted due to death or Recovery of Spontaneous Circulation (ROSC). Finally, we performed a multivariate analysis to assess which of the variables considered had the greatest impact on the outcome. Results We analysed 708 patients (mean age 76 + 14.09 years; 40% women). Overall mortality was 89%. During the peaks there was an increase in mortality compared to the pre-pandemic period (first peak 96% vs. 83%, OR 4.49; second peak 92% vs. 83%, OR 2.45) (Figure 1). The time between the collapse and the call for help was significantly higher during the first pandemic peak compared to the second peak and the pre-pandemic period (P = 0.003); the time between the call and the arrival on the patient was significantly longer during both pandemic peaks than in the previous period (P = 0.002) and there was no significant difference in CPR duration time between the periods analysed. In a multivariate model, the only time associated with an increase in mortality is the period between the call for help and the arrival on the patient, regardless of the COVID-19 pandemic. Conclusions During the COVID-19 pandemic there has been an increase in mortality of patients with OHCA. Among the variables considered, the increase in mortality is mainly associated with the delay in the arrival of emergency vehicles on site. This delay, although decreasing, was also maintained during the second peak of the pandemic.

Aims The long-term clinical effects of Levosimendan in patients (pts) with heart failure and reduced ejection fraction (HFrEF) are mainly mediated by its long-acting metabolite, OR-1896, whose half-life is much longer (81 h vs. 1–1.5 h), although with similar inotropic and vasodilatory effect. Echocardiographic data are still lacking, expecially in the chronic setting. Global longitudinal strain (GLS) and left ventricular myocardial work index (LVMWI) are novel non-invasive methods for left ventricle (LV) function evaluation that consider myocardial deformation and afterloads using LV strain combined with the non-invasive estimation of LV pressure. The aim of this study was to perform an echocardiographic assessment in pts with advanced HFrEF before and after infusion of Levosimendan in a chronic setting, using GLS and LVMWI. Methods and results 6 pts with ischaemic HFrEF were prospectively enrolled in the study. Echo-data were collected from all patients using a Vivid E95 system (GE Healthcare), before and after the end of infusion (24–48 h). Moreover, 4 pts underwent another echo evaluation 96 h after the infusion to assess the long term effect of OR-1896. Although mean end-diastolic volume decreased after 24–48 h, increased after 96 h, as reported in Table 1. As to the Ejection Fraction (EF), strain-parameters and stroke volume (SV) remain unchanged before and after the infusion. Similarly LVMWI-derived parameters also remain overall unchanged (Table 1). Conclusions In pts with ischaemic HFrEF undergoing periodical infusion of Levosimendan, we very preliminary observed a reduction of LV size short after the infusion, which interestingly do not persist after 96 h. The other considered echocardiographic parameters (EF, SV, strain-derived parameters) did not show significant differences before and after the infusion. An explanation is that Levosimendan improves LV congestion but not the contractile force in pts with advanced HFrEF, whose myocardial performance is too compromised. Therefore the haemodynamic benefits observed chronically in pts with Levosimendan might be due to the initial decongestion and its vasodilatory effect, and it may not persist in mid-term, depending on basal myocardial conditions. Larger studies should be conducted to conferm these findings.

Aims Severe pulmonary complications are well described in the coronavirus disease 2019 (COVID-19) and cardiovascular diseases (CVDs) have been documented as well. Most patients (pts) recover quickly; nevertheless, the potential long-term cardiovascular sequalae of COVID-19 remain currently unknown. The aim was to report cases of acute coronary syndromes (ACS) after healing from COVID-19 and their features at coronary angiography; secondary purpose was to hypothesize the underlying mechanisms. Methods and results A retrospective study was performed by acquiring data from the electronic medical record. From January to June 2021, four hypertensive pts (64 ± 17 years old; three males) with no history of CVDs and previous symptomatic SARS-CoV-2 infection (mean interval from first positive molecular swab 47 ± 32 days; all recovered after 15 days with double negative swab) were admitted to the emergency department for ST-elevation myocardial infarction (3 anterior and one inferior). At admission, the SARS-CoV-2 molecular swab tested negative, left ventricle ejection fraction was 42 ± 12%, troponin T and Nt-proBNP values were 47 ± 24 ng/l and 1180 ± 978 ng/l, respectively. Emergency coronary angiography showed single-vessel acute thrombotic occlusion (in three cases of the anterior descending artery and in one case of the right coronary artery), with no evidence of atherosclerotic disease. Because of the high thrombotic burden, in all cases a mechanical thrombus aspiration system was used, tirofiban infusion started and no balloon angioplasty or drug-eluting stent implantation was necessary (Figures A–D). After 72 h, a second SARS-CoV-2 molecular swab tested also negative. In the following days, the pts gradually recovered and they were discharged home. Conclusions These cases deserve specific considerations both on the pathophysiologic mechanisms of the ACS possibly related to SARS-CoV-2 and on the subsequent long-term sequelae. Among various pathophysiologic mechanisms proposed, the high affinity of the spike protein for the angiotensin converting enzyme two receptor (expressed by both cardiac and endothelial cells) could explain direct cardiac viral infection and vasculitis with possible development of thrombosis. The latter could contribute both to acute and long-term cardiac sequelae, even months after the acute infection, configuring a sort of ‘cardiac post-Covid syndrome’. Whether and how long this status persists, making COVID-19 a risk factor for subsequent CVDs, is still an unresolved question. In this regard, continuous monitoring of these pts and larger future studies will be essential.